Prestonwood Rehabilitation & Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from sexual abuse for 2 residents (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. On 02/21/25, Resident # 1 inappropriately touched Resident # 22 and asked Resident #22 to kiss him. On 02/21/15, Resident # 1 grabbed the hand of Resident #52 and put Resident # 52's hand in his groin area. Resident # 1 then attempted to bend over and kiss Resident # 22. Resident # 1 asked Resident #52 to go to his room. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. The facility had corrected the noncompliance before the Incident investigation began on 03/31/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of 2 (Resident #22 and Resident #52) of 24 residents reviewed for abuse and neglect. 1) LVN E and LVN M failed to immediately report sexual abuse incidents involving Resident #1 against Residents #22 and #52 to the Abuse Coordinator/the Administrator. 2) The facility failed to follow their policy to immediately protect Resident #22 and #52 from harm. 3) LVN E failed to identify sexual abuse when Resident #1 attempted to inappropriately touch Resident #52. A past noncompliance IJ was identified on 04/17/2025, and the IJ template was provided to the facility on [DATE] at 01:45 PM. The noncompliance began on 02/21/2025 and ended on 02/25/2025. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse, to the Administrator of the facility and the State Survey Agency for two (Residents #22 and #52) of 24 residents reviewed for abuse and neglect. LVN E and LVN M failed to immediately report the sexual abuse incidents involving Residents #22 and #52 to the Administrator. LVN M observed an incident of suspected sexual abuse involving Resident #1 and Resident #22 on 02/21/2025 at 09:36 AM and LVN E observed another incident of suspected sexual abuse involving Resident #1 and Resident #52 on 02/21/2025 at 01:34 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #16) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #16's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 (Resident #32) of 4 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 32's pressure ulcers. This failure could place residents at risk of not having a plan developed to address care needs.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors for 1 of 5 residents (Resident #38) reviewed for pharmacy. The facility failed to ensure the medication Lisinopril tablet 2.5 mg, twice a day was given to Resident #38 on 03/29/2025, 03/30/2025 and 03/31/2025. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility walk-in freezer were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #32) of 1 resident reviewed for catheter care. 1. The facility failed to ensure CNA C and CNA D maintained the foley catheter drainage bag below Resident #32's bladder during a mechanical lift transfer. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 1 (Nursing Medication cart hall 500 ) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when LVN B did not report a damaged blister pack of Lorazepam 0.5 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.

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 2 of 6 residents (Resident #32 and Resident #222) observed for infection control. The facility failed to ensure CNA C and CNA D used the required PPE for Resident#32 who was on enhanced barrier precautions due to his foley catheter, and wound , while performing a mechanical lift transfer on 04/01/25. The facility failed to ensure CNA C and CNA D used the required PPE for Resident#222 who was on enhanced barrier precautions due to his foley catheter, and wound, while performing a two person assist transfer on 04/02/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date food stored in the walk-in refrigerator. 2. The facility failed to date food stored in the walk-in freezer . 3. The facility failed to cover and date food in the dry storage. 4. The facility failed to sanitize the food thermometer while measuring entrée temperatures. These failures could place residents who at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination trough support of resident choice for 4 of 24 residents reviewed for resident rights. The facility failed to ensure residents were informed and provided the right to eat in the dining room. This deficient practice could place residents at risk of having their rights violated, poor self-esteem and socialization and a poor quality of life.

Inspectors wroteBased on, interview and record review the facility ensure residents had the right to and the facility made prompt efforts to resolve grievances the resident may for 3 of 24 residents (Residents #18, #32, #50) reviewed for resident rights. The facility failed to ensure residents received responses to grievances and concerns. This deficient practice could place residents at risk of having their rights violated, not receive responses to their grievance, a decreased of self-worth and a decline in quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible for three of four residents (Residents #20, #8 and #38) reviewed for incontinence and foley catheter care. 1. CNA N failed to provide adequate perineal care for Resident #20, after an incontinent episode, when she failed to ensure all fecal matter was removed from the resident's perineal area. 2. CNA E failed to provide adequate perineal care for Resident #8, after an incontinent episode, when she failed to ensure all fecal matter was removed from the resident's perineal area and failed to clean the residents' buttocks from front to back. 3. [...]

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 six (Resident #11, Resident #113, Resident #42, Resident #114, Resident #20, and Resident # 8) of ten residents observed for infection control. 1. LVN A failed to decontaminate the glucometer which was used to obtain a fingerstick blood sugar on Resident #11 when she failed to allow the glucometer that was sanitized with a germicidal wipe to air dry before returning the glucometer to the medication cart. 2. LVN A failed to prevent cross contamination of Resident #11's insulin and a bottle of test strips, used to obtain glucose levels, when she carried both items into Resident #11's room. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #13) reviewed for respiratory care. The facility failed to ensure Resident #13's nasal cannula tubing was labeled or dated. This failure could place residents at risk of respiratory infections.