St John Neumann CTR for Rehab & Healthcare

In the surveyor’s words

From the most serious findings on record at St John Neumann CTR for Rehab & Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF584Jan 24, 2025

  Based on observation, reviews of the electronic maintenance communication logs, interviews with staff and residents, policy and procedure reviews, and clinical record review, it was determined the facility failed to ensure comfortable air temperature levels were provided on the 300 nursing unit placing residents at risk for developing hypothermia (condition of having a lower body temperature than normal body temperature). The cold air temperatures placed 19 of 32 cognitively impaired residents on the 300 nursing unit in an Immediate Jeopardy situation. […]

• Immediate jeopardy, isolatedF689Sep 9, 2022

  Based on observations, clinical record review, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to adequately supervise one of five residents reviewed (Resident R1), resulting in Resident R1 eloping from a medical facility and missing for a period of almost 55 hours. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy title, Elopement dated December 1, 2021, revealed the facility's protocol and guidelines to follow when a resident cannot be located. […]

• Immediate jeopardy, isolatedF600Jul 29, 2022

  Based on observations, review of clinical records, interviews with staff, review of facility policies and documentation, it was determined the facility failed to ensure that Resident R1 was free from sexual abuse for one of five clinical records reviewed (Resident R1). This failure resulted in an Immediate Jeopardy situation for Resident R1 who was a subject to a nonconsensual sexual activity by Resident R2 with a history of incarceration. Findings include: Review of the facility's policy titled, Prohibition of Resident Abuse & Neglect not dated, stated that each resident will be Free from abuse and neglect. The policy continued to state that the facility practices zero tolerance of resident abuse and neglect . including Staff members and other residents. […]

• Immediate jeopardy, isolatedF689Jul 11, 2022

  Based on observations, review of clinical records, interview with facility staff, review of facility policies and documentation, it was determined that the facility failed to adequately supervise and maintain each residents' environment free from accidents for one of six residents reviewed (Resident R1) who dismounted the air conditioning unit and eloped from a secured memory care unit. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility's policy titled, Missing Resident, not dated, stated the facility's protocol and guidelines to follow when a resident cannot be located. […]

• Actual harm, isolatedF656Jun 9, 2021

  Based on interviews, and the review of clinical records, it was determined that the facility failed to ensure that a comprehensive plan of care was developed for a resident with a history of suicide attempts for one out of 18 residents reviewed (Resident R12). This failure resulted in actual harm to Resident R12 who attempted self harm. Findings include: Review of the resident's Physician Narrative History and Physical dated February 7, 2021, and completed by the physician at the facility, indicated that the resident was admitted into the facility from the hospital on February 5, 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]