Deanwood Rehabilitation and Wellness Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 4, 2026

  Based on observation, record review, resident and staff interview, for one (1) of eight (8) sampled residents, facility staff failed to ensure that Resident #4 was provided with adequate supervision and assistance to prevent accidents. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervisions/Devices on January 30, 2026 at 6:14 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on January 30, 2026 at 8:21 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 2, 2026 at 4:30 PM. […]

• Immediate jeopardy, isolatedF689May 23, 2024

  Based on observations, record reviews, resident and staff interviews, for three (3) of 94 sampled residents, facility staff failed to provide adequate supervision for residents as evidenced by: 1. Resident #120, who uses a wheelchair for locomotion and requires medications to treat multiple diagnoses, eloped from the facility on 04/29/24; 2. Resident #64 having an unwitnessed fall from her wheelchair; and 3. Resident #79 having multiple falls with injury. The facility's census on 04/29/24 was 265. Due to this failure, an Immediate Jeopardy was identified on May 2, 2024, at 11:30 AM related to the elopement of Resident #120. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on May 3, 2024, at 12:18 AM. […]

• Immediate jeopardy, isolatedF600Jan 18, 2023

  Based on review of facility reported incidents, medical records, facility documentation/policies, resident, and staff interviews, for two (2) of three (3) sampled residents, facility staff failed to implement safeguards to protect and prevent further potential abuse of residents by Employee #3 (Maintenance Worker/alleged perpetrator) as evidenced by allowing ongoing, unrestricted, and unsupervised access to residents by the alleged perpetrator. Residents' #1 and #2. Due to these failures, an Immediate Jeopardy situation was identified on January 12, 2023, at 10:00 AM. The facility submitted a Plan of Action to the survey team that was on onsite at 8:14 PM on January 12, 2023, and the plan was accepted. […]

• Actual harm, patternF600Apr 20, 2022

  Based on observation, record review, resident and staff interviews, for seven (7) of 105 sampled residents, facility staff failed to ensure residents were free from abuse (willful infliction of injury) and neglect as evidenced by: failure to prevent the willful infliction of serious injury of Resident #404 by Resident #82; failure to implement person center care measures for Resident #151 who had incidences of aggressive behavior towards Resident #71 and willful infliction of injury to Resident #67; failure to ensure staff received training to provide person-centered care to Resident #409 post hip replacement, subsequently the resident sustained a dislocated hip; failure to ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently,… […]

• Actual harm, patternF689Apr 20, 2022

  Based on observation, record review, resident, family and staff interviews, for 11 of 105 sampled residents, the facility's staff failed to ensure that residents received adequate supervision as evidenced by failure to 1. ensure that Resident #404 received adequate supervision to prevent an altercation with Resident #82, resulting in serious injury, 2. provide adequate supervision for Resident #56 who sustained a fall outside in front of the facility resulting in serious injury, 3. provide Resident #409 who was status post hip surgery with adequate supervision to prevent an injury of unknown origin (dislocated hip), 4. provide adequate supervision of Resident #151 to prevent altercations with Residents #71 and #67, 5. […]