Mission at Community Living Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Mission at Community Living Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Sep 12, 2023

  Based on interview it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not have a system to test for Legionella. Findings include: On 9/12/23 at 10:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she was tracked infections for the facility. The ADON stated she was not aware of a program to test for Legionella. On 9/12/23 at 11:14 AM, an interview was conducted with the Plant Operations. The Plant Operations stated he had not been testing for Legionella and was not aware of what it was. […]

• No harm, potential for more than minimal, patternF842Jun 25, 2025

  Based on interview and record review it was determined, for 4 of 24 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, documentation regarding resident's immunization history was not in the medical record. Resident identifiers: 6, 14, 21 and 30. Findings included: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included dementia, osteoporosis, macular degeneration and chronic pain. The immunization record for resident 6 was not located in the medical record. 2. Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, morbid obesity and anxiety. […]

• No harm, potential for more than minimal, patternF880Jun 25, 2025

  2. On 6/23/25 at 12:20 PM, a Laundry Staff (LS) was observed to push a cart which had resident clean laundry hanging from the railing. There was no cover over the laundry. The LS passed residents and staff members in the hallways as she took the laundry to rooms 120, 121, 122, 123, and 124. On 6/24/25 at 11:24 AM, an observation was made of the LS. The LS carried laundered resident clothing on her shoulder and entered resident room [ROOM NUMBER] and put some clothing into the closet of room [ROOM NUMBER]. The LS was then observed to take the remaining resident clothing into room [ROOM NUMBER] and put it into the closet. On 6/24/25 at 11:40 AM, an interview was conducted with the LS. The LS stated the clothes are washed and then taken to the resident's rooms. […]

• No harm, potential for more than minimal, patternF609Sep 12, 2023

  Based on interview and record review it was determined, for 5 out of 19 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. In addition, the facility did not ensure report the results of all investigations were submitted to the State Survey Agency (SSA) within 5 working day of the incident. Specifically, the facility did not report an allegation of abuse within 2 hours of the incident and the results of the investigation were not reported to the SSA within 5 working days. Resident identifiers: 2, 25, 26, 28 and 85. Findings include: 1. […]

• No harm, potential for more than minimal, patternF711Sep 12, 2023

  Based on interview and record review it was determined the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, during required visits. Specifically, for 3 of 19 sampled residents, the physician did not include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. Resident identifiers: 28, 29 and 31. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with diagnosis that included major depressive disorder, oral mucositits (ulcerative), atrial fibrillation, essential hypertension, and dysphagia. Resident 31's medical record was reviewed 9/12/23. […]