Community Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observations, the facility failed to ensure residents had a clean and sanitary environment as evidenced by residents' personal items not labeled and stored appropriately for each resident in 5 out of 9 rooms sampled.The findings include:An observation was made on the north hallway of Unit 2 on 8/25/25 at 11:00 AM. The following issues were observed:In room [ROOM NUMBER], personal items were not labeled and not separated for each resident residing in the room. In room [ROOM NUMBER], a bedpan was sitting in the bathroom in between the handrail and wall and was not bagged.In room [ROOM NUMBER], a resident's urinal was hanging on the garbage can next to the bed out of the resident's reach.In room [ROOM NUMBER], a bedpan was observed in the bathroom sitting between the handrail and the wall.A second observation was made on this hall on 8/25/25 at 3:00 pm. The following issues were observed.In room [ROOM NUMBER], the personal items sitting in the resident's bathroom was still not labeled or separated for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record reviews, and policy review, the facility failed to ensure the provision of care in accordance with professional standards by not ensuring that wound care was provided as stated in the physician order in a timely manner and failed to assess and document a newly identified skin impairment for 2 of 2 residents sampled for non-pressure related skin impairments. (Resident #9 and #106)The findings include: Resident #106 On 8/25/25 at approximately 12:00 PM, an interview and observation was conducted with Resident #106. A Negative Pressure Wound Device (wound vac) was sitting on the bed with the hose not connected to Resident #106. The resident stated it was removed by the nurse at approximately 6:00 AM on 08/25/25 due to becoming loose from the dressing to the lower back surgical wound. A gauze with tape was noted on the lower back with no date present. A Peripherally Inserted Central Catheter (PICC) was in place to the inner right upper arm with the date of 8/14 written on the dressing. On 8/25/25 at approximately 2:05 PM, an observation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain sanitary food practices and ensure kitchen staff wore required hair covering while preparing resident meals. The findings include:On 08/25/2025 at approximately 10:30AM, during kitchen tour with Food Service Director observed staff K cooking lunch without a hair net. Food Service Director asked staff if staff K was wearing a hair net. Staff K stated, No, I am not wearing one. During the same tour at approximately 10:55AM observed in the vegetable freeze a 16 oz Pepsi on the top shelf. Interviewed Food Service Director confirming the drink belong to a staff member. On 8/28/25 at approximately 9:33AM observed staff J cooking meal without facial covering for beard and mustache. Food Service Director informed staff J to put facial covering on. After reviewing emergency food, staff J was still without facial covering. Food Service Director informed staff J to leave the area to put facial covering on.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure each resident bedroom was equipped to provide full visual privacy for 1 of 19 sampled resident bedrooms. (room [ROOM NUMBER])An observation of room [ROOM NUMBER]A was conducted on 8/26/25 at 2:09 PM. The room was occupied by a resident. The privacy curtain was observed to be about 3 feet too short in width to provide full visual privacy of the resident. In addition, the existing curtain was stuck and would not pull in the curtain track. Another observation of room [ROOM NUMBER]A was conducted on 8/27/25 at 10:07 AM with the Housekeeping Supervisor. She observed the curtain and stated the track was coming loose from the ceiling and confirmed the curtain was too short in length to provide full visual privacy. (Photographic evidence was obtained.) She stated she had a list of rooms regarding privacy curtain issues that was created on 8/26/25 and room [ROOM NUMBER] was included on the list.

Based on observation, staff interview, resident interview, and records review, the facility failed to ensure the interdisciplinary team assessed and determined residents were capable of self-administration of medications prior to allowing 2 of 4 residents sampled for medication administration to self-administer medications. (Residents #32 and #61) The findings include: During the observation of medication administration on 06/04/2024 at 9:13 AM with Registered Nurse (RN) I, it was observed that oral medications, including a schedule II medication, Hydrocodone-Acetaminophen Tablet 5-325 milligrams (mg) (a medication used for pain), were placed in a medicine cup and left at the bedside for Resident #61 to self-administer. Following this observation, an interview was completed with RN I. She said that Resident #61 was not assessed for self-administration. An observation on 6/4/2024 at about 9:20 AM found Resident #32 with 8 pills loose on the breakfast tray in front of him/her. (photographic evidence obtained) During a follow up interview on 6/4/24 at about 9:30 AM with RN I, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure that wound assessments, dressing changes and wound care were provided in accordance with physician orders and facility policy for 2 of 3 residents sampled for wound care observations (Resident #7 & #24). The findings include: Resident #24: On 6/3/24 at approximately 11:46 AM, an interview and observation was conducted with Resident #24. The surveyor entered the room as the resident repeatedly said, help me, help me. The resident indicated she wanted to get up. The resident showed the surveyor her left leg. She indicated that her leg was bothering her. Resident #24 had a small, round, uncovered open area lateral to her left knee. Her left lower leg had a dressing. The dressing was dated 5/30 (4 days ago). The dressing had visible dried brown drainage present. (photographic evidence obtained) On 6/4/24 a review of Resident #24's record was conducted. A review of the progress notes and hospital discharge summary from 5/29/24 for Resident #24 revealed that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for tube feeding formula for 1 of 1 resident reviewed for tube feeding. (Resident #26) The findings include: During a tour of the facility conducted on 06/03/24 at 11:45 AM, Resident #26 was observed lying in her bed with tube feeding hanging but not infusing. The bottle of tube feeding formula that was observed was Jevity 1.5 (photographic evidence obtained). A second observation was conducted on 06/03/24 at 2:30 PM of Resident #26's tube feeding infusing-the bottle infusing was Jevity 1.5 formula. Initial review of Resident #26's record revealed the tube feeding order written by the physician on 09/24/23 was for Jevity 1.2 formula. This indicates Resident #26 was receiving the wrong tube feeding formula. Resident #26 was last readmitted to the facility on [DATE]. Review of Resident #26's medical history revealed she has a history of Cancer, Difficulty Swallowing, and Gastrostomy Tube Dependency. An interview was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, interviews, and policy review, the facility failed to obtain physician orders to administer oxygen for 1 of 4 residents sampled for respiratory care. (Resident #15) The findings include: On 6/3/24 at 12:04 PM, 6/4/24 at 12:48 PM and 3:16 PM, and 6/5/24 at 8:45 AM, Resident #15 was observed in bed receiving humidified oxygen via nasal cannula at 1.5 liters (L) from an oxygen concentrator. On 6/5/24 at 11:17 AM, Resident #15 was observed sitting up in a wheelchair in the hall near their room receiving oxygen via nasal cannula at 2 L from portable oxygen tank. On 6/3/24, a record review was conducted for Resident #15. The record review included a review of the current and discontinued/completed physician orders. There were no orders for oxygen therapy. On 6/5/24 at 8:46 AM, an interview was conducted with Resident #15, who stated they have been using oxygen for 2 to 3 weeks prior to admission to the facility and has been on oxygen continuously since admission to the facility. On 6/5/24 at 10:23 AM, an interview was conducted with Staff H, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control protocol for 1 of 1 resident reviewed for transmission based precautions. (Resident #44) The findings included: During a tour of the facility conducted on 06/03/24 at 11:45 AM, Resident #44's room door had an isolation sign for Enhanced Barrier Precautions. An initial review of Resident #44's record revealed a physician's order written on 06/02/24 for Contact Isolation. Further review of Resident #44's record revealed this Contact Isolation order was written due to Resident #44 having an Extended Spectrum Beta-Lactamase (ESBL) infection in her urine requiring the use of Macrobid (an oral antibiotic) from 05/26/24 to 06/09/24. Resident #44 was last readmitted to the facility on [DATE]. A review of Resident #44's medical history revealed she had a history of Chronic Kidney Disease, Urinary Tract Infections, and Dementia. Continued observations were conducted on 06/04/24 and 06/05/24 revealed the Enhanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and resident interview the facility failed to ensure sufficient nurse staffing on all shifts resulting in 5 of 5 sampled residents not receiving physician ordered medications on the morning of 8/26/23. (Residents #1,# 2, #3, #4, and #5) The findings include: Review of the staff assignment sheet for 11:00 PM-7:00 AM shift beginning on 8/25/23 and ending on 8/26/23 revealed the south unit had only one nurse for the shift (Employee A, who is a licensed practical nurse (LPN)). The other nurse that was scheduled did not report to work for the assigned shift. An interview was conducted with the Administrator on 8/31/23 at 10:53 AM. The Administrator stated that, on the 8/25/23 11:00 PM-7:00 AM shift, the facility had 3 nurses scheduled to work, but one nurse was absent. The Director of Nursing (DON) nor himself were notified the nurse did not report for work until about 3:00 AM on 8/26/23. They attempted to find a nurse to come in but were not successful. He stated the DON had worked from 7 AM - 11 PM on 8/25/23 and had worked as on the floor for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record reviews and policy reviews, the facility failed to ensure accurate accounting of controlled substances for 3 of 7 residents sampled (Residents #20, #57, and #155). The findings include: A review was conducted of the controlled drug declining inventory sheets and the electronic medication administration record. The following discrepancies were identified: Resident # 155 Diazepam (anxiety) 2 mg (milligrams) - 6 tablets were marked as on hand on 3/9/23 on the Controlled Drug Declining Inventory Sheet. Further review of the sheet revealed that one tablet of diazepam was administered on 3/9/23 at 8:30 AM, 3:00 PM, and 9:00 PM, 3/10/23 at 3:00 AM, 1:30 PM, and 11:00 PM, equaling 6 tablets with zero tablets remaining. However, review of the Medication Administration Record (MAR) for March 2023 revealed the medication was documented as administered 4 times (3/9/23 at 8:21 AM and 2:56 PM and 3/10/23 at 11:10 AM and 11:11 PM) indicating that there should be 2 tablets remaining and not zero as documented on the controlled drug inventory sheet. There were 2 tablets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.