Promenade Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Promenade Rehabilitation and Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725Jun 12, 2026

  Based on record review and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services necessary to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, Specifically, 1.) Residents reported the facility was short staffed of Certified Nursing Assistants which resulted in lack of timely staff response to residents who needed assistance, 2.) Multiple nursing staff members reported lack of sufficient staffing, 3.) Facility's staffing levels were repeatedly below facility assessed levels, and 4.) Excessively low weekend staffing was triggered in the Payroll Based Journal Staffing Data Report for Quarter 2 2026 (January 1 - March 31). […]

• No harm, potential for more than minimal, patternF584Aug 7, 2024

  Based on observations and interviews during the recertification survey on 07/31/2024 to 08/07/2024 the facility did not ensure that housekeeping and maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, observations of multiple floors revealed rooms, corridors, and dining rooms with chipped, broken plaster, bubbled up paint, furniture and wall hanging in disrepair, torn window screens, loose and dirty moldings. This was evident on 5 of 6 Units. […]

• No harm, potential for more than minimal, isolatedF580Jun 12, 2026

  Based on observation, record review, and interviews, the facility failed to ensure the resident representative was notified of an accident involving the resident which results in injury and has the potential for requiring physician intervention. This was evident in one of one resident (Resident #25) reviewed for notification of change out of 38 total sampled residents. Specifically, the facility failed to notify Resident #25's representative of the resident's fall with injury on 03/23/2026.The findings include:The Facility's Policy titled Family/Responsible Party Notification of Change in Condition and Hospital Transfer, last reviewed on 05/2026, requires timely notification of a resident's representative following accidents or injuries. […]

• No harm, potential for more than minimal, isolatedF604Jun 12, 2026

  Based on record review and interviews, the facility failed to ensure that a resident was free from physical restraints. This was evident in one (Resident #52)of three residents reviewed for abuse out of 35 total sampled residents. Specifically, on 09/26/2024, Resident #52 was observed by the staff with their hand mitten tied to the bed side rail.Refer to F609 - Reporting of Alleged ViolationsThe findings include:The facility's Physical Restraint-Free Care policy dated 05/2026 stated the use of physical restraint shall be considered only when clinically justified to address a specific assessed medical symptom. It should never be used for staff convenience and behavior management. […]

• No harm, potential for more than minimal, isolatedF609Jun 12, 2026

  Based on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, including to the State Survey Agency. This was evident in two (Residents #52 and #75) of five residents reviewed for abuse and accidents out of 35 total sampled residents. […]