City Scape Rehabilitation & Care Center LLC

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#7, #3 and #5) of four residents reviewed for abuse out of seven sample residents were kept free from abuse. On 5/21/25 Resident #7 was physically abused by Resident #2. Resident #2 used a belt to hit Resident #7 on top of his head and struck Resident #7 with his belt buckle. Resident #7 sustained a laceration to his head, requiring transfer to the emergency room where Resident #7 received five sutures. Additionally, Resident #5 was physically abused by Resident #1 on 3/22/25 and Resident #3 and Resident #1 were physically abused by each other on 5/3/25. Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #2;-Protect Resident #5 from physical abuse by Resident #1; and, -Protect Resident #3 and Resident #1 from physical abuse by each other.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of three sample residents. Resident #4 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 5/28/25 Resident #4 was found on the floor in her room with blood coming from her head. Resident #4 was transported to the hospital for further evaluation. Resident #4 sustained a subdural hematoma (brain bleed) and was diagnosed with a traumatic brain injury. The facility failed to implement person-centered interventions after the resident sustained a fall on 5/28/25. Observations revealed the facility failed to consistently implement the fall interventions on the resident's care plan. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of four sample residents. Specifically, the facility failed to implement person-centered fall interventions in a timely manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that two (#155 and #25) of two residents reviewed for abuse out of 31 sample residents were kept free from physical abuse. Resident #38 had a known history of physically aggressive behaviors towards others. Nursing progress notes documented the resident had a tendency to throw food, drinks, plates and cups in the dining room. On 3/22/24, the facility initiated behavior monitoring of Resident #38's physically aggressive behavior, including biting and scratching, during activities of daily living (ADL) and refusal of care. However, staff did not consistently document the behavior monitoring. Additionally, the facility failed to identify specific person-centered interventions to address Resident #38's physically aggressive behaviors. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an appropriate facility-initiated discharge procedure was followed for one (#105) of two residents reviewed for discharge out of 31 sample residents. Resident #105, who had a diagnosis of rheumatoid arthritis, anxiety disorder, depression, attention-deficit hyperactivity disorder and chronic pain, was admitted to the facility on [DATE] and involuntarily discharged to a homeless shelter on 2/20/24. The facility failed to provide preparations for a safe and orderly facility-initiated discharge or provide a reason for the discharge. Resident #105 began discharge planning with the facility on 1/11/24 during a care conference where his stated goal was to discharge to an assisted living facility (ALF). [...]

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of two certified nurse aides (CNA). Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for CNA #1 and CNA #3.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination; and, -Ensure safe holding temperatures for food items were maintained.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of two units. Specifically, the facility failed to: -Ensure residents' rooms were cleaned in a sanitary manner; and, -Ensure staff and residents performed hand hygiene during mealtime.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to effectively implement and reassess their pest control program.

Inspectors wroteBased on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three out of three CNAs reviewed. Specifically, the facility failed to: -Ensure a system was in place to track the CNAs training to ensure they met the annual training requirements; -Ensure CNA #1 and CNA #3 received the required 12 hours of training per year; and, -Ensure CNA #2 received abuse and dementia training upon hire.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#105) of two residents and/or their responsible person and the ombudsman were provided a written discharge notice to include the reasons for the move in a language and manner they would understand out of 31 sample residents. Specifically, the facility failed to provide Resident #105 an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -The location to which the resident was transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request; [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one (#19) of two residents reviewed for care planning out of 31 sample residents. Specifically, the facility failed to identify and implement an appropriate care plan in a timely manner for Resident #19's exit seeking behaviors.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 7.14%, or two errors out of 28 opportunities for error.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#7) of one resident out of 31 sample residents. Specifically, the facility failed to ensure Resident #7's medical record was consistently accurate regarding the pressure injury to the resident's left heel.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#27) of two residents reviewed for hospice services out of 31 sample residents. Specifically, the facility failed to maintain written communication records with the hospice providers for Resident #27.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to have the state contact information posted in a readable font size and placed in an area that had ease of access for the residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to have a qualified activities director.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#1) of three residents out of three sample residents reviewed for abuse. Specifically, the facility failed to prevent a resident to resident altercation between Resident #1 and Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement appropriate and timely interventions to ensure two (#24 and #44) of six sample residents received the necessary care and treatment to prevent the development of a pressure injury out of 31 sample residents. The facility failed to put interventions in place to prevent pressure injury for Resident #24. Resident #24 was admitted to the facility on [DATE]. At the time of the admission she was evaluated to be at risk for developing pressure injuries. On 11/1/22 resident developed two unstageable pressure injuries on her legs. She was evaluated by a wound care physician who recommended treatments. However, the resident's care plan was not updated with new interventions, and on 12/30/22 she developed a large unstageable pressure injury on her hip. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure two (#41 and #154) of five residents reviewed for accidents out of 31 sample residents remained as free from accident hazards as possible. The facility failed to thoroughly investigate what happened when Resident #41 sustained a left hip and rib fracture on 2/12/23 that required hospitalization. The facility identified the resident's numerous fall risks which included gait problems, forgetfulness and overestimation of limits, muscle weakness, and cognitive communication deficit. The facility determined the likely cause of the resident's fractures were due to an unwitnessed fall (see medical directors interview). In addition, for Resident #154 the facility failed to investigate, identify and put interventions in place to prevent trauma injury on the resident's right shin.

Inspectors wroteBased on staff interviews and record review, the facility failed to complete a performance review of every certified nurse aide (CNA) at least once every 12 months, or provide regular in-service education based on the outcome of these reviews. Specifically, the facility failed to complete a performance review of every CNA for more than a year or provide any associated training, for five (#2, #5, #6, #7 and #8) of five CNAs reviewed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure proper hand hygiene and glove usage in the main kitchen.

Inspectors wroteBased on record review and staff interviews, the facility failed to document resuscitation choices accurately in the medical record for five (#18, #2, #12, #303 and #154) out of 10 residents reviewed for advance directions out of 31 sample residents had the right to formulate an advanced directive. Specifically, the facility failed to ensure: -Resident #18, #2, #12, #303 and #154 had physician orders for their cardiopulmonary resuscitation (CPR) wishes in their medical record; -Resident #12 and #154 medical orders for scope of treatment (MOST) forms were signed timely; and, -Resident #2 care plan was accurate with her CPR wishes.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for nine (#12, #15, #27, #28, #32, #34, #37, #39, and #43) residents reviewed for activity programming out of 31 sample residents. Specifically, the facility failed to: -Offer and provide personalized activity programs for Resident #12, #15, #28, #32, #34, #37 and #39 on secure unit and Residents #27 and #43 on the non-secure unit as documented in their care plan; and, -Conduct activty assessments for Resident #12, #15 #28 #32, #34, #37 and #39.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plans for two (#153 and #154) residents out of five sample residents reviewed for care planning were reviewed and revised by the interdisciplinary team out of 31 sample residents. Specifically, the facility failed to: -Update comprehensive care plan for Resident #154 after he developed injury to his legs, and failed to include the care for the gastrointestinal tube (G-tube, to provide nutrition directly to the stomach) that resident had in place; and, -Update Resident #153's care plan regarding catheter care.

Inspectors wroteBased on record review and interviews, the facility the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one resident (#18) of two residents reviewed out of 31 sample residents. Specifically, the facility failed to for Resident #18: -Ensure monitoring and treatment were in place for a chemotherapy port; and, -Ensure weeklyskin assessement were completed consistenty and doocumented all skin conditions.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive device to maintain vision abilities for one (#18) of one resident reviewed for vision out of 31 sample residents. Specifically, the facility failed to offer vision and hearing services to Resident #18.

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with profession standard of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one (#18) resident reviewed for pain management out of 31 sample residents. Specifically, the facility failed to: -Offer non-pharmacological pain interventions for Resident #18, -Determine an acceptable pain level for Resident #18; and, -Administer pain medications per physician's order.

Inspectors wroteBased on interviews and record review, the facility failed to assist a resident in obtaining routine or emergency dental services, as needed for one (#18) of one residents reviewed for dental care out of 31 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #18.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care was provided in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality, in two of two dining areas. Specifically, the facility failed to allow residents to a dignified eating experience by providing plastic silverware and paper plates and paper cups instead of metal silverware and regular dishware for the residents to eat their meals with in the main dining room and in the memory care dining room including Resident #26.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike resident environment for one of three neighborhoods. Specifically, the facility failed to ensure: -The residents were given bath linens, washcloths and towels in their rooms for daily use for one of three neighborhood units; and, -The bathroom and toilet seat riser in room [ROOM NUMBER] A was clean.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for four (#44, #45, #20 and #152) of five residents reviewed out of 29 sample residents. Specifically, the facility failed to: -Ensure Resident #44 was groomed and wore clean clothes daily; and, -Provide nail care for Resident #45 and to assist Residents #20 and #152 with toileting needs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide all residents on the secured unit and including one resident (#29) of seven an ongoing program to support residents in their choice of activities, through organized group activities, individual activities and independent activities, to meet the interests of and support the physical, mental, and psychosocial well-being of each resident on a consistent basis out of 29 sample residents. Specifically, the facility failed to implement individualized approaches for activities for Resident #29 who was a cognitively impaired resident and ensure the facility provided a consistent meaningful activity programming to include group activities, individual activities and one to one visits on the secured memory care unit.

Inspectors wroteBased on observations, interviews and record review, the facility failed to honor resident choices for one (#18) of one reviewed for choices out of 29 sample residents. Specifically, the facility failed to honor Resident #18's request for juice and provide an alternative beverage of her choice.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide respiratory care services for one (#33) of three residents reviewed for respiratory care services out of 29 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #33.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#22) of one resident reviewed out of 29 sample residents received specialized rehabilitative services in accordance with professional standards of practice. Specifically, the failed to ensure Resident #22 was provided occupational therapy or restorative care for a left hand contracture.