Kadima Rehabilitation & Nursing at Irwin

In the surveyor’s words

From the most serious findings on record at Kadima Rehabilitation & Nursing at Irwin, in the surveyor’s own words.

• Immediate jeopardy, patternF888Aug 9, 2022

  Based on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 and mitigation actions for non-vaccinated staff were implemented. This failure created an Immediate Jeopardy situation for 32 of 103 residents not up-to-date with the COVID-19 vaccination, or for whom vaccination status is unknown (Residents R1, R5, R9, R11, R12, R13, R14, R15, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R31, R32, R33, R34, R , R37, R38, R39, R40, R41, R42, R43). […]

• Immediate jeopardy, isolatedF600Jul 25, 2023

  Based on review of facility provided policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to protect residents from staff-initiated physicial abuse and involuntary seclusion. This failure resulted in a staff member restraining a resident to a wheelchair with a bed sheet and placing the resident into a dark room with the door closed unable to exit which created an Immediate Jeopardy situation for one of 94 residents (Resident R1). Findings include: Review of facility policy Abuse: Protection from Abuse, reviewed 4/1/23, revealed that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. […]

• Immediate jeopardy, isolatedF609Jul 25, 2023

  Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse and involuntary seclusion for one of three residents reviewed (Resident R1), which provided the opportunity of an additional seven days for abuse to possibly continue. This failure created an Immediate Jeopardy situation for one of 94 residents (Resident R1). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. […]

• Immediate jeopardy, isolatedF744Jul 25, 2023

  Based on clinical record and facility document review and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of 94 residents. This failure created an immediate jeopardy situation for one of 94 residents (Resident R1). Findings include: Review of the facility policy, Guidelines for Caregiver Interaction with Dementia dated 4/1/23, indicated that staff will interact with residents in a manner that supports dignity and enhances residents abilities to successfully participate in life. Staff will recognize that the resident cannot always control his/her behavior. […]

• Actual harm, widespreadF886Aug 9, 2022

  Based on Centers for Medicare & Medicaid Services (CMS) guidance, review of facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 in the month of July 2022, for 30 of 30 unvaccinated employees (Employees E13 through E42). Findings include: Review of Centers for Medicare and Medicaid Services (CMS) document QSO-20-38-NH Revised 3/10/22, indicated routine staff testing frequency for staff who are not up to date on their vaccinations should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing. […]