Newman Rehab & Health Care CTR

In the surveyor’s words

From the most serious findings on record at Newman Rehab & Health Care CTR, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Mar 9, 2023

  Based on observation, interview and record review the facility failed to ensure a severely cognitively impaired resident (R1) was positioned safely away from an electric baseboard heater that had been turned to the highest temperature setting, resulting in R1 suffering second and third degree burns, requiring hospitalization , antibiotics, and skin grafting, when staff positioned R1's bed directly next to the heater. This failure has the potential to affect all 43 residents residing in the facility all of whom have electric baseboard heaters in their rooms. This failure resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF760Aug 9, 2023

  Based 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. Findings include: R90's Physician Order Sheet (POS) dated 7/17/23- 7/31/23 documents R90 was admitted on [DATE] on Hospice (care services for terminally ill). […]

• No harm, potential for more than minimal, widespreadF801Sep 17, 2024

  Based 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. Findings include: On 9/15/24 at 8:16 AM, there were opened food items in the refrigerator that were not labeled with open dates and there were open food items in the dry storage room that were not labeled with open dates. At this same time there was dust and debris hanging directly above the cook top and the toaster was dirty with crumbs inside and around the outside. On 9/16/24 at 9:00 AM, V19 Dietary Manager stated that she is not a certified Dietary Manager. V19 stated that she has taken some courses but has not had time to complete all of the courses. […]

• No harm, potential for more than minimal, widespreadF812Sep 17, 2024

  Based 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. Findings include: The facility's storage policy with a revised date of October 2020 documents, It is the policy of (the facility) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food costs. Procedure: 1. […]

• No harm, potential for more than minimal, widespreadF880Sep 17, 2024

  Failures 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. […]