Callaway Good Life Center, Inc

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(2)The facility failed to ensure that 12 hours of required ongoing education was documented for nurse aides and medication aides who had been working in the facility for longer than one year and who required 12 hours of yearly training for 3 of 3 sampled staff. This had the potential to affect all residents. The census was 29.

Inspectors wroteLicensure Reference Number 12-006.12(D)(i)Based on observation and record review the facility failed to ensure items the medication room refrigerator was stored separately by route of administration and food stuff items were not stored with medication items. This had the potential to affect all the residents in the facility. The facility census was 28.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Payroll Based Journal was submitted for the first quarter of 2026 by the due date of February 14, 2026. This had the potential to affect all residents. The facility census was 29. Record review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (PBJ) (a CMS-mandated system for nursing facilities to electronically report auditable staffing data, including hours worked, job roles, and pay types, to ensure transparency and quality of care, revealed that the PBJ data which must be submitted and received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely) was not submitted to or received by CMS by the date that the PBJ was required. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review, and interview the facility failed to ensure that staff delivered resident meals in a sanitary manner to prevent the potential for foodborne illness and cross-contamination. This affected 15 of 22 residents in the facility dining room (Residents 22, 28, 19, 10, 35, 27,15, 20, 17, 16, 23, 21, 18, 25, and 9). The facility census was 29.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)Based on record review and interview the facility failed to ensure a prescribed psychotropic medication had an approved diagnosis or indication for use for 1 resident (Resident 5) of 5 sampled residents. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G)(ii)Based on record review and interview, the facility failed to complete a summary or recapitulation of stay as required for 1 resident (Resident 32) of 2 sampled residents. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 2 residents (Resident 5 and Resident 6) of 5 sampled residents and failed to comprehensively complete the Care Area Assessment (CAA) a critical component of MDS that functions as a decision making frame work to determine if a specific person centered care plan intervention is required) for 1 residents (Resident 5) of 5 sampled residents, and failed to complete an Prospective Payment System (PPS) a standardized, Medicare-required evaluation used to classify patients into payment groups based on clinical needs) Discharge assessment as required for 1 resident (Resident 1) of 5 [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09FBased on record review and interview the facility failed to complete a baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed for staff to provide initial effective and person-centered quality care for a resident) within 24 hours as required for 1 of 3 residents (Resident 15) and failed to provide a written summary of the baseline care plan to the resident/resident representative for 1 of 3 residents (Resident 16). The facility census was 29.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E)(i)Based on record review and interview the facility failed to develop a comprehensive care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident based on the resident comprehensive assessment) for resident care needs identified in the resident assessment for 2 of 2 residents reviewed (Residents 16 and 12). The facility census was 29.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)Based on observation, record review, and interview, the facility failed to ensure a residents Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) was revised reflecting a resident current fall prevention intervention was listed for 1 resident (Resident 5) of 5 sampled residents. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC, 12-006.09Based on observation, interview, and record review the facility failed to ensure a topical medication gel was applied in the amount as ordered by the provider for 1 resident (Resident 20) of 1 sampled resident. The facility census was 28.

Inspectors wroteLicensure Reference Number 175NAC 12-006.11(E) Based on record review, observation and interviews, the facility failed to ensure that food was stored and prepared in a manner to prevent food borne illnesses. This had the potential to affect all residents eating food prepared in the kitchen. The facility census was 28.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of abuse and misappropriation of resident property within the regulated time period. This affected one resident (Resident 1). The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews, the facility failed to prepare and serve food in a safe manner to prevent the potential for foodborne illness. This had the potential to affect all facility residents eating out of the kitchen. The facility census was 28.

Inspectors wroteLicensure Reference Number 175NAC 12-0006.04(B) Based on record review and interview the facility failed to ensure that Nurse Aides completed the required continuing education hours for 3 of 5 sampled Nurse Aides. The facility census was 28. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide M (NA-M) had completed 2.37 hours of continuing education hours from 01/01/2024 to 02/10/2025. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide N (NA-N) had completed 1.63 hours of continuing education hours from 01/01/2024 to 02/10/2025. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide O (NA-O) had completed 4 hours of continuing education hours from 01/01/2024 to 02/10/2025. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04(D) Based on observation and interview, the facility failed to ensure that the ventilation system was operational in in rooms 7, 8, 9, 10, 11, 14, 15, and 19. This affected 8 bathrooms used by 13 residents. facility census was 28. An observation on 02/04/2025 at 11:45 AM revealed that bathrooms in rooms [ROOM NUMBER] did not have functional ventilation as tested when a 1-ply square of toilet paper was held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-006.09 C Based on record review and interview the facility failed to ensure a comprehensive resident assessment was completed once every 12 months for 1 resident (Resident #8) of 3 sampled residents, and a Quarterly Assessment (which a non-comprehensive assessment of a resident) was completed at least every 92 days for 1 resident (Resident #4) of 3 sampled residents. The facility census was 28. A. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2024 revealed an comprehensive annual assessment must be completed on an annual basis at least every 366 days. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-006.09 (B) Based on record review and interview the facility failed to ensure that Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) assessments were completed accurately for 2 (Resident #8 and Resident #25) of 5 sampled Residents. The facility census was 28. A. Review of a facility policy titled Resident Assessments dated 05/2022 revealed that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and all persons who have completed any portion of the MDS for must sign the document attesting to the accuracy of the information. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-0006.12 Based on interview and record review the facility failed to ensure residents medication regimen were free from unnecessary medications for 1 resident (Resident #25) of 3 sampled residents. The facility census was 28. Record review of Drugs.com on 02/06/2025 revealed Ketoconazole is an antifungal medication that is only recommended when other effective antifungal therapy is not available or tolerated. Record review of Drugs.com on 02/06/2025 revealed Nystatin Powder is a topical antifungal medication. Record review of Resident #25 Physician Orders on 02/06/2025 revealed Resident #25 had orders to receive Ketoconazole External Cream 2% to affected areas topically at bedtime dated 05/20/2024 and Nystatin External Powder topically every morning and at bed time under the right breast dated 07/02/2024. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-00006.12 Based on record review and interview the facility failed to ensure that an antipsychotic medication had the correct diagnosis for use. This affected 1 resident (Resident # 3) of 5 sampled residents. The facility census was 28. Record review of a facility policy titled Behavioral Assessment Intervention and Monitoring revealed the facility will comply with regulatory requirements related to the use of medication. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to ensure a medication error of less than 5% with an actual observed medication error rate of 7%. This affected 2 residents (Resident # 13 and Resident #4) of 6 observed medication administrations. The facility census was 28. Review of a facility policy titled Insulin Pen and dated 01/11/2024 revealed to prime the insulin pen by dialing 2 units by turning the dose selector clockwise and with the needle pointing up push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle the turn the selector to the desired dose. In an observation of medication administration completed on 02/05/2025 at 11:27 AM by Registered Nurse-C (RN-C) the following was observed: -RN-C obtained an insulin pen from the medication cart. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-0006.12(D)(i) Based on observation, record review, and interview the facility failed to ensure that medications were securely stored. This affected 1 resident (Resident #25) of 3 sampled residents. The facility census was 28. Record review of a facility supplied policy titled Storage of Medications dated 11/2020 revealed drugs and biologicals used in the facility are stored in locked compartments. In an observation completed on 02/04/2025 at 5:00 PM an opaque plastic bottle with a white cap and a pharmacy label with Resident #25's name and Nystatin Powder apply to red skin folds may keep at bed side was located within eyesight on the residents over bed table beside the resident's recliner. [...]

Inspectors wroteLicensure Reference Number 175NAC 12-006.10D Based on record review and interview, the facility failed to protect residents from significant medication errors for 1 resident (Resident 1) of 5 residents reviewed. This caused the resident to require hospitalization for treatment. The facility census was 33.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.10D Based on observation, interview, and record review, the facility failed to ensure 1 resident (Resident 6) out of 5 sampled residents in the facility receiving insulin, received the correct amount of insulin. This caused the resident to be transported to the hospital for treatment. The total facility census was 32.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(8) Based on record review and interviews; the facility failed to notify and submit a written investigation report to the State Agency within the required timeframe for 2 (Resident 136 and Resident 14) of 3 sampled residents. The facility census was 32.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(5) Based on record review and interviews the facility failed to provide transfers for 2 (Resident 12 and Resident 7) of 2 sampled residents, to the Ombudsman. Facility census was 32. A. A record review of Resident 12's undated Facesheet revealed, that the facility admitted Resident 12 on 9/10/20. A record review of Residnet 12's Progress Notes revealed, that Resident 12 had been sent to the hospital on 8/13/23 and returned to facility on 8/15/23. The Progress Notes did not reveal, any documentation that Ombudsman had been notified of Resident 12's transfer to the hospital. In an interview with the Administrator on 02/28/24 at 3:09 PM revealed, that when [gender] called the Ombudsman office, the Ombudsman representitive confirmed that the office had not received any notifications for transfers or discharges from the facility in over a year. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a notice of the bed hold policy to the resident or resident representative which affected 2 (Resident 12 and Resident 7) of 2 sampled residents. The facility census was 32.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C3 Based on interview and record review, the facility the facility failed to complete a recapitulation of stay for 1 (Resident 33) of 1 resident sampled for discharged residents. The facility census was 32.