Community Health and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF725Aug 31, 2023

  Based on record review, staff interviews, and resident interview the facility failed to ensure sufficient nurse staffing on all shifts resulting in 5 of 5 sampled residents not receiving physician ordered medications on the morning of 8/26/23. (Residents #1,# 2, #3, #4, and #5) The findings include: Review of the staff assignment sheet for 11:00 PM-7:00 AM shift beginning on 8/25/23 and ending on 8/26/23 revealed the south unit had only one nurse for the shift (Employee A, who is a licensed practical nurse (LPN)). The other nurse that was scheduled did not report to work for the assigned shift. An interview was conducted with the Administrator on 8/31/23 at 10:53 AM. […]

• No harm, potential for more than minimal, patternF755Mar 16, 2023

  Based on interviews, record reviews and policy reviews, the facility failed to ensure accurate accounting of controlled substances for 3 of 7 residents sampled (Residents #20, #57, and #155). The findings include: A review was conducted of the controlled drug declining inventory sheets and the electronic medication administration record. The following discrepancies were identified: Resident # 155 Diazepam (anxiety) 2 mg (milligrams) - 6 tablets were marked as on hand on 3/9/23 on the Controlled Drug Declining Inventory Sheet. Further review of the sheet revealed that one tablet of diazepam was administered on 3/9/23 at 8:30 AM, 3:00 PM, and 9:00 PM, 3/10/23 at 3:00 AM, 1:30 PM, and 11:00 PM, equaling 6 tablets with zero tablets remaining. […]

• No harm, potential for more than minimal, isolatedF584Aug 28, 2025

  Based upon observations, the facility failed to ensure residents had a clean and sanitary environment as evidenced by residents' personal items not labeled and stored appropriately for each resident in 5 out of 9 rooms sampled.The findings include:An observation was made on the north hallway of Unit 2 on 8/25/25 at 11:00 AM. The following issues were observed:In room [ROOM NUMBER], personal items were not labeled and not separated for each resident residing in the room. In room [ROOM NUMBER], a bedpan was sitting in the bathroom in between the handrail and wall and was not bagged.In room [ROOM NUMBER], a resident's urinal was hanging on the garbage can next to the bed out of the resident's reach.In room [ROOM NUMBER], a bedpan was observed in the bathroom sitting between the handrail and… […]

• No harm, potential for more than minimal, isolatedF684Aug 28, 2025

  Based on observation, staff interview, record reviews, and policy review, the facility failed to ensure the provision of care in accordance with professional standards by not ensuring that wound care was provided as stated in the physician order in a timely manner and failed to assess and document a newly identified skin impairment for 2 of 2 residents sampled for non-pressure related skin impairments. (Resident #9 and #106)The findings include: Resident #106 On 8/25/25 at approximately 12:00 PM, an interview and observation was conducted with Resident #106. A Negative Pressure Wound Device (wound vac) was sitting on the bed with the hose not connected to Resident #106. […]

• No harm, potential for more than minimal, isolatedF812Aug 28, 2025

  Based on observation and interview, the facility failed to maintain sanitary food practices and ensure kitchen staff wore required hair covering while preparing resident meals. The findings include:On 08/25/2025 at approximately 10:30AM, during kitchen tour with Food Service Director observed staff K cooking lunch without a hair net. Food Service Director asked staff if staff K was wearing a hair net. Staff K stated, No, I am not wearing one. During the same tour at approximately 10:55AM observed in the vegetable freeze a 16 oz Pepsi on the top shelf. Interviewed Food Service Director confirming the drink belong to a staff member. On 8/28/25 at approximately 9:33AM observed staff J cooking meal without facial covering for beard and mustache. […]