Le Reve Rehabilitation & Memory Care

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 2 (Resident #7 and Resident #8) of 6 residents reviewed for comprehensive care plan revisions. 1. The facility failed to update Resident #7's care plan for skin laceration to her right toe. 2. The facility failed to update Resident #8 and Resident 8's care plan non-pressure wound to his thigh. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need.

Inspectors wroteBased on interview and review record, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #9) reviewed for personal hygiene. The facility failed to provide Resident #9 with scheduled showers between 12/22/2025 and 03/04/2026. This failure could place residents, who require assistance from staff for personal hygiene, at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that were accurately documented for 1 (Resident #2) of 6 residents reviewed for administration. The facility failed to document, at least once per shift, that the task turn/reposition for Resident #2 was completed. This failure could place residents at risk of developing skin breakdowns.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, 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 (Resident #1) of five residents reviewed for reporting. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8consecutive hours a day, 7 days a week for 7 of 31 days in March 2026 reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 03/05/2026 (Friday), 03/06/2026 (Saturday), 03/11/2026 (Wednesday), 03/17/2026 (Tuesday), 03/18/2026 (Wednesday), 03/23/2026 (Monday) and 03/24/2026 (Tuesday). This failure placed residents at risk of missing nursing assessments, interventions, care and treatment.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure each resident had the right to be free from neglect. For one resident (Resident #1) out of 5 residents reviewed for deprivation of goods and services. LVN A failed to follow protocol after Resident #1 had a fall. LVN A picked Resident #1 off the floor and returned her to her bed without conducting an assessment and reporting the incident to RP, DON, and Physician. This resulted in Resident #1 not being diagnosed with a fracture on her left hip and a right dislocated shoulder for 11 hours. An IJ was identified on 09/19/2025, the IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on 9/22/2025. [...]

Inspectors wroteBased on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process. For one resident (Resident #1) out of 5 residents reviewed for neglect and abuse. The facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment by LVN A by allowing him to work and have direct contact with the resident while the allegations were still under investigation. An IJ was identified on 09/20/2025. The IJ template was provided to the facility on [DATE] at 8:07 pm. [...]

Inspectors wroteBased on interviews and record reviews LVN A failed to assess Resident #1 which prevented her from receiving timely treatment. LVN A failed to follow protocol after Resident #1 had a fall. LVN A picked Resident #1 off the floor and returned her to her bed without conducting an assessment and reporting the incident to RP, DON, and Physician. This resulted in Resident #1 not being diagnosed with a fracture on her left hip and a right dislocated shoulder for 11 hoursFindings include:Record review of facility PIR dated 08/22/2025, with an allegation of neglect, reflected that Resident #1 sustained a fall in her room on 08/16/2025 at approximately 5:00 am. When the family notified the facility staff of Resident #1's fall, staff completed an x-ray. The x-ray revealed that the resident sustained a femur fracture. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 days of 60 days reviewed for RN coverage. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 days of 60 days reviewed for RN coverage. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

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 four of four ( Resident #46, #16, #17, and #54) and two of three (DA A and DA B) staff members reviewed for infection control procedures. Dietary Aide A failed to perform hand hygiene after direct contact with Residents #46 and #16 while serving meals in the main dining room. Dietary Aide B failed to perform hand hygiene after direct contact with Residents #17 and #54 while serving meals in the main dining room. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was stored securely on 1 of 1 medication cart (hall100) reviewed. The facility did not ensure Hall 100 medication cart was locked when unattended. This failure could place residents who reside on hall 100 at risk of drug diversion. Findings Include: Observation on 03/21/2025 at 4:30 AM revealed a medication cart parked on hall 100 and the lock was in the open (unlocked) position. The surveyor was able to open the cart drawers. Observation and interview on 03/21/2025 at 4:32 AM revealed LVN A exited a resident room and approached the medication cart. LVN A stated he was assigned to the medication cart, and it was unlocked. Interview on 03/21/2025 at 5:42 am with LVN A revealed, the medication cart contained wound care supplies, resident medications and narcotics. [...]

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 one (Resident #1) of three resident reviewed for infection control. The facility failed to ensure on 12/09/24 LVN A avoided taking a bottle of wound cleanser and a tube of medicated cream into the resident's room, and then returning the containers to the treatment cart, which contained treatment supplies for other residents. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Residents #1 and #2) of ten residents reviewed for call lights. 1. Resident #1 was observed in bed (closest to the door) and her call light was observed hung on a dresser drawer beside the bed closest to the window separated by a wheelchair and privacy curtain. 2. Resident #2 was observed in bed and her call light was rolled up and hung on the wall between Resident #2's bed and the bed closest to the window. These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #2) of ten residents reviewed for care plans. The facility failed ensure Resident #2's care plan was followed to ensure fall mats were placed on either side of Resident #2's bed while she was in it. This failure could place residents at risk of injury and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of ten residents reviewed for accidents. The facility failed to ensure fall mats were placed on either side of Resident #2's bed while she was in it. Resident #2 was observed in bed (in the lowest position), closest to the door and fall mats were observed folded and leaning against the window wall across the room. This failure could place residents at risk of injury and a decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to notify the physician when a resident experienced ant bites and pain for 1 (Resident #21) of 5 residents reviewed for a notification of a change of condition, in that: RN II did not notify the Physician of Resident #21's change of condition on 08/13/24 when CNA R reported that Resident #21 had indicated experiencing pain to the anterior area of her right elbow to RN II concerns that Resident #21 had suffered ant bites that had resulted in welts on Resident #21's right arm. An Immediate Jeopardy was (IJ) was identified on 08/14/24 at 5:53 PM while the IJ was removed on 08/16/24, the facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for quality of care. 1) The facility nurses failed to assess, treat, or monitor ant bites and pain for Resident #21 or seek treatment instructions from the physician. An Immediate Jeopardy was (IJ) was identified on 08/14/24 at 5:53 PM while the IJ was removed on 08/16/24, the facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to a worsening of their condition, hospitalization, or death. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for six (Residents #1, #6, #23, #42, #38, and #53) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #1, #6, #23 #42, #38, and #53. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 of 90 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on for 4 days: 10/21/23; 11/14/23; 11/20/23 and 11/26/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

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 service safety in the facility's only kitchen, reviewed for food safety. 1. The facility failed to ensure the ice machine vent was free from dirt and dust. 2. The facility failed to ensure food items in the refrigerators, freezer and dry storage room were labeled with the item description (handwritten or manufacturer's label), the opened date and or the consume by or expiration by dates (if opened, 72 hours per the facility's policy or the manufacturer's expiration date); and stored in accordance with the professional standards for food service. 3. [...]

Inspectors wroteBased on interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 (Resident #21) of 5 Residents reviewed for pest infestations. The facility failed to ensure the facility was free from ants. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Residents #4, #41 and one unidentified resident) of four residents reviewed for infection control. LVN A failed to disinfect the blood pressure cuff (machine used for checking blood pressure) in between blood pressure checks for Residents #4, #34, and an unknown resident. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter received appropriate treatment and services for 1 (Resident #1) of six residents reviewed for quality of care, in that: LVN A, DON, and ADON failed to follow-up with physician after leaking was reported to the suprapubic catheter on 06/16/24 until 06/29/24 when surveyor intervened. An Immediate Jeopardy (IJ) was identified on 06/30/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results according to facility policies and procedures for notification and the medical orders for 1 (Resident #1) of six residents reviewed for laboratory services, in that: The facility failed to notify the physician of the urinalysis (UA) results that were reported on 06/28/24. The UA results suggested Resident #1 may have had an UTI. This deficient practice placed residents at high risk of, or the likelihood of, delay in care or treatment.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on for 5 days: 09/03/22; 09/04/22; 09/12/22; 09/18/22 and 09/24/22. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for one (Resident #49) of three residents reviewed for PASRR assessments. The facility failed to recognize Resident #49 had diagnosis of anxiety disorder, major depressive disorder, and bipolar disorder on admission and as a result she never received a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs.