Physical Rehabilitation and Wellness Center of Spa

Inspectors wroteBased on review of facility policy, manufacturer manual, record review, and interview, the facility failed to properly secure Resident (R)4 for transfer via hoyer lift. Specifically, the facility used the incorrect size sling to transfer R4, resulting in R4 slipping out of the sling, falling to the floor, and suffering a hematoma to the back of the head.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident (R)1, who was on NPO (nothing by mouth) status, was adequately supervised to prevent the resident from receiving a cereal bar and a cup of water. Resulting in the resident experiencing symptoms of projectile vomiting and clamminess, which resulted in hospital transfer. On 02/19/26 at 03:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/20/26 at 09:35 AM, the Administrator was notified that failure to ensure a resident who was on NPO status was adequately supervised to prevent the resident from receiving a cereal bar and cup of water constituted Immediate Jeopardy (IJ) at F689. [...]

Inspectors wroteBased on facility policy review, record review, and interviews, the facility failed to protect the Resident (R)19's rights to be free from sexual abuse, from R79, for 1 of 7 residents reviewed for abuse. This failure had the likelihood of causing physical, mental, and psychosocial harm. On 01/14/26 at 3:45 PM, the Administrator and Director of Nursing (DON) were notified that the failure to protect a resident from sexual abuse constituted Immediate Jeopardy at F600. On 01/14/26 at 3:45 PM, the survey team provided the Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 12/09/25. The IJ was related to 42 Code of Federal Regulations (CFR) 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 01/16/26 at 3:04 PM, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on observation, interview, facility document review and policy review, the facility failed to ensure dietary staff followed proper personal hygiene practices to prevent food contamination when serving food for residents and failed to ensure food items were labeled appropriately and that the refrigerator was maintained at a proper temperature in 1 (Unit 100) of 3 snack/nourishment room refrigerators.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to protect residents' personal information for 5 Residents (R)27, 70, 78, 107, and 121of 23 sampled residents. Specifically, staff left a computer monitor that was on a medication cart unsecure where resident protected health information (PHI) was displayed for anyone to see.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 Resident (R)103 of 1 resident reviewed for bowel and bladder incontinence.

Inspectors wroteBased on interview, record review, facility document review, and policy review, the facility failed to ensure that the safety locks on a shower chair were properly locked and secure for 1 of 5 residents (R)1 reviewed for accident hazards. This failure resulted in R1 experiencing a fall without injury.

Inspectors wroteBased on facility policy, record review, and interviews, the facility failed to provide the bed hold policy to Resident (R)1 and/or Resident Representative (RR) in a timely manner for 1 of 1 reviewed for hospitalization.

Inspectors wroteBased on review of facility policy, observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with aggressive behaviors for 1 of 2 residents reviewed, Resident (R)02.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to 1.) complete wound care in a manner to prevent cross-contamination for one of four residents (Resident (R) 25) reviewed for pressure ulcers, 2.) and failed to administer medications in a manner to prevent cross-contamination for three of three residents (R50, R53, and R31) observed for medication administration out of a total sample of 25, and 3.) failed to complete yearly reviews of the facility's infection control policies and procedures. These failures had the potential for spreading infections to the vulnerable population in the facility.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to promote dignity during a dressing change for one of one resident (Resident (R) 25) of 25 sample residents. This failure caused R25 to have increased anxiety during a dressing change.

Inspectors wroteBased on interviews, record review, and review of facility documents, the facility failed to ensure showers were conducted according to resident preferences for one (Resident (R) 24) of 25 sampled residents. This failure denied the resident the right to self-determination for showers. Findings Include: Review of the facility's policy titled, Social Service Policies and Procedures, revision date of 10/01/20, revealed The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. The Facility has established the Patient/Resident [NAME] of Rights and Responsibilities in accordance with state and federal regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue accurate Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to one of two residents (Resident (R) 74) and a Notice of Medicare Non-Coverage (NOMNC) forms and a SNFABN to one of two residents (R75) reviewed for liability and beneficiary notices out of total sample of 25. This failure had the potential for residents or their responsible parties not to have all the information to make an educated decision about the ending of skilled services.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 25) reviewed for baseline care plans of 25 sample residents. This failure had the potential for residents and/or RP not to be informed of the plan of care.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to 1.) ensure the comprehensive care plan included the resident's religious preference for one of one resident (Resident (R) 42) reviewed for activities based on a resident's mental and psychosocial needs out of 25 sample residents. This failure had the potential to cause R42's psychosocial needs not to be met, and 2.) failed to develop a comprehensive care plan (CP) for a pressure ulcer for one of four residents (Resident (R) 25) out of 25 sampled residents. This failure had the potential for R25 to have an inaccurate plan of care for a stage four pressure ulcer.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's order prior to the administration of oxygen for one of two residents (Resident (R) 25) out of 25 sampled residents. This failure had the potential for R25 to have adverse reactions from the administration of oxygen.

Inspectors wroteBased on record review and interview, the facility failed to have collaboration of care with the dialysis center for one of two resident (Resident (R) 21) reviewed for dialysis out of 25 sampled residents. This failure had the potential to put R21 at risk for lack of communication between the facility and the dialysis center

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to maintain a medication error rate below five percent. Three errors/omissions out of 26 opportunities resulted in a medication error rate of 11.54% for three of three residents (Resident (R)13, R31, and R30) of 25 sample residents. This failure had the potential to cause residents to not receive the proper dosages of their medications.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for one of one resident (Resident (R) 13) and failed to ensure that all drugs and biologicals were stored in locked compartments for one of one resident (R30) out of 25 sample residents. This failure had the potential to cause residents to receive the wrong or contaminated medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food palatability for one of one resident (Resident (R) 73) reviewed for dialysis out of a total sample of 25. This failure had the potential to affect the resident's nutritional intake and cause food-borne illnesses.

Inspectors wroteBased on observations, interviews, and documentation review, the facility failed to ensure the proper handling of ready-to-eat foods in one of one kitchen. This had the potential to result in the transmission of foodborne illnesses for 107 of 112 residents residing in the facility.

Inspectors wroteBased on record review, interviews, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for two of five residents (Residents (R) 25 and R37) and/or their representatives the opportunity for the residents to receive flu and/or pneumonia vaccines out of 25 sample residents. This failure had the potential to put these residents at more risk of developing flu and pneumonia.

Inspectors wroteBased on observation and interviews, the facility failed to ensure a safe, functional, sanitary, and comfortable environment which included clean baseboards in the hallways, clean mats in the kitchen, and clean and well repaired resident rooms for two of two residents (Resident (R) 124 and R209) reviewed for environment out of a total sample of 25. This failure could place residents and visitors in uncomfortable and unsanitary conditions.

Inspectors wroteBased on observations, interviews, document review, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility: - Failed to label, date, and timely dispose of food items stored in one of one walk-in refrigerator. - Failed to keep the floor clean and boxes of food stored off the floor in one of two dry storage areas. - Failed to maintain food temperature logs for meals. - Failed to ensure dietary staff practiced hand hygiene during meal service. - Failed to record the temperature of one of one walk-in refrigerator. - Failed to monitor and clean three of three nourishment room refrigerators. The facility's resident census was 102 residents; the failed practices had the potential to affect 100 residents who received meals from the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a wheelchair was provided to meet the resident's needs and enable the resident to get out of bed when desired for 1 (Resident (R)102) of 3 sampled residents reviewed for accommodation of needs.

Inspectors wroteBased on record review, interviews, and document and policy review, the facility failed to ensure residents were free from any significant medication errors when it failed to administer a prescribed medication for one (Resident #351) of six residents reviewed for medication administration.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility's Quality Assessment and Assurance (QAA) Committee developed, implemented, and monitored a corrective action plan to address kitchen concerns identified in July 2022. The facility's census was 102 residents; the failed practice had the potential to affect 100 residents who received nutrition from the kitchen.