Weston County Health Services

Inspectors wroteThis requirement was not met as evidenced by:Based on observation, resident trust account review, Amazon order review, medical record review and staff and resident representative interview, the facility failed to protect residents from misappropriation of resident property for 1 of 3 sampled residents (#2) reviewed for misappropriation of property.

Inspectors wroteBased on medical record review, facility incident review, resident and staff interview, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 6 sample residents (#50) reviewed for abuse. This failure resulted in actual physical harm to resident #50.

Inspectors wroteBased on observation, staff interview, temperature log review, policy and procedure review, and 2022 Food Code review, the facility failed to ensure a professional standards for food service safety were followed in 1 of 1 kitchen. The census was 53.

Inspectors wroteBased on resident, resident representative, and staff interview, grievance log review, call light log review, and policy and procedure review, the facility failed to ensure sufficient nursing staff was provided to ensure the highest practicable physical, mental and psychological well-being of 3 of 4 units (Four Corners, [NAME] Creek, Unit 6) reviewed for staffing.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure call lights were placed within residents' reach to accommodate resident needs for 1 of 19 sample residents (#45) reviewed. 1. Review of the quarterly MDS assessment dated [DATE] showed resident #45 had a BIMS score of 8 out of 15, which indicated the resident was moderately impaired and had diagnoses which included, chronic pain syndrome, urinary and bowel incontinence, hemiplegia, and was dependent upon staff for functional abilities, including mobility. Review of the care plan, last revised 10/20/25, showed the resident had a morse fall score of 55, which indicated a high fall risk and required his/her call light within reach. The following concerns were identified:a. Observation on 12/9/25 at 8:22 AM showed CNA #1 and CNA #2 provided cares for the resident. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure adequate monitoring of psychotropic medications for 2 of 5 sample residents (#1, #7) reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a transfer notice and bed-hold notice was provided in writing for 2 of 2 sample residents (#9, #50) reviewed for hospitalizations.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure preadmission screening was performed and was accurate for 2 of 3 sample residents (#1, #39) with qualifying diagnoses.

Inspectors wroteBased on observation, staff interview, record review, and policy and procedure review, the facility failed to ensure thorough wound assessments were completed for 1 of 4 sample residents (#8) reviewed for wound care.

Inspectors wroteBased on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 1 of 2 sample residents (#27) reviewed for urinary catheters.

Inspectors wroteBased on medical record review and staff interview, the facility failed to offer and/or provide pneumococcal vaccination for 1 of 5 sample residents (#1) reviewed for immunization status.

Inspectors wroteBased on observation, QAPI minutes review, and staff interview, the facility failed to ensure a qualified administrator was able to manage the facility and report to the governing body. The census was 38.

Inspectors wroteBased on staff interview and review of the Payroll Based Journal (PBJ), the facility failed to ensure the mandatory submission of staffing was submitted to CMS for 1 of 4 quarters reviewed (10/1/23 through 12/31/23). The census was 38.

Inspectors wroteBased on observation, QAPI minutes review, job posting review, and staff interview, the facility failed to ensure the QAPI committee included a qualified administrator who attended meetings. The census was 38.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure clean dressing changes were kept clean for 1 of 1 wound care observation (resident #8).

Inspectors wroteBased on observation and staff interview the facility failed to to ensure the activities program was directed by a qualified professional. The census was 39.

Inspectors wroteBased on staff interview, review of staff schedules, and review of the Staffing Data Submission Payroll Based Journal (PBJ) report, the facility failed to ensure an RN worked at least 8 consecutive hours within each 24 hour period, 7 days a week. The census was 39.

Inspectors wroteBased on review of the facility investigation report, staff and resident representative interview, review of policy and procedure, review of facility training documentation, and State Survey Agency incident report review, the facility failed to protect the residents right to be free from physical abuse by staff for 1 of 1 sample residents (#23) reviewed for abuse allegations.

Inspectors wroteBased on review of facility policies, the review of State Survey Agency incident report logs, and staff interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act for 1 of 1 allegations of abuse reviewed.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide a written notice of transfer and notify the ombudsman for 1 of 2 sample residents (#90) reviewed for a facility-initiated transfer.

Inspectors wroteBased on observation, staff and resident interview, and medical record review, the facility failed to ensure 1 of 12 sample residents (#10) had resident-specific care plans that reflected individual needs in all required areas.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure the provision of necessary behavioral health care and services for 1 of 4 sample residents (#27) reviewed for behaviors.

Inspectors wroteBased on observation, staff interview, medical record review and facility policy review, the facility failed to administer medications as ordered by the prescriber for 1 out of 5 residents (#8) reviewed for medication administration.

Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 1 of 5 sample residents (#3) reviewed for psychotropic medication use.

Inspectors wroteBased on review of staff vaccination records, staff interview, and review of policy and procedure, the facility failed to ensure the development and implementation of additional precautions designed to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated for COVID-19. The census was 39.