Downs Care and Rehab

In the surveyor’s words

From the most serious findings on record at Downs Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 26, 2021

  The facility had a census of 36 residents. The sample included six residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure four of six sampled residents were free from inappropriate touching by Resident (R) 1, who made sexual actions toward women on multiple different occasions. This deficient practice placed all 23 female residents in immediate jeopardy. Findings included: - R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of five. R1 required limited assistance of one staff for transfers, walking in his room, and locomotion on the unit. […]

• Immediate jeopardy, isolatedF610Apr 26, 2021

  The facility had a census of 36 residents. The sample included six residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to protect the 23 female residents that resided in the facility when R1 exhibited inappropriate touching and sexual actions on multiple different occasions. This deficient practice placed all 23 female residents in immediate jeopardy. Findings included: - R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of five. R1 required limited assistance of one staff for transfers, walking in his room, and locomotion on the unit. […]

• No harm, potential for more than minimal, widespreadF812Jun 24, 2026

  Based on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen. The facility failed to label, seal, and date food stored in the refrigerator/freezer and dry storage area. The facility also failed to consistently log freezer/refrigerator temperatures. Findings included:- On 04/13/26 at 08:10 AM, observation in the kitchen revealed the following:A white upright freezer had approximately 1/4 inch (in) ice buildup along the inside of the freezer and the shelves.The refrigerator located in the kitchen had a plastic bag with unlabeled, undated sliced yellow cheese.The March Freezer/refrigerator temperature logs lacked documentation of the readings for the following freezers… […]

• No harm, potential for more than minimal, widespreadF880Jun 24, 2026

  Based on observation, record review, and interview, the facility failed to implement adequate infection control practices when staff failed to change gloves during incontinent care for Resident (R) 26. Staff also failed to place Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) signage for R11 and R44's and failed to ensure personal protective equipment (PPE- gowns and gloves) was readily available for use for R11 and R44, who shared a room, cares. Staff also failed to provide appropriate complete urinary catheter care for R44. […]

• No harm, potential for more than minimal, widespreadF801Jul 31, 2024

  The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 40 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 07/29/24 at 08:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 07/29/24 at 09:40 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had seven residents with mechanical soft diets and one with a pureed diet. […]