Downtown Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 11, 2025

  Based on interviews, observations, and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #2) of five residents reviewed for abuse. The facility failed to prevent Resident #2 from being abused by Resident #1 on the secure unit, who had a history of being verbally and physically aggressive to other residents. Resident #1 physically attacked Resident #2 which resulted in him being sent to the hospital and sustained a serious injury to his right eye on 12/29/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/29/24 and ended on 12/29/24. The facility corrected the non-compliance before surveyor's entrance. […]

• Actual harm, isolatedF684Mar 5, 2024

  Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of six residents reviewed for quality of care. The facility failed to ensure medication administration and storage protocols were implemented when the facility lost Resident # 1's medications (narcotics used for withdrawal symptoms) upon admission into the facility, which resulted in Resident #1 not receiving the medication and experiencing withdrawal symptoms. The noncompliance was identified as PNC. The noncompliance began on 02/10/24 and ended on 02/15/24. […]

• Actual harm, isolatedF684Sep 26, 2023

  Based on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident that residents received treatment and care in accordance with professional standards or practice, the comprehensive person-centered care plan and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure fall protocols were implemented when Resident # 1 was found on the floor on 9/15/23. The noncompliance was identified as PNC. The noncompliance began on 9/15/23 and ended on 9/16/23. The facility had corrected the noncompliance before the survey began. […]

• Actual harm, isolatedF684Apr 26, 2023

  Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for skin integrity. The facility failed to identify drainage, blisters, and redness to Resident #1's right thigh surgical incision. The Wound Care Nurse failed to transcribe Resident #1's physician's orders on 04/20/23 for the treatment of his surgical wound on the bottom of his amputated leg when the wound was draining. The deficient practice could affect residents with skin conditions and place them at risk for not receiving the appropriate care and services. […]

• Actual harm, isolatedF689Feb 13, 2023

  Based on observations, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. CNA A failed to transfer Resident #1 to the bed with two person assist as documented in her medical record, which resulted in Resident #1 falling on 01/15/23. CNA B failed to perform peri care and transfer Resident #1 from the bed with two person assist as documented in her medical records, which resulted in Resident #1 falling on 01/18/23 and sustaining a closed facture of neck of right humerus (caused by a fall on the outstretched arm or elbow). […]