Nevins Nursing & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF656Jun 18, 2024

  Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her plan of care, when on 05/22/24, Nurse #1 left Resident #1 alone, without an alarm in place, seated on the commode in his/her room, Resident #1 fell , later complained of pain, was transferred to the Hospital Emergency Department and was diagnosed with a fractured right hip which required surgical intervention to repair. […]

• Actual harm, isolatedF689Jun 18, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to maintain his/her safety, when on 05/22/24, after disabling his/her alarm, Nurse #1 left Resident #1 unattended on the commode, Resident #1 fell to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured right hip, which required surgical intervention to repair Findings include: The… […]

• Actual harm, isolatedF689Apr 18, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and who required physical assistance with the use of a gait belt by staff during transfers and ambulation, the facility failed to ensure Resident #1 was provided with an adequate level of staff assistance which included the use of an assistive device (gait belt) in an effort to maintain his/her safety during a transfer, to prevent an incident or accident resulting in an injury. On 03/20/23, Certified Nurse Aide (CNA) #1 provided Resident #1 with assistance with toliting. […]

• Actual harm, isolatedF686Oct 14, 2022

  Based on observation, record review and interview the facility failed to identify and obtain treatment orders for 2 unstageable pressure areas on 1 Resident's (#4) foot out of a total sample of 26 residents. Findings include: Review of the facility policy titled Sin Management Program Assessment and Prevention of Skin Breakdown and not dated, indicated to check the resident's skin condition daily and whenever giving care for any signs or symptoms of skin irritation or breakdown. Further review indicated that if a wound is identified the area will be assessed, measured and documented weekly in the electronic health record. […]

• No harm, potential for more than minimal, patternF695Jan 7, 2026

  Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents, (#2, #136 and #66) out of a sample of 34 Residents. Specifically,1.For Resident #2, the facility failed to provide oxygen to the Resident as indicated in the physician's orders.2.For Resident #136, the facility failed to ensure oxygen equipment and tubing was labeled, when changed/dated and that respiratory assessments were documented as indicated in the physician's orders. 3. For Resident #66, the facility failed to ensure nebulizer equipment and tubing was labeled, when changed/dated. […]