Lions Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jan 13, 2022

  Based on observation, record review, and staff interview it was determined that the facility failed to prevent abuse of residents from other residents who exhibited behaviors triggering resident-to-resident physical altercations. This was evident for 4 (#8, #9, #10, and #11) of 5 residents reviewed for abuse. Because of these findings, an Immediate Jeopardy(IJ) was called on 1/10/22 at 1:25 PM, related to the facility's failure to prevent abuse of residents from other residents who exhibited behaviors triggering resident to resident altercations. The facility submitted three plans of removal. The first removal plan was submitted on 1/10/22 at 4:25 PM, but was not accepted. The second removal plan was submitted on 1/10/22 at 6:17 PM, but was not accepted. […]

• Immediate jeopardy, patternF689Jan 13, 2022

  Based on observation, record review, resident and staff interview, it had been determined that the facility failed to provide adequate supervision for residents with intrusive behavior that wander throughout the facility. This was evident for 3 (#9, #10, and #11) of 11 residents reviewed for wandering. Because of these findings, an Immediate Jeopardy was called on 1/6/22 at 5:03 PM, regarding the facility's failure to provide adequate supervision for residents with intrusive wandering behaviors to ensure their safety and the safety of other residents in the facility. The facility submitted three plans of removal. The first removal plan that was submitted on 1/6/22 at 5:50 PM, was not accepted. The second removal plan that was submitted on 1/6/22 at 6:45 PM, was not accepted. […]

• Actual harm, isolatedF757Jul 6, 2026

  Based on the review of a facility reported incident interviews, medical record review and review of facility policy, it was determined that the facility staff failed to ensure that medication was administered correctly. These failures led to the findings of actual harm to Resident #7. This was evident during the review of 1 of 1 Residents (#7) The findings include:Brief interview for mental status (BIMS) used to determine the individual's attention, orientation and ability to register and recall new information.Resident #7 was admitted to the facility with an assessed BIMS of 15, meaning that s/he was cognitively intact and would verbalize his/her needs and was self-directed in activities.Review of the facility reported incident 3013734 on 9:40 AM on 6/26/26 revealed and incident occurring… […]

• Actual harm, isolatedF686Mar 22, 2023

  Based on observation, interview and medical record review, it was determined the facility failed to prevent the development of a stage 4 pressure ulcer, failed to notify the physician when a weekly wound assessment began to indicate potential signs of infection, failed to implement a physician order for a surgical consult, and failed to ensure that a physician or nurse practitioner assessed the pressure ulcer from the time it was first identified as a stage 2 in January of 2022 until May of 2022, at which time the wound specialist assessed the wound as stage 4 ulcer. […]

• No harm, potential for more than minimal, widespreadF812Jan 17, 2025

  Based on observations, interviews, and record review, it was determined that the facility failed to monitor temperatures for the dishwasher machine to ensure adequate sanitation, and ensure temperatures were checked for mechanical soft and pureed foods before serving. This was evident for 5 of 8 daily dish machine logs and 3 of 13 daily food temperature logs reviewed. The findings include: 1) On 1/8/25 during the initial entrance conference, the Director of Nursing (DON) reported that the facility was currently experiencing a GI (gastrointestinal) outbreak. A tour of the kitchen on 1/8/25 at 11:10 AM, revealed that the dish machine log had no entries since 1/3/25. […]