Kutz Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Kutz Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jul 1, 2022

  Based on interviews, review of clinical records and other documentation as indicated, it was determined that for one (R1) out of five residents reviewed for death in the facility, the facility delayed in providing CPR to R1 upon finding the resident unresponsive at approximately 2:30 AM on [DATE]. Facility nursing staff failed to locate R1's accurate code status in the electronic health record (EHR) and called 911 three (3) times. Due to the confusion and the inability to locate/confirm R1's accurate code status, the facility failed to call a Code Blue and to initiate CPR timely, resulting in an approximate 45 minute delay. R1 was pronounced by the Paramedics at 3:42 AM. The facility's failure placed R1 in situation with a serious adverse outcome, a potential [CONDITION(S)]. […]

• Actual harm, isolatedF684Mar 26, 2025

  3. A review of R11's clinical record revealed: 3/24/21 - R11 was admitted to the facility. 11/16/24 - R11 was admitted to hospice care. 3/12/25 - A review of the medications on the 2/26/25 hospice plan of care document in the electronic medical record (EMR) compared to the medications that the facility had profiled for R11 in the facility EMR revealed the following discrepancies: -Ativan 0.5 mg by mouth every four hours as needed for agitation that was ordered by hospice on 11/16/24 was on the hospice medication list but not on the current facility medication list. -Miralax 17 grams, 1 scoop daily by mouth for constipation, was ordered by the facility on 11/1/24 was on the facility medication profile, but not on the hospice list of medications. […]

• Actual harm, isolatedF689Mar 26, 2025

  Based on interview and review of clinical records and other documentation as indicated, it was determined that for four (R63 and R23) out of eight residents reviewed for falls, the facility failed to ensure that each residents' plan of care was followed to prevent accidents. For R63, the facility improperly transferred the resident using one staff person stand and pivot when R63 required two staff persons and hoyer lift. As a result, R63 was harmed when the resident sustained a lower leg laceration requiring sutures in the emergency room. For R23, a dependent resident for bed mobility, rolled off the bed on to the floor during incontinence care. R23 was sent to the emergency room after the fall. Findings include: A facility policy titled Falls revised 3/2025 documented . 1. […]

• Actual harm, isolatedF689Feb 16, 2024

  Based on observations, interviews, record review, and facility policy review, the facility failed to prevent a fall for one of seven residents reviewed for falls (Resident (R) 30). This failure resulted in harm to R30 when the nursing assistant failed to ensure R30 was safe while dressing her in her room; R30 fell and suffered a concussion and an abrasion to her forehead and was hospitalized for eight days. Findings include: Review of R30's undated ''Admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed R30 was admitted to the facility on [DATE] with multiple diagnoses to include dementia with agitation, epilepsy, and heart failure. […]

• Actual harm, isolatedF690Feb 16, 2024

  Based on observation, interview, record review, and policy review, the facility failed to ensure one out of two residents (Resident (R) 8) reviewed for bowel and bladder was assessed following a decline in continence. In addition, the facility failed to ensure R8 had services and care implemented to maintain as much continence as possible. R8 declined from being continent/mostly continent of urine to becoming incontinent of urine and wearing incontinent briefs following a decline in her ability to use the walker and go to the toilet. […]