Downtown Health and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys 1 of 7 residents (Residents #1) reviewed for hazards. The facility failed to ensure Resident #1 did not have a bottle of Core Strength pills in his room on 06/16/26. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 (Resident #2) reviewed for infection control. The facility failed to ensure that CNA C had on PPE when providing high contact care for Resident #1. This failure could place the residents at risk for spread of infection through cross-contamination of pathogens and illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three of seven residents (Resident #1, Resident #2 and Resident#3) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2 was free from abuse by Resident #1. The facility failed to ensure Resident #3 was free from verbal abuse by LVN B. This failure could place residents at risk for abuse or neglect that could lead to serious harm.

Inspectors wroteBased on interviews and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for one of seven residents (Resident #3) reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report the incident of alleged verbal abuse on 05/03/2025 for Resident #3. This failure could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for one of seven residents (Resident #3) reviewed for abuse and neglect. The facility did not investigate an incident in which Resident #3 was cussed by LVN B. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for one of eight residents (Resident #4) and the facility's water management system reviewed for infection control. 1. The facility failed to perform wound care by not covering Resident #4's right foot prior to leaving the room and being in common areas.2. The facility failed to identify situations that could lead to Legionella growth and to implement measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. This failure could place residents at risk of cross-contamination, increased risk of infection and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to residents with reasonable accommodations of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 12 (Resident #91) reviewed for call lights. The facility failed to keep Resident #91's call light off the floor and within his grasp so Resident #91 could communicate to staff when he needed assistance. This failure placed residents at risk for not getting their needs met and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure at the time each resident was admitted the facility had a physician order for the resident's immediate care for 1 of 5 (Resident #25) reviewed for residents receiving care and services upon admission. The facility failed to ensure Resident #25 had a current physician's order for use of oxygen after readmission to the facility. This failure could place residents at risk of not receiving necessary care and services. Record review of Resident #25's annual MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of 12 (Resident #104) reviewed for ADLs. The facility failed to ensure Resident #104's shirt and pants were changed, which were covered in food, after being fed lunch on 3-10-2026. This failure could place residents at risk for low self-esteem and self-worth causing negative psychosocial outcomes affecting their health.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living (ADLs) to maintain good personal hygiene, for 1 of 8 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 was provided with a shower on 01/20/2026 and 02/09/2026. This failure could place residents at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological well-being. Record review of Resident #1's admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted from an acute care hospital on [DATE]. She was assessed as cognitively intact with a BIMS score of 15. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident's right to be free from abuse for one (Resident #1) of 4 residents reviewed for abuse, in that: On 09/16/2025 the facility failed to ensure that Resident #1 was not spoken to in a verbally abusive way by CNA A who called Resident #1 an expletive. This failure could result in resident abuse and mental decline.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 3 (Resident #2) residents reviewed for abuse and neglect. The facility LVN A, LVN B, CNA C and CNA D did not report Resident #2's allegations of abuse and neglect to the Admin who was the abuse coordinator. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (medication cart) of 1 medication cart on the memory care unit reviewed for pharmacy services The facility failed to ensure discontinued medication were removed from the medication cart. Resident #1's Diazepam that was DC on 12/30/24 was in the narcotic box on the secure unit medication cart. This failure could place residents at risk of unnecessary medication error and/or lead to possible harm or drug diversion.

Inspectors wroteBased on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of four residents reviewed for medications. 1. Resident #1's Lisinopril and Metoprolol (medications used to lower blood pressure) were not held per physician's order on 07/13/25, 07/21/25, 07/23/24, and 07/25/24 when the resident's blood pressure was below parameters. These failures could place residents at risk of not receiving their medications as ordered or possible illness.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to address Resident #1's multiple refusals of care and services on the comprehensive care plan This failure could place residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 3 residents reviewed for infection control. 1. The Treatment Nurse failed to discard contaminated gauze after performing wound care on Resident #2 on 05/07/25. This failure could put residents at risk of infection from cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) of two residents reviewed for nutrition. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 25.96% weight loss in 4 months. She had an active decline in her weight from 01/08/25 - 04/15/25. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Residents #6) of four reviewed for adequate supervision. LVN R failed to complete a fall assessment and implement interventions for Resident #6 after a fall, to prevent reoccurrence. The facility failed to ensure an updated fall assessment was complete for Resident #6. This failure could affect residents by not having the necessary resources to ensure appropriate care, interventions, and supervision were provided.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of 3 residents reviewed for Respiratory Care. The facility failed to ensure that Resident #6's nasal cannula and tubing was off the floor, properly stored when not in use, and her humidifier bottle water was dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #2) of five residents reviewed for abuse. The facility failed to prevent Resident #2 from being abused by Resident #1 on the secure unit, who had a history of being verbally and physically aggressive to other residents. Resident #1 physically attacked Resident #2 which resulted in him being sent to the hospital and sustained a serious injury to his right eye on 12/29/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/29/24 and ended on 12/29/24. The facility corrected the non-compliance before surveyor's entrance. This failure could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #5) of 3 residents were reviewed for pharmaceutical services. The facility failed to ensure Resident #5 did not miss a dose of antibiotic medication that was to be administered on 12/21/24. This failure could place residents at risk of not receiving their medications as ordered by their physician. Review of Resident #5's Face Sheet, dated 12/23/24, reflected Resident #5 admitted [DATE] with paraplegia (paralysis in lower half of body) and right femur (large bone in upper leg) chronic osteomyelitis (bone infection). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional standard for 1 of 2 medication rooms (Med Room A) reviewed for storage of drugs. ADON A failed to ensure medications were secured and not left out in the open outside Med Room A. This could affect residents by placing them at risk of medication not meeting therapeutic levels, misuse and diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, and accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure stored food was properly labeled (marked or identified with the contents in the bag), dated ( date the item was received into the facility) . These failures could place all residents at risk of cross contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 2 of 2 residents (Resident #1 and Resident #111) reviewed for specialized rehabilitative services. The facility failed to screen Resident #1 and Resident #111 for physical therapy. This failure could place residents who required rehabilitative services at risk of a decline or decrease in their physical capabilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 30 residents reviewed for infection control (Resident 34, #59, #88, and #369) 1. The facility failed to follow EBP (Enhanced Barrier Precautions) procedures for Resident #34 when LVN Failed to wear PPE while administering medications to Resident #34. 2. The facility failed to follow contact isolation precautions (this is a precaution used to prevent the spread of germs that are spread by touching a person or their belonging) when ADON A and the wound care physician failed to don (to put on) PPE while providing wound care for Resident #369. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of four residents (Resident #59 and 88) reviewed for resident rights. CNA C failed to ensure the dignity of Residents #59 and #88 was respected during the breakfast meal when CNA C yelled in front of the residents at Laundry Aide D while they were being fed. This failure could place residents who need assistance with eating at risk for weight loss and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #115) reviewed for accidents and supervision. The facility failed to ensure Resident #115 received adequate supervision when he went out into the courtyard to smoke during non-smoking times. This failure placed residents who required supervision at risk of injury or accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two (Resident #34 and Resident #74) of five residents reviewed for pharmaceutical services. LVN E failed to hold medication Furosemide 40 MG with parameter to hold at SBP less than110 when Resident #34's BP was 95/84. LVN E failed to check vancomycin blood level (trough) results for Resident #74 before administering vancomycin antibiotic. These failures placed residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 4 residents (Resident #5) reviewed for preadmission screenings. The facility failed to refer Resident #5 for PASRR Evaluation after a positive Level 1 PASRR 1 screening. This failure could place residents at risk of receiving inadequate care. The surveyor was unable to interview and observe Resident #5, as he was discharged on 11/02/24. Record review of Resident # 5's face sheet dated 12/04/24 revealed that he was a 68 -year-old male who admitted to the facility on [DATE] and discharged on 11/02/24. His active diagnosis included: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission for 1 (Resident #5) of 4 residents reviewed for baseline care plans. The facility failed to ensure Resident #5's baseline care plan addressed his Level 1 PASSR, mental illness, anxiety, and depression within 48 hours of resident's admission. This failure could place the residents at increased risk of not having their individual needs identified, met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to prevent accidents for 4 (Resident#1, Resident#2, Resident#3, and Resident#4) of 6 residents reviewed for hazards. The facility failed to ensure Resident#1 and Resident#4 did not keep cigarettes and lighters on themselves. The facility failed to ensure (Resident#2 and Resident#3) did not pick up cigarette butts left on the ground to reuse. These failures placed residents at risk of being burned.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents received proper treatment and care to maintain mobility and good foot health, and failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 1 resident (Resident #1) reviewed for foot care. The facility failed to ensure Resident #1 had her toenails trimmed by a podiatrist. This failure could place residents at risk of discomfort, poor foot hygiene, or a decline in residents' physical condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 3 residents (Resident #2 and Resident #3) reviewed for ADL care. The facility failed to ensure Resident #2 and Resident #3 were provided nail care as needed. These failures could place residents at risk of not receiving services and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #10 and Resident #11) of 9 residents reviewed for ADL care. The facility failed to ensure Resident #10, and Resident #11 were provided showers as scheduled. These failures could place residents at risk of not receiving services and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 secured unit dining room reviewed for accidents and hazards. The facility failed to ensure residents who used the dining/activity room in the secured unit were free of hazards, when a window air condition unit cord was loose while plugged into a live extension cord coiled unsecured above a doorway. This failure could place residents at risk for accidents or injuries resulting from hazards in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one (Resident #1) of one incident reviewed for reporting according to facility policy. CNA A failed to follow the facility's policy to report allegations of abuse when allegedly she observed CNA B hold Resident #1 down in a choke hold on 04/24/24. This failure could place the residents in the facility at risk of abuse and lack of timely reporting of incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 (Resident #1) of 5 residents reviewed for reporting abuse and neglect. CNA A failed to immediately report to the Administrator an allegation of abuse involving CNA B and Resident #1 that allegedly occured on 04/24/24. The failure placed residents at risk of not having abuse allegations reported.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to review and revise care plans for 2 (Residents #1 and #2) of 5 residents reviewed for care plan revision. The facility failed to revise Resident #1 and #2's care plans to reflect their need for direct supervision while smoking. This failure could place the residents at risk of harm to themselves or other residents

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident receives adequate supervision and assistance devices to prevent accidents for 5 (Residents #1, #2, #3, #4, and #5) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Residents #1, #2, #3, #4, and #5 were supervised while smoking This failure could place the residents at risk of injuring themselves or harming another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure full visual privacy for 2 (Residents #6 and #7) of 5 residents reviewed for privacy. The facility failed to provide privacy curtains for Residents #6 and #7 while their curtains were being laundered. This failure could place the residents at risk of decreased feelings of self -worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and care to maintain good foot health by providing foot care and treatment, in accorance with professional standards of practice, including to prevent complications from the resident's medical condition, for four of eight residents (Residents #1, #2, #3 and #4) reviewed for foot care. The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1, #2, and #3. This failure could result in residents developing fungal infections or other podiatric problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed for quality of care. The facility failed to ensure medication administration and storage protocols were implemented when the facility lost Resident # 1's medications (narcotics used for withdrawal symptoms) upon admission into the facility, which resulted in Resident #1 not receiving the medication and experiencing withdrawal symptoms. The noncompliance was identified as PNC. The noncompliance began on 02/10/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident's #1) reviewed for abuse. 1. The facility failed to implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2. 2. The facility failed to implement their policy and procedures on investigating allegations of abuse for a resident-to-resident altercation that occurred on 02/18/2024 between Resident #1 and Resident #2. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 4 residents (Residents #1 and Resident #2) reviewed for abuse. The facility failed to report a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified. This failure could place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations were thoroughly investigated for 1 of 4 residents (Residents #1) reviewed for abuse. The facility failed to thoroughly investigate a resident-to-resident altercation that occurred on 02/18/24 between Resident #1 and Resident #2. This failure could place residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical and psychosocial needs for one (Resident #2) of 2 residents reviewed for care plans. The facility failed to develop and implement a care plan addressing Resident #2's behaviors. This failures placed residents at risk of not receiving necessary care and services to meet his individual needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents observed for accidents. Resident #1's bed's wheels failed to lock when placed in the lowest position allowing the bed to roll away from the wall, which caused Resident #1 to fall through the gap. This deficient practice has potential to affect residents by placing them at risk for serious injuries and accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a physician signed and dated orders for 2 of 2 residents (Resident #66 and Resident #256) reviewed for medical records. The facility failed to obtain orders for contact isolation for Resident #66 and Resident #256. This failure placed residents at risk for not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for: 1. The facility failed to ensure food items, placed in the refrigerator, were dated, and labeled appropriately. This failure could affect residents by placing them at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards for 1 of 1 kitchen for kitchen sanitation. The facility failed to keep garbage receptacles covered with lids, in the kitchen area, while food was being prepared. This failure could place residents at risk for contracting food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one (secure unit hall) of three halls reviewed for environment. The facility failed to ensure a safe, functional, sanitary and comfortable environment for residents staff and the public. The facility failed to ensure the secure unit did not have a strong urine odor. This failure could place residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident that residents received treatment and care in accordance with professional standards or practice, the comprehensive person-centered care plan and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure fall protocols were implemented when Resident # 1 was found on the floor on 9/15/23. The noncompliance was identified as PNC. The noncompliance began on 9/15/23 and ended on 9/16/23. The facility had corrected the noncompliance before the survey began. This failure could residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death.