Mission at Community Living Rehabilitation Center

Inspectors wroteBased on interview and record review it was determined, for 4 of 24 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, documentation regarding resident's immunization history was not in the medical record. Resident identifiers: 6, 14, 21 and 30.

Inspectors wrote2. On 6/23/25 at 12:20 PM, a Laundry Staff (LS) was observed to push a cart which had resident clean laundry hanging from the railing. There was no cover over the laundry. The LS passed residents and staff members in the hallways as she took the laundry to rooms 120, 121, 122, 123, and 124. On 6/24/25 at 11:24 AM, an observation was made of the LS. The LS carried laundered resident clothing on her shoulder and entered resident room [ROOM NUMBER] and put some clothing into the closet of room [ROOM NUMBER]. The LS was then observed to take the remaining resident clothing into room [ROOM NUMBER] and put it into the closet. On 6/24/25 at 11:40 AM, an interview was conducted with the LS. The LS stated the clothes are washed and then taken to the resident's rooms. The LS stated that she did not cover the laundry when she took it to the residents. [...]

Inspectors wroteBased on interview, and record review, for 3 of 24 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, a staff member was arrested for driving under the influence (DUI), had alcohol in the facility vehicle while transporting residents and the State Survey Agency was not notified. Resident identifiers: 6, 10 and 90.

Inspectors wroteBased on interview and record review, the facility in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 3 out of 24 sampled residents, allegations of a staff member driving residents while being intoxicated was not investigated or the allegations were not investigated thoroughly. Resident identifiers: 6, 10 and 90.

Inspectors wrote2. Resident 90 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lupus, major depressive disorder, dementia, anxiety and history of falling. Resident 90's medical record was reviewed 6/23/25 through 6/25/25. Resident 90 had a Physician's order for a urine analysis with culture to be collected on 1/25/25. The urine analysis was documented in resident 90's medical record. The urine culture was not located in the medical record. On 6/25/25 at 10:27 AM, an interview was conducted with the ADON. The ADON stated that the facility relied on the lab to give them the results, but the shift nurse would check with the lab daily to see if the labs were available. The ADON stated if orders get faxed over the nurse will note them and put them in the binder for medical records to scan them into the medical record. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, chemicals were stored in the dry storage room with food, the thermometer for the freezer was not functional and there was no backup thermomter inside the freezer, and there was an observation of the Dietary Manager not properly wearing a hairnet.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide training to staff that educated on activities that constituted dementia management, abuse, neglect exploitation and misappropriation of property, procedures for reporting abuse, and resident abuse prevention. Specifically, the facility did not provide ongoing substance abuse training with the facility staff after a staff member was arrested for drinking while driving residents in the facility van. Resident identifiers: 6, 10 and 90.

Inspectors wroteBased on interview it was determined that the facility did not 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. Specifically, the facility did not have a system to test for Legionella.

Inspectors wroteBased on interview and record review it was determined, for 5 out of 19 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. In addition, the facility did not ensure report the results of all investigations were submitted to the State Survey Agency (SSA) within 5 working day of the incident. Specifically, the facility did not report an allegation of abuse within 2 hours of the incident and the results of the investigation were not reported to the SSA within 5 working days. Resident identifiers: 2, 25, 26, 28 and 85.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, during required visits. Specifically, for 3 of 19 sampled residents, the physician did not include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. Resident identifiers: 28, 29 and 31.

Inspectors wroteBased on interview and record review it was determined, for 1 of 19 sampled residents, when the facility anticipated discharge, a resident did not have a discharge summary that included, but was not limited to the following: (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that was available for release to authorized persons and agencies, with the consent of the resident or resident's representative. Specifically, a resident discharged home and there was not discharge summary completed. Resident identifier: 33.

Inspectors wroteBased on interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not ensure a resident with urinary incontinence was provided appropriate treatment and services to prevent urinary tract infection (UTI). Specifically, a CNA reported the resident had dark, odiferous urine. A urinalysis was completed but there was insufficient follow-up by the facility and the physician. Resident identifier: 29.

Inspectors wroteBased on interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist and any irregularities were reported to the physician and were acted upon. Specifically, the physician did not document in the resident's medical record that the identified irregularities had been reviewed and what action had been taken to address the irregularity. Resident identifier:

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not provide or obtain outside resources for routine and emergency dental services to meet the needs of the residents. Specifically, a resident was not provided dental services for dentures. Resident identifier: 31.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not provide food prepared in a form designed to meet individual needs. Specifically, a resident requested a pureed diet but remained on a mechanical soft diet. Resident identifier: 31.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were open to air.

Inspectors wroteBased on interview and record review it was determined that for 2 of 21 sample residents the facility did not ensure that the drug regimen of the residents were reviewed at least monthly by a licensed pharmacist. Specifically, the attending physician did not document that the identified irregularities had been reviewed and what, if any, action had been taken to address it. Resident identifiers: 1 and 3.

Inspectors wroteBased on interview and record review, it was determined, for 2 of 21 sample residents, that the facility did not 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, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, the facility did not update the care plan for a resident who experienced a fall and the facility did not update the care plan for a resident with new physician orders for a larger catheter size. Resident identifiers: 2 and 3.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not ensure that the facility met the residents' medical needs. Specifically, for 1 out of 21 sampled residents, the facility did not provide ordered medications since staff were unaware of the location of the medication's delivery device. Resident identifier: 35.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that the residents' medical record was accurate. Specifically, for 1 out of 21 sampled residents, the facility did not have accurate records of medications given and not given. Resident identifier: