Cisne Rehabilitation and Health Care Center

Inspectors wroteBased on interview and record review the facility failed to administered pain medication as ordered by physician for 1 (R1) of 3 residents reviewed for pain in a sample of 11. This failure resulted in R1 experiencing unrelieved pain and having been sent to the local hospital for pain management. Findings Include:R1's admission Record documented an admission date of 6/9/2026 with the following diagnoses including anxiety disorder, unspecified, chronic kidney disease, unspecified, depression, unspecified, complete traumatic amputation of two or more left lesser toes, subsequent encounter and diabetes mellitus with other skin complications. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Interview Score (BIMS) of 15 indicating that R1 is cognitively intact. Under section M1040 Wounds and Skin problems documented R1 had a surgical wound. Under section J0100: [...]

Inspectors wroteBased on interview and record review the facility failed to administer antianxiety medication, administer sliding scale insulin and monitor blood sugars as directed per physician orders for 2 (R1, R2) of 3 residents reviewed for medication administration in the sample of 11. This failure resulted in R1 being sent to the emergency room for chest pain.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available as ordered by the physician for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 11.

Inspectors wroteBased on interview, observation, and record review, the facility failed to timely treat and develop/implement interventions for a pressure ulcer for 1 (R1) of 3 residents reviewed for pressure ulcers in the sample of 4. This failure resulted in R1's pressure ulcer worsening, with tunneling and developing an infection in the wound. The Findings Include:R1 admission Record documented admission to the facility on [DATE] and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. R1's Minimum Data Set (MDS) assessment dated [DATE] and coded as an admission assessment documents R1 has a Brief Interview for Mental Status (BIMS) score of 07, indicating R1 has severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain assessment and pain relief medication for 1 (R1) of 3 residents reviewed for pain management in the sample of 4. This failure resulted in R1 feeling helpless and having uncontrolled pain which was worse during wound care treatments. The Findings Include:R1's admission Record documented admission to the facility on [DATE] and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. R1's Care Plan includes a Focus area of the resident has actual impairment to the skin integrity related to coccyx pressure wound with an initial date of 05/13/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices, including Enhanced Barrier Precautions were implemented for 1 (R1) of 3 residents reviewed for infection control in the sample of 4. The Findings Include:R1's admission Record documented an admission date of 04/10/2026 and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. R1's Minimum Data Set (Minimum Data Set) assessment dated [DATE] and coded as an admission assessment documents a Brief Interview for Mental Status (BIMS) score of 07, indicating R1 has severe cognitive impairment. The same MDS documents R1 is occasionally incontinent of bowel and bladder and further documents R1 has a stage 2 pressure ulcer. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide opioid pain medication to a resident with chronic and acute pain for 1 of 4 residents (R1) reviewed for pain in the sample of 10. This failure resulted in R1 experiencing opioid withdrawal symptoms and pain at a level of ten on a zero to ten scale, R1 signing herself out of the facility AMA (Against Medical Advice), and R1 calling 911 to have an ambulance take her to the ER (Emergency Room) for treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow it's policy to obtain emergency controlled medications for 1 of 7 residents (R1) reviewed for pharmacy services in the sample of 10. R1's admission Record documented an admission Date of 4/3/26 and listed diagnoses including Unspecified Fractures of the First and Second Thoracic Vertebrae, Traumatic Pneumothorax, Bilateral Contusions of the Lungs, Multiple Rib Fractures to the Right Side, One Rib Fracture to the Left Side, Major Laceration of the Liver, Moderate Laceration of the Spleen, Hemoperitoneum, Fracture of the Superior Rim of the Right and Left Pubis, a Displaced Fracture of the Lateral Condyle of the Left Humerus, a Severely Displaced Zone 2 Fracture of the Sacrum, and an Unspecified Fracture of the Ilium. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a physician's order for treatment of a skin tear and to obtain physician's order for monitoring of the wound until it was healed for 1 (R1) of 3 residents reviewed for wounds in a sample of 8. R1's admission record dated 2/4/26 documents an admission date of 1/2/26. Same admission record documents diagnoses including but not limited to end stage renal disease, type II diabetes, and epilepsy. R1's minimum data set/MDS dated [DATE] documents R1 has a brief interview for mental status/BIMS score of 11 indicating resident has moderately impaired cognition. R1's most recent care plan undated has a focus area for R1 indicating he has potential for impairment of skin integrity dated 2/2/26. [...]

Inspectors wroteBased on interview and record review the facility failed to have a licensed administrator licensed in accordance with state law. This failure has the potential to affect all 19 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions and dietitian recommendations as ordered for 1 (R12) of 1 resident reviewed for nutrition in a sample of 22. This failure resulted in R12 experiencing a 10.26 percent weight loss within three months.

Inspectors wroteBased on observation and interview, the facility failed to ensure that dishes were effectively sanitized in the dish machine. This failure has the potential to affect all 17 residents residing in the facility. The Findings Include: On 6/3/25 at 9:45 AM, V3 (Cook) was observed using a quaternary test strip on the chlorine sanitizer. V3 stated at this time that she wasn't sure why the strip wasn't showing any sanitizer in the water. V3 asked V4 (Dietary Aide) about the the testing of the sanitizer level and V4 stated that the bucket needed to be checked first to see if it is empty because they have been having problems getting it delivered. V4 stated that the jug is empty, and they need to go to the store to get bleach to use in the interim until a delivery is made. V4 stated that is what was recommended to use if they ran out. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately report Registered Nurse (RN) hours to the payroll-based journal. This has the potential to affect all 17 residents residing in the facility. Findings Include: Review of Staffing Data Submission Payroll Based Journal (PBJ) found at, https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission and last modified 9/23/23 stated, .CMS (Centers for Medicare & Medicaid Services) has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy. Review of the facility's PBJ report for Fiscal Year Quarter 1 2025 (October 1 - December 31), documented No RN hours on the following dates: [...]

Inspectors wrote2. On 06/04/25 10:00 AM, while passing ice to residents, V7 (Certified Nurse Assistant/CNA) was observed bending down to pick up a bag off the hallway floor, then placed the ice scoop in the bag and attached it back to the ice cart. On 06/04/25 10:10 AM, V7 (CNA) stated, she did pick the scoop bag up off the floor because it fell off the ice cart. V7 stated, she did put the ice scoop back in the scoop bag and secured it to the ice cart to be used. V7 stated, she should not have put the scoop bag back in use once it had been on the floor. On 06/04/25 10:36 AM, V2 (Director of Nursing/DON) stated her expectation for staff is to follow standard infection control practices. V2 stated V7 (CNA) should have replaced the ice scoop bag instead of putting it back on the ice cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatment and services for range of motion were provided for 1 (R11) of 1 resident reviewed for mobility in the sample of 22. Findings Include: R11's admission Record documented an admission date of 12/10/2000 and included diagnoses of unilateral primary osteoarthritis of left knee, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, peripheral vascular disease, chronic kidney disease, unspecified Dementia, anxiety, essential hypertension, localized edema, atherosclerosis of native arteries of extremities with ulceration and diastolic (congestive) heart failure. R11's physician orders with a print date of 06/05/2025 does not document an order for passive or active range of motion restorative nursing program. [...]

Inspectors wroteBased on interview and record review the facility failed to promptly notify the resident representative of a fall for 1 (R1) of 3 residents reviewed for notification of changes in a sample of 7. Findings Include: R1's admission Record documented an admission date to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. A Skilled Progress Note for R1 dated 10/05/2024 , authored by V2 (Director of Nursing), documented on 10/06/2024 at 2:30 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect and safeguard controlled substances for 1 (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. Findings Include: R1's admission Record documented an admission date to the facility of [DATE] with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of [DATE], documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of resident property within the required time frames for 1 (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. The Findings Include: R1's admission Record documented an admission date to the facility of [DATE] with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's Order Summary Report with a print date of [DATE] documented an order for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely initiate an investigate of an allegation of missing controlled substances for 1 of 3 residents (R1) reviewed for misappropriation of property in a sample of 7. Findings Include: R1's admission Record documented an admission date to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment , documented a Brief Interview for Mental Status Score of 13, indicating that R1 is cognitively intact. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to account for, maintain records of, and document the administration of controlled substances for two (R1 and R3) of three residents reviewed for pharmacy services in the sample of 7. Findings Include: 1. R1's admission Record documented an admission date to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents are free from significant medication errors for 1 (R4) of 3 residents reviewed for medication administration in the sample of 7. Findings Include: R4's admission Record documented an admission date to the facility of 04/14/2023 with diagnoses including unspecified dementia, acute cystitis, gastro-esophageal reflux disease, essential hypertension, insomnia, mixed hyperlipidemia, major depressive disorder, generalized anxiety and delusional disorders. R4's Order Summary Report with a printed date of 11/22/2024, with an order date of 10/29/2024 documented an order for Clonazepam (benzodiazepine) 0.5 mg (Milligram) by mouth two times a day . R4's (Name of Pharmacy) Controlled Drug Administration Record documented on 11/08/2024 that R4 was administered Clonazepam at 5:00 A.M. by V15 (Licensed Practical Nurse) 6: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure chemical products were stored per current standards of practice and failed to ensure person centered fall interventions were implemented after a fall incident for 2 (R15 and R12) of 2 dementia care residents reviewed for accidents/hazards in the sample of 22. This failure resulted in R15 experiencing nausea and vomiting. Findings Include: 1. R15's Profile Face Sheet documented an Original admit date to the facility as 12/31/22. This form also documented R15 as being a [AGE] year old female. R15's Cumulative Diagnosis Log documented a diagnosis of Early onset Alzheimer's Dementia with Behavioral Disturbance. A Nurses Note dated 1/16/24 at 5 PM documented R15 was observed in her room with a bottle of (Odor Eliminator) in hand and large emesis on the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary ice machine. This failure has the potential to affect all 20 residents residing in the facility. The Findings Include: During initial tour of the kitchen on 4/30/24 at 9:30 AM, the ice machine was found to have a black substance on the inside flap of the ice machine where the ice drops into the bin. Along the hinges of the door and the edges of the lid of the ice machine was a white hard water build up. On 4/30/24 at 9:30AM, V8 (Dietary Manager) stated that the maintenance man cleans the ice machine once a month after hours so the kitchen staff are done with feeding residents. V8 stated that there was not a 2024 monthly cleaning log in the kitchen, so she cannot say for sure when it was last cleaned. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep resident care areas and equipment clean and in a good state of repair for 19 (R1, R2, R3, R5, R6, R7, R9, R10, R11, R12, R13, R14, R15, R17, R18, R121, R122, R123, R171) of 20 reviewed for clean, comfortable, homelike environment in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop person centered comprehensive care plans for 1 (R18) of 12 residents reviewed for care plans in the sample of 22. Findings Include: R18's Profile Face sheet documented R18 as [AGE] years old with an admission date to the facility of 02/20/2024. Diagnoses listed on the Cumulative Diagnosis Log include Odynophagia, Diabetes Mellitus Type II, Chronic Pancreatitis, Superior Mesenteric Artery Syndrome, Distal Esophageal ulceration with possible Barrets, and microcytic anemia. R18's current Physician's Orders documented Tube Feeding Orders Flush Gastrointestinal (G) Tube with 60 ml (milliliters) each side every shift. Also documented is an order for Isosource 1.5 at 25 ml/hour for 240 ml daily if meal intakes are less than 50 percent. R18's Resource: [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to add identified problem areas and to revise care plans timely for 1 (R12) of 12 residents reviewed for care plan timing and revision in the sample of 22. Findings Include: R12's Profile Face Sheet documents R12 was admitted to the facility on [DATE]. Diagnoses listed on R12's Cumulative Diagnosis Log include Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia. On 5/2/24 at 9:31 AM, R12's wound treatment was observed. R12 was noted to have a betadine treatment applied to the left toes which appeared to be scabbed over. R12 was also observed to have a pressure wound to the left heel. R12's Physician's Orders dated May 2024 documents under Treatment Orders to paint left great toe with iodine daily. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow policy and procedure for enhanced barrier precautions for 3 of 12 residents (R2, R12, and R18) reviewed for infection control in the sample of 22. The Findings Include: During initial tour of the facility on 4/30/24 there were no isolation rooms observed in the facility. On 4/30/24 a Resident Matrix was provided with no residents marked for transmission based precautions. 1. R18's Profile Face Sheet documents an admission date of 2/20/24. R18's May 2024 physician orders document a tube feeding order of Isosource 1.5 240mL (milliliters) daily after each meal if meal intake is less than 50% at meals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly assessments were completed timely for 6 of 6 (R5, R10, R12, R13, R14, and R15) residents reviewed for quarterly assessments in a sample of 22. The Findings Include: 1. R5's profile face sheet documents an admission date of 4/2/17. R5's quarterly Minimum Data Set (MDS) dated [DATE] Section I documents the following diagnoses: Hypertension, Alzheimer's, and Diabetes. On 5/2/24 at 9:30 AM, V6 (Care Plan Coordinator/MDS) confirmed that R5's quarterly MDS had a target due date of 2/18/24 and was not completed and transmitted until 4/24/24. An MDS validation report provided by V6 on 5/2/24 documents that R5's MDS was transmitted on 4/24/24. 2. R15's profile face sheet documents an admission date of 12/31/22. R15's quarterly MDS dated [DATE] Section I documents the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's wheelchair had foot rests in place when transporting a resident for 1 (R1) of 3 residents reviewed for accidents in a sample of 3. This failure resulted in R1 falling forward out of the wheelchair, sustaining a head laceration requiring R1 to be transferred to the hospital, and receiving sutures to close the wound. This past noncompliance occurred from 11/18/23 to 11/20/23.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize its Covid-19 Policy and to follow CDC (Centers for Disease Control) guidelines by testing and immediately isolating two residents (R9, R11) with respiratory symptoms consistent with infection by the Covid-19 virus. This failure has the potential to affect all 25 residents living at the facility.