Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Englewood Post Acute And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in documentation. One resident's MDS did not reflect their PASRR Level II diagnosis or hospice services, another's did not document their PASRR Level II diagnosis, and a third's did not indicate they were receiving dialysis. Staff interviews revealed that the MDS coordinator was responsible for accuracy but was on extended leave, leading to these oversights.
The facility failed to maintain an effective infection prevention and control program. Housekeeping staff did not adhere to proper hand hygiene practices and disinfectant dwell times, while the MDSC did not follow appropriate infection control practices during wound care. Observations revealed that disinfectants were not left on surfaces for the required time, and hand hygiene was not performed when changing gloves. Additionally, wound care supplies were placed directly on a resident's mattress, and gloves were not changed between tasks.
A facility failed to investigate allegations of resident-to-resident abuse and staff neglect involving two residents. One resident, with a history of aggression, was found standing over another resident, who reported being punched. The investigation lacked detailed witness statements and did not determine the root cause. The aggressive resident's care plan did not address his history or provide interventions for future incidents.
The facility failed to maintain a homelike environment, with several resident rooms in disrepair due to paint chips and dirty baseboards in common areas. A resident expressed dissatisfaction with the room conditions. The maintenance director cited a backlog of tasks and prioritization of empty rooms, while the NHA acknowledged a lack of planning for occupied rooms.
A facility failed to update the PASRR Level I screening for a resident with anxiety disorder, depression, and unspecified affective mood disorder. Despite receiving psychotropic medication and being diagnosed with major depressive disorder, the facility did not submit a new PASRR Level I to trigger a Level II assessment. Staff interviews revealed a lack of clarity on notifying the PASRR oversight agency of the resident's mental health diagnoses.
A facility failed to maintain professional standards by leaving medications unattended. An RN left medications unsecured on a cart while retrieving applesauce, and later left them in a resident's room while fetching a stethoscope. The resident had severe cognitive impairments and was left with the medications, posing a risk of unauthorized access. The RN acknowledged the oversight, and the DON confirmed that medications should always be attended or secured.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents, leading to deficiencies in documentation. Resident #15's MDS assessment did not accurately document the resident's PASRR Level II diagnosis of major depression and an extensive history of psychiatric treatment, nor did it reflect that the resident was receiving hospice services. This oversight occurred despite the comprehensive care plan indicating these conditions and services. Resident #36's MDS assessment also failed to document the resident's PASRR Level II diagnosis, despite the PASRR Level II assessment and the comprehensive care plan confirming the resident's qualifying diagnosis for PASRR Level II. The resident had been diagnosed with bipolar disorder before 2018, and the state mental health authority had determined that the individual met the criteria for a PASRR mental illness. Resident #63's MDS assessment did not accurately document that the resident was receiving dialysis, even though the resident's diagnoses included dependence on renal dialysis and chronic kidney disease stage 5. Interviews with staff revealed that the MDS coordinator was responsible for ensuring the accuracy of the MDS assessments, but due to an extended leave, the coordinator was unsure why the assessments were not accurate. The social services director and the MDS coordinator were responsible for updating the MDS assessments with accurate information, but this was not done for the three residents in question.
Infection Control Deficiencies in Housekeeping and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by observations and interviews. Housekeeping staff did not adhere to proper hand hygiene practices and disinfectant dwell times when cleaning residents' rooms. Specifically, Housekeeper #1 did not allow the Clorox disinfectant to sit for the required 30 seconds on various surfaces and failed to change gloves and perform hand hygiene when moving between different cleaning tasks. Similarly, Housekeeper #2 did not follow the manufacturer's recommended dwell time for the Comet disinfectant and did not change gloves or perform hand hygiene after cleaning the bathroom and toilet. Additionally, the facility did not ensure appropriate infection control practices during wound care. The Minimum Data Set Coordinator (MDSC) failed to set up a clean field for wound care supplies, placing them directly on a resident's mattress. The MDSC also did not change gloves or perform hand hygiene after cleansing the wound and before applying the dressing, which is contrary to the facility's policy and CDC guidelines. Interviews with staff revealed a lack of understanding and adherence to infection control protocols. Housekeepers were unaware of the need for hand hygiene when changing gloves, and there was confusion about the required dwell times for disinfectants. The Director of Nursing confirmed that staff should change gloves and perform hand hygiene between tasks, and that clean supplies for wound care should be placed on a clean area near the resident.
Failure to Investigate Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident physical abuse and staff-to-resident neglect, specifically involving two residents. Resident #18, with a known history of aggressive behavior, was found standing over Resident #60, who reported being punched by Resident #18. The facility's investigation did not adequately assess Resident #18's cognitive status or potential hallucinations at the time of the incident, nor did it gather comprehensive observations to determine the necessary interventions to prevent further abuse. The facility's policy required a thorough investigation of all abuse allegations, including interviews with involved parties and a review of medical records. However, the investigation into the incident between Resident #18 and Resident #60 lacked detailed witness statements and failed to determine the root cause of the altercation. The facility did not substantiate the abuse allegation, as neither resident was injured or fearful, and Resident #18 claimed to have been hallucinating. Resident #18's care plan did not address his history of aggression or provide interventions for future altercations. Despite a psychiatric assessment indicating a history of aggression, the facility did not incorporate this into the care plan. The facility's response to the incident was limited to separating the residents and prescribing medication for aggression, without addressing the potential for future incidents or monitoring for hallucinations.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment in one of its units, as observed and reported by surveyors. Specifically, several resident rooms, including rooms #204, #206, #209, and #212, were found to be in disrepair with multiple paint chips on the walls. These paint chips were observed to be six to twelve inches in size, particularly on the walls between the bathroom and closet areas. A resident expressed dissatisfaction with the condition of the rooms, indicating a preference for a well-maintained living space. Additionally, the common areas on the second floor were not maintained in a clean state, with baseboards exhibiting several black skid marks. Interviews with the maintenance director revealed a backlog of maintenance tasks and a prioritization of repairs in empty rooms over those occupied by long-term residents. The nursing home administrator acknowledged the ongoing repaint project but admitted to a lack of planning for addressing maintenance in occupied rooms, contributing to the deficiency in maintaining a homelike environment.
Failure to Update PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a Level II PASRR evaluation and determination for services. The resident, a 74-year-old individual, was admitted with diagnoses of anxiety disorder, depression, and unspecified affective mood disorder. Despite these diagnoses, the initial PASRR Level I screening did not reflect any known or suspected major mental illness, and the facility did not submit a new PASRR Level I when the resident's mental health status changed. The resident's medical records indicated that they were receiving psychotropic medication upon admission, and subsequent assessments revealed additional mental health diagnoses. On multiple occasions, the resident was diagnosed with major depressive disorder, including with psychotic features, and was prescribed antipsychotic medication. However, the facility did not update the PASRR Level I screening to reflect these changes, failing to trigger a Level II assessment that could have provided treatment recommendations. Interviews with facility staff revealed a lack of clarity regarding the need to notify the PASRR oversight agency of the resident's mental health diagnoses. The social services director acknowledged that PASRR assessments should be completed upon admission and with any change in mental health condition, but the facility did not follow through with this process for the resident in question.
Unattended Medications Compromise Safety Standards
Penalty
Summary
The facility failed to ensure that medications were not left unattended, compromising professional standards of quality. During an observation, a registered nurse (RN) prepared medications for a resident and left them unsecured on top of the medication cart while retrieving applesauce from the dining room. The medications, including a cup of pills, eye drops, and a tube of Aspercreme, were left unattended, with the cart out of the RN's sight. This occurred in a hallway where other residents, including a cognitively impaired individual, were present, posing a risk of unauthorized access to the medications. Additionally, the RN left the prepared medications unattended in the resident's room while retrieving a stethoscope to recheck the resident's pulse. The resident, who had severe cognitive impairments and a history of renal failure, dementia, anxiety, and depression, was left with the medications in the room, along with a roommate. The RN acknowledged the oversight, admitting that the medications should not have been left unsecured on the cart or in the resident's room. The Director of Nursing confirmed that facility policy requires medications to be attended or secured at all times.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellsprings Care Center | 0.1 mi | ★★★★★ | 15 | 0 |
| Julia Temple Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Suites At Clermont Park Care Center, The | 2.5 mi | ★★★★★ | 8 | 0 |
| Cherrelyn Healthcare Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Heights Care & Rehabilitation Llc | 2.7 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.