Calder Woods

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to ensure that dietary staff wore hair restraints to prevent hair from contacting food, on 1/28/2026. 2. The facility failed to ensure trash cans were properly covered on 1/28/2026.3. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 01/28/2026 and 01/29/2026. 4. The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air on 01/28/2026 and 01/29/2026. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for medication and supply storage room [ROOM NUMBER] of 1 reviewed for pharmacy services. The facility failed to ensure expired medical supplies were removed from the singular medication and supply storage room. This failure could place residents at risk of contamination causing illness and decreased effectiveness or failure of medical supplies.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 3 out of 4 residents (R #18, R #32, R #21) reviewed for infection control. MA D failed to disinfect the blood pressure cuff between residents (R#5, R #18, R #32, R #21) while performing medication pass. The failure placed residents at risk for cross contamination and the development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 10 (Resident #28) residents in 1 of 3 (DR #1) dining rooms. The facility failed to promote Resident #28's dignity during lunch on 01/28/2026 when staff did not serve Resident #28's lunch tray until twenty-two minutes after her tablemates were served. This failure could affect all residents who eat in the dining room, by contributing to poor self-esteem, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance devices and adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A utilized a gait belt and had assistance from another staff member during a bed to wheelchair transfer on 11/19/24 which resulted in Resident #1 having a fall and complaints of pain. Resident #1 was sent to the local hospital emergency room where she was found to have fractured neck bones. She was care flighted to another hospital out of town for surgery to the neck. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/19/24 and ended on 12/05/24. The facility had corrected the noncompliance before the investigation began. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 (Resident #2) residents who were reviewed for respiratory care. 1. The facility failed to ensure Resident #2 had orders for her oxygen therapy. 2. The facility failed to ensure Resident #2's oxygen humidifier was changed when emptied. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records maintained for each resident were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure CNA Z documented that incontinent care was provided for Resident #1 from 6:27 p.m. on 08/09/25 through 6:00 a.m. on 08/10/25. The facility failed to ensure LVN V documented on a nurse progress note on 08/10/25 when Resident #1 was crying in pain, level of pain, and required pain medication. These failures could place residents at risk for delayed care and appropriate interventions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #3) residents reviewed for infection control. 1. CNA B failed to perform hand hygiene while performing incontinent care for Resident #3. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to document a physician ordered x-ray was completed, the results, or physician notification in Resident #1's medical record. This failure could place residents at risk for delayed care and appropriate interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents for 1 (Resident #139) of 13 residents reviewed for controlled medications. Resident #139's hydrocodone 5mg / acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) 20 tablets were not accounted for at the time of discharge 09/11/24 and remained unaccounted for 55 days. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 residents (Resident #136) reviewed for infection control. LVN C failed to wear a gown during wound care for Resident #136 who was on Enhanced Barrier Precautions (EBP). This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on interviews and record review, the facility failed to immediately notify the resident physician regarding a change in a resident's condition for one (Resident #1) of seven residents reviewed for changes in condition. The facility failed to inform the physician immediately of Resident #1's witnessed fall on 12/15/2023. This failure could place residents' physician at risk of not being aware of any changes in their conditions and could result in a delay in treatment and a decline in residents' health and well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN C documented Resident #1's change of condition and physician notification on 12/17/2023. This failure could place residents at risk for delayed care and appropriate interventions.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of 10 residents reviewed for changes in condition. The facility failed to notify the responsible party (FM F) for Resident #1 when she developed a deep tissue injury on her left buttock that required treatment. The facility failed to notify the responsible party (FM F) for Resident #1 when she was transferred to the local hospital for a change in condition and respiratory distress. The facility failed to notify the responsible party (FM F) for Resident #1 when she had abnormal lab results of RBC of 3.4 (Reference range 4,14-5.8), low Hemoglobin of 8.7 (Reference range 13.0-17.7), and a low Hematocrit of 27.3 (Reference range 37.5-51.0). [...]

Inspectors wroteBased on interview and record review, the facility failed conduct initially a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 calendar days of admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition for 2 of 7 residents (Residents #1 and #2) reviewed for comprehensive assessments and timing. The facility failed to ensure a MDS Assessment for Residents #1 and #2 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 7 residents reviewed for comprehensive plans of care. (Resident #3) The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment or no more than 21 days after admission for Resident #3. This failure could place residents at risk of not receiving appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 7 residents reviewed for accurate medical records. The facility staff (RN B) failed to document on the admitting orders and MAR/TAR regarding Resident #1's indwelling Foley catheter care and maintenance, PICC line care and maintenance, and enteral feeding dosing upon admitting to the facility. The facility staff (LVN A) failed to document an accurate assessment of a new wound identified on 02/05/2024. The facility staff (RN B) failed to ensure physician's orders were written for removing a PICC line on 02/05/2024. These failures could place resident at risk of having errors in care and treatment decisions being based on incomplete and inaccurate medical records.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 1 of 3 residents (Resident #23) and a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #133) reviewed for indwelling catheters. 1. The facility failed to have an appropriate diagnosis for Resident #23's Foley catheter. 2. The facility failed to prevent Resident #133's urinary catheter drainage bag from touching the floor. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #24) reviewed for unnecessary medication. The facility failed to monitor Resident #24 for side effects of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 13 residents (Resident #24) reviewed for unnecessary medications. The facility failed to monitor Resident #24 for behaviors or side effects for the antidepressant medication, Lexapro. This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications.