Caring Heights Community Care & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Caring Heights Community Care & Rehab CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF700Sep 5, 2025

  Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of four residents (Residents R5, R6, R92, and R103).Findings include:Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/15/25, indicated diagnoses of hyponatremia (low levels of sodium in the blood), cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue), and malnutrition (lack of sufficient… […]

• No harm, potential for more than minimal, patternF623Oct 25, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents (Residents R14, R49, R59, R120). Findings include: Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R14's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/19/24, indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). […]

• No harm, potential for more than minimal, patternF625Oct 25, 2024

  Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) for four of four resident hospital transfers (Resident R14, R49, R59, and R120). Findings Include: Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R14's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 7/19/24, indicated diagnoses of adult failure to thrive, high blood pressure, and atrial fibrillation (irregular heart beat). […]

• No harm, potential for more than minimal, patternF641Oct 25, 2024

  Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of eight residents (Residents R68, and R114). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: -Section O 1. Code 0, no: if the resident ' s pneumococcal vaccination status is not up to date or cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received, state reason. 2. Code 1, yes: if the resident ' s pneumococcal vaccination status is up to date. […]

• No harm, potential for more than minimal, patternF692Jul 25, 2024

  Based on clinical records and staff interviews, it was determined that the facility failed to monitor residents' weight for three of three residents reviewed. (Resident R1, Closed Record Resident CR1 and CR2) Findings include: Review of the facility policy Resident Weight Policy, dated 7/1/24, indicated weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. […]