Prestonwood Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Prestonwood Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 17, 2025

  Based on interview and record review, the facility failed to protect the residents right to be free from sexual abuse for 2 residents (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. On 02/21/25, Resident # 1 inappropriately touched Resident # 22 and asked Resident #22 to kiss him. On 02/21/15, Resident # 1 grabbed the hand of Resident #52 and put Resident # 52's hand in his groin area. Resident # 1 then attempted to bend over and kiss Resident # 22. Resident # 1 asked Resident #52 to go to his room. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. […]

• Immediate jeopardy, patternF607Apr 17, 2025

  Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of 2 (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. 1) LVN E and LVN M failed to immediately report sexual abuse incidents involving Resident #1 against Residents #22 and #52 to the Abuse Coordinator/the Administrator. 2) The facility failed to follow their policy to immediately protect Resident #22 and #52 from harm. 3) LVN E failed to identify sexual abuse when Resident #1 attempted to inappropriately touch Resident #52. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. […]

• Immediate jeopardy, patternF609Apr 17, 2025

  Based on observation, interviews, and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse, to the Administrator of the facility and the State Survey Agency for two (Residents #22 and #52) of 24 residents reviewed for abuse and neglect. LVN E and LVN M failed to immediately report the sexual abuse incidents involving Residents #22 and #52 to the Administrator. LVN M observed an incident of suspected sexual abuse involving Resident #1 and Resident #22 on 02/21/2025 at 09:36 AM and LVN E observed another incident of suspected sexual abuse involving Resident #1 and Resident #52 on 02/21/2025 at 01:34 PM. […]

• Actual harm, isolatedF689Aug 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #1) reviewed for accident hazards. The facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in the resident sustaining a left kneecap fracture. The noncompliance was identified as PNC. The noncompliance began on 07/30/26 and ended on 08/05/26. The facility had corrected the noncompliance before the survey began. […]

• No harm, potential for more than minimal, widespreadF812Feb 29, 2024

  Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date food stored in the walk-in refrigerator. 2. The facility failed to date food stored in the walk-in freezer . 3. The facility failed to cover and date food in the dry storage. 4. The facility failed to sanitize the food thermometer while measuring entree temperatures. These failures could place residents who at risk for food-borne illness and food contamination. Findings included: Observation in facility's kitchen on 02/27/24 at 09:51 AM revealed hard boiled eggs in the walk-in refrigerator were not dated. […]