City Scape Rehabilitation & Care Center LLC

In the surveyor’s words

From the most serious findings on record at City Scape Rehabilitation & Care Center LLC, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 1, 2025

  Based on record review and interviews, the facility failed to ensure three (#7, #3 and #5) of four residents reviewed for abuse out of seven sample residents were kept free from abuse.On 5/21/25 Resident #7 was physically abused by Resident #2. Resident #2 used a belt to hit Resident #7 on top of his head and struck Resident #7 with his belt buckle. Resident #7 sustained a laceration to his head, requiring transfer to the emergency room where Resident #7 received five sutures.Additionally, Resident #5 was physically abused by Resident #1 on 3/22/25 and Resident #3 and Resident #1 were physically abused by each other on 5/3/25. […]

• Actual harm, isolatedF689Jul 1, 2025

  Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of three sample residents. Resident #4 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 5/28/25 Resident #4 was found on the floor in her room with blood coming from her head. Resident #4 was transported to the hospital for further evaluation. Resident #4 sustained a subdural hematoma (brain bleed) and was diagnosed with a traumatic brain injury. The facility failed to implement person-centered interventions after the resident sustained a fall on 5/28/25. […]

• Actual harm, isolatedF600Jul 16, 2024

  Based on interviews and record review, the facility failed to ensure that two (#155 and #25) of two residents reviewed for abuse out of 31 sample residents were kept free from physical abuse. Resident #38 had a known history of physically aggressive behaviors towards others. Nursing progress notes documented the resident had a tendency to throw food, drinks, plates and cups in the dining room. On 3/22/24, the facility initiated behavior monitoring of Resident #38's physically aggressive behavior, including biting and scratching, during activities of daily living (ADL) and refusal of care. However, staff did not consistently document the behavior monitoring. […]

• Actual harm, isolatedF622Jul 16, 2024

  Based on record review and interviews, the facility failed to ensure an appropriate facility-initiated discharge procedure was followed for one (#105) of two residents reviewed for discharge out of 31 sample residents. Resident #105, who had a diagnosis of rheumatoid arthritis, anxiety disorder, depression, attention-deficit hyperactivity disorder and chronic pain, was admitted to the facility on [DATE] and involuntarily discharged to a homeless shelter on 2/20/24. The facility failed to provide preparations for a safe and orderly facility-initiated discharge or provide a reason for the discharge. Resident #105 began discharge planning with the facility on 1/11/24 during a care conference where his stated goal was to discharge to an assisted living facility (ALF). […]

• Actual harm, isolatedF686Mar 2, 2023

  Based on observations, record review and interviews, the facility failed to implement appropriate and timely interventions to ensure two (#24 and #44) of six sample residents received the necessary care and treatment to prevent the development of a pressure injury out of 31 sample residents. The facility failed to put interventions in place to prevent pressure injury for Resident #24. Resident #24 was admitted to the facility on [DATE]. At the time of the admission she was evaluated to be at risk for developing pressure injuries. On 11/1/22 resident developed two unstageable pressure injuries on her legs. She was evaluated by a wound care physician who recommended treatments. […]