Rehabilitation Center of Lisbon

In the surveyor’s words

From the most serious findings on record at Rehabilitation Center of Lisbon, in the surveyor’s own words.

• Actual harm, isolatedF689May 17, 2021

  Based on observation, record review, resident and staff interviews the facility failed to identify an environmental hazard when they left a shower chair unlocked while a resident showered. The staff member stepped away from Resident #11 to obtain a towel, the resident attempted a self-transfer, and fell when the shower chair rolled away. The fall resulted in a right [CONDITION(S)] for 1 of 2 residents reviewed for accidents. (Resident #11). The facility reported a census of 50 residents. Findings Include: Resident #11's Minimum Data Set (MDS) assessment dated [DATE] showed the resident required assistance of one staff for bathing. The MDS identified the resident with a Basic Interview for Mental Status (BIMS) score of 12 indicating the resident had mildly impaired cognitive skills. […]

• No harm, potential for more than minimal, patternF880Dec 12, 2024

  Based on observation, staff interview, and policy review the facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items. The facility reported a census of 61 residents. Findings include: During an observation on 12/11/24 at 8:09 AM Staff B, laundry aide, put on gloves and took plastic laundry bags out of bins and placed them onto the sorting counter. She then failed to put on a gown, sorted the linens, and placed them into bins. She then tossed the plastic bags in the garbage. Staff B cleaned the counter and performed hand hygiene. In an interview on 12/11/24 at 8:03 AM the Environmental Supervisor explained soiled laundry arrived in plastic bags in a covered yellow cart. The laundry then got sorted into bins. […]

• No harm, potential for more than minimal, isolatedF689Jan 21, 2026

  Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to ensure that interventions to prevent falls were implemented for 1 of 6 residents reviewed for falls (Resident #52). The facility reported a census of 62 residents. Findings include: Review of the MDS assessment, dated 12/03/25, revealed that Resident #52 had a BIMS score of 15/15, which indicated intact cognition. The list of diagnoses included fracture and other multiple trauma, Cerebral Vascular Accident (CVA or stroke), muscle wasting and atrophy. Resident #52 required supervision or touching assistance with transfers and walking. […]

• No harm, potential for more than minimal, isolatedF760Jan 21, 2026

  Based on clinical record review, staff interviews and facility policy review the facility failed to administer medication as ordered to 3 out of 11 resident reviewed (Resident#4, Resident #9,& Resident #47).The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 7/2/25, listed diagnoses of gastrointestinal hemorrhage (bleeding), Alzheimer's disease, anemia (lack of healthy red blood cells), heart failure, and orthostatic hypotension (low BP). The Brief Interview for Mental Status Score (BIMS) reflected 5 out of 15, which indicated severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF658Dec 8, 2022

  Based on clinical record review, policy review, and staff interview, the facility failed to carry out physician's orders for 2 of 24 residents reviewed (Resident #13 and #14). The facility reported a census of 58 residents. Findings: 1. The Minimum Data Set (MDS) Assessment Tool, dated 10/13/22, listed diagnoses for Resident #13 included Type 2 diabetes, chronic kidney failure, and history of stroke. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and total dependence of 1 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating a moderate cognitive impairment. […]