The Commons Skilled Nursing & Rehabilitation

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was provide quality care and treatment that met professional standards of practice, when on 01/23/26, after telling Certified Nurse Aide (CNA) #1 that he/she could not stand up any longer, CNA #1 helped lowered Resident #1 to the floor in his/her bathroom, however CNA #1 did not immediately inform nursing of the incident so he/she could be assessed for potential injury prior moving him/her, but instead waited to notify nursing after he picked Resident #1 up off the floor and transferred him/her back to bed.

Inspectors wroteBased on records reviewed and interviews, for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the facility failed to ensure they maintained complete and accurate medical records, when their Certified Nurse Aide (CNA) flow sheets were left blank and the provision of care (e.g. bathing, dressing, grooming etc.) each resident required, was not documented as provided.

Inspectors wroteBased on observation, record review and interview the facility failed to report an injury of unknown origin immediately, but not later than 2 hours after the injury was discovered, to the state agency, for one Resident (#51) out of a total sample of 17 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to immediately investigate an injury of unknown origin for one Resident (#51) out of a total sample of 17 residents.

Inspectors wroteBased on interview and record review, the facility to ensure that services provided met professional standards for one Resident (#39), out of 17 total sampled residents. Specifically, for Resident #39, the facility failed to complete a baseline AIMS (Abnormal Involuntary Movement Scale) assessment upon admission when prescribed an antipsychotic medication.

Inspectors wroteBased on record review and interviews, the facility failed to maintain medical records in accordance with Nursing professional standards. Specifically, the facility failed to accurately transcribe physician's orders for one Resident (#8) out of a sample of 17 Residents.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreement explicitly stated that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreement provides for the selection of a venue that is convenient to both parties. The binding arbitration agreement must allow for the selection of a venue that is suitable in meeting the needs of both the resident or his or her representative, and the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to use appropriate infection control practices. Specifically,1. The facility failed to use appropriate hand hygiene and use PPE (Personal Protective Equipment) in a room with Enhanced Barrier Precautions (EBPs) for one Resident (#8) out of a sample of 17 Residents.2. The facility failed to maintain infection control practices consistent with professional standards during the medication pass.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness and needed further evaluation) for two Residents (#3 and #16), out of a total sample of 15 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the care plan for an air mattress setting causing one Resident (#21) increased pain/discomfort out of a total sample of 15 residents. Resident #21 was admitted to the facility in October 2022 with diagnoses including Chronic Obstructive Pulmonary Disease, hypertension, and muscle weakness. Review of the Most Recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 15 out of possible 15 indicating intact cognition. On 9/13/23 at 8:48 A.M., the surveyor observed Resident #21 sitting up in bed eating breakfast with an air mattress set to 400 lbs. Additional observations of the air mattress set to 400 pounds (lbs.). were made on 9/13/23 at 11:18 A.M. and 3:10 P.M., 9/14/23 at 12:27 P.M. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with grooming, for one Resident (#17) out of a total sample of 15 residents. Review of the facility policy titled Activities of Daily Living (ADL), last revised 3/2018, indicated the following: Policy Statement: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: *2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#3), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 15 sampled residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. once opened, were dated as required for 2 out of 2 observed medication carts.

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program for one resident (#16) out of a total sample of 15 residents.