Community Care Center

In the surveyor’s words

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

• Actual harm, isolatedF677Jun 3, 2021

  Based on observation, interview, and record review, the facility failed to ensure two of three residents (Residents 1 and 2) reviewed for activities of daily living (ADLs, self-care activities, which included personal care) received assistance with grooming. This failure resulted in: - Resident 1 having tangled and matted hair, in which the resident verbalized feelings of negative self-image. In addition, the matted and tangled hair caused Resident 1 pain and discomfort, and the matted sections of hair had to be cut out close to the scalp. […]

• No harm, potential for more than minimal, patternF755Apr 30, 2026

  Based on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when:Random controlled medication (medications with a high abuse potential) use audit for three of four sampled residents (Residents 73, 4, and 50) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. In addition, for Resident 50, an administration was documented on the MAR, but not signed out on the CDR. […]

• No harm, potential for more than minimal, patternF686Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to prevent and treat three of five residents (Residents 99, 11 and 12) who were identified as being at risk of pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence) when: 1a. Resident 99 was not turned and repositioned every two hours; 1b. Resident 99 had missing entries on his daily wound treatment log; and 2. Resident 11 had missing entries on her daily wound treatment log; and 3. Resident 12 had missing entries on her daily wound treatment log. These failures had the potential for additional or worsening skin injuries to occur. 1a. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice, when two green cutting boards with deep cuts and food stains were stored in the clean area. In addition, one red cutting board and one brown cutting board with deep cuts were also stored in the clean area, when reviewed for food sanitation. This failure exposed residents to contaminated food surfaces and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Findings: On 2/12/25 at 11:13 A.M. an observation and interview was conducted with Dietary Worker 1 (DW 1). A green chopping board was observed on the kitchen counter, next to the 3-compartment sink. […]

• No harm, potential for more than minimal, patternF686Oct 21, 2021

  The facility failed to implement preventative skin maintenance measures for two of seven residents (46, 95 ) reviewed for pressure ulcers and one unsampled resident (100) when: 1. Resident 46 had the potential for his heel pressure ulcers (injury to the skin and underlying tissue, caused by prolonged pressure) to worsen when his heels were in direct contact with the mattress; 2. Resident 100 did not have her elbow offloaded as ordered by the wound physician, and; 3. Resident 95 was not turned and repositioned every 2 hours. As a result, there was the risk for residents to develop skin issues and have a decline in existing pressure ulcers. Findings: 1. Resident 46 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 11:41 A.M. […]