Doctors Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Doctors Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 10, 2026

  Based on interview and record review, the facility failed to follow physician's orders and monitor resident's declining conditions for 2 of 3 residents (R1 and R3) reviewed for resident death in a sample of 8. A. This failure resulted in worsening of R1's infection of bilateral lower leg venous wounds causing sepsis and subsequent death. B. This failure resulted in exacerbation of R3's congestive heart failure resulting in hospitalization and subsequent death. This failure resulted in an Immediate jeopardy, which was identified to have begun on:A. [DATE] when the facility failed to follow physician's orders for antibiotics for R1's infection of venous stasis ulcers. This failure resulted in R1 developing sepsis leading to R1's death on [DATE].B. […]

• Actual harm, patternF584Aug 12, 2025

  Based on observation, interview, and record review, the facility failed to provide Heat, Ventilation, and Air Conditioning (HVAC) systems to maintain a comfortable temperature and failed to maintain flooring that was clean and free from damage. This failure resulted in R1 and R6 experiencing difficulty breathing and R5 and R7 experiencing difficulty sleeping, resulting in significant discomfort. This failure has the potential to affect all 58 residents residing in the facility.Findings include:1. On 7/30/25 at 10:03 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. […]

• Actual harm, isolatedF689Feb 26, 2024

  Based on interview and record review, the facility failed to safely transport 1 (R1) of 3 residents reviewed for accidents. This failure resulted in R1 receiving a fracture to R1's fifth and sixth cervical vertebrae and right radius. This past noncompliance occurred between 1/29/2024 - 2/01/2024. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE], with diagnoses of Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Unspecified fracture of the lower end of right radius, subsequent encounter for closed fracture with routine healing, Other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, Unspecified fracture of right femur, subsequent… […]

• Actual harm, isolatedF600Aug 25, 2023

  Based on interview and record review, the facility failed to ensure residents are free from staff to resident abuse for one resident of four residents (R3) reviewed for abuse in the sample of 4. This failure resulted in R3, during care on 7/6/23, experiencing physical pain and emotional distress with continued feelings of intimidation, fear, sadness, anxiety and helplessness. Findings include: R3's Face Sheet documented an admitted [DATE], and diagnoses including Quadriplegia, Tracheostomy, Pressure Ulcer of the Sacrum, Diabetes Type 2, Morbid Obesity, Hypertension, Anxiety Disorder, Insomnia, Unspecified Depressive Episodes, and Polyneuropathy. […]

• Actual harm, isolatedF686Jul 17, 2023

  Based on interview and record review, the facility failed to notify a resident's Primary Care Physician of a worsening wound, failed to ensure ordered weekly wound care physician visits were done, and failed to notify the resident's Primary Care Physician of the lack of a wound care physician for 1 of 3 residents (R1) residents reviewed for pressure wounds in the sample of three. These failures resulted in R1's wound worsening to a Stage 4 that developed an infection requiring hospitalization , Intravenous (IV) antibiotic therapy, and surgical debridement. […]