Waverly Hills Post Acute

Inspectors wroteBased on policy review, medical record review, facility investigation review, Emergency Medical Services, Police Department Incident Narrative, and interview, the facility failed to ensure safety interventions were implemented and failed to ensure an environment free of accident hazards for 1 of 3 (Resident #4) sampled resident reviewed for accidents, resulting in significant injury and death to Resident #4 . On 1/9/2026, Resident #4, who was moderately cognitively impaired and required staff assistance with transfers, was found unresponsive by Certified Nursing Assistant (CNA) A and lying supine (lying on back with face upward) on the floor with the bed control cord stretched across her body and neck area and pinned under her back near her left shoulder. Resident #4's head and torso were partially under the bed, with the bed resting on the Resident's head and chest. [...]

Inspectors wroteBased on the facility policy review, medical record review, observation, and interview the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in resident's room for 1 of 57 (Resident #37) residents reviewed for accidents. Observations during survey revealed no wandering residents on Resident #37's hall.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to follow Physician's Orders and provide care and services regarding oxygen therapy for 3 of 6 (Resident #57, #257, and #308) residents reviewed for oxygen therapy.

Inspectors wroteBased on facility policy review, Quarterly Payroll Based Journal (PBJ) review, and interview, the facility failed to submit accurate staffing data for 1 of 4 (Quarter 2, January 1-March 31, 2025) quarters reviewed.

Inspectors wroteBased on policy review, review of the facility's Infection Control Program documents, medical record review, observation and interview, the facility failed to follow Infection Control practices when they failed to track pathogens in the Monthly Surveillance Report, when facility staff left a contaminated ice scoop in the ice chest for 1 of 2 (300 and 400 hall) nourishment rooms and when the facility failed to use enhanced barrier precautions for 1 of 3 (Resident #8) residents reviewed for pressure ulcers.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure food was stored, prepared, and served under sanitary conditions related to unlabeled, undated, food items, expired foods, and dirty metal carts, food containers, food carts, floors, and nourishment refrigerators.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 6 of 60 (Resident #6, #21, #22, #35, #36, and #45) resident shared bathrooms observed.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 3 of 12 (Certified Nursing Assistance (CNA) A, B, C), failed to knock and/or announce self when entering resident rooms and failed to use courtesy titles when addressing residents during dining.

Inspectors wroteBased on facility policy, medical record review, and interview the facility failed to follow Physician Order for 2 of 5 (Resident #23 and #213) sampled residents reviewed.

Inspectors wroteBased on policy review, medical record review, observation and interview the facility failed to obtain physician's orders for a resident with dialysis, failed to assess and monitor dialysis sites for thrill, bruit, and infection, and failed to follow/implement individualized care plan for 1 of 1 (Resident #263) sampled residents for dialysis.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 staff members (Registered Nurse (RN) A) left the medication cart unlocked, unattended, and out of sight for 1 of 7 (100 Hall medication cart) medication storage areas and when medications were left unsecured and unattended, at the bedside, in Resident #41's and Resident #52's room.

Inspectors wroteBased on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 6 of 8 residents (Resident #11, #14, #18, #52, #163, and #215) reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct appropriate fall investigations to identify all contributing factors (root causes) including the disabling of the courtyard door alarm on the 400 hall and failed to implement appropriate interventions to ensure resident safety. [...]

Inspectors wroteBased on facility policy review, Certified Nursing Assistant (CNA) Assignment Sheets, Nursing Home Licensing Checklist, facility time punches, the facility working schedule, and interview, the facility failed to ensure Daily Assignment Sheets were completed for 18 of 18 (1/2/2023, 1/9/2023, 1/13/2023, 2/10/2023, 2/14/2023, 2/15/2023, 3/4/2023, 3/5/2023, 3/14/2023, 3/21/2025, 3/25/2023, 3/31/2023, 4/2/2023, 4/8/2023, 4/14/2023, 5/11/2023, 7/1/2023, and 7/29/2023) days and sufficient staff were scheduled for 2 of 218 (3/23/2023 and 4/2/2023) days reviewed.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 5 staff member (Licensed Practical Nurse (LPN #3)) left the medications unattended, when 2 of 5 staff members (LPN #4 and #LPN #7 ) left the medication cart and treatment cart unlocked and unattended, and when 2 of 7 medication storage areas (Station 2 Medication Room, and Station 2 medication Cart) had expired medications, open undated medications, had externals and internals stored together, and a medication was left at a resident's bedside.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure practices that prevent the potential spread of infection were maintained when 2 of 5 nurses (Licensed Practical Nurse (LPN #3, and #4) failed to clean reusable equipment before and after use, and when 1 of 3 staff Certified Nurse Assistant (CNA #7) failed to wear proper Personal Protective Equipment when entering the room of a resident positive for Covid-19.

Inspectors wroteBased on facility policy, Facility Assessment, employee training records, and interviews, the facility failed to develop, implement, and maintain an effective behavioral health training program for all staff (direct care staff, indirect care staff, contract staff and volunteers, as appropriate to their roles).

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 5 residents (Resident #32) reviewed for self-administration of medication.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 1 of 32 (Resident #213) resident bathrooms observed.

Inspectors wroteBased on review of facility policy, medical record review, facility investigations and interview, the facility failed to report the results of abuse allegation investigation outcomes within 5 working days of the alleged violation for 3 of 3 residents (Residents #11, #48, and #51) sampled for abuse allegation investigations.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a physician's order for a urinary catheter and failed to ensure appropriate diagnoses for the indwelling urinary catheter for 1 of 2 residents (Resident #214) sampled residents reviewed with urinary catheters.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of medical records for 2 of 5 (Resident #32 and #113) residents observed during medication administration.

Inspectors wroteBased on facility policy, facility data, and interview, the facility's QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI) program failed to identify issues, take appropriate actions, ensure appropriate interventions, and monitor effectiveness for falls related to 71 resident falls in the last 120 days.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure 2 of 5 sampled residents (Resident #33 and #47) were vaccinated for Pneumonia.