Johnson County Health and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Johnson County Health and Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 12, 2025

  Based on observation, record review, and interviews, the facility failed to ensure residents were free from elopement for 1 (Resident #1) of 3 sampled residents reviewed for elopement risks. Specifically, Resident #1 was admitted on [DATE] with diagnoses of dementia and psychotic disorder and was severely cognitively impaired. When the resident exited the facility an alarm sounded, and within one minute, an office aide turned the alarm off. The office aide did not notify any other staff that the alarm had sounded and continued working. On 02/28/2025 at 08:06AM, staff confirmed Resident #1 eloped by video, called a Code Green, and notified the Administrator. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2023

  Based on observation, and interview, the facility failed to ensure dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen and baking products were dated when received to assure first in first out usage to prevent potential for food borne illness. These failed practices had the potential to affect 104 residents who received meals from the kitchen (total census: 106) as documented on a list provided by the Dietary Supervisor on 03/23/23 at 3:02 PM. The findings are: a. On 03/22/23 at 9:18 AM, Dietary Employee (DE) #1 removed a bag of chopped lettuce and loose fresh tomatoes from the walk-in refrigerator and placed them on the counter. […]

• No harm, potential for more than minimal, patternF550Apr 12, 2024

  Based on observation and interview, the facility failed to ensure residents who reside on the secure unit were fed in a manner that provided dignity to each resident. This failed practice had the ability to effect 28 residents residing on the secured unit. The findings are: a. On 04/09/2024 at 12:23 PM, Certified Nursing Assistant (CNA) #2 was providing feeding assistance to a resident in the secure unit while standing over them. b. On 04/09/2024 at 12:27 PM, CNA #3 was standing while providing feeding assistance to a resident in the secure unit. c. On 04/09/2024 at 12:29 PM, CNA #1 was standing while providing feeding assistance to a resident in the secure unit. d. […]

• No harm, potential for more than minimal, patternF761Apr 12, 2024

  Based on observations, interview and manufacturer guidelines, the facility failed to ensure two (300 Hall and 600 Hall) of six medication carts assessed had medication properly labeled with an open date. The findings are: On 04/11/2024 at 10:04 AM, the Surveyor observed an open bottle of eye drops on the 300 Hall medication cart with no open date. The medication was received from the pharmacy with a date of 02/28/2024. On 04/11/2024 at 10:33 AM, the Surveyor observed (1) an open bottle of eye drops on the 600 Hall medication cart with no open dated. The medication was received from the pharmacy on 02/09/2024. (2) An open inhaler with no open date or received date from pharmacy. (3) A second open bottle of eye drops with no open date. […]

• No harm, potential for more than minimal, patternF812Apr 12, 2024

  Based on observation, interview and record review, the facility failed to ensure food items were sealed or covered during meal preparation; and failed to ensure equipment was cleaned, rinsed, and sanitized to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 104 residents who received meals from the 1 of 1 affected kitchen. The findings are: A facility policy titled Safe Food handling Practices,dated 02/25/2029, specified, All food is purchased, stored, prepared and distributed in clean safe sanitary manner promoting safe food handling and compliance with state and federal guidelines. To minimize contamination and bacteria while providing nutritious meals. […]