Community Skilled Healthcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Apr 17, 2026

  Based on closed record review, review of an Emergency Medical Services (EMS) Run Report, review of the American Heart Association (AHA) 2025 guidance for adult Cardiopulmonary Resuscitation (CPR), review of the facility CPR policy and interview, the facility failed to promptly and correctly provide basic life support (BLS) including Cardio-Pulmonary Resuscitation (CPR) to Resident #92, (a resident with advance directives for a Full Code status), when the resident was found unresponsive and absent of vital signs. This resulted in Immediate Jeopardy and actual serious life-threatening harm and subsequent death of Resident #92 on 03/07/26 at approximately 9:00 A.M. when Transportation Aide (TA) #873 identified Resident #92 was unresponsive. […]

• Immediate jeopardy, isolatedF686Jul 23, 2024

  Based on observation, medical record review, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of facility policy, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the development of, worsening of and promote the healing of a facility acquired pressure ulcer for Resident #44, a resident who was at risk for pressure ulcer development and dependent on staff for all activities of daily living (ADLs) including bed mobility, turning and repositioning, incontinence care for both bowel and bladder, showering, and dressing. […]

• Immediate jeopardy, isolatedF689Aug 15, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of a Police Report, review of the facility Elopement Policy and Procedure and interviews, the facility failed to provide adequate supervision and failed to respond and act appropriately when a door alarm sounded to prevent Resident #43, who was cognitively impaired, required a front wheeled walker for mobility with stand by assist (SBA) for ambulation, and demonstrated previous exit seeking behaviors, from eloping. This resulted in Immediate Jeopardy and the potential for actual harm, injury, or death on [DATE] at approximately 11:00 A.M. […]

• No harm, potential for more than minimal, widespreadF565Apr 17, 2026

  Based on interview and record review, the facility failed to take reasonable steps to ensure residents were assisted by a designated staff member for conducting resident council meetings and residents were timely informed of meetings in advance. This had the potential to affect all 83 residents residing in the facility. The facility census was 83. Findings include:Record review of the facility Activity Calanders dated January 2025, February 2025, March 2025, April 2025, October 2025, November 2025, December 2025, January 2026, February 2026, March 2026, and April 2026 revealed there were no resident council meetings identified on the calendars. […]

• No harm, potential for more than minimal, widespreadF572Apr 17, 2026

  Based on record review and staff and resident interviews, the facility failed to ensure residents were informed of their rights on an ongoing basis. This had the potential to affect all 83 residents currently residing in the facility.Findings include:On 04/08/26 at 10:40 A.M. an interview with the Administrator revealed there were no Resident Council meetings held in February of 2026 and March of 2026 due to lack of a president for the meetings. The Administrator handed the surveyor one month of council meeting minutes dated 01/28/26. Interview with the Administrator further revealed there was no evidence that Residents' Rights were discussed at the January 2026 Resident Council Meeting. Completion of the Resident Council portion of the annual survey on 04/13/26 between 10:30 A.M. […]