Community Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF755Nov 13, 2025

  Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for receipt of physician-ordered medications received their ordered anti-convulsant (seizure prevention medications) and/or anti-anxiety medications as ordered for 3 consecutive days, resulting in an increase in the number of seizures and a hospitalization related to the increase in seizures. (Resident B) Findings include:The clinical record of Resident B was reviewed on 11-12-25 at 11:14 a.m. His diagnoses included, but were not limited to, traumatic hemorrhage of the cerebrum (brain bleed), seizures, general anxiety, impulse disorder, aphasia (does not speak/nonverbal). It indicated he was admitted to the facility on [DATE], from an area hospital. […]

• Actual harm, isolatedF697Jan 21, 2022

  Based on interview and record review, the facility failed to monitor and address a resident's pain for 1 of 3 residents reviewed for wounds. This resulted in a resident admitted to the hospital with severe pain. (Resident C) Findings include: The clinical record for Resident C was reviewed on 1/20/22 at 2:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant change MDS (Minimum Data Set) assessment dated [DATE] indicated Resident C was cognitively intact. A care plan dated 9/20/21 indicated Resident [C] is at risk for pain related to: CA [cancer] of bone and kidney, GERD, [CONDITION(S)], [CONDITION(S)] [[CONDITION(S)]], amp [amputation] L [left] foot, amp R [right] great toe, DJD [[CONDITION(S)] joint disease], vit [vitamin] D deficiency, gangrene right foot .Approach… […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2025

  A. Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and in good repair, the staff contained their hair in the kitchen, and food was not open to air, labeled, dated and not expired. This had the potential to affect 54 of 54 residents that eat food prepared in the facility kitchen. B. Based on observation, interview, and record review, the facility failed to cover trash cans when not in use in the kitchen with the potential to affect 54 or 54 residents who receive food out of the facility kitchen. Findings include: A. On [DATE] at 6:25 p.m., the facility kitchen was observed with Dietary Aide (DA) 15. The walk- in refrigerator was observed to have a metal can of butterscotch pudding with a piece of plastic wrap covering the open can. […]

• No harm, potential for more than minimal, widespreadF727May 11, 2023

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) had worked 8 hours in the facility. This had a potential to effect 44 of 44 residents on 10/1/22, 46 of 46 residents on 10/2/22, 44 of 44 residents on 10/16/22, 43 of 43 residents on 10/22, 43 of 43 residents on 10/23/22, 43 of 43 residents on 11/12/22 and 44 of 44 residents on 12/17/22. Findings include: The PBJ Staffing Data Report that was generated from October 1, 2022 - December 31, 2022 indicated the following days the facility did not have an RN working 8 hours in the building: 10/1/22, 10/2/22, 10/8/22, 10/16/22, 10/22/22, 10/23/22, 11/12/22 and 12/17/22. An interview was conducted with the Float Director of Nursing Services (FDNS) on 5/9/23 at 3:30 p.m. […]

• No harm, potential for more than minimal, widespreadF812Nov 19, 2021

  Based on observation, interview, and record review the facility failed to ensure foods were stored without scoops in the container and serve food in accordance with professional standards for food service safety by touching a resident's food with bare hands. This had the potential to affect 47 of 47 residents served from the facility kitchen. (Resident 37) Findings include: 1. On 11/15/21 at 9:43 a.m., the kitchen was observed with the Dietary Manager. A pan of macaroni salad was observed sitting on the preparation table covered with plastic wrap. […]