Intercommunity Healthcare & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 2), did not develop an avoidable unstageable (an injury where the true depth cannot be determined due to the injury being partially or fully covered with eschar (dead tissue brown, black or tan) and or slough (yellowish, soft, moist tissue indicating deeper tissue damage and advancement of the pressure injury) pressure injury (PI - injury to skin and underlying tissue resulting from prolonged, unrelieved pressure on bony areas of the skin) by failing to:1. Follow the physicians' orders dated 4/21/2026 and 4/28/2026 to change Resident 2's dressing once daily, and as needed when the dressing became soiled or dislodged. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing progress notes were accurately and individually documented by two Licensed Vocational Nurses (LVN 3 and LVN 4). LVN 3 and LVN 4 entered identical progress notes for one of 1 sampled resident (Resident 97). This failure had the potential to create an inaccurate legal medical record by failing to accurately identify which licensed nurse provided care and communicated with the Physician and Resident 97's Responsible Party.

Inspectors wroteBased on interview and record review, the facility failed to address the following for one of 10 sampled residents (Resident 2) by failing to initiate and implement a care plan for Resident 2, who developed a stage 2 pressure ulcer (a partial-thickness skin loss where the outer layer epidermis and part of the second layer dermis are damaged) that progressed to a unstageable pressure ulcer (a severe full-thickness tissue loss where the true depth and exact stage cannot be seen) and ultimately becoming a stage 4 pressure ulcer (a severe, deep wound with full-thickness tissue loss). This deficient practice resulted in Resident 2's wound becoming a stage 4 pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to address the following for one of 10 sampled residents (Resident 78) by failing to: Failing to initiate a care plan for Resident 78's abuse allegation, monitor Resident 78 for 72 hours when there was a chance of condition (COC), and conduct an Interdisciplinary Team (IDT Resident healthcare team consisting of various specialties) meeting post abuse allegation. This deficient practice increased the risk for Resident 78 to continue feeling unsafe and subjected to continued neglect, verbal, mental, and physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect two of three sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 3 that Resident 2 accused her (CNA1) of abuse on 3/1/2026. CNA 1 was reassigned to another area in the facility away from Resident 2 and on 3/2/2026 she was assigned to care for two residents who were Resident 2's roommates instead of suspending CNA 1 and removing her from the facility. 2. Registered Nurse (RN) 1 reassigned LVN 1 to care for other residents in the facility instead of suspending her and removing her from the facility when she was made aware of an allegation that LVN 1 inappropriately touched Resident 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to immediately report an allegation of abuse for two of three sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 3 that Resident 2 accused her of abuse on 3/1/2026 and Resident 2 reported to her that CNA 1 twisted her (Resident 2) arm on 3/2/2026 but LVN 3 did not report the allegation of abuse to the Administrator (ADM), who is the facility's abuse coordinator. 2. Registered Nurse (RN) 1 was made aware of an allegation that LVN 1 inappropriately touched Resident 1 on 3/4/2026 but she did not report the allegation of abuse to the ADM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that signs were posted at the facility entrance indicating the presence of Coronavirus Disease ([COVID-19] a potentially severe respiratory illness caused by coronavirus and characterized by fever, coughing, and shortness of breath) cases in the facility. This deficient practice had the potential to increase the risk of further spreading COVID-19 to visitors, staff, family members, and the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. five boxes of tea bags were stored in the dry storage area with no date and label.2. An opened Clorox disinfecting wipes stored in the dry storage area.3. Three gallons of rainbow sherbet were stored in freezer #2 with no date and label.4. Dietary Aide 1 (DA 1) did not wear hair covering in the food preparation area. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 45 out of 80 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to follow its policy regarding monitoring and documenting the temperature of laundry equipment (water temperature for washers and temperature for dryers) and logs daily. This failure had the potential to result in compromised infection control measures of the facility laundry and the spread of infection from bacteria (microorganisms that can cause infectious disease) throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to:1. Complete and transmit the Minimum Data Set ([MDS]- a resident assessment tool ) within the regulatory timeframe to the Center of Medicare and Medicaid Service (CMS) for two of two sampled residents (Resident 56 and 82). This deficient practice had the potential to result in a billing error and inaccurate data on resident care needs.

Inspectors wroteBased on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for two of 18 sampled residents (Residents 54 and 49) by failing to: 1. Ensure Resident 54 who was receiving Restorative Nursing Assistant ([RNA], nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services seven times a week and receiving splint (knee braces that improve range of motion and assist with contracture management) placement had an accurate assessment.2. Ensure Resident 49 had accurate documentation in the MDS to reflect his current tobacco use. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for one of three sampled residents (Resident 66), when Resident 66 was non-compliant by refusing to open his mouth for dental assessments during multiple dental staff visits. This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 66 to prevent him from achieving his highest practical well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications, syringes, hand sanitizers and wound cleanser were not stored beyond their expiration dates in one of one disaster boxes (a container filled with emergency supplies e.g., medications, flashlights, extension cords, items for use in case of an emergency) stored in the Station 1 medication room. This deficient practice had the potential to result in the administration or use of expired medications and products, which had reduced effectiveness and the protentional to cause adverse effects to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 73) was informed of the dental treatment recommendation for tooth extraction (the process of removing a tooth from its socket in the jawbone). This deficient practice violated Resident 73's rights to be fully informed and had the potential to result in delay of care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 2 was not administered Carvedilol (used to treat high blood pressure) when Resident 2's systolic blood pressure (SBP) was less than 110 and when heart rate (HR) was lower than 60 beats per minute (BPM) as ordered by physician. This deficient practice had the potential to cause Resident 2 hypotension (blood pressure is too low) with dizziness and fainting which can lead to fall and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice by failing to:1. Elevate the head of the bed while receiving formula through the gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of three sampled residents (Resident 40). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) that could lead to pneumonia (lung infection) for Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and properly disposed discontinued medications per the facility's policy. This deficient practice had the potential to result in the residents accidentally ingesting unknown medications and increased the risk of diversion (any use other than that intended by the prescriber) of unknown medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 2), had monitoring for complications related to Xarelto (an anticoagulant medication used to treat and prevent harmful blood clots) a medication that may increase the risk of bleeding. This deficient practice placed Resident 2 at risk of bleeding a possible side effect of anticoagulant medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up on dental services for one of six sampled residents (Resident 32). This deficient practice had the potential to place Resident 32 at risk for poor self-esteem and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide foods that aligned with one of six sampled residents (Resident 51's) ethnic (of or relating to large groups of people classed according to common racial, national, tribal, religious, linguistic [language], or cultural origin or background) preferences. This deficient practice resulted in Resident 51 disliking the food provided and at times refused to eat meals provided by the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement an individualized person-centered care plan to meet the residents' needs for one of three sampled residents (Resident 5) by failing to develop an individualized/person-centered care plan to address Resident 5's preferred activities. This deficient practice had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN 2) failed to rinse G-tube (gastrostomy tube, a feeding tube inserted through the abdominal wall directly into the stomach) syringe after medication administration on one of two sampled residents (Resident 1). This deficient practice had the potential to spread infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to re-admit one of three sampled residents (Resident 1), after Resident 1 was transferred on 10/1/2024 to a General Acute Care Hospital (GACH) for evaluation of a possible small bowel obstruction (SBO-a blockage in the small intestine that prevents food, liquids, gas and stool from passing through normally), and the GACH cleared Resident 1 to return to the facility on [DATE]. This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered his home, for about 12 months, once deemed appropriate for transfer back to the SNF. Resident 1 had an unnecessarily prolonged stay of 14 days at the GACH placing Resident 1 at risk for unmet care needs, disorientation, confusion, psychosocial harm from being displaced and risk of acquiring infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 60) received appropriate services, did not acquire a decline (reduction) in range of motion (ROM, full movement potential of a joint) and did not develop a contracture (chronic loss of joint motion associated with deformity and joint stiffness) to both hands and both wrists. The facility failed to: 1. Provide appropriate monitoring of Resident 60's ROM on a quarterly basis to determine any changes in ROM in accordance with the facility's policy titled Joint Mobility Assessment, ([JMS] a brief assessment of a resident's ROM in both arms and both legs) which indicated, all residents shall be assessed for joint mobility limitations upon admission and reviewed every three months thereafter. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures on nine of 20 sampled residents (Resident 3,17, 20, 22, 33, 37, 60, 68 and 76) by failing to: a. Ensure the soiled tracheostomy (an opening surgically created through the neck into the trachea [also known as windpipe] to allow air to fill the lungs) supplies of (Resident 68 was disposed properly by the licensed staff. b. Ensure Certified Nursing Assistant (CNA) 3 wore personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) who was on Enhanced Barrier Precaution (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms) during mealtime for Resident 33. c. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendation for three of three sampled residents. Facility failed to a. Obtain a PASARR Level II evaluation for Residents 54 and 36 and Level I evaluation for Resident 4 during admission. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for three of three sampled residents (Resident 36,54 and 4).

Inspectors wroteBased on interview and record review, the facility failed to ensure a plan of care was formulated for two of three sampled residents: a. Resident 50 who was prescribed an anticoagulant medication (a medication used to lower the risk of stroke or blood clot in people); and b. Resident 68 who was prescribed an anti-anxiety medication (a medication used to treat excessive worry and feelings of fear, dread, and uneasiness). These failures have the potential for delayed in the delivery of care and services to Resident 50 and Resident 68.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure measurement of siderails to the bedframe and mattress were implemented and documented prior to installation of a full side rails to the bed of four of four sampled residents (Resident 55 and Resident 69, 14 and 80). This failure had the potential to physical harm from possible entrapment (when a person is trapped by the bed rail in a position they cannot move from) from the use of bed rails for Resident 55 and Resident 69, 14 and 80.

Inspectors wroteBased on interview and record review the facility failed to ensure non-pharmacological interventions (intervention that does not primarily use medication) were ordered for three of three sampled residents (Resident 50,68, and 75) who were prescribed psychotropic (any drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications. This failure had the potential to result in use of unnecessary psychotropic drugs for Resident 50, 68, and 75 that can lead to side effect (effect of a drug or other type of treatment that is in addition to or beyond its desired effect) and adverse drug reaction (unintended, harmful events attributed to the use of medicines).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dietary aide was knowledgeable on how to identify the amount of chlorine level in the dish washing machine by failing to: a. Ensure the chlorine level is 50 to 100 parts per million (PPM, concentration of chlorine used to sanitize dishes) of the dishwashing machine after the final rinse. b. Ensure the dish washing machine was checked and monitored for the right temperature of water and correct amount of chlorine before using. These failures had the potential to place residents at risk for food-borne illnesses due to improper testing of chlorine level of the dishwashing machine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) for one of eight sampled residents (Resident 60) with limited range of motion (ROM, full movement potential of a joint [where two bones meet]) concerns by failing to: 1. Report Resident 60's decline in ROM of both wrists and both hands to the physician in accordance with the facility's job description titled, Restorative Nursing Assistant, and policy and procedure tilted, Change in a Resident's Condition or Status. This failure resulted in Resident 60 from not receiving interventions to improve ROM, including intervention to prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate Minimum Data Set Assessment (MDS, a standardized assessment and care screening tool) for restraint who is using full side rails for one of one sampled resident (Resident 14). This deficient practice has the potential to result in Resident 14 not receiving the necessary care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foot care to one of four sampled residents(Resident 38) by: 1. Failing to check and monitor if a podiatry service ( diagnose and treat any foot or ankle problem) is needed for Resident 38 's toenails who had thick and overgrown toenails. This failure had the potential to cause discomfort and for Resident 38's toenails to cut into the skin due to their length.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for the use of a controlled substance (a medication with a high potential for abuse) on Controlled Drug Record (CDR- a log signed by the nurse with the date and time each time a controlled substance is given to a resident) for one resident (Resident 44) in one out of three medication carts reviewed (Middle Medication Cart Sub-Acute). This failure had the potential to result in unintended use of Tramadol (a controlled substance used to relieve and manage pain) and placed the facility and Resident 44 at risk for medication errors, drug loss and diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove an expired insulin (a medication used to treat high blood sugar) per manufacturer's requirements, affecting one resident (Resident 56) in one of three inspected medication carts (Medication Cart 3 Back Cart.) This failure had the potential to result in hyperglycemia (a medical term used to describe high blood sugar) and/or hospitalization for Resident 56 because of receiving an expired insulin that could have been ineffective or toxic due to improper storage conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure staff's personal items were not stored in the refrigerator and dry storage area. b. Ensure frozen food items were safely stored in the freezer. c. Ensure open food items are stored properly in the storage area. d. Ensure the [NAME] performed hand washing and change of glove after and before switching tasks in the kitchen. e. Ensure the drain area of ice machine was clean and free of grime. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement a care plan to meet the needs for one of three sampled residents (Resident 1). Resident 1 was assessed at risk for elopement (leaving an institution without notice or permission) and required a wander guard (a system used to alarm staff of a potential elopement of a resident) to be applied. This deficient practice resulted a wander guard not being applied to Resident 1 and Resident 1 eloping from the facility on 11/26/2023. This deficient practice had the potential for Resident 1 to sustain an injury and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 1), who was assessed as at risk for elopement (leaving an institution without notice or permission) with a wander guard, per their elopement Risk Evaluation. This deficient practice resulted in Resident 1 eloping from the facility on 11/26/2023, without a wander guard in place. This deficient practice had the potential for Resident 1 to sustain an injury and/or death.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) by: a. Failing to notify the responsible party of Resident 1 that an intruder entered Resident 1's room through the sliding door. This deficient practice potentially affected the delivery of care and services for Resident 1. b. Failing to assess Resident 1 for any physical or psychological problems after the intruder was observed in Resident 1's room. This deficient practice potentially placed Resident 1 at risk for unidentified harm that the intruder might have caused.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the sliding door for one (Resident 1) of four sampled resident's rooms were secured and locked after certified nurse assistant (CNA) 1 and licensed vocational nurse (LVN) 1 identified an intruder in the patio on 8/20/2023 at 10:10 p.m. This deficient practice resulted in the intruder entering the facility through Resident 1's sliding door and ending up in Resident 2's room on 8/20/2023 at 10:15 p.m., risking the health and safety of the residents and staff of the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete the comprehensive Minimum Data Set ([MDS] part of the U.S. federally mandated process for clinical assessment of all residents in Medicare-Medicaid certified nursing homes) within the regulatory timeframe for 21 of 22 sampled residents. This deficiency had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One Influenza (Flu) vaccine vial was labeled with an open date. 2. One Tuberculin protein purified derivative [(PPD), protein used in the diagnosis of tuberculosis (bacterial infection of the lungs)] multidose vial was dated with an open date. 3. Resident 11's humulin insulin (medication used to control high blood sugar) vial was labeled with an open date. 4. Resident 368's Tramadol ([controlled substance] medication to treat moderate to severe pain) 50 milligram (mg) bubble pack (sealed card that packages doses of medication) was stored in the medication cart eight days after the resident was discharged from the facility. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 43 and 119), who required staff's assistance with meals, were cared for with dignity and respect by sitting and not standing while feeding the residents during mealtimes. This deficient practice potentially violated Residents 43 and 119 rights, and had the potential to negatively affect the resident's self-esteem and self-worth.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a comprehensive assessment of each resident's functional capacity for 21 of 22 sampled residents. Cross Reference F640. This deficiency had the potential to incorrectly identify each resident's preferences and goals of care, and their functional and health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate and implement a comprehensive care plan for one of one sampled residents (Resident 21), after Resident 21 verbalized to the Director of Nursing (DON) and Administrator (ADM) that she felt uncomfortable interacting with Resident 56. This deficient practice resulted in Resident 21 wanting to avoid Resident 56 and not wanting to participate in group activities.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of one sampled resident (Resident 45) received the minimum amount of oxygen required based on the resident's oxygen saturation (the amount of oxygen traveling through your body with your red blood cells) according to physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer the correct dosage of Docusate Sodium (stool softener) capsule and properly dispose of a Lovenox (blood thinner) injection syringe into the biohazard container for one of six sampled residents (Resident 46). These deficient practices resulted in Resident 46 receiving an inaccurate dose of medication which had the potential to result in constipation (difficulty in emptying the bowels), and the improper disposal of a syringe had the potential to cause injury to staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed by failing to don (put on) gloves and use an alcohol swab to disinfect a resident's abdomen prior to administering a subcutaneous (under the skin) injection. These deficient practices resulted in improper infection control practices performed by staff placing the residents at risk for infection.