Community Care and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 4, 2024

  Based on interview and record review, the facility failed to ensure facility policy and procedures were implemented to prevent and identify the development of a pressure injury (PI- bed sore) for one of two sampled residents (Resident 1), when an open area of the skin identified on Resident 1 ' s sacrum (a large, triangular bone at the base of the spine) on August 30, 2024, was not assessed and was not provided treatment. These failures resulted in Resident 1 developing a stage 3 PI (full -thickness tissue loss, exposing fat tissue) which was identified on September 13, 2024. Findings: On October 22, 23, and November 4, 2024, unannounced visits were conducted at the facility to investigate a complaint. […]

• Actual harm, isolatedF689Aug 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident A), did not use oxygen (O2) while smoking. Resident A lit a cigarette while receiving O2 resulting in burns to his face and the left side of his abdomen. This failure also created an unsafe environment for other residents who smoked. Findings: During an observation on June 26, 2023, at 2:11 p.m., Resident A was observed sitting in a wheelchair. Resident A was observed receiving O2 at six L (liters - a unit of measurement) via nasal cannula (N/C - a device used to deliver O2 through a tube and into the resident's nose) via the oxygen concentrator (a machine that converts room air to air with a higher oxygen level). […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2021

  Based on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: 1(a) Multiple food items stored in the dry storage area were not labeled with the name of the food item, the opened date, or use-by date; 1(b) Multiple food items stored in the refrigerator were not labeled with opened dates or use-by dates; 2. The kitchen ice machine had a yellowish-brown slimy substance located on the inside cover; and 3. The kitchen manual can opener had an accumulation of a dry reddish brown stain on and around the blade and on the base of the can opener. […]

• No harm, potential for more than minimal, patternF684May 9, 2025

  2. On May 7, 2025, Resident 187's record was reviewed. Resident 187 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a lung disease causing restricted airflow and breathing problems). A review of the physician's progress notes dated March 25, 2025, at 7:02 a.m., indicated, .breath sounds dull at bases with intermittent congestion .Resident had chronic respiratory failure and emphysema (long term lung condition that causes shortness of breath) . There was no respiratory rate documented on March 23, 24, and 25, 2025. […]

• No harm, potential for more than minimal, patternF755May 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when three (3) of five (5) residents reviewed (Residents 94, 97, and 110) were missing documentation for the administration of controlled substance (CS, those with high potential for abuse and addiction) medications. The CS medication was signed out of the Controlled Drug Record (an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was administered to the residents. These failures resulted in inaccurate accountability of CS medications, which had the potential for misuse or diversion. Findings: 1a. […]