Centennial Healthcare and Rehabilitation Center

Inspectors wroteBased on review of facility documentation, observations, and staff interviews it was determined that the facility failed to ensure safe and secure storage of all medications for three of three nursing units (Second, Third, Fourth Floor). Findings Include: Review of facility documentation revealed a June 2026 temperature log for the second-floor nursing unit medication refrigerator. The temperatures of the medication refrigerator were only documented twice. No temperature monitoring was documented for the remaining days of the month. Observations on June 29, 2026, inside the medication refrigerator on the fourth-floor nursing unit revealed it was operating at an excessively low temperature, with multiple medications observed to be encased in ice. [...]

Inspectors wroteBased on review of clinical records, and staff and resident interviews it was determined that the facility ensure residents received shower as scheduled for one of 31 residents reviewed (Resident R23).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and interviews with staff and residents, it was determined that the facility failed to provide resident care and treatment in accordance with standards of professional practice and physician orders for two of 31 residents reviewed (Resident R182 and R176). Findings Include: Review of the facility policy, Charting and Documentation Change, revised July 2021, indicated that treatments and services performed must be documented in the resident's medical record. Record review revealed Resident R176 was admitted to the facility on [DATE], with diagnoses including flaccid hemiplegia affecting the right dominant side (paralysis of the right side of the body), muscle weakness, and sepsis (a serious infection affecting the whole body). [...]

Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain an environment free of accidents and hazards related to medications for two of three nursing units observed (Second floor and Third floor).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide necessary respiratory care and services for one of 31 residents reviewed (Residents R35). Findings Include: Review of the facility policy titled, Oxygen Therapy Policy dated January 2026 states, Policy Statement- This policy is to instruct on how to treat hypoxemia, decrease work of breathing and decrease myocardial work in patients requiring supplemental oxygen therapy due to respiratory or cardiac insufficiency. Further review of the facility policy states, Procedure 1. Follow Standard Precautions 2. Verify the physician's order (should include liter flow, type of oxygen delivery device). [...]

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that arbitration agreements granted residents the right to rescind the agreements within 30 calendar days of signing it, for three of three residents reviewed (Residents R33, R68 and R187).

Inspectors wroteBased on review of facility policy and observations it was determined that the facility failed to implement and maintain effective infection control practices related to feeding assistance for two of 31 residents reviewed (Residents R20 and R165). Findings Include: Review of the facility policy titled, Assistance with Meals last revised December 2025 states, Policy Statement- Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of the facility policy titled, Handwashing/Hand Hygiene Policy last updated September 2024 states, Policy Statement- This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Further review of the facility policy states, Indications for Hand Hygiene: 1. Hand hygiene is indicated:.d. after touching a resident e. [...]

Inspectors wroteBased on interviews with resident and facility staff, review of resident and facility documentation and policy it was determined that the facility did not ensure one resident was free from verbal and mental abuse during two incidents for 39 resident records reviewed (Resident R116).

Inspectors wroteBased on interviews with resident and staff, review of clinical records, facility documentation and policy it was determined that the facility failed to complete a thorough investigation to rule out verbal and mental abuse for one resident during two incidents with staff of 39 resident records reviewed ( Resident R116).

Inspectors wroteBased on observations of care and treatments, clinical record review, interviews with residents and staff, and reviews of policies and procedures, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing and mental and psychosocial needs identified in the comprehensive assessment for two of 31 residents reviewed. (Resident R116 and R180).

Inspectors wroteBased on observation, clinical records review and staff interview, it was determined that the facility failed to ensure that a resident on oxygen therapy was assessed for the need of oxygen for one of 31 resident records reviewed. (Resident R127)Findings Include: Review of facility policy titled Oxygen Therapy dated February 10, 2010, revealed that under section Policy: It is the policy of the facility that oxygen therapy is administered per physician's order or as an emergency measure util a physician order is obtained. Under section Steps to administer oxygen # 12. Document the procedure in the medical record. Review of Resident R127 revealed that Resident R127 was admitted to the facility on [DATE], with a diagnosis of Peripheral Vascular Disease (poor circulations of the extremities). [...]

Inspectors wroteBased upon interviews with staff, review of residents' records, and facility policy it was determined the facility failed to determine one resident with a substantial weight loss was reweighed in a timely manner for one of 39 resident records reviewed (Resident R99)

Inspectors wroteBased on observation, review of clinical records and staff interview, it was determined that the facility failed to ensure that oxygen was administered in accordance with physician orders for one of one resident observed in oxygen therapy. (Resident R167)Findings Include: Review of facility policy entitled Oxygen Therapy dated February 10, 2010, revealed that under section Policy: It is the policy of the facility that oxygen therapy is administered per physician's order or as an emergency measure util a physician order is obtained. Review of Resident R167's clinical record revealed that resident was admitted to the facility on [DATE], with the diagnosis of Chronic Obstructed Pulmonary Disease (COPD). [...]

Inspectors wroteBased on interviews with staff, reviews of clinical records and policies and procedures, observations of resident care and treatment, it was determined that for one of 31 residents reviewed, the facility failed to administer and use its' resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. (Resident R180). Findings Include: A review of the facility's policy titled incident and accident dated July 2025, revealed the facility was responsible to complete a report of all accidents/incidents for each resident. The facility was responsible for investigation of the incident/accident for each resident to determine the risk factors that contributed to the event. The facility was also responsible to ensure that the resident's environment was free of accident hazards as possible. [...]

Inspectors wroteBased on observation, clinical records review and staff interview, it was determined that the facility failed to ensure that residents clinical records were completed related to oxygen therapy for one of 31 resident records reviewed. (Resident R127)Findings Include: Review of facility policy titled Oxygen Therapy dated February 10, 2010, revealed that under section Policy: It is the policy of the facility that oxygen therapy is administered per physician's order or as an emergency measure util a physician order is obtained. Under section Steps to administer oxygen # 12. Document the procedure in the medical record. Review of Resident R127 revealed that Resident R127 was admitted to the facility on [DATE], with a diagnosis of Peripheral Vascular Disease (poor circulations of the extremities). [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to follow infection control procedures during medication administration to one of one resident observed during medication pass. (Resident R127)Findings Include: Review of an undated facility policy entitled Infection Control Policy revealed that under section Policy #1. The infection control nurse, in conjunction with the Quality Assurance committee, has responsibility for overall infection control in the building. Under section Purpose In order to provide maximum protection to residents, visitors, and personnel from pathogenic microorganisms and infectious diseases, methods of prevention and control shall be implemented. [...]

Inspectors wroteBased on observations, review of facility policy, staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that medications were administered on time, as ordered by the physician for 3 out of 3 residents reviewed (Resident R1, R2 and R3).

Inspectors wroteBased on review of clinical records, interview with staff and review of facility policy, it was revealed that the facility did not ensure revision were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for four out of 34 residents reviewed. (Resident R62, R88. R26, R23)

Inspectors wroteBased on observations and interviews with facility staff, it was determined that he facility did not ensure to accurately post information regarding daily nurse staffing data as required.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the PASRR-ID (Preadmission Screening and Resident Review Identification) was not appropriately completed for one of 34 residents reviewed (Resident R2).

Inspectors wroteBased on observations, reviews of resident clinical records, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for one out of 34 residents reviewed. (Resident R122)

Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of four residents' medication administration observed, resulting in a significant medication error (Resident R151).

Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that the facility failed to notify the Office of the State Long - Term Care Ombudsman of initiated emergency transfers and discharges for two out of three months reviewed (July 2024/August 2024)

Inspectors wroteBased on clinical record review, observations, and interview with staff, it was determined that facility failed to provide incontinence care in a timely manner for one resident out of 34 reviewed. (Resident R81)

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with residents and staff, the facility failed to follow physician orders related to medication administration for one of seven reviewed (Residents R73).