Center for Living & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 13, 2026

  Based on interview and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent avoidable accidents for 1 of 3 sampled residents (Resident #1). For Resident #1, who was at high risk for falls and required supervision while walking, staff failed to implement person-centered care plan interventions after multiple falls, ensure the resident was care planned for adequate supervision, and ensure staff assigned to care for residents in those rooms had the ability to provide the required supervision. On 6/30/26, Resident #1 experienced an unwitnessed fall and was found on the floor unresponsive and passed away on 7/01/26 from injuries sustained from the fall. […]

• Actual harm, isolatedF600Dec 16, 2025

  Based on interviews and record review, the facility failed to ensure residents' right to be free from physical and verbal abuse from another resident for 2 of 3 sampled residents (Resident #1 and Resident #2). The facility did not implement effective interventions to prevent recurrence after a prior altercation on 8/7/25, nor did it update care plans to address ongoing risk. On 9/17/25, Resident #1 sustained blunt trauma to the nose with bleeding after being struck by Resident #2 during a physical altercation, and Resident #1 expressed feeling unsafe and distressed in his/her home. This deficient practice resulted in actual physical harm and psychosocial harm. […]

• Actual harm, isolatedF657Dec 16, 2025

  Based on record review and interviews, the facility failed to review and revise the comprehensive care plans for 2 of 3 sampled residents (Residents #1 and #2) after significant changes in condition related to two resident-to-resident altercations. Despite an initial incident on 8/7/25 and a subsequent altercation on 9/17/25 resulting in Resident #1 sustaining blunt trauma to the nose and expressing fear and distress, the facility did not update either resident's care plan or Kardex to include interventions to prevent recurrence, such as separation or monitoring. Staff interviews confirmed reliance on informal redirection rather than documented interventions. This failure resulted in actual physical harm and psychosocial harm to Resident #1. […]

• Actual harm, isolatedF692Feb 16, 2022

  Based upon interview and record review, the facility failed to ensure a resident receiving enteral feedings maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 resident [Res. #67] of 1 residents receiving tube feedings. Findings include: Review of the medical record for Res. #67 reveals the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Res. #67's Care Plan reveals the resident was identified as having 'a PEG tube due to [CONDITION(S)]' [Percutaneous Endoscopic Gastrostomy (PEG) is a procedure to place a feeding tube, called PEG tubes]. Review of Res. #67's Minimum Data Sheet [MDS] Quarterly Review, dated 1/5/22, under Sec. […]

• Actual harm, isolatedF693Feb 16, 2022

  Based upon interview and record review, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for 1 resident [Res. #67] of 1 residents receiving tube feedings. Findings include: Review of the medical record for Res. #67 reveals the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Res. #67's Care Plan reveals the resident was identified as having 'a PEG tube due to [CONDITION(S)]' [Percutaneous Endoscopic Gastrostomy (PEG) is a procedure to place a feeding tube, called PEG tubes]. Review of Res. #67's Minimum Data Sheet [MDS] Quarterly Review, dated 1/5/22, under Sec. K: Swallowing and Nutritional Status lists Res. […]