Reservoir Center for Health & Rehabilitation, The

In the surveyor’s words

From the most serious findings on record at Reservoir Center for Health & Rehabilitation, The, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 26, 2021

  Based on observation, record review, and interview, the facility failed to provide adequate supervision and develop or implement effective fall prevention interventions for two Residents (#116 and #35) related to three falls with major injury, failed to investigate a fall for one Resident (#116) and failed to provide adequate supervision during meals for one Resident (#3) at risk for aspiration, out of a total sample of 24 residents. Findings include: Review of the facility's Accident/Incident (A/I) Policy, revised 12/2018, indicated, but is not limited to: -All occurrences are investigated in a timely manner and preventative measures initiated. […]

• No harm, potential for more than minimal, widespreadF812Jul 11, 2023

  Based on inspection and interview, the facility failed to label, date and maintain food products that were not expired, in four out of four Unit Nourishment kitchenettes. Findings include: Review of the Use and Storage of Food Brought to Residents by Family and Visitors Policy, revised ,d+[DATE], included, but not limited to: -Perishable foods must be stored in the nursing unit kitchen nourishment refrigerator and identified with the resident's name, food item and use by date. Facility staff is responsible to discard perishable foods within 72 hours of being brought in from outside. 1. […]

• No harm, potential for more than minimal, patternF584Jan 13, 2026

  Based on observations, record review, and interviews, the facility failed to provide residents with a homelike environment on three out of four Resident Units (East Two, [NAME] One, and [NAME] Two) and for one Resident (#71) out of total sample of 28 Residents. Specifically, 1. the facility failed to provide Residents #41 and #69 and other residents with appropriate and comfortable air temperature levels during Resident meals in the Sitting Rooms on the East Two, [NAME] One, and [NAME] Two resident Units. 2. the facility failed to ensure safe and sanitary side rail pads for Resident #71's bed, placing the Resident at the risk of injury and contamination. […]

• No harm, potential for more than minimal, patternF865Jan 13, 2026

  Based on records reviewed, interviews, and observations, the facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility.Specifically, the facility failed to develop and implement an effective performance improvement plan to address the non-operational heating units on three out of four Resident Sitting Rooms, utilized for Resident meals. Findings include:Review of the Facility's policy for QAPI Program, last revised October 2024 indicated:-Our facility provides services across the continuum of care. […]

• No harm, potential for more than minimal, patternF880Oct 2, 2024

  Based on observation, interview, record and policy review, the facility failed to implement infection control measures according to professional standards of practice on one Unit (East One Unit) out of four resident units, and for two Residents (#65 and #84) out of a total sample of 27 residents. Specifically, the facility failed to: 1. Ensure that staff who worked on the East One Unit and considered as exposed to COVID-19, completed initial and requisite outbreak testing when the facility was experiencing an outbreak of COVID-19 on the East One Unit, increasing the risk for transmission of infection to residents and staff. 2. Ensure timely and effective implementation of interventions to prevent the transmission of Clostridium Difficile (C. […]