Lions Rehab Center

EHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (May 8, 2026)

EProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (May 8, 2026)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (May 8, 2026)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (May 8, 2026)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Deficient, Provider has date of correction (May 8, 2026)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (May 8, 2026)

DPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605 · Deficient, Provider has date of correction (May 8, 2026)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (May 8, 2026)

DCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0655 · Deficient, Provider has date of correction (May 8, 2026)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (May 8, 2026)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (May 8, 2026)

DEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (May 8, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (May 8, 2026)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (May 8, 2026)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0742 · Deficient, Provider has date of correction (May 8, 2026)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (May 8, 2026)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (May 8, 2026)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (May 8, 2026)

DMake sure that a working call system is available in each resident's bathroom and bathing area.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0919 · Deficient, Provider has date of correction (May 8, 2026)

DMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0921 · Deficient, Provider has date of correction (May 8, 2026)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Nov 19, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Nov 19, 2025)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

DEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jul 2, 2025)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Feb 7, 2025)

EEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

EProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0697 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

DHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0557 · Deficient, Provider has date of correction (Feb 7, 2025)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

DProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0568 · Deficient, Provider has date of correction (Feb 7, 2025)

DHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (Feb 7, 2025)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (Feb 7, 2025)

DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

DProvide doctor's orders for the resident's immediate care at the time the resident was admitted.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0635 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Feb 7, 2025)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Feb 7, 2025)

DObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0710 · Deficient, Provider has date of correction (Feb 7, 2025)

DEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0711 · Deficient, Provider has date of correction (Feb 7, 2025)

DEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0726 · Deficient, Provider has date of correction (Feb 7, 2025)

DHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0727 · Deficient, Provider has date of correction (Feb 7, 2025)

DEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Feb 7, 2025)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Deficient, Provider has date of correction (Feb 7, 2025)

DEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Feb 7, 2025)

DEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Feb 7, 2025)

DEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Potential for more than minimal harm · Administration Deficiencies · Tag F0836 · Deficient, Provider has date of correction (Feb 7, 2025)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Deficient, Provider has date of correction (Feb 7, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Feb 7, 2025)

DEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0887 · Deficient, Provider has date of correction (Feb 7, 2025)

EHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (May 23, 2023)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (May 23, 2023)

ENotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (May 23, 2023)

EEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (Jun 22, 2023)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (May 23, 2023)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (May 23, 2023)

EProvide activities to meet all resident's needs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0679 · Deficient, Provider has date of correction (May 23, 2023)

EProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0725 · Deficient, Provider has date of correction (May 23, 2023)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (May 23, 2023)

DHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0561 · Deficient, Provider has date of correction (May 23, 2023)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (May 23, 2023)

DGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0582 · Deficient, Provider has date of correction (May 23, 2023)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (May 23, 2023)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Deficient, Provider has date of correction (May 23, 2023)

DNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Deficient, Provider has date of correction (May 23, 2023)

DPrepare residents for a safe transfer or discharge from the nursing home.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0624 · Deficient, Provider has date of correction (May 23, 2023)

DEnsure a qualified health professional conducts resident assessments.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0642 · Deficient, Provider has date of correction (May 23, 2023)

DPASARR screening for Mental disorders or Intellectual Disabilities

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0645 · Deficient, Provider has date of correction (May 23, 2023)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (May 23, 2023)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (May 23, 2023)

DTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (May 23, 2023)

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

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0730 · Deficient, Provider has date of correction (May 23, 2023)

DEnsure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0741 · Deficient, Provider has date of correction (May 23, 2023)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Deficient, Provider has date of correction (May 23, 2023)

DImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Jun 22, 2023)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (May 23, 2023)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (May 23, 2023)

DEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0887 · Deficient, Provider has date of correction (May 23, 2023)

DEnsure staff are vaccinated for COVID-19

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0888 · Deficient, Provider has date of correction (May 23, 2023)