Todd-Dickey Nursing and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 2, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff provided effective assistance with drinking in accordance with the plan of care and failed to implement effective interventions to prevent the spillage of hot coffee to a resident with upper extremity tremors for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident spilling the hot coffee and sustaining second degree burns on right lateral chin, right and left thighs; and a third degree burn on right upper inner groin area. Findings include: On 10/1/24 at 10:35 a.m., Resident B was observed resting in bed with her eyes open and watching television. The resident was observed with tremors of persistent movement to the arms, hands, and head. […]

• No harm, potential for more than minimal, patternF690May 20, 2022

  Based on observation, record review, and interview, the facility failed to ensure proper catheter care, handling of the indwelling urinary catheter bag or tubing, and monitoring of urinary output or fluid intake for 4 of 4 residents reviewed for indwelling urinary catheters. (Residents 29, 25, 31, and 55) Findings include: 1. During an observation on 5/16/22 at 11:30 a.m., Resident 29's indwelling urinary catheter was at the bedside with 500 mL (milliliters) of tea colored urine in the catheter bag and tubing with a heavy amount of yellow [MEDICATION(S)] in the tubing but clear urine in the catheter bag. The resident indicated he had an infection and blood clots in the catheter bag. He wished the staff would take the catheter out. […]

• No harm, potential for more than minimal, isolatedF690Jul 2, 2025

  Based on observation, record review, and interview, the facility failed to ensure a resident was provided proper management of the urinary catheter drainage system related to placement of the tubing and bag for 1 of 2 residents reviewed for bowel and bladder. (Resident 35) Findings include: During an observation on 6/30/25 at 8:59 a.m., Resident 35 was sitting in a wheelchair conducting a corn hole activity in the dining room. Her urinary catheter tubing, which was down the resident's left pant leg, was dragging on the floor as she moved. There was clear yellow urine in the tubing. The catheter bag was scrunched up on the left side of her wheelchair in a urinal basket. The Activity Aide was sitting to the right side of the resident, but didn't notice the tubing being on the floor. […]

• No harm, potential for more than minimal, isolatedF755Jan 18, 2024

  Based on interview and record review, the facility failed to ensure medication errors did not occur for 1 of 3 residents reviewed for medication administration. (Resident C) Findings include: 1. The clinical record for Resident C was reviewed on 1/17/24 at 1:02 p.m. The diagnoses included, but were not limited to, congestive heart failure, depression, anxiety and hypertension. The incident report, dated 6/10/23 at 1:33 p.m., indicated Resident C had a medication error. The resident was sent to the hospital and diagnosed with a urinary tract infection. The progress note, dated 6/10/23 at 8:15 a.m., indicated QMA (Qualified Medication Aide) 4 administered the wrong medication to Resident C. […]

• No harm, potential for more than minimal, isolatedF684May 20, 2022

  Based on observation, record review, and interview, the facility failed to ensure accuchecks (blood glucose level monitoring) were performed as ordered, and insulin pens were primed prior to administration of insulin for 2 of 3 residents reviewed for insulin administration. (Residents 258 and 9) Findings include: 1. During an observation on 5/17/22 at 8:42 a.m., LPN (Licensed Practical Nurse) 1 dispensed medications for Resident 258. She prepared [MEDICATION(S)] 5 mg (milligrams), [MEDICATION(S)] 2 mg, [MEDICATION(S)] 40 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] 5 mg, and [MEDICATION(S)] 7.5 mg, by removing the medications out of the packaging and placing them directly into her bare, ungloved hand, and then placing the medication into a clear medication cup with bare fingers. […]