Medicana Nursing and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 2, 2021

  Based upon interview, observation and record review the facility failed to provide a safe environment to prevent a resident from eloping. This affected 1 of 3 sampled residents reviewed for wandering/elopement risk, Resident #1. Resident #1 exited the facility without staff knowledge on 03/19/21 at approximately 1:00 AM. The facility's system failure with a lack of adequate supervision, an exit door where the door alarm did not sound and the alarm annunciator at the nurses' station not being loud enough to be heard, allowed the resident to elope without staff knowledge and wander outside of the facility unsupervised. Resident #1 was returned to the facility, unharmed, by the police at 1:25 AM on 03/19/21. […]

• No harm, potential for more than minimal, isolatedF552May 14, 2026

  Based on interview and record reviews, the facility failed to ensure a completed informed consent for psychotropic medication was obtained for 1 of 5 sampled residents reviewed for unnecessary medication (Resident #1). The findings included:Review of the facility policy titled, Psychotropic Medication Assessment and Monitoring: with a revised date of 08/2023 included in part the following: Procedure: a) Obtain physician's order, b)Psychoactive Medication Consent signed by the resident/resident representative.A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. […]

• No harm, potential for more than minimal, isolatedF692May 14, 2026

  Based on interviews, and record review, the facility failed to provide nutritional interventions in a timely manner to prevent weight changes including significant weight loss and/or gain for 5 of 6 sampled residents reviewed for nutrition (Resident #30, Resident #27, Resident #36, Resident #49, and Resident #20).The findings included: Review of the facility's policy titled, Weight Measurements, dated 08/2023, included the following: Body weight is a value used to monitor the nutritional status of the resident.Frequency of measurements & Calculations:Residents are weighed weekly, monthly, or according to physician orders. Residents should be weighed at the same time of day, in similar clothing, and using the same scale. […]

• No harm, potential for more than minimal, isolatedF693May 14, 2026

  Based on observations, interviews and record review the facility failed to ensure tube feeding administered as ordered and ensure the tube feeding bottle was labeled with a time started for 1 of 2 sampled residents reviewed for tube feeding (Resident #6). The findings included:Review of the facility's policy titled, Person-Centered Medication Administration Schedule with a revised date of 08/14/24 included in part the following: Medications shall be administered according to established schedules. Medications may be administered one hour before to one hour after the prescribed times. […]

• No harm, potential for more than minimal, isolatedF756May 14, 2026

  Based on observations, interviews, and record review, the facility failed to implement physician response to pharmacy recommendations for 1 of 5 sampled residents reviewed for Medication Regimen Review. (Resident #3).The findings included:Review of the facility's policy titled, Medication Regimen Review (MRR), dated 06/01/24, included the following: 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing act upon the recommendations contained in the MRR.Record review for Resident # 3 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Atheroscherotic Heart Disease of native coronary artery without angina pectoris, a condition where plaque builds up in the heart that restricts… […]