Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Newman Rehab & Health Care Ctr during CMS and state inspections, most recent first.
A facility failed to maintain dignity and respect for two residents with significant cognitive and physical impairments. One resident with hemiplegia and moderate cognitive impairment was reportedly spoken to with profanity in front of others, while another resident with dementia and severe cognitive impairment was reportedly yelled at during care and allegedly subjected to hair pulling, being struck with a pillow, and profanity. Staff and the DON acknowledged the language and behavior were inappropriate, and the Administrator stated residents have the right to be treated with dignity and respect.
Failure to timely report allegations of abuse: staff did not immediately report verbal and physical abuse concerns involving one severely cognitively impaired resident and one moderately cognitively impaired resident. A CNA reported another CNA allegedly pulled hair, hit a resident with a pillow, and used profanity, while an RN had earlier heard the resident scream and say, "Don't hurt me!" but did not report it. Another staff member also failed to report profanity used in front of a resident. Facility policy required immediate reporting of suspected or alleged mistreatment to a supervisor and the administrator.
A resident with multiple medical conditions, including dementia and pressure ulcers, was found with a bruise of unknown origin. The injury was documented by staff, but the administrator was not made aware and did not report the incident to the state agency, resulting in a failure to follow required abuse reporting procedures.
A resident with multiple medical conditions, including dementia and anticoagulant use, was found with an unwitnessed bruise of unknown origin. The facility did not conduct a prompt or thorough investigation as required by its abuse prevention policy, and the administrator was unaware of the incident until informed by surveyors.
A resident with multiple medical conditions and a full code status was found unresponsive and did not receive CPR according to current standards. Staff initiated CPR on a soft mattress without using a backboard or moving the resident to a firm surface, and did not perform required pulse checks during compressions. EMS later moved the resident to the floor and continued resuscitation efforts, but the resident was pronounced deceased. Staff interviews confirmed a lack of adherence to established CPR protocols.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 35 residents. Opened food items were unlabeled, and the kitchen area was unclean. The Dietary Manager admitted to not being certified, despite the facility's assessment requiring a qualified professional.
The facility was found to have deficiencies in food storage and kitchen sanitation. A refrigerator lacked an internal thermometer, and several food items were not labeled with preparation or opening dates. Additionally, unsanitary conditions were observed, including dust and debris on the range hood and crumbs in a toaster. These issues were confirmed by the Dietary Manager and have the potential to affect all 35 residents.
The facility failed to identify high-risk areas for Legionella and implement control measures, potentially affecting all 35 residents. The Maintenance Director did not identify any high-risk areas, and there was no documentation of routine control measures. Additionally, during a COVID-19 outbreak, a Dietary Aide was observed serving meals with her mask pulled down, exposing her nose and mouth, contrary to the facility's policy requiring N95 masks. Since the outbreak began, nine residents and ten employees tested positive for COVID-19.
The facility failed to complete a Level II PASARR for two residents with mental health diagnoses. One resident with Schizoaffective Disorder and another with Affective Psychosis and Dementia were not properly screened, despite being prescribed psychotropic medications. The facility's staff acknowledged the oversight and the absence of a PASARR policy.
A resident's care plan lacked documentation for necessary positioning aids and oxygen administration. The resident, with a contracted right hand, reported that staff often forgot to apply her hand splints. Observations confirmed the absence of splints, and the care plan did not include these aids. Additionally, the care plan failed to document the resident's oxygen needs, despite physician orders and daily administration records indicating its necessity.
The facility failed to provide proper incontinence and catheter care for two residents. One resident received incontinence care without changing gloves between cleaning the buttocks and frontal area, against facility policy. Another resident's catheter drainage bag was improperly positioned, lying on the floor and lifted above bladder level, risking backflow. The resident had a recent UTI with a multi-drug resistant organism.
A facility failed to document the daily intake of enteral feeding for a resident with a G-tube, leading to unmonitored weight loss. The resident, with multiple diagnoses including Alzheimer's and Dysphagia, was ordered specific feeding and water flushes, but only output was recorded. The DON confirmed the lack of documentation and had not informed the Dietician of the resident's weight loss, which was only reviewed at the end of the month.
The facility failed to manage psychotropic medications properly for two residents, both with severe cognitive impairment and under hospice care. The facility did not document nonpharmacological interventions, obtain consents, or complete necessary assessments for Lorazepam use. Additionally, there were no stop dates for PRN orders, and care plans were incomplete. The Director of Nursing acknowledged these oversights, partly attributing them to the involvement of agency nurses and the residents' hospice status.
The facility did not secure controlled medications, specifically Lorazepam, in a locked refrigerator as required. An unlocked refrigerator was found to contain five bottles of Lorazepam for three residents. The facility's policy requires Schedule II drugs to be double-locked, but this was not followed. Both a RN and the DON confirmed the refrigerator should have been locked.
The facility failed to document COVID-19 vaccination status for three residents, all over 65 with significant medical histories, leading to a deficiency. The facility's policy requires offering and documenting COVID-19 vaccines, but there was no record of booster offers or declinations for two residents, and one resident's vaccination record was incomplete.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure dignity and respect for two residents. R4’s record showed diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, schizoaffective disorder bipolar type, cerebral infarction, anxiety, and a history of TIA. R4’s MDS documented moderate cognitive impairment and the need for moderate assistance with transfers, and the care plan indicated total dependence on one staff member for wheelchair locomotion. A witness stated a CNA used profanity in front of R4, saying, “Let’s go to f****** bed,” while standing by R4’s dinner table and then removed R4 from the dining room. R4 later stated the CNA had used profanity to and in front of him and that he did not like being spoken to that way. R3’s record showed diagnoses including dementia, seizures, obstructive and reflux uropathy, spinal stenosis, unsteady gait, abnormal posture, and disorder of muscle. R3’s MDS documented severe cognitive impairment and dependence on staff for toileting and transfers, and the care plan directed staff to provide dignity, allow sufficient time, and avoid rushing R3. Staff reported concerns that the same CNA pulled R3’s hair, hit R3 with a pillow, and told R3 to shut the f*** up. An RN stated she heard R3 yelling, “Don’t hurt me! Don’t hurt my back!” during incontinence care and later heard R3 yelling that the CNA was a b**** and evil. R3 stated staff did not treat him very well and yelled at him at night, and the Administrator stated staff should always treat residents with dignity and respect.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to timely report allegations of verbal and physical abuse involving two residents to the abuse coordinator. One resident was severely cognitively impaired, required moderate assistance for bed mobility and personal hygiene, and was dependent on staff for toileting and transfers. A CNA reported that another CNA allegedly verbally and physically abused this resident, including pulling hair, hitting the resident with a pillow, and using profanity. The reporting CNA stated she witnessed the incident but did not immediately report it because the other CNA was present and she did not want to upset her. An RN also stated she had heard the resident screaming on an earlier occasion, found the CNA providing incontinence care, and heard the resident say, "Don't hurt me!" and later make repeated statements calling the CNA evil and using profanity, but the RN did not report those concerns when they occurred. A second resident was moderately cognitively impaired and required moderate assistance with transfers. A staff member stated she witnessed the administrator use profanity in front of this resident about a month earlier, but did not report it immediately because she believed it was already known. The administrator later stated that the CNA’s abuse allegations were reported to the RN and then to the DON, and that the staff members should have reported the allegations immediately to the administrator. The facility policy required employees to immediately report any observed, heard, or suspected mistreatment, exploitation, neglect, abuse, or misappropriation of resident property to a supervisor and the administrator.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident, as required by its Abuse Prevention Program and state regulations. The policy mandates that nursing staff report any appearance of bruises or injuries of unknown origin on a facility incident report, and that the Nursing Supervisor assess the resident, review documentation, and report to the administrator or designee. Additionally, the policy requires a final investigation report to be sent to the administrator and the Department of Public Health. In this case, a resident with multiple diagnoses, including encephalopathy, mild dementia, and pressure ulcers, was found to have a bruise on the right buttock, which was documented as an injury of unknown origin. The event was unwitnessed, and the resident was unable to provide details due to their condition. Despite the documentation of the injury, the administrator stated that no complete report was made and the incident was not reported to the state agency because the administrator was unaware of the injury. The lack of awareness led to the absence of an immediate investigation and failure to notify the appropriate authorities, as required by facility policy and regulation. This inaction resulted in noncompliance with the facility's abuse reporting procedures for injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to promptly and thoroughly investigate an injury of unknown origin for one resident. According to the facility's Abuse Prevention Program, nursing staff are responsible for reporting incidents such as bruises or injuries of unknown origin, and the Nursing Supervisor must assess the resident, review documentation, and report to the administrator. The policy also requires a final investigation report to be completed within five working days, including detailed information about the incident, witnesses, and a summary of interviews, with a written report sent to the Department of Public Health. A resident with multiple diagnoses, including encephalopathy, mild dementia, and use of anticoagulants, was found to have a bruise on the right buttock that was unwitnessed and of unknown origin. The injury was documented in the resident's record, noting that the resident was unable to provide details and there were no witnesses. During an interview, the administrator acknowledged that a complete investigation was not conducted because they were unaware of the incident until it was brought up by the surveyor.
Failure to Provide CPR According to Current Standards of Practice
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) according to current standards of practice for one resident who was a full code, as indicated by their POLST form. The resident had multiple diagnoses, including cardiac arrhythmia, congestive heart failure, and was admitted for rehabilitation following a hospital stay for urinary tract infection with sepsis and metabolic encephalopathy. On the day of the incident, the resident was found unresponsive and cold to the touch in the dining room by a CNA, who then brought the resident to the nurse's station. Nursing staff assessed the resident, found no pulse or respirations, and initiated CPR with the assistance of other staff members. Despite having backboards available, staff placed the resident on a soft mattress rather than a firm, flat surface or using a backboard, which is required for effective chest compressions. Staff admitted that in the urgency of the situation, they did not use a backboard or move the resident to the floor. Additionally, staff were not aware of the expectation to periodically check for a femoral or carotid pulse during compressions to verify effective perfusion. The facility's policy and American Red Cross guidelines both require CPR to be performed on a firm, flat surface, and for staff certified in CPR to initiate and maintain resuscitation efforts until emergency responders arrive. Emergency Medical Services arrived and moved the resident to the floor, continued CPR, and used a defibrillator, but the resident was ultimately pronounced deceased. Interviews with staff confirmed that standard procedures for effective CPR, including use of a backboard or firm surface and pulse checks during compressions, were not followed. The Advanced Practice Nurse verified that these steps are expected practice in such situations.
Failure to Employ Qualified Director of Food and Nutrition
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 35 residents residing in the facility. During an inspection, it was observed that there were opened food items in the refrigerator and dry storage room that were not labeled with open dates. Additionally, there was dust and debris hanging directly above the cooktop, and the toaster was dirty with crumbs inside and around the outside. The Dietary Manager, identified as V19, admitted to not being a certified Dietary Manager, stating that she had taken some courses but had not completed all of them. The facility's assessment indicated that a dietician or other clinically qualified nutrition professional should serve as the director of food and nutrition services.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to its food storage and kitchen sanitation policies, leading to several deficiencies. During an inspection, it was observed that a refrigerator in the kitchen lacked an internal thermometer, which is necessary for monitoring proper food storage temperatures. Additionally, several food items, including a pitcher of tomato juice and a carton of liquid eggs, were found without labels indicating their preparation or opening dates. This lack of labeling is contrary to the facility's policy, which requires all food items to be dated upon receipt and when opened to ensure proper stock rotation and food safety. Further observations revealed unsanitary conditions in the kitchen, including dust and debris hanging from the range hood and pipes above the cooktop, and crumbs inside and around a toaster. These conditions were confirmed by the Dietary Manager, who acknowledged the absence of a cleaning schedule for the range hood and the need for the toaster to be cleaned after each use. The report indicates that these deficiencies have the potential to affect all 35 residents residing in the facility.
Inadequate Infection Control Measures for Legionella and COVID-19
Penalty
Summary
The facility failed to identify high-risk areas for Legionella and implement control measures, potentially affecting all 35 residents. The Legionella Policy and Procedure outlined necessary actions to prevent bacterial growth, such as maintaining water temperatures above 60 degrees Celsius and regular cleaning of water systems. However, the facility's Legionella risk assessment, completed by the Maintenance Director, did not identify any high-risk areas, and there was no documentation of routine control measures. The Maintenance Director was unaware of any dead ends in the plumbing and did not use a plumbing map for evaluation. The Administrator confirmed the lack of documentation for routine control measures, believing the policy was sufficient. Additionally, during a COVID-19 outbreak, the facility failed to ensure staff wore personal protective equipment properly. The COVID-19 Control Measures policy required staff to wear N95 masks during an outbreak. However, a Dietary Aide was observed serving meals with her mask pulled down, exposing her nose and mouth, due to difficulty breathing. The Director of Nursing/Infection Preventionist confirmed that staff should wear N95 masks covering both nose and mouth during an outbreak. Since the outbreak began, nine residents and ten employees tested positive for COVID-19.
Failure to Complete Level II PASARR for Residents
Penalty
Summary
The facility failed to ensure that a Level II PASARR (Preadmission Screening and Resident Review) was completed for two residents, R11 and R10, who were reviewed for PASARR screening. R11 was admitted to the facility with a diagnosis of Schizoaffective Disorder and was prescribed Buspirone, an antidepressant. Despite the diagnosis and medication, a Level II PASARR was not conducted. The facility's administrator acknowledged that R11 was being treated for mental health issues and admitted that the requisite Level II PASARR screen was not completed when the new diagnosis was made or when the psychotropic medication was first ordered. Similarly, R10, who had a diagnosis of Affective Psychosis and Dementia with Behavioral Disturbances, did not have a Level II PASARR completed. The facility's records indicated that R10 was receiving Olanzapine, an antipsychotic medication, but there was no documentation of a Level II PASARR. The administrator and the Director of Nursing were unable to locate R10's admission history and confirmed that a Level II PASARR would be necessary if R10 did not have a diagnosis of psychosis upon admission. The Business Office Manager later confirmed that a Level II PASARR was not completed for R10.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to initiate a comprehensive care plan for a resident, identified as R11, which included necessary resident-centered problems, goals, and interventions. Observations revealed that R11 had a contracted right hand and required hand splints to prevent further contraction. However, R11 reported that the staff often forgot to apply the splints, and at the time of observation, no splints were in use. A Licensed Practical Nurse later found a right hand splint and hand roll in R11's bedside drawer, and a Certified Nursing Assistant confirmed that R11 had a hand roll earlier in the day. Despite these needs, R11's care plan did not document the use of splints or hand rolls, indicating a lack of proper care planning for positioning aids. Additionally, the facility failed to include oxygen administration in R11's care plan. R11 was observed wearing oxygen at two liters per nasal cannula, although she stated that she usually only wore it at night. The physician's order required oxygen administration as needed to maintain oxygen saturation levels above 92 percent, yet the treatment administration record showed daily oxygen use. The care plan did not reflect this requirement, further demonstrating the facility's failure to maintain an updated and comprehensive care plan for R11. The Director of Nursing acknowledged that the care plan should have included both positioning aids and oxygen administration.
Improper Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide proper hygienic incontinence and urinary catheter care, leading to potential cross-contamination for two residents. One resident, who has severe cognitive impairment and is always incontinent of bowel and bladder, was observed receiving incontinence care that did not follow proper hygiene protocols. A Certified Nursing Assistant (CNA) used the same gloves to clean both the buttocks and the frontal perineal area, contrary to the facility's policy, which requires changing gloves after cleaning the buttocks and before cleaning the frontal area. The CNA admitted to not knowing when to change gloves, and the Director of Nursing confirmed the correct procedure was not followed. Another resident with a suprapubic catheter was observed with the catheter drainage bag improperly positioned on multiple occasions. The drainage bag was seen lying on the floor and was lifted above the level of the bladder, which could allow urine to flow back into the bladder. This resident had a diagnosis of Obstructive Uropathy and a recent urinary tract infection with a multi-drug resistant organism. The facility's care plan for this resident included instructions to keep the catheter bag below the bladder level, which was not adhered to, as confirmed by the Director of Nursing.
Failure to Document Enteral Feeding Intake
Penalty
Summary
The facility failed to adhere to its Enteral Feeding policy by not documenting the daily amount of enteral feeding administered to a resident with a Gastrostomy tube (G-tube). The resident, who has diagnoses including Alzheimer's, Failure to Thrive, Dysphagia, Metabolic Encephalopathy, and Gastroesophageal Reflux Disease, was ordered to receive Fibersource HN via G-tube at a continuous rate of 70 ml/hr for 20 hours daily, along with water flushes every six hours. However, the Treatment Administration Record (TAR) for the resident did not document any intake, only output, for the months of August and September. The resident experienced a weight loss of 3.71% from August to September, with a pattern of weight loss observed in previous months. The Director of Nursing confirmed the lack of documentation for the resident's G-tube feedings and had not informed the Dietician of the weight loss, as the Dietician visits at the end of the month. The Dietician was unaware of the weight loss and assumed the feeding orders were being followed, as she had not been notified otherwise.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to its psychotropic medication policy, resulting in deficiencies related to the management of psychotropic medications for two residents. The policy requires the ruling out of social and environmental factors, completion of assessments, documentation of nonpharmacological interventions, obtaining consent, and inclusion of psychotropic medication use in the care plan. However, for Resident 10, the facility did not document nonpharmacological interventions for behaviors, failed to obtain consent for Lorazepam use, and did not complete psychotropic medication assessments when the medication was increased. Additionally, there was no stop date for the PRN Lorazepam order, and the care plan did not include all psychotropic medications being used. Resident 10, who has severe cognitive impairment and is under hospice care, was prescribed Lorazepam and Olanzapine without proper documentation or assessments. The nursing notes indicated behavioral issues, but there was no documentation of nonpharmacological interventions used. The Director of Nursing confirmed the lack of assessments and consents for Lorazepam and acknowledged that the medication orders were not properly managed, partly due to the involvement of an agency nurse. Similarly, Resident 12, also with severe cognitive impairment and under hospice care, was prescribed Lorazepam without a stop date or documented assessments. The care plan did not reflect the use of Lorazepam, and the Director of Nursing admitted that the orders were overlooked due to the residents being on hospice care. The pharmacy had recommended a stop date for the PRN Lorazepam, but this was not implemented, and the necessary documentation was not completed.
Failure to Secure Controlled Medications
Penalty
Summary
The facility failed to properly store and secure controlled medications, specifically Lorazepam, which is a Schedule IV controlled substance. During an observation, it was found that an unlocked refrigerator contained five bottles of Lorazepam, each with a concentration of 2 milligrams per milliliter. These bottles were designated for three residents. The facility's policy, last reviewed in October 2006, mandates that Schedule II drugs be stored under a double-lock system with a different key. However, this policy was not adhered to, as evidenced by the unlocked refrigerator. A Registered Nurse and the Director of Nursing both confirmed that the refrigerator should have been locked to secure the controlled substances.
Deficiency in COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status for three residents, leading to a deficiency in their immunization records. The facility's policy requires offering the current recommended COVID-19 vaccine upon admission and documenting immunizations on the resident's Immunization Record. However, for one resident, there was no documentation that a COVID-19 booster was offered after their last recorded vaccination. Another resident's vaccination record was incomplete, and there was no documentation of a booster offer after their admission. Additionally, the facility lacked documentation of declination for a booster vaccine for two residents, as the process was managed by an outside company. The residents involved were all over the age of 65 and had significant medical histories, including conditions such as Congestive Heart Failure, Coronary Artery Disease, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. One resident tested positive for COVID-19, highlighting the importance of maintaining up-to-date vaccination records. The facility's failure to document the offering and administration of COVID-19 boosters, as well as the lack of declination records, contributed to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Meadows Senior Living | 15.8 mi | ★★★★★ | 13 | 1 |
| The Haven Of Tuscola | 16.2 mi | ★★★★★ | 6 | 0 |
| Hilltop Skilled Nsg & Rehab | 16.4 mi | ★★★★★ | 4 | 0 |
| The Haven Of Arcola | 19 mi | ★★★★★ | 20 | 0 |
| The Haven Of Paris | 19 mi | ★★★★★ | 38 | 0 |
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