West Janisch Health Care Center

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 Halls (400 Hall) 22 of 22 residents (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect.- On [DATE] the facility failed to timely extinguish the fire when CR #44 was engulfed in flames and failed to assess and render aid to CR #44 after the fire was extinguished. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 13 of 22 residents (CR #44, Resident #2 Resident #3, Resident #6, Resident #11, Resident #18, Resident #20, Resident #36, Resident #43, Resident #48, Resident #54, Resident #58, and Resident #60) and 1 of 4 Halls (400 Hall) reviewed for quality of care.- Facility staff failed to immediately put out CR #44 when she was engulfed in flames with a fire extinguisher, a non-fire retardant blanket was used that worsened the fire. After the fire was extinguished staff failed to assess and render aide to CR #44. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #24) residents reviewed for parenteral fluids. - The facility failed to follow physician orders for Resident #24 to receive an oncologist evaluation for the removal of her implanted central venous access (port) for 58 days after the order was given on 07/23/25. On 09/19/25 the facility scheduled Resident #24 for evaluation by her oncologist on 10/07/25. This failure could place residents at risk of unwanted infections, hospitalization and further decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 6 of 6 meals reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch and dinner meals on 10/02/25, 10/03/25, and 10/04/25. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in condition in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 2 of 8 residents (Resident #1 and Resident #24) reviewed for notification of changes. - The facility failed to notify Resident #1's RP of physician orders on 10/01/25 for a chest x-ray due to a newly identified cough. The RP was notified on 10/06/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 22 of 22 (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure that assessments accurately reflected residents' status for 2 (CR #44 and Resident #28) of 6 residents reviewed for accuracy of assessments. The failed to ensure CR #44's left sided hemiplegia and hemiparesis (paralysis and weakness was documented accurately in her Quarterly MDS dated [DATE] as a functional limitation in range of motion and diagnosis. The facility failed to ensure that Resident #28's behavior of wandering was documented on their quarterly MDS assessment dated [DATE].

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1(Resident #11) of 6 residents reviewed for care plan. Resident #11's care plan printed 9/30/25 was not revised to reflect removal of a urinary catheter with an order to remove the foley catheter on 8/13/24 and when a pressure ulcer wound resolved with a discontinued order dated 9/1/25. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nurses were able to demonstrate competency in skills to provide nursing and related services for 1 of 1 resident (Resident #1) by 1 of 2 nurses (LVN G) reviewed for competent staff, in that: The facility failed to ensure LVN G was competent to administer medications and knowledgeable regarding Enhanced Barrier Precautions. This failure could place residents at complications from g-tube medication administration or possible infection risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 9% based on 4 errors out of 43 opportunities, which involved 1 of 1 resident (Resident #1) and 1 of 2 staff (LVN G) observed during medication administration reviewed for medication error. The facility failed to ensure Resident #1 received the complete doses of:1. Multivitamin Oral Tablet2. Sennosides-Docusate Sodium Oral Tablet 8.6-50 mg3. Vitamin C 500 mg4. Thiamine HCL Oral Tablet 100 mgThe failure could place residents at risk of not receiving therapeutic dosages and/or effects of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured and locked in accordance with currently accepted professional principles during medication administration of 1 of 2 staff (LVN G). The facility failed to ensure that LVN G did not throw Resident #1's crushed Metoprolol in the trashcan in the resident's room. This failure could place residents at risk of obtaining medications that were not ordered for them and potential adverse reactions or side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide diagnostic services to meet the needs of its residents in a timely manner for 1 of 1 (Resident #1) residents review for radiology services. - The facility failed to ensure a chest x-ray was performed timely for Resident #1 following his physicians order given to rule out pneumonia on 10/01/25. The chest x-ray was performed on 10/06/25. This failure could place residents at risk of delayed diagnosis and medical treatment to prevent complications and injuries. Findings Included: Resident #1 Record review of Resident #1's Face Sheet dated 10/02/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #41) of 7 resident reviewed for infection control. The facility failed to ensure LVN C wore a gown while performing wound care for Resident #41. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 09/29/25, 10/03/25 and 10/04/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 09/29/25 at 10:16 AM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 09/24/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure comprehensive care plans with the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being were developed for 2 of 3 residents (Resident #34 and #28) reviewed for care plans, in that: Resident #34 and #28, who were both identified as high risk for falls and in need of fall mats, did not have the intervention of fall mat included in their care plans. This failure places residents at for not receiving adequate care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of two medication carts reviewed for medication storage. The facility failed to keep resident medications in their original containers/packaging located in the medication cart assigned to LVN M. There were 18 loose pills at the bottom of one of the drawers belonging to unknown residents. These failures could affect residents receiving medications placing them at risk of receiving the wrong medication and adverse side effects.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 4 (Residents #1, #2, #3, and #4) of 6 residents reviewed for wound care. -The facility failed to provide wound care services for Resident #1 as ordered for 08/18/23 to 08/19/23, 09/02/23, 09/07/23, 09/10/23, 09/16/23, 09/17/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, 10/01/23, and 10/14/23. -The facility failed to provide wound care services for Resident #2 as ordered on 10/01/23. -The facility failed to provide wound care services for Resident #3 as ordered for 08/01/23, 8/11/23, 08/24/23, 08/26/23 to 08/27/23, 09/02/23, 09/10/23, 09/16/23, 09/17/23, 09/24/23, 09/26/23, 09/27/23, 09/28/23, 10/01/23, 10/02/2023, and 10/14/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10.26 % based on 4 errors out of 39 opportunities, which involved 2 of 6 residents (Resident #167, Resident #26) reviewed for medication errors. 1. The facility failed to ensure Medication Aide A administered medications as ordered to Resident #167 by administering Ferrous Sulfate 325 mg instead of the ordered Ferrous Fumarate 325 mg (medication for low red blood cells). 2. Medication Aide A failed to administer medications as ordered to Resident #26 by omitting the ordered Potassium Chloride ER 8 mEq (medication for build-up of fluid in the body's tissue). 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the MDS assessment was accurately completed for 1 of 15 residents (Resident #50) reviewed for MDS assessments, in that: - The facility failed to ensure Resident #50 was accurately assessed to not need translation services although she could only communicate in the Russian language. This failure placed residents at risk of not receiving adequate services and/or care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain highest practical physical and psychosocial well-being for 1 of 15 residents (Resident #27) reviewed for ADL care, in that: - The facility failed to ensure Resident #27 did not have long fingernails with black grime packed underneath the nails. This failure placed residents at risk of experiencing a decreased quality of life and an increase risk of infection.