Cisne Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Cisne Rehabilitation and Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF697Jul 9, 2026

  Based on interview and record review the facility failed to administered pain medication as ordered by physician for 1 (R1) of 3 residents reviewed for pain in a sample of 11. This failure resulted in R1 experiencing unrelieved pain and having been sent to the local hospital for pain management.Findings Include:R1's admission Record documented an admission date of 6/9/2026 with the following diagnoses including anxiety disorder, unspecified, chronic kidney disease, unspecified, depression, unspecified, complete traumatic amputation of two or more left lesser toes, subsequent encounter and diabetes mellitus with other skin complications. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Interview Score (BIMS) of 15 indicating that R1 is cognitively intact. […]

• Actual harm, isolatedF760Jul 9, 2026

  Based on interview and record review the facility failed to administer antianxiety medication, administer sliding scale insulin and monitor blood sugars as directed per physician orders for 2 (R1, R2) of 3 residents reviewed for medication administration in the sample of 11. This failure resulted in R1 being sent to the emergency room for chest pain. Findings include:1.R1's admission Record documented an admission date of 6/9/2026 with the following diagnoses including anxiety disorder, unspecified, chronic kidney disease, unspecified, depression, unspecified, complete traumatic amputation of two or more left lesser toes, subsequent encounter and diabetes mellitus with other skin complications. […]

• Actual harm, isolatedF686May 18, 2026

  Based on interview, observation, and record review, the facility failed to timely treat and develop/implement interventions for a pressure ulcer for 1 (R1) of 3 residents reviewed for pressure ulcers in the sample of 4. This failure resulted in R1's pressure ulcer worsening, with tunneling and developing an infection in the wound. The Findings Include:R1 admission Record documented admission to the facility on [DATE] and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. […]

• Actual harm, isolatedF697May 18, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate pain assessment and pain relief medication for 1 (R1) of 3 residents reviewed for pain management in the sample of 4. This failure resulted in R1 feeling helpless and having uncontrolled pain which was worse during wound care treatments. The Findings Include:R1's admission Record documented admission to the facility on [DATE] and included diagnoses of heart failure, thrombocytopenia, depression, anxiety, obstructive sleep apnea, personal history of malignant neoplasm of thyroid, and lymphedema. R1's Care Plan includes a Focus area of the resident has actual impairment to the skin integrity related to coccyx pressure wound with an initial date of 05/13/2026. […]

• Actual harm, isolatedF697Apr 30, 2026

  Based on interview and record review, the facility failed to provide opioid pain medication to a resident with chronic and acute pain for 1 of 4 residents (R1) reviewed for pain in the sample of 10. This failure resulted in R1 experiencing opioid withdrawal symptoms and pain at a level of ten on a zero to ten scale, R1 signing herself out of the facility AMA (Against Medical Advice), and R1 calling 911 to have an ambulance take her to the ER (Emergency Room) for treatment. Findings include:R1's admission Record documented an admission Date of 4/3/26 and listed diagnoses including Unspecified Fractures of the First and Second Thoracic Vertebrae, Traumatic Pneumothorax, Bilateral Contusions of the Lungs, Multiple Rib Fractures to the Right Side, One Rib Fracture to the Left Side, Major… […]