Doctors Nursing & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to respond to call lights in a timely manner for 3 of 12 residents (R3, R11 and R12) reviewed for call lights in a sample of 12 residents. This past noncompliance occurred from 7/8/26-7/9/26.

Inspectors wroteBased on interview and record review the facility failed to ensure staffing is sufficient to meet the needs of the residents timely. This has the potential to affect all 50 residents currently residing at the facility. Findings Include:The facility Resident Roster dated 4/8/26 documents 50 residents currently reside at the facility.1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes. R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for toilet hygiene. R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered timely for 2 of 4 (R1 and R2) residents reviewed for call lights in the sample of 14. Findings Include:1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes. R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 was dependent on staff for toilet hygiene. R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comfortable water temperatures for 3 of 4 residents (R1, R2, and R14) residents reviewed for environment in the sample of 14. Findings Include: 1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes. R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for bathing. R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from misappropriation of medications for 3 of 3 (R3, R4, and R5) residents reviewed for abuse in the sample of 14. This past non-compliance occurred between 3/27/26 and 4/1/26. Findings Include:The Long Term Care Facility and IID (Individuals with Intellectual Disabilities) -Serious Injury Incident Report dated 3/28/26 documents under Detailed Incident Summary, Administration was notified of possible drug diversion at the facility regarding (R3's) oxycodone. It was discovered that (R3's) narcotic card had been tampered with and the medication in the card was metoprolol and not oxycodone. Investigation continued and MD (physician), POA (power of attorney) and local police were notified of the investigation. Nurses currently on shift were immediately drug tested and were negative. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure incontinence care was provided timely for 2 of 4 (R1 and R2) residents reviewed for activities of daily living (ADL) in the sample of 14. Findings Include:1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include heart failure, age related physical disability, and diabetes. R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for toilet hygiene and has occasional urinary and bowel incontinence. R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a urinalysis was obtained timely for 1 of 3 (R1) residents reviewed for urinary tract infections in the sample of 14. Findings Include:1. R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include urinary tract infections. R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. R1's current Care Plan documents a Problem area with a start date of 2/24/26 of, Resident: admitted for skilled care. I require a Baseline Care Plan identifying care needs, risks, strengths, and goals within the first 48 hours. This Problem area includes the intervention with a start date of 2/24/26 of, Bowel and Bladder: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medications were crushed prior to administration for 1 of 3 (R1) residents reviewed for pharmacy services in the sample of 14. Findings Include:R1's Resident Face Sheet with a print date of 4/11/26 documents R1 was admitted to the facility on [DATE] and discharged from the facility on 4/8/26, with diagnoses that include dysphagia, oropharyngeal phase, heart failure, age related physical disability, and diabetes. R1's MDS (Minimum Data Set) dated 2/27/26 documents a Brief Interview for Mental Status) score of 11, indicating R1 has a moderate cognitive deficit. This same MDS documents R1 is dependent on staff for bathing. R1's current Care Plan does not document a Problem area related to medication administration. R1's Physician Order Report dated 2/24/26 through 3/30/26 documents an order dated 3/10/26 of Diet: [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure there was hot water for showers and personal care for the 21 residing on the 200 and 300 halls. The Findings Include: On 3/11/26 at 1:00 PM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. On 03/11/2026 at 1:12 PM, R10 who was alert and oriented, stated her biggest concern is that the facility does not have hot water. R10 stated when the CNA's (Certified Nurse Assistants) have to clean her up the water is freezing cold. R10 stated it is awful to get your butt wiped with a cold washcloth. On 3/11/26 at 1:15 PM, R23 who alert and oriented, stated that he never has hot water in his sink in his room that he uses to wash up with at night and in the morning. [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staff to meet residents needs in a timely manner. These failures have the potential to affect all 10 residents residing on the 100 hall.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of expired stock medical equipment, expired resident and stock medications, and failed to label medications with residents' names, and document the date opened on multi-use vials of medications for 4 of 6 residents (R5, R12, R26, and R44 ) reviewed for medication storage in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restraint assessments for 2 (R3, R7) of 2 residents reviewed for physical restraints in the sample of 26. The Findings Include: 1. R3's Face Sheet documented an admission date of 2/10/2026 and included diagnoses of cerebral infarction, dependence on respirator, chronic respiratory failure with hypercapnia, and acute pulmonary disease. R3's Minimum Data Set (MDS) with assessment reference date as 2/16/2026 documents no Brief Interview for Mental Status score because resident is rarely/never understood, indicating significant cognitive impairment. This same assessment documented under Section P0-Restraints and Alarms of limb restraint is used less than daily. R3's Care Plan documented a focus area of physical restraints; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents are free from unnecessary medication 1 of 5 residents (R2) reviewed for unnecessary medications in a sample of 26. The Findings Include:R2's face sheet indicates an admission date of 11/7/24 and also includes the following diagnosis: anxiety disorder and depression. R2's current physician order sheet for March 2026 includes the following medications: lorazepam 0.5 milligram (mg) once day per gastric tube as needed for anxiety. This order has a start date of 1/09/2026 with no end date. R2's behavior tracking for the last 3 months has no behaviors listed. R2's medication administration record for the last three months list that R2 received lorazepam 1/15/26-1/20/26, 2/2/25, 2/3/26, 2/5/26, 2/9/26-2/12/26, 2/15/26-2/18/26, and 2/24/26-2/26/26. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (R9) of 12 residents reviewed for position and mobility in the sample of 26. The Findings Include:R9's resident face sheet documents an admission date of 10/12/2018. This same document includes the following diagnoses: Parkinsonism, symptomatic epilepsy, partial seizures, hypotension, anemia, asthma, contracture of the right hand, and chronic pain. R9's most recent quarterly MDS (Minimum Data Set) dated 12/30/2025 documents section C, that R9 has a BIMS (Brief Interview of Mental Status) of 15, indicating that R9 is cognitively intact. Section GG documents for functional limitation in range of motion that R9 has an impairment on one side for upper extremity. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that meals served were served at palatable temperature for 3 of 3 (R1, R5 and R23) residents reviewed for palatability in a sample of 26. The Findings Include: During the resident council meeting held on 3/11/26 at 2:00 PM, R1 and R5 both stated that the evening meals are cold and often times they just eat it cold rather than regularly asking for it to be reheated. R1 is the resident council president and was alert to person place and time. R5 stated he attends resident council meetings regularly and was alert to person place and time. On 3/11/26 at 11:40 AM, R23 who was alert to person, place and time stated his family often brings in food for him at dinner so he doesn't have to eat cold food. On 3/12/26 at 12:45 PM, R5 stated that the cold food in the evening has been brought up in resident council meetings regularly. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control practices for 3 (R1, R2, and R3) of 12 residents reviewed for infection control in the sample of 26. The Findings Include:Facility policy titled Cleaning of Durable Medical Equipment with a revision date of 01/18/2021 documented under section titled Policy: All Durable Medical Equipment will be disinfected with appropriate disinfectant between resident uses. Including but not limited to blood glucose monitoring machines, pulse oximeters, thermometers, etc. Under Section titled procedure, to clean, disinfect, and deodorize in one step: wipe surface with towel until completely wet. Allow to remain wet for one minute at room temperature. Wipe dry or allow to air dry. [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staff to meet residents needs in a timely manner. These failures have the potential to affect all 47 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders and monitor resident's declining conditions for 2 of 3 residents (R1 and R3) reviewed for resident death in a sample of 8. A. This failure resulted in worsening of R1's infection of bilateral lower leg venous wounds causing sepsis and subsequent death. B. This failure resulted in exacerbation of R3's congestive heart failure resulting in hospitalization and subsequent death. This failure resulted in an Immediate jeopardy, which was identified to have begun on:A. [DATE] when the facility failed to follow physician's orders for antibiotics for R1's infection of venous stasis ulcers. This failure resulted in R1 developing sepsis leading to R1's death on [DATE]. B. [DATE] when the facility failed to complete ordered lab work and administer medications as ordered for R3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adhere to infection control protocols and failed to follow physician orders for wound care for 1 of 1 resident (R4) reviewed for pressure ulcers in a sample of 9.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 of 5 residents (R2) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Heat, Ventilation, and Air Conditioning (HVAC) systems to maintain a comfortable temperature and failed to maintain flooring that was clean and free from damage. This failure resulted in R1 and R6 experiencing difficulty breathing and R5 and R7 experiencing difficulty sleeping, resulting in significant discomfort. This failure has the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a temperature of less than 70 degrees Fahrenheit in the dietary dry storage area in accordance with facility policy. This failure has the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on interview, and record review the facility failed to ensure the facility was administered and operated in a manner to ensure the safety and overall wellbeing for all 58 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light system for 3 (R2, R3, and R4) of 6 residents reviewed for resident call system in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) and Standard Precautions for 5 (R35, R319, R33, R15, and R31) of 9 residents reviewed for Infection Control in a sample of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain comfortable temperatures in the facility for 9 (R1-R9) residents living in the facility. The facility also failed to maintain ceiling tiles and HVAC (Heating Ventilation and Air Conditioning) Units in a safe and sanitary condition. This failure has the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu and diet orders for 6 of 6 (R2, R3, R5, R6, R7 and R8) residents reviewed for menus meeting resident needs in the sample of 8. The Findings Include: On 10/3/2024 at 11:53 AM, R5 who was alert and oriented to person, place and time, stated he did not get any eggs or double meat with his breakfast this morning. R5 stated, today he had one biscuit and gravy. R5 stated, he does not normally get eggs or double meats for breakfast at all. On 10/08/2024 at 7:26 AM during breakfast meal observation, V14 (Cook) stated, they are serving biscuits and gravy, super cereal, and oatmeal for breakfast today. V14 stated, the kitchen had run out of meats and eggs for breakfast this morning. V14 stated, the delivery truck will be in around 11:30 AM today with those items. [...]

Inspectors wroteBased on interview, observations, and record review the facility failed to provide water and other fluids to meet the residents needs and preference for 18 out of 47 residents (R1, R2, R3, R4, R6, R7, R8, R9, R10, R15, R20, R22, R24, R26, R30, R33, R37, and R46) reviewed for hydration in a sample of 47.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain air conditioning equipment and provide comfortable temperatures for 47 of 47 residents (R1-R47) reviewed for environment in a sample of 47.

Inspectors wroteBased on interview and record review, the facility failed to safely transport 1 (R1) of 3 residents reviewed for accidents. This failure resulted in R1 receiving a fracture to R1's fifth and sixth cervical vertebrae and right radius. This past noncompliance occurred between 1/29/2024 - 2/01/2024.

Inspectors wroteBased on interview and record review, the facility failed to reorder regularly scheduled pain medication in a timely manner for 1 (R5) of 3 residents reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident free from abuse for 1 of 1 resident (R2) reviewed for abuse in the sample of 11.