Englewood Health and Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 17, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of written statements, review of hospital records, and review of facility policy, the facility failed ensure a resident was provided incontinence care with two-person assistance. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when Resident #01, who required the assistance of two staff for bed mobility, was provided incontinence care by only one staff, State tested Nursing Assistant (STNA) #05. Resident #01 rolled off the bed and onto the floor, suffering closed fractures to both femurs that required surgical repair. […]

• Actual harm, isolatedF790Aug 4, 2026

  Based on record review, staff and resident interviews, observation and policy review, the facility failed to ensure resident dental appointments were scheduled timely to relieve dental pain. This resulted in Actual Harm on 03/03/26 when Resident #75 had three root tips exposed and extraction was recommended. No dental appointment was scheduled for over four months and Resident #75's teeth continued to deteriorate to class three fractures (a serious dental emergency where the break goes through the outer enamel and middle dentin layers to expose the soft nerve center). Resident #75 complained of oral pain rating it a 10 on a one to ten scale. This affected one (Resident #75) out of two reviewed for dental. […]

• Actual harm, isolatedF686Jul 21, 2022

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, policy review, and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, the facility failed to ensure timely and adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#03) of three residents reviewed for wound prevention. The census was 84. Findings include: Review of Resident #03's closed medical record revealed an admitted [DATE]. Resident #03 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Jul 21, 2022

  Based on resident record reviews, staff interview, review of a personnel file, fall investigation review, Self-Reported Incident (SRI) review, and policy review, the facility failed to ensure a resident was provided adequate staff assistance with bed mobility. Actual harm occurred when one resident (#07) requiring two persons for bed mobility was rolled in bed and experienced a fall resulting in the fracture of the right knee and ankle. Additionally, the facility failed to ensure a second resident (#02) was provided adequate assistance during a mechanical (Hoyer) lift transfer that did not result in harm, but had the potential for more than minimal harm. This affected two (#02 and #07) of four residents reviewed for falls. The census was 84. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Aug 4, 2026

  Based on observations, staff interviews, and policy review, the facility failed to ensure food items were stored in a safe manner, failed to dispose of outdated/expired food, and failed to serve food in a safe manner. This had the potential to affect 91 of the 96 residents who reside in the facility who receive meals from the kitcehn, the facility identified five residents (#4, #8, #33, #63, and #100) whom are nothing by mouth (NPO). The facility census was 96. Findings include: Brief tour of kitchen on 07/20/26 at 8:21 A.M. revealed in the small refrigerator a bundle of saran wrapped cheese slices with an expiration date of 07/01/26, an opened package of butter with no open date in the large refrigerator, and an open and exposed bag of [NAME] cheese omelets in the walk-in freezer. […]