Newman Rehab & Health Care Ctr

Inspectors wroteBased on interview and record review the facility failed to ensure residents dignity and respect for two (R3, R4) residents out of five residents reviewed in a sample list of nine residents.

Inspectors wroteBased on interview and record review the facility failed to report allegations of verbal and physical abuse to the abuse coordinator for two of five residents (R3, R4) reviewed for abuse in a sample list of nine residents.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin to the Administrator and the State Agency for one resident (R1) of three residents reviewed for abuse in a sample list of five residents.

Inspectors wroteBased on interview and record review the facility failed to promptly and thoroughly investigate an injury of unknown origin for one resident (R1) of three residents reviewed for abuse in a sample list of five residents.

Inspectors wroteBased on interview and record review the facility failed to provide CPR (cardiopulmonary resuscitation) according to current standards of practice for one resident (R1) of three residents reviewed for Cardiopulmonary Resuscitation in a sample list of five residents. Findings Include: R1's diagnoses list printed [DATE] at 2:52 PM includes the following diagnoses: Encephalopathy, Fall, Urinary Tract Infection, Cardiac Arrhythmia, Anticoagulant Use, Congestive Heart Failure, Hypertension, Hyperlipidemia, Mild Dementia with Anxiety, Protein Calorie Malnutrition, Weakness, and Pressure Ulcers of both heels Stage II. R1's Hospital Discharge Orders dated [DATE] document R1 was hospitalized from [DATE] to [DATE] for Urinary Tract Infection with Sepsis and Metabolic Encephalopathy. [...]

Inspectors wroteBased on interview and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 35 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly label the open date on open food items, failed to have an internal thermometer in a refrigerator and failed to maintain the range hood and the toaster in sanitary conditions to protect food that was being prepared on the range and in the toaster. This failure has the potential to affect all 35 residents residing in the facility.

Inspectors wroteFailures at this level require more than one deficient practice statement. A. Based on interview and record review the facility failed to identify high risk areas for Legionella and implement control measures. This failure has the potential to affect all 35 residents that reside in the facility. B. Based on observation, interview, and record review the facility failed to ensure staff wore personal protective equipment (PPE) properly during a COVID-19 (human coronavirus infection) outbreak. This failure affects eight of sixteen residents reviewed for infection control in the sample list of 25.

Inspectors wroteBased on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review) was completed for two (R11, R10) of two residents reviewed for PASARR screening in the sample list of 25 residents.

Inspectors wroteBased on observation, interview and record the facility failed to initiate care plans to include resident centered problems, goals, and interventions for one (R11) of 16 residents for care plans from a sample list of 25 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hygienic incontinence and urinary catheter care to prevent cross contamination for two (R12, R18) of four residents reviewed for urinary care in the sample list of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to follow facility policy and document/record the daily amount of enteral feeding administered to a resident for one of one resident (R18) reviewed for Gastrostomy tube feedings in the sample list of 25.

Inspectors wroteBased on interview and record review the facility failed to obtain consents, complete assessments, document nonpharmacological interventions, develop a care plan and document stop dates for psychotropic medications for two (R10, R12) of six residents reviewed for unnecessary medications in the sample list of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to store and secure controlled medications behind a separately locked compartment for three (R10, R12 and R23) of three residents reviewed for medication storage from a total sample list of 25 residents.

Inspectors wroteBased on interview and record review the facility failed to maintain documentation of COVID-19 vaccination for three (R9, R19, R36) of five residents reviewed for immunizations in the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapy services were provided for two (R1 and R3) of three residents reviewed for therapy services in the sample of three.

Inspectors wroteBased on record review and interview the facility failed to administer the accurate dose of a liquid concentration, of the physician ordered, Oxycodone (narcotic analgesic) medication. Subsequently, R90 was administered an excessive dose of Oxycodone, twenty times greater than prescribed. The significant medication administration error resulted in R90 experiencing depressed respirations, prolonged apnea episodes, unresponsiveness, and lethargy. R90 is one of one resident reviewed for Hospice/Pain management on the sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to designate a qualified director of food and nutrition services. This failure has the potential to affect 38 out of 39 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food and food service utensils in a manner to prevent cross contamination of residents food. This failure has the potential to affect 38 of 39 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to provide alternate meals to residents that did not eat what was served/or requested a substitute menu item. This failure affected five R9, R11, R17, R32, and R89 reviewed during resident group on the sample list of 20.

Inspectors wroteBased on interview and record review the facility failed to notify resident's family and physician of changes in condition for two (R25, R31) of 16 residents reviewed for change in condition in the sample list of 20.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately encode three falls, on three different minimum data set assessments for a resident. The facility also failed to make corrections on the minimum data sets regarding residents falls, as directed by the facility policy. This failure affects one resident (R16) out of four residents reviewed for accident hazard/falls on the sample list of 20.

Inspectors wroteBased on interview and record review the facility failed to update comprehensive care plans for three residents (R2, R26, R31) of 12 residents reviewed for care plans in a sample list of 20. The facility failed to update care plans in four care areas (accidents, nutrition, anticoagulant, urinary catheter).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with shaving/grooming for two (R19, R25) of three residents reviewed for Activities of Daily Living (ADLs) in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to clean a wound during a wound treatment and label a dressing with a date for one resident (R31) reviewed for wounds in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to label a pressure ulcer dressing with a date, implement pressure relieving interventions, and implement a treatment order for one resident (R31) reviewed for pressure ulcers in the sample list of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for residents at risk for falls, failed to care plan a targeted intervention post fall, failed to investigate an improper transfer of a resident and implement interventions to prevent improper transfers. This failure affects three of four residents (R4, R16, R239) reviewed for accidents/falls on the sample list of 20.

Inspectors wroteBased on interview and record review the facility failed to timely report urine culture results to the physician and timely implement antibiotic orders for one resident (R26) reviewed for Urinary Tract Infections (UTIs) in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer nutritional supplements as ordered, failed to document nutritional supplement intakes, and failed to timely identify significant weight loss and report significant weight loss to the physician and dietitian for two (R31, R2) residents reviewed for nutrition in the sample list of 20. This failure resulted in R31 experiencing a significant weight loss of 13.53% in 90 days.

Inspectors wroteBased on interview and record review the facility failed to assess at least quarterly, document nonpharmacological interventions, and obtain informed consent for one resident (R2) who receives psychotropic medication of five residents reviewed for psychotropic medications in a sample list of 20 residents. Findings Include: R2's Physician's Order Sheet (POS) for August 1st, 2023, through August 31st, 2023, includes the following current physician's orders for psychotropic medication: Citalopram (Antidepressant) 40 milligrams daily. 2. Risperdal (Antipsychotic) 2 milligrams twice daily. 3. Geodon (antipsychotic) 60 milligrams twice daily. 4. Trazadone (antidepressant) 50 milligrams twice daily. and 5. Melatonin (sleep aid) 3 milligrams at bedtime daily. The most recent assessment for R2's citalopram, Risperdal, and Geodon are dated 4/7/23. [...]

Inspectors wroteBased on interview, and record review, the facility failed to designate a Registered Nurse to serve as the Director of Nursing. This failure has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the ice machine in a sanitary manner and failed to store food products with documented dates of opening packages and dates to discard opened food items. This failure has the potential to affect nearly all 43 residents who reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to include a minimum required member, the Director of Nursing, in their Quality Assessment and Assurance Committee for the past three quarterly meetings. This failure has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete quarterly assessments not less frequently than once every three months. This failure affects seven residents (R1, R2, R3, R4, R6, R8, and R12) out of nine reviewed for assessments on the sample list of 29.

Inspectors wroteBased on record review and interview, the facility failed to complete required comprehensive assessments within 14 days after admission, and annually. This failure affects two residents (R5 and R135) out of nine reviewed for assessments on the sample list of 29.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a Comprehensive Plan of Care for R135. R135 is one of one resident reviewed as a new admission on the sample list of 29.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement fall prevention interventions according to resident's care plans. This failure affects two residents (R1 and R11) out of five reviewed for falls on the sample list of 29.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide nutrition, according to Dietician recommendations and physician orders, through a gastrostomy tube for a resident experiencing weight loss. This failure affects one resident (R19) out of four reviewed for nutrition on the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to complete Quarterly Psychotropic Medication Assessments and failed to complete an Abnormal Involuntary Movements Scale (AIMS). This failure effected one of five residents (R10) reviewed for Psychotropic Medications on the sample list of 29.