Presentation Rehab and Skilled Care Center

In the surveyor’s words

From the most serious findings on record at Presentation Rehab and Skilled Care Center, in the surveyor’s own words.

• Actual harm, isolatedF580Apr 28, 2025

  Based on observations, interviews and record review, the facility failed to ensure timely and accurate physician notification of a significant decline in status for one Resident (#109) out of a total sample of 27 residents. Specifically, for Resident #109, the facility failed to notify the physician or nurse practitioner when his/her respiratory status declined, resulting in the facility initiating a code blue (emergency response) and the Resident expired. Findings Include: Review of the facility policy titled Physician Notification, undated, included the following but not limited to: -Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to… […]

• Actual harm, isolatedF695Apr 28, 2025

  Based on observation, record review and interview, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, and in accordance with physician's orders were provided for two Residents (#44, and #109) out of a total sample of 27 residents. Specifically: 1. For Resident #44 the facility failed to, ensure oxygen tubing was changed and dated accurately and ensure the oxygen filter was wiped down. 2. For Resident #109, the facility failed to ensure that a significant change in respiratory status was monitored, assessed, medications ordered by the physician were utilized, and changes in condition were reported timely to the physician for Resident #109; resulting in oxygenation levels falling below parameters, and subsequent death. […]

• No harm, potential for more than minimal, patternF550Apr 28, 2025

  Based on observations and interviews, the facility failed to provide a dignified dining experience for the residents on one of two floors (second floor). Specifically, the facility failed to ensure staff did not refer to residents by the level of assistance they required, and to serve all residents seated at the same table at the same time. Findings Include: Review of the facility policy titled, Dignity, revised June 2022, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances his or herself well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. - Staff strive to treat residents with dignity and respect. […]

• No harm, potential for more than minimal, patternF565Apr 28, 2025

  Based on record review and interview, the facility failed to ensure that concerns expressed by the Resident Council Group had sufficient follow-up to respond to and effectively resolve concerns or prevent recurrence. Findings include: The facility reported they do not have a Resident Council policy and follow state guidelines. Review of the policy titled, Grievance/Concerns Program, dated as revised 3/1/22, indicated the following: - It is the policy of this facility to support employee, resident and family advocacy efforts. All employees, residents and family members (or responsible parties) have a right to voice grievances and recommendations for change. Grievances will be documented and responded to in an orderly and timely manner. A. […]

• No harm, potential for more than minimal, patternF804Apr 28, 2025

  Based on observation and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on two of two floors. Findings include: During the initial tour of the facility on 4/23/25 the surveyors met with residents; ten residents voiced dissatisfaction with the temperature and/or taste of the food served at the facility. Review of the resident council minutes, dated 2/13/25, indicated the residents asked for trays to be passed out faster so that food could remain warm when they received their meals. During the resident group meeting on 4/23/25 at 11:00 A.M. […]