Professional Post Acute Center

In the surveyor’s words

From the most serious findings on record at Professional Post Acute Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Mar 1, 2023

  Based on observation, interview and record review, the facility failed to ensure effective administration of its operations when the facility: 1.a) Did not ensure sufficient dietary staff (cooks and dietary aides) were employed and working in the dietary services, 1.b.) Did not ensure Registered Dietitian (RD) oversight in the kitchen and the Administrator did not provide the RD consult reports (documenting issues in the kitchen), dating back to [DATE], and 2) Did not ensure dietary services had adequate supervision when the facility did not employ a fulltime dietary manager, dating back to [DATE]. […]

• Actual harm, patternF684Sep 8, 2022

  Based on observation, interview, and record review, the facility failed to ensure 3 of 4 sampled residents (Residents 1, 2, and 3) received necessary care and treatment in accordance with professional standards of practice, when facility staff: 1. Delayed scheduling Resident 1's appointment for a routine suprapubic catheter (A hollow flexible tube used to drain urine from the bladder, inserted into the bladder through the abdomen) change months longer than indicated by physician order. The order indicated to have the catheter changed every 6 to 8 weeks, but it took more than four months (From 10/13/21 to 2/16/22) to have it changed. 2. […]

• Actual harm, patternF600May 19, 2021

  Based on observation, interview, and record review, the facility failed to ensure eight residents (Residents 2, 23, 54, 56, 62, 67, 72, 235) were free from verbal abuse and neglect by staff, including Staff I (Licensed Nurse), when: 1) Staff I communicated with residents in ways that caused discomfort to both residents and staff. 2) Staff I intimidated Resident 235 and Resident 54. 3) Resident 2 was afraid to ask Staff I for his as-needed pain medication to manage moderate or severe pain. 4) Six Residents in Resident Council vocalized fear of retaliation from Staff I. 5) Resident 23, Resident 2, Resident 62, Resident 67, and Resident 72 observed nursing staff sleeping during regular work hours at night. […]

• Actual harm, isolatedF689Jul 17, 2026

  Based on observation, interview and record review, the facility failed to ensure resident safety for two of three residents sampled for falls (Resident 75 and Resident 66) when: 1. Resident 75 was receiving incontinent care (toileting; changing a soiled adult brief) by one Certified Nursing Assistant (CNA J) when she required two caregivers to assist, and subsequently fell out of her elevated bed (a mattress raised to the caregivers preference to provide care comfortably) when she was turned on her side; and, 2. Resident 66 fell after she was left unattended at her bedside while sitting in a shower chair (a specialized, waterproof chair used for bathing residents). These failures: 1. […]

• Actual harm, isolatedF689Aug 13, 2025

  Based on interview and record review, the facility failed to ensure an environment free of falls for one resident (Resident 1) of three sampled residents when the facility:1. Did not initiate a person-centered care plan for Resident 1's fall risk prior to [DATE]; and,2. Did not analyze Resident 1's risk for a fall after worsening edema (swelling from an accumulation of fluid in the body's tissues) and possible deep vein thrombosis (DVT, a blood clot in a deep vein which can cause pain and swelling) in her lower legs.These failures contributed to Resident 1 sustaining a left fibula (one of the two bones in the calf) [NAME] fracture (a break of the upper fibula usually caused by twisting or forceful rotation of the ankle) from a fall. Cross reference F557.Findings:1. […]