Rawlins Rehabilitation and Wellness

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678May 2, 2024

  Based on medical record review, staff and physician interview, and policy review, the facility failed to provide CPR in accordance with a resident's advance directive for 1 of 1 sample resident (#36) who expired. The emergency happened shortly after admission. The facility had not identified the issue, which left all new admits at risk and a determination of immediate jeopardy. The census was 35 and there were two new admits in the last 30 days. The findings were: 1. Medical record review for resident #36 showed an admission and discharge date of [DATE]. Further review showed the resident signed the admission paperwork, including a POLST [physician orders for life-sustaining treatment] dated [DATE] that indicated the resident chose to be a full code. […]

• Immediate jeopardy, isolatedF600Mar 31, 2023

  Based on medical record review, staff interview, facility-reported incident review, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 5 sample residents (#23) reviewed for allegations of abuse. This failure resulted in a determination of immediate jeopardy due to inadequate protections from sexual abuse for vulnerable residents. The findings were: 1. Review of the 1/20/23 quarterly MDS assessment for resident #23 showed the resident had a BIMS score of 4 out of 15, indicating the resident had significantly impaired cognition. The review showed the resident had diagnoses that included epilepsy, dementia, cognitive communication deficit, depression, irritability and anger. […]

• Actual harm, isolatedF684Aug 22, 2022

  Based on medical record review, staff interview, and review of the facility's neurological evaluation form, the facility failed to follow physician orders, and failed to assess or monitor changes in condition for 2 of 4 sample residents (#1, #2,) reviewed for changes in condition requiring transport to the hospital. This failure resulted in harm to resident #1, whose need for assessment, treatment, and monitoring of his/her diabetes mellitus went unaddressed, and whose change in condition on 7/8/22 was not evaluated in a timely manner. Resident #1 required emergency transport to the hospital, where his/her prognosis was determined to be [NAME]. The findings were: 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 28, 2022

  Based on observation, staff interview, review of the Food Code, and maintenance record review, the facility failed to ensure food storage areas (the walk-in cooler, ice machine) were kept sanitary. The census was 40. The findings were: 1. Observation on 3/21/22 at 1:05 PM showed the condenser unit in the walk-in-cooler was leaking. The condenser unit was located above the slatted food storage shelves and there was a bucket on the top shelf collecting the water. Next to the collection bucket were bags of bread and buns. There were also boxes of food stored on the shelves below. Interview with cook #1 on 3/21/22 at 1:05 PM revealed she was unsure how long the leak had been there. 2. […]

• No harm, potential for more than minimal, widespreadF801Apr 1, 2021

  Based on staff interview, review of the facility staff list, and review of the facility job description, the facility failed to ensure a dietitian or qualified clinical nutrition professional was designated as the director of food and nutrition services. The census was 43. The findings were: 1. Interview with the dietary manager on 3/31/21 at 11:35 AM revealed she was not a certified dietary manager, the facility did not have a full time dietitian, and she had been employed by the facility for 3 months. Further interview revealed the dietary manager was enrolled in a training course. 2. Review of the staff list provided by the facility on 4/1/21 showed the dietary manager had a hire date of 12/1/20. 3. […]