The Commons Skilled Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Commons Skilled Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF842Jan 14, 2026

  Based on records reviewed and interviews, for three of three sampled residents (Resident #1, Resident #2, and Resident #3), the facility failed to ensure they maintained complete and accurate medical records, when their Certified Nurse Aide (CNA) flow sheets were left blank and the provision of care (e.g. bathing, dressing, grooming etc.) each resident required, was not documented as provided.Findings include: Review of the facility's policy titled, Charting and Documentation, with a revision date of 07/2017, indicated the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.1. […]

• No harm, potential for more than minimal, patternF640Aug 11, 2022

  Based on record review and interview, the facility failed to transmit discharge Minimum Data Sets (MDS's) within 14 days after completion for 22 Residents (#9, #6, #23, #4, #3, #25, #18, #22, #26, #21, #19, #7, #20, #13, #11, #14, #5, #15, #12, #8, #16, and #10) out of a total sample of 34 residents. Findings include: Review of the Minimum Data Sets for the following residents indicated that a discharge MDS had been started, and not transmitted within 14 days, on the following dates: - Resident #9 had a discharge MDS initiated on 3/8/22. - Resident #6 had a discharge MDS initiated on 3/28/22. - Resident #23 had a discharge MDS initiated on 4/3/22. - Resident #4 had a discharge MDS initiated on 3/5/22. […]

• No harm, potential for more than minimal, patternF880Jan 8, 2021

  Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing to perform hand hygiene when indicated on 1 of 1 resident units. Findings include: Review of the Centers for Disease Control (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: *Hand Hygiene-HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. […]

• No harm, potential for more than minimal, isolatedF684Mar 25, 2026

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was provide quality care and treatment that met professional standards of practice, when on 01/23/26, after telling Certified Nurse Aide (CNA) #1 that he/she could not stand up any longer, CNA #1 helped lowered Resident #1 to the floor in his/her bathroom, however CNA #1 did not immediately inform nursing of the incident so he/she could be assessed for potential injury prior moving him/her, but instead waited to notify nursing after he picked Resident #1 up off the floor and transferred him/her back to bed. […]

• No harm, potential for more than minimal, isolatedF609Nov 26, 2025

  Based on observation, record review and interview the facility failed to report an injury of unknown origin immediately, but not later than 2 hours after the injury was discovered, to the state agency, for one Resident (#51) out of a total sample of 17 residents. Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation Prohibition and Prevention Program, dated August 2023 indicated that an injury of origin is an injury that is not observed by anyone, and cannot be explained by the resident. This type of injury is reported and investigated as potential abuse. Further review indicated that the facility must report injuries of unknown origin to the state agency within two hours. […]