Physical Rehabilitation And Wellness Center Of Spa

In the surveyor’s words

From the most serious findings on record at Physical Rehabilitation And Wellness Center Of Spa, in the surveyor’s own words.

• Immediate jeopardy, patternF760Jan 19, 2023

  Based on review of the facility's policy, record reviews, and interviews, the facility failed to protect 18 of 25 residents from significant medication error. Facility failed to administer evening medication passes to Residents (R)1-R18 on 11/26/2022. Review of facility investigation and interview with Licensed Practical Nurse (LPN)1 confirmed that LPN1 failed to administer medication to an entire medication cart assignment. On 01/19/2023 at approximately 10 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF689Feb 20, 2026

  Based on record reviews and interviews, the facility failed to ensure a resident (R)1, who was on NPO (nothing by mouth) status, was adequately supervised to prevent the resident from receiving a cereal bar and a cup of water. Resulting in the resident experiencing symptoms of projectile vomiting and clamminess, which resulted in hospital transfer.On 02/19/26 at 03:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 02/20/26 at 09:35 AM, the Administrator was notified that failure to ensure a resident who was on NPO status was adequately supervised to prevent the resident from receiving a cereal bar and… […]

• Immediate jeopardy, isolatedF600Jan 16, 2026

  Based on facility policy review, record review, and interviews, the facility failed to protect the Resident (R)19's rights to be free from sexual abuse, from R79, for 1 of 7 residents reviewed for abuse. This failure had the likelihood of causing physical, mental, and psychosocial harm.On 01/14/26 at 3:45 PM, the Administrator and Director of Nursing (DON) were notified that the failure to protect a resident from sexual abuse constituted Immediate Jeopardy at F600.On 01/14/26 at 3:45 PM, the survey team provided the Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 12/09/25. […]

• Immediate jeopardy, isolatedF600Nov 23, 2022

  Based on review of the facility policy, record review and interviews, the facility failed to ensure 3 of 3 Residents (R) were free from sexual abuse. R1 and R2 were involved in a sexual relationship without being properly assessed by the facility, proper documentation and notification. R2 and R8 was also involved in a sexual relationship without proper assessments, documentation, and notifications in place to prevent sexual abuse. On 11/22/22 at 3:45 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF600Sep 22, 2022

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse for 5 (Residents #248, #398, #75, #63, and #54) of 6 sampled residents reviewed for abuse. Specifically, the facility failed to prevent staff-to-resident verbal abuse for Resident #248 and failed to prevent resident-to-resident physical abuse for Resident #398, Resident #75, Resident #63, and Resident #54. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised 11/01/2017, revealed, The facility's leadership prohibits neglect, mental, physical, and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and… […]