West Rest Haven

Inspectors wroteBased on observation and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two1 (Resident #1 and Resident #2) of 6 residents reviewed for quality of care. * CNA A failed to provide care to Resident #1 on 4/28/2026 when she turned the call light off and left the resident's room without meeting the resident's needs. *Nurse B failed to provide care to Resident #2 on 4/28/2026 when she turned the call light off and left the resident's room without meeting the resident's needs.* CNA A failed to provide care to Resident #2 on 4/28/2026 when she turned the call light off and left the resident's room without meeting the resident's needs. These failures placed the Resident at risk of not receiving adequate care and services, increased risk of injury, decreased self-worth and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision and fall interventions on [DATE] when Resident #1 fell and received a laceration to the back of his head and a trace subarachnoid hemorrhage of the anterior interhemispheric fissure (a specific pattern of bleeding, often indicating a ruptured aneurysm of the anterior communicating artery). This failure could place all residents at risk for serious injury and accidents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to ensure Resident #1 was provided a mechanical lift transfer by two staff to move between surfaces which resulted in a transfer with injuries including an acute fracture of the greater trochanter (femur) which was slightly displaced on 11/29/2025. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 11/29/2025/and ended on 12/05/2025. The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 5 residents (Resident #1) reviewed for professional standards. The facility failed to ensure RN A provided services that met professional standards of care when she practiced outside her scope of practice and ordered/administered an antibiotic for Resident #1 without obtaining a physician's order on 08/14/25This failure could place residents at risk of inadequate care, possible adverse drug reaction or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any medication errors for 1 of 5 (Resident #1) residents reviewed for medication errors. The RN ordered and administered an antibiotic Ceftriaxone (an antibiotic used to treat infection) 1gram intramuscularly without a physician's order to Resident #1 on 08/14/25. These failures could place residents at risk of being administered medications that have not been prescribed.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Residents #36, #39, #43, #15, #10, and #8) of 25 residents reviewed for care plans. A) The facility failed to ensure Residents #36, #39, and #43's care plans addressed the specific individualized method of transfer needed (etc. use of a gait belt, mechanical lift, stand aid) for resident transfers. An Immediate Jeopardy (IJ) was identified on 6/25/2025. The IJ template was provided to the facility on 6/25/2025 at 12:24pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (Residents #19, #36, #39, and #43) of 24 residents reviewed for accidents and hazards. A) The facility failed on [DATE] to ensure Resident #43 was provided contact guard assistance during sit to stand transfers which resulted in an actual fall which resulted in 9th, 10th and 11th right rib fractures, C4 spinous process fracture, T10 compression fracture, and a frontal scalp hematoma/laceration. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:00pm. [...]

Inspectors wroteB) Review of Resident #10's face sheet, printed on 06/27/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (not enough oxygen in the blood), post-traumatic stress disorder (PTSD - a mental health condition caused by a traumatic event), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and low back pain. Review of Resident #10's quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 which indicated moderately impaired cognition. The MDS reflected Resident #10 received antipsychotic, antidepressant, antianxiety, and anticonvulsant medications. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 4 (Station 1 south-hall, Station 1 east-hall, Station 2 south-hall, Station 2 north-hall, of 5 medication carts reviewed for medication storage. - The facility failed to ensure an undated bottle of Systane eye drops without a resident name or label were removed from the Station 1 South-hall medication cart. - The facility failed to ensure the Station 1 east-hall med cart did not contain three loose pills, the Station 2 south-hall med cart did not contain one loose pill, and the Station 2 north-hall med cart did not contain 18 loose pills. - The facility failed to ensure an expired bottle of magnesium oxide, best by 02/2025, was removed from the Station 2 north-hall med cart. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to the facility, make prompt efforts by the facility to resolve grievances the resident may have, and make information on how to file a grievance or complaint available to the resident for 1 of 12 residents (Resident #11 ) reviewed for grievances. 1. On an unknown date and time, the SW heard a grievance on Resident #11's behalf and failed to initiate the grievance process. 2. On an 06/26/2025 at unknown time, LVN I heard a grievance on Resident # 11's behalf and failed to initiate the grievance process. These failures could place residents at risk of not having their grievances heard and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, to other officials (including to the State Agency) for one resident (Resident #43) of eight reviewed for abuse and neglect. The facility failed on 4/14/2025 to immediately report to the State Agency (within 2 hours) Resident #43's witnessed fall which resulted in 9th, 10th and 11th right rib fractures, C4 spinous process fracture, T10 compression fracture, and a frontal scalp hematoma/laceration. This failure placed residents at risk of further potential neglect.

Inspectors wroteBased on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for 1 of 3 discharged residents (Resident #16) reviewed for closed records. The facility failed to complete and transmit a discharge MDS assessment for Resident #16, who discharged on [DATE], within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 (Resident #39) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS accurately reflected Resident #39's broken natural teeth. This deficient practice could place residents at risk of inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #74) of three residents reviewed for PASRR Level 1 screenings. The facility's failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #74. The PASRR Level 1 Screening dated 01/22/25 did not indicate a diagnosis of mental illness, although the diagnoses of psychotic disorder with hallucinations, major depressive disorder, and anxiety disorder were present upon Resident #74's admission on [DATE]. This failure could place residents with mental illness of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 1 (Resident #89) of 6 residents reviewed for comprehensive care plan revisions. The facility failed to update Resident #89's care plan to reflect the current need for extensive assistance for transfers. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1of 2 residents reviewed with limited range of motion (Resident #15), received appropriate treatment and services to prevent a decrease in range of motion. The facility failed to ensure Resident #15 had interventions in place for her left- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her left hand. This deficient practice could place residents with contractures at risk for decrease in mobility, range of motion, and could contribute to worsening of contractures. Findings Include: Review of Resident #15's face sheet dated 06/26/2025 reflected she was admitted on [DATE] with the diagnoses of hemiplegia and hemiparesis (one-sided paralysis) . [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #10) of 6 reviewed for trauma-informed care. The facility failed to identify possible triggers when Resident #10 had a history of trauma. This failure could place residents at risk for severe psychological distress due to re-traumatization, decreased quality of life and psychosocial emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications when used in excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. The facility failed to ensure Resident #8 did not received Keflex (is used to treat urinary tract infections (is a bacterial infection in the urinary system)) for prophylactic use. [...]

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 nourishment refrigerators for 2 (Station #1, and Station #2) of 2 nourishment room refrigerators reviewed for food and nutrition services. 1. The facility failed to ensure the nourishment room refrigerator temperature log was maintained in station #2's nourishment room. 2. The facility failed to ensure station #2's refrigerator stayed within a temperature range to maintain effective refrigeration. 3. The facility failed to ensure all items in station #1's refrigerator was labelled and dated. These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rational, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 2 residents reviewed for antibiotic stewardship. (Resident #8). The facility failed to ensure they were using an established and accepted criteria to determine if her UTI met the criteria for antibiotic use and failed to ensure she was not receiving a prophylactic antibiotic without written justification for use regards to Resident #8's prophylactic antibiotic Keflex. This failure could place residents at risk of inappropriate antibiotic use, medication side effects and increased antibiotic-resistant infections. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility to ensure that the residents had the right to and that the facility promoted and facilitated resident self-determination through support of resident choice for 26 (Resident #'s 1, 3, 6, 10, 14, 15, 16, 17, 20, 25, 28, 36, 37, 41, 42, 46, 47, 67, 68, 79, 83, 92, 96, 105, 107, and 362) of 26 residents whose care was reviewed, in that: 1) The facility denied Resident #16 the right to sell her car by declaring her incompetent to make her own decisions. 2) The facility was applying an order for all (Resident #'s 1, 3, 6, 10, 14, 15, 16, 17, 20, 25, 28, 36, 37, 41, 42, 46, 47, 67, 68, 79, 83, 92, 96, 105, 107, and 362) residents upon admission related to their resident rights that stated, It is my determination that this resident is not capable of understanding and exercising his/her rights d/t their medical diagnosis. [...]

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 in 1 of 1 kitchen reviewed for dietary services. Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 6 residents (Resident #1) reviewed for resident rights; in that: The facility failed to ensure Resident #1's call lights was within reach. This failure could place residents at risk of needs not being met.

Inspectors wroteCitation Text for Tag 0641, Regulation FF14 [NAME], [NAME] Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 10 residents (Residents #83) reviewed for resident assessments. The facility failed to ensure the MDS assessment accurately reflected: Resident #83's moderately impaired vision. This deficient practice could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #67) of 6 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #67's risk for falls resulting in no fall interventions in place for this resident. This failure could place residents of risk for not receiving appropriate care and treatment, lack of fall interventions, a delay in treatment, a decline in health, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #16) of 6 residents reviewed for pharmacy services. The facility failed to monitor Resident #16 for side effects/adverse reactions for the use of Xarelto (an anticoagulant medication- blood thinner). These failures could place residents at risk of bruising, and bleeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents in obtaining routine dental services for 2 of 6 (Resident #47 and Resident #107) residents reviewed for dental services. The facility failed to assist Resident #47 and Resident #107 in obtaining dental services since their admission to the facility to assess for dental care needs. This deficient practice could affect residents by placing them at risk of not receiving necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being which could result in a decreased quality of life.

Inspectors wroteBased on observation, interview, 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 infection for 1 of 5 residents (Resident #61) reviewed for infection. The facility failed to ensure LVN A performed hand hygiene prior to medication administration for Resident # 61. The facility failed to ensure LVN A performed hand hygiene after glove use during medication administration for Resident #61. The facility failed to ensure LVN A performed cleaning and disinfecting of blood pressure cuff after use on Resident #61. These failures could lead to the spread of infection to residents, residents illness, and /or resident distress.

Inspectors wroteBased on interview and record review the facility failed to develop a Comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes any services that would otherwise be required but are not provided due to the resident's exercise of rights including the resident right to refuse treatment for 10 (Resident #29, 49, 13, 92, 43, 14, 65, 93, 60, 99) of 20 resident Care Plans reviewed in that: The facility failed to address Resident's #29, #49, #13, #92, #43, #14, #65, #93, #60 and #99 Code Status on their comprehensive person-centered care plan. This failure could affect residents and could result in resident's needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's environment remains as free of accident hazards as is possible for 2 of 4 used sharps (used to store sharp medical instruments) containers on treatment carts reviewed for accidents and hazards. The facility failed to ensure the storage of contaminated sharps bins on two treatment carts on Station One were secured and safe. These failures placed residents at risk of being exposed to contaminated sharps and possible bloodborne pathogens.

Inspectors wroteBased 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 three (Memory Care, 1East Hall, and 2North Hall) of six clean linen closets and one of one mecanical lifts reviewed for infection control. The facility failed to ensure clean linen closets were kept free of equipment that had not been sanitized before and after use. The facility failed to ensure CNAs K and L sanitized the mechanical lift (equipment used to lift residents) between use on two residents. This failure could place residents at risk of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments, permit only authorized personnel to have access to the keys, and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for two (Nurses' Station Two Medication Cart #1 and #2) of five medication carts reviewed for security. 1. The facility failed to ensure staff maintain medication cart keys in a safe and secure manner. This failure placed the residents at risk for diversion of controlled substances.