Center for Living & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent avoidable accidents for 1 of 3 sampled residents (Resident #1). For Resident #1, who was at high risk for falls and required supervision while walking, staff failed to implement person-centered care plan interventions after multiple falls, ensure the resident was care planned for adequate supervision, and ensure staff assigned to care for residents in those rooms had the ability to provide the required supervision. On 6/30/26, Resident #1 experienced an unwitnessed fall and was found on the floor unresponsive and passed away on 7/01/26 from injuries sustained from the fall. These were systemic failures in supervision, care planning, and addressing repeated falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision related to smoking for 1 of 1 sampled residents (Resident #15). Additionally, the facility failed to monitor the storage of Resident #15's lighter and cigarettes. This is a repeat deficiency, with the violation being cited during the past two recertification surveys dated 4/30/25 and 3/27/24.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that 1 of 4 residents in the sample were treated with dignity and respect (Resident #1).

Inspectors wroteBased upon observations, interviews, and record review, the facility failed to ensure adequate pain control was provided for 1 of 4 sampled residents (Resident #1).

Inspectors wroteBased on observation and interview, the facility failed to ensure that of 1 of 4 sampled residents had access to the call bell in their room (Resident #1).

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' right to be free from physical and verbal abuse from another resident for 2 of 3 sampled residents (Resident #1 and Resident #2). The facility did not implement effective interventions to prevent recurrence after a prior altercation on 8/7/25, nor did it update care plans to address ongoing risk. On 9/17/25, Resident #1 sustained blunt trauma to the nose with bleeding after being struck by Resident #2 during a physical altercation, and Resident #1 expressed feeling unsafe and distressed in his/her home. This deficient practice resulted in actual physical harm and psychosocial harm.

Inspectors wroteBased on record review and interviews, the facility failed to review and revise the comprehensive care plans for 2 of 3 sampled residents (Residents #1 and #2) after significant changes in condition related to two resident-to-resident altercations. Despite an initial incident on 8/7/25 and a subsequent altercation on 9/17/25 resulting in Resident #1 sustaining blunt trauma to the nose and expressing fear and distress, the facility did not update either resident's care plan or Kardex to include interventions to prevent recurrence, such as separation or monitoring. Staff interviews confirmed reliance on informal redirection rather than documented interventions. This failure resulted in actual physical harm and psychosocial harm to Resident #1.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three residents in the applicable sample, (Resident #1) were free from accidents and hazards, causing the Resident to sustain a skin tear. Per record review on 7/4/2025 Resident #1 was found by staff in bed with a large skin tear on her/his right lower leg. Resident #1 had a care plan focus of ADL (activities of daily living) self-care deficit with a transfer status of 2 staff assist that was implemented on 10/20/2024. Per review of the facility's internal investigation, it states that Resident #1 was care planned for a 2 person stand pivot transfer to all surfaces and for Dermasaver skin tubes (used to protect skin from injury) to always be on when out of bed. The Dermasavers are to be removed only when s/he has been safely transferred back into bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident did not develop an avoidable pressure ulcer for 1 of 3 residents in the sample (Resident #1).

Inspectors wrote2. Per record review of Resident #80's medical record reveals that Resident #80 had medical diagnoses of hemiplegia and hemiparesis (weakness and/or paralysis) following a cerebral infarction (a stroke) affecting his/her right dominant side, dysphagia (difficulty swallowing), aphasia (a communication disorder that affects how individuals produce and understand language), and paroxysmal atrial fibrillation (an irregular heartbeat). Per record review of Resident #80's care plan states, [Resident #80] has had actual falls r/t [related to] gait/balance problems, psychoactive drug use, right side weakness, and increased behaviors after family leaves. Most falls out of bed are to [his/her] right. Per record review of the facility's Fall Prevention and Protocol policy [modified 4/26/24] states, Every resident admitted to [the facility] will have a fall risk evaluation .after each fall. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 3 of the 4 medication carts observed, and 2 of 2 medication storage rooms observed.

Inspectors wrote2. During observation on 4/29/25 at approximately 9:30 AM of medication passes on the [NAME] Unit, a male nurse pouring/pushing tablets from a blister packet (a form of tamper resistant packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) for Resident #108 into his ungloved hand and then placed these medications into a medication cup and administered them to the resident. The nurse did not perform hand hygiene prior to preparing Resident #482's medications in which he again poured/pushed tablets from a blister packet directly into his ungloved hand and then placed these medications into a medication cup and administered them to the resident. During interview on 4/30/25 at approximetly 9:45 AM, the nurse confirmed that he had poured medications from the blister pack for 2 residents into his ungloved hand. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Residents' power of attorney (POA) was assisted with developing advanced directives consistent with their wishes for 1 of 40 residents in the sample (Resident #40).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident with a nutritional problem was given nutritional supplements and appetite stimulants as ordered by a physician for one resident [Resident #106] of 7 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to maintain drug regimen reviews for one out of five sampled residents (Resident #88).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary maintenance services to ensure residents have a safe, clean, comfortable and homelike environment for 4 of 6 resident units.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice including prevention of complications from the resident's medical condition for 1 of 2 residents in the applicable sample [Resident # 1].

Inspectors wroteBased on observations and staff interview, the facility failed to provide necessary maintenance services to ensure residents have a safe, clean, comfortable, and homelike environment for 6 of 6 resident units.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement policies for screening employees by not completing the required criminal background checks for 4 out of 5 sampled staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue the drugs for 1 of 5 sampled residents (Resident #13); failed to ensure that there was a specific diagnosis/condition documented in the medical record for psychotropic medications for 1 of 5 sampled residents (Resident #100); and failed to ensure that residents who use psychotropic drugs are accurately monitored for behaviors and medication side effects (Residents # 13, #100, and #30).

Inspectors wroteBased on resident interview, staff interview, and record review, the facility failed to ensure that all residents were treated with respect and dignity by all staff for one of 29 sampled residents (resident #87).

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident's physician of significant weight loss for 1 of 29 sampled residents (Resident #100).

Inspectors wroteBased upon interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 resident [Res.#101] of 2 sampled residents regarding abuse allegations.

Inspectors wroteBased upon interview and record review, the facility failed to assure that further potential abuse, neglect, exploitation, or mistreatment did not occur after an allegation of abuse for 1 resident [Res.#101] of 2 sampled residents regarding abuse allegations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that staff implemented a resident's individualized comprehensive care plan related to fall prevention for 1 of 29 residents in the sample (Resident #266).

Inspectors wroteBased upon interview and record review, the facility failed to review and revise Care Plans regarding prevention of future falls for 1 of 29 residents sampled (Res.#62). The facility also failed to ensure that the Resident's comprehensive care plan was reviewed and revised by the interdisciplinary team for one of 79 sampled residents (Resident #79).

Inspectors wroteBased on resident/representative interview, staff interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living without assistance receives the proper level of assistance for one of 29 sampled residents (Resident #100).

Inspectors wroteBased on interview and record review, the facility failed to assist residents in making audiology appointments for 1 of 29 sampled residents (Resident #71).

Inspectors wroteBased upon interview and record review, the facility failed to ensure an environment free of Accident hazards regarding implementing interventions to reduce hazards and risks and monitoring for effectiveness related to falls for Res.#62, and regarding falls with a possible brain bleed for Res.#266, 2 of of 29 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents maintain acceptable parameters of nutritional status as evidenced by the facility failing to obtain weights as care planned and identify weight loss for 1 of 29 sampled residents (Resident #100).

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an individualized person-centered plan to render trauma informed care to a resident with a personal history of trauma for 1 of 29 residents (Resident #30).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that residents are free from significant medication errors for one of 29 sampled residents (Resident #266) as evidenced by administration of an anticoagulant for a resident with a brain bleed.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that each resident's medical record contains documentation that indicates that the resident or resident's representative was provided education regarding the benefits and potential side effects of the COVID-19 immunization before receiving the vaccine for 1 of 5 sampled residents (Residents #100). The facility also failed to ensure that each eligible resident receives the COVID-19 vaccine for 1 of 5 sampled residents (Resident #6).

Inspectors wroteBased on staff interview and record review the facility failed to ensure that 1 of 4 residents (Resident #3) in the applicable sample were treated with dignity and respect related to refusal of care. Per record review Resident #3 is frequently resistive and combative, which includes fighting, yelling, screaming, punching, pinching, and kicking staff during episodes of care. Review of nursing progress notes reveals that staff continue to provide care to Resident #3 even when s/he is resisting and refusing care. A care plan focus initiated on 2/11/21 states that the resident is at risk for a behavior problem r/t severe agitation history secondary to Alzheimer's and bipolar disease. [S/He] does threaten to bite staff at times . Can be combative with care . There are no specific interventions for staff to implement related to combativeness with care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a care plan and to revise a care plan for 1 out of 4 Residents sampled (Resident #1).

Inspectors wroteBased on Observation, Interview, and Record review the facility failed to assess and provide mental health services for 2 of 4 residents sampled (Residents #1 and #2).