Advanced Center for Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Advanced Center for Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF656Apr 7, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for four of six residents (Residents #1, 2, 3, and 12) reviewed for a change in condition, the facility failed to ensure comprehensive resident care plans were developed related to a substance use disorder including assessing leave of absence status for residents who were identified with contraband or required administration of [MEDICATION(S)]. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Leave of Absence Policy form dated 11/17/2021, signed by Resident #1, indicated Resident #1 was educated regarding the Leave of Absence (LOA) policy. […]

• Immediate jeopardy, patternF684Apr 7, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4), reviewed for diabetes management, the facility failed to ensure staff reviewed hospital insulin recommendations for a new admission, and the facility failed to ensure staff notified the provider timely of an elevated blood sugar for a resident receiving insulin when the blood sugar was equal to or greater than 200, and the resident had a change in condition resulting in a hospital admission with the blood sugar over 600, and for one of three residents (Resident #12) reviewed for a change in condition, the facility failed to ensure the resident was transferred to the hospital for evaluation after the administration of [MEDICATION(S)]. […]

• Immediate jeopardy, patternF689Apr 7, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of six residents (Resident #1) reviewed for a change in condition, the facility failed to ensure adequate supervision was provided to ensure a resident was free from possession of drug paraphernalia, and for three of six residents (Residents #2, 3, and 12) reviewed for a change in condition, the facility failed to ensure adequate supervision to ensure residents did not have access to contraband which resulted in the residents requiring administration of [MEDICATION(S)], and failed to follow facility leave of absence policy. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. […]

• Immediate jeopardy, patternF740Apr 7, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for four of six residents (Residents #1, 2, 3 and 12) reviewed for a change in condition, the facility failed to provide adequate psychosocial oversight to ensure residents received adequate emotional and behavioral services to address their dependency for residents who were identified to have possession of contraband or required administration of [MEDICATION(S)]. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission assessment dated [DATE] identified Resident #1 was alert and oriented and was ambulatory. […]

• Immediate jeopardy, isolatedF695Oct 2, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for supplemental oxygen, the facility failed to assess the resident and notify the provider when Resident #2 experienced Shortness of Breath (SOB) related to the facility's lack of oxygen concentrators and emergency tank supplies. The facility failed to ensure continuous, functioning supplemental oxygen and failed to provide timely, appropriate intervention for Resident #2's acute respiratory distress, resulting in Resident #2's condition deteriorating to acute respiratory arrest, ultimately leading to death. The failures resulted in the finding of Immediate Jeopardy. […]