City Scape Rehabilitation & Care Center LLC

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of three sample residents. Resident #4 was admitted on 10/10/22 for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 5/28/25 Resident #4 was found on the floor in her room with blood coming from her head. Resident #4 was transp.. *** CITATION TEXT NOT FOUND *** A survey prompted by complaint #CO40599 was completed on 6/30/25 to 7/1/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure three (#7, #3 and #5) of four residents reviewed for abuse out of seven sample residents were kept free from abuse.On 5/21/25 Resident #7 was physically abused by Resident #2. Resident #2 used a belt to hit Resident #7 on top of his head and struck Resident #7 with his belt buckle. Resident #7 sustained a laceration to his head, requiring transfer to the emergency room where Resident #7 received five sutures.Additionally, Resident #5 was physically abused by Resident #1 on 3/22/25 and Resident #3 and Resident #1 were physically abused by each other on 5/3/25. Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #2;-Protect Resident #5 from physical abuse by Resident #1; and, -Protect Resident #3 an.. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of three sample residents. Resident #4 was admitted on 10/10/22 for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 5/28/25 Resident #4 was found on the floor in her room with blood coming from her head. Resident #4 was transported to the hospital for further evaluation. Resident #4 sustained a subdural hematoma (brain bleed) and was diagnosed with a traumatic brain injury. The facility failed to implement person-centered interventions after the resi.. *** CITATION TEXT NOT FOUND *** A survey for Incident #40170, Incident #40171, Incident #40361 and Incident #40431was conducted on 6/30/25 to 7/1/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure three (#7, #3 and #5) of four residents reviewed for abuse out of seven sample residents were kept free from abuse.On 5/21/25 Resident #7 was physically abused by Resident #2. Resident #2 used a belt to hit Resident #7 on top of his head and struck Resident #7 with his belt buckle. Resident #7 sustained a laceration to his head, requiring transfer to the emergency room where Resident #7 received five sutures.Additionally, Resident #5 was physically abused by Resident #1 on 3/22/25 and Resident #3 and Resident #1 were physically abused by each other on 5/3/25. Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #2;-Protect Resident #5 from physical abuse by Resident #1; and, -Protect Resident #3 and Resident #1 from physical abuse by each other.Findings include:I. Facility policy and procedureThe Abuse Neglect and Exploitation policy, dated 5/16/25, was provided by the nursing home administrator (NHA) on 6/30/25 at 3:00 p.m. ..

A complaint survey, prompted by #CO39752 was conducted on 5/1/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of four sample residents.Specifically, the facility failed to implement person-centered fall interventions in a timely manner.Findings include:I. Facility policy The Fall/Accident Assessment Prevention and Review policy, undated, was provided by the nursing home administrator (NHA) on 5/1/25 at 12:42 p.m. It read in pertinent part:"The goal of the facility is for residents to remain as free from falls and accidents as possible. To provide guidelines for the assessment, prevention and review of falls and/or accidents."The interdisciplinary team (IDT) will review the forms at the morning quality improvement meeting to determine what immediate action may be necessary."The IDT will again review the forms in greater detail at the weekly IDT meeting. Data collected will be reviewed in an attempt to determine causal factors and trends. Specific approaches to prevent further falls will be determined based on the reasons for the falls as determined in the assessment and review. The care plan will be updated and interventions will be put into place."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 5/3/24. According to the May 2025 computerized physician orders (CPO), diagnoses included Parkinson' s disease with dyskinesia (involuntary movements), difficulty in walking, generalized muscle weakness, lack of coordination and chronic pain.The 2/9/25 minimum data set (MDS) assessment revealed that Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 required partial to moderate assistance for sit-to-stand and all surface transfers.B. Resident interviewResident #1 was interviewed on 5/1/25 at 12:00 p.m. Resident #1 said she fell a lot because she waited for help from staff for a long time and transferred herself. She said she did not have fall interventions in place.C. Record..

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.