Agape Rehabilitation & Nursing Center, A Waters CM

In the surveyor’s words

From the most serious findings on record at Agape Rehabilitation & Nursing Center, A Waters CM, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 22, 2024

  Based on facility policy review, observations and interview, the facility failed to ensure kitchen cooking/serving equipment was maintained in a sanitary condition, failed to ensure food items were sealed properly, and failed to ensure dented cans were discarded, which had the potential to affect 65 of 65 residents. The findings include: Review of the facility's policy titled, Food Storage dated 11/25/2019, showed .Food storage areas are clean .containers for bulk items .have tight-fitting lids .dented cans are returned to the vendor upon delivery or stored in a separate area . […]

• No harm, potential for more than minimal, isolatedF641May 19, 2026

  Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, observation, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 2 residents (Resident #13 and #62) of 18 residents reviewed for MDS assessments.The findings include: Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition .Section GG .Functional Abilities .Limitation in Range of Motion .Code 1 .if resident has impairment on one side . […]

• No harm, potential for more than minimal, isolatedF656May 19, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a person-centered care plan related to a left-hand contracture for 1 resident (Resident #13) of 4 residents reviewed for care plans for range of motion (ROM) and resident mobility.The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/23/2021, revealed .The Comprehensive Care Plans will be reviewed and updated .based on changes in the resident's condition and/or newly developed health/psycho [psychological]-social issues .The .Care Plan Coordinator .will attend the Morning .meetings .review 24 Hour Report(s) .new or changed orders .They [Care Plan Coordinator] will then see that the care plans for these… […]

• No harm, potential for more than minimal, isolatedF609Feb 22, 2024

  Based on facility policy review, medical record review and interviews, the facility failed to report an allegation of abuse timely for 1 resident (Resident #20) of 24 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Prevention Program dated 1/19/2017, showed .When an alleged or suspected case of abuse .is reported .the administrator, or person in charge of the facility, will notify the following .agencies of such incident immediately .State Licensing and Certification Agency . Resident #20 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Mild Intellectual Disabilities, Anxiety Disorder, Osteoporosis and Hypertension. […]

• No harm, potential for more than minimal, isolatedF645Feb 22, 2024

  Based on facility policy review, medical record review and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) screen was accurate after a mental health diagnosis was identified for 2 of 5 residents (Resident #2 and #38) reviewed for PASARR. The findings include: Review of the facility's policy titled, PASRR [PASARR] PROCESS undated, showed .federally mandated process that requires all states to pre-screen all residents .identify people, including adults, (residents), with mental illness .to ensure people [residents], receive the required services for mental illness . […]