Westpark a Waters Community

Inspectors wroteBased on observation, interview and record review, the facility failed to have the interdisciplinary team determine and document that a resident was capable to safely self-administer medications for 1 of 1 resident randomly observed. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications were obtained timely from the pharmacy for 3 of 3 residents reviewed for availability of medications. (Residents B, C, and D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 15 of 16 residents reviewed for dignity. (Residents' 6, 8, 9, 12, 13, 14, 16, 24, 28, 34, 37, 42, 44, 47, and an Anonymous Resident)

Inspectors wrote3. On 6/6/25 at 11:04 a.m., Licensed Practical Nurse (LPN) 2 was randomly observed administering medications to Resident 33. LPN 2 removed the medication cards from the medication cart and began to place the prescribed medication doses into a plastic medication cup. LPN 2 indicated that Resident 33's folic acid, multivitamin, vitamin B-12 and Thiamine (Vitamin B-1) were not available to be given in the medication cart. LPN 2 went to the Cubex (machine that supplies medications at the facility) to obtain the folic acid, multivitamin, vitamin B-12 and Thiamine for Resident 33. LPN 2 was unable to obtain the medications from the Cubex. LPN 2 went to the drug overflow cart and attempted to find the folic acid, multivitamin, vitamin B-12 and Thiamine to administer. LPN 2 was unable to locate the missing medications from the overflow medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure palatable food was provided for 12 of 14 residents reviewed for food. (Residents' 6, 8, 9, 13, 14, 16, 24, 26, 28, 34, 37, and 42)

Inspectors wroteBased on interview and record review, the facility failed to adequately document a discharge in a resident's electronic health record (EHR) for 1 of 1 resident reviewed for discharge in a closed record review (Resident 43).

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 1 of 1 resident reviewed for care planning. (Resident 42)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely perineal (genital and anal area) care for 1 of 1 resident observed for activities of daily living (ADLs). (Resident 24)

Inspectors wroteBased on interview and record review, the facility failed to hold cardiac medication when vital signs were outside of prescribed parameters and to administer insulin as ordered for 2 of 5 residents reviewed for unnecessary medications. (Resident 14 and Resident 17)

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were received timely from the pharmacy for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for tube feedings (Resident 14 and Resident 41).

Inspectors wroteBased on interview and record review, the facility failed to ensure a partial dose of a controlled substance (oxycodone) was destroyed and recorded in the presence of two licensed personnel for 1 of 5 residents reviewed for unnecessary medications. (Resident 17) The clinical record for Resident 17 was reviewed on 6/5/25 at 10:30 a.m. The diagnoses included, but were not limited to, cocaine abuse, opioid use, and major depressive disorder. An Annual Minimum Data Set assessment, dated 3/24/25, indicated Resident 17 was cognitively intact. A physician's order, dated 4/3/25, noted to administer oxycodone 5 milligrams (mg) tablet, give one tablet by mouth every six hours as needed for pain. A nursing progress note, dated 5/21/25, indicated Resident 17 requested a dose of oxycodone for pain, but the facility had run out of oxycodone 5 mg tablets. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with severe cognitive impairment did not enter into binding arbitration agreements for 1 of 3 residents reviewed for arbitration. (Resident 20)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control was maintained during medication administration by not performing hand hygiene before coming into contact with a resident and donning gloves, not donning new gloves before touching a resident's medications, ensuring medications were not touched with bare hands, administered medications after being dropped on to a medication cart, and not disinfecting insulin pen hubs prior to use for 3 of 3 residents randomly observed during medication administration (Resident 8, Resident 33, and Resident 47).

Inspectors wroteBased on observation and interview, the facility failed to maintain the floors in good repair with the potential to affect 39 of 39 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were stored closed and labeled with open dates. This had a potential to effect 38 of 39 residents that eat food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the Administrator of an allegation of abuse for 2 of 2 residents reviewed for abuse. (Resident 1 and 28)

Inspectors wroteBased on interview and record review, the facility failed to provide showers, as care planned and preferred, for 1 of 3 residents reviewed for ADL (Activities of Daily Living) care (Resident 35).

Inspectors wroteBased on interview and record review, the facility failed to clarify and administer a resident's medication, as ordered; to ensure physician orders were followed, as ordered, for a resident with elevated blood sugars; and to monitor blood pressure, as ordered, prior to administering a medication for 3 of 5 residents reviewed for unnecessary medications. (Resident 10, 11, and 21)

Inspectors wroteBased on interview and record review, the facility failed to ensure vision services was provided for 1 of 1 residents reviewed for vision services. (Resident 38)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services were provided for 2 of 2 residents reviewed for dental (Resident 25 and Resident 38)

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document that self administration of medications and treatments were clinically appropriate for 1 of 1 residents randomly observed for medications at bedside. (Resident 10)

Inspectors wroteBased on interview and record review, the facility failed to assure a resident was informed of a grievance resolution for 1 of 3 residents reviewed for grievances (Resident 139).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths for 1 of 2 residents reviewed for activities of daily living (ADLs). (Resident 19)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure implementation of fall interventions per the resident's plan of care for 1 of 3 residents reviewed for accidents. (Resident 7)

Inspectors wroteBased on interview and record review, the facility failed to timely obtain laboratory test, as ordered by the physician, for 1 of 5 residents review for unnecessary medications (Resident 26).