Armstrong Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Armstrong Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jul 17, 2026

  Based on review of facility policy, documents, and staff interviews, it was determined that the facility failed to ensure an environment free of hazards which is likely to cause serious injury, harm, impairment, or death when an employee (RN Employee E1) entered the facility with a shot gun and ammunition. This failure created an immediate jeopardy situation for all residents.Findings include: Review of the facility's Employee Handbook dated 6/1/21, indicated the definition of an act of violence, for purposes of this policy, the facility will interpret an act of violence whether it is physical violence, verbal or non-verbal threats, damage to or theft of property and/or any related actions in the broadest sense possible to include (but not limited to) any of the following acts on facility… […]

• Immediate jeopardy, patternF689Mar 25, 2026

  Based on facility policy review, clinical record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for 10 of 94 residents assessed by the facility to be at risk for elopement (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings Include: Review of the facility policy Missing Resident / Elopement Procedures dated 8/8/25, defined elopement: Occurs when a resident leaves a safe area without staff knowledge OR the patient enters an unsafe area without staff knowledge or presence. […]

• Immediate jeopardy, isolatedF689Apr 20, 2023

  Based on review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to provide adequate supervision for two residents resulting in an elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision). This failure created an immediate jeopardy situation for two of eleven residents (Closed Record Resident CR1 and Resident R2). Findings include: The facility Elopements and wandering residents policy last reviewed on 2/21/23, indicated that the facility ensures that residents who exhibit wandering behaviors or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of… […]

• Actual harm, isolatedF726Jul 1, 2025

  Based on review of facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration for one of two residents reviewed (Resident R1) which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1. […]

• Actual harm, isolatedF760Jul 1, 2025

  Based on review of facility policy, clinical record review, facility documents, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. […]