White Settlement Nursing Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 residents (Resident #6) reviewed for treatment of pressure ulcers.1. The facility failed to implement interventions for Resident #6's right arm contracture which led to the development of a stage 3 pressure ulcer (wound developed from pressure that extends through the skin into the fatty layer but not into the muscle, tendon or bone) to the right palm identified on 06/03/2026.2. The facility failed to ensure Resident #6's dressing to the left hip was dated and initialed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a clean, safe, and functional environment for 1 of 8 rooms (room [ROOM NUMBER]) and 2 of 2 halls (Station 1 and Station 2) reviewed for environment. 1. The facility failed to repair the blinds in Resident #27's room.2. The facility failed to ensure there was not a foul odor that lingered into the hall from the soiled utility room in Station 1 hall.3. The facility failed to ensure there was not a strong urine odor in Station 2 hall near Resident #28, Resident #16 and Resident #85's rooms. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 16 residents (Residents #26 and #6) reviewed for ADL care. The facility failed to ensure nail care, to include trimming, was provided to Residents #26 and #6, observed on 7/28/26, 7/29/26, and 7/30/26. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 1 resident (Resident #6) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #6's contractures to right and left hands and arms. The failure could place residents at risk for decline in range of motion, decreased mobility, pain, and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 6 residents (Residents #7, #10, 6#2) reviewed for accidents and supervision. 1. The facility failed to ensure Residents #10 was covered with a smoking apron while being supervised during smoking breaks. 2. The facility failed to ensure Residents #7, #10, and #62 received quarterly smoking assessments. These deficient practices could place residents at risk for burns causing injury or harm.

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 the facility's only kitchen. 1. The facility failed to ensure a large piece of meat stored in the refrigerator was properly sealed and stored to prevent liquid from spilling over other food items that were not properly sealed, labeled or dated.2. The facility failed to ensure staff that worked or entered the kitchen wore and maintained proper use of hair nets. This failure could place all residents at risk for food contamination and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents for 1 of 2 halls (Station 1), Resident #6's room, and 1 of 1 kitchen reviewed[VT69.1] for pest control. The facility failed to ensure Station 1 hall and the kitchen were free from pests. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 5 residents reviewed for comprehensive care plans. The facility failed to update Resident #10's care plan to address the use of a smoking apparatus. The facility failed to ensure Resident #10 was wearing an apron as it was on the ground underneath table where CNA C was standing. This failure could result in the resident not receiving appropriate supervision, protection and care during smoking breaks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 3 residents (Resident #6) reviewed for enteral feeding. The facility failed to ensure LVN F checked G-tube (tube placed into the stomach to deliver food, liquids, and medicine) placement prior to administering Resident #6's medications on 07/29/26 per facility policy and physician's order. These failures could place residents at increased risk of aspiration, bloating discomfort, and not receiving the full benefit of the medications administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 2 of 6 residents (Resident #60 & #76) and 1 of 3 medication carts (Station 2 Nurse cart) reviewed for pharmaceutical services. 1. MA E failed to supervise Resident #60 after she left the resident's medications in his room during morning medication administration on 07/28/26. 2. The facility failed to ensure that one bottle of OTC Famotidine 10 mg, with an expiration date of January 2026, and a bubble pack of Ondansetron 8 mg tablets prescribed to Resident #76, with an expiration date of 06/20/26, had been removed from the Station 2 nurse cart. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 27.59%, based on 8 errors out of 29 opportunities, which involved 1 of 5 residents (Resident #6) and 1 of 3 staff (LVN F) observed during medication administration reviewed for medication error. The facility failed to ensure LVN F mixed each crushed medication with water and administered one medication at a time through Resident #6's g-tube. This failure could place residents at risk of medication interactions leading to an altered therapeutic response.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen. The facility failed to ensure water in the compartment sink had an appropriate ppm of sanitizer. This failure could place residents at risk for food contamination and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility's only kitchen free of pest when reviewed for pest control. The facility failed to ensure the facility's kitchen was free of gnats and roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to ensure staff consistently performed resident rounds every two hours as required by facility policy and Resident #1's care plan. This failure could place residents at risk for complications associated with delayed care which could negatively affect the resident's safety, comfort, and skin integrity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff work area for 1 of 5 resident rooms (Resident #1) reviewed for call lights. The facility failed to ensure a call light in Resident #1 room was accessible. Resident #1's call light was observed on the floor out of his reach while he was in bed on 10/18/25. This failure could place residents who rely on the call light system to have delayed response or no way to contact staff to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely and allowed the resident to use his or her belongings to the extent possible for 1 of 5 residents (Resident #1) reviewed for sanitary and comfortable environment.1. The facility failed to maintain Resident #1's wheelchair in a sanitary and safe operating condition leaving food, liquid, dirt, and debris to collect down both sides of the wheelchair. 2. The facility failed to ensure Resident #1's wheelchair padding on both arm rests were not torn and didn't expose padding on 08/11/25. These failures could place residents at risk of contamination, infections, skin tears and bruising.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were provided comfortable and safe temperature levels maintained at a range of 71 to 81 degrees Fahrenheit for 16 of 26 residents (Residents #1, #2, #3, #4, #5, #6,#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) of 26 residents reviewed for environment. The facility failed to ensure Residents #1, #2, #3, #4, #5, #6,#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 had adequate cooling. This failure could place residents at risk of heat related illnesses and dehydration.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse , neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Residents #17 and #18) reviewed for abuse. The facility failed to ensure Resident #17 was not abused by Resident #18 who hit her in the face. The noncompliance was identified as PNC. The noncompliance began on 05/22/25 and ended on 05/22/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for one of one meal (lunch on 05/07/25) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by: - leaving out the dinner roll for the pureed diets on 05/07/25, and - substituting greens for broccoli florets This failure could place residents at risk of weight loss, altered nutritional status and diminished quality of life.

Inspectors wroteBased on observations, and interviews, and record review, the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 5 of 20 residents (Residents #20, #24, #65, #78, and #200) reviewed for privacy. The facility failed to ensure full visual privacy for Residents #20, #24, #65, #78, and #200. This failure could cause residents embarrassment, of loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 2 halls (station 2) and 1 of 1 activity room and 1 of 4 community bathrooms (community bathroom [ROOM NUMBER]), and 1 of 12 (room [ROOM NUMBER]) resident rooms. The facility failed to ensure an effective pest control program was in place to keep cockroaches out of the facility. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good grooming, and personal hygiene for 1 of 3 residents (Resident #96) reviewed for ADL care. The facility failed to ensure Resident #96's fingernails were cut. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #45) reviewed for enteral feeding. The facility failed to follow physician order for Resident #45 pertaining to his enteral feeding downtime. This failure placed residents at risk of dehydration, aspiration pneumonia, and metabolic abnormalities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 1 (Resident #46) residents reviewed for tracheostomy care. The facility failed to ensure Residents #46 had an emergency tracheostomy kit at the resident's bedside. This failure placed the resident at risk of delayed lifesaving interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rates are not 5 percent or greater. There were 5 errors out of 44 opportunities which resulted in an 11% percent medication error rate for 1 of 6 residents (Resident #87) reviewed for medication administration. RN F cocktailed (mixed together) five of Resident #87's medications instead of administering them separately via his feeding tube, creating an error rate of 11%, (5 errors out of 44 opportunities). This failure could place residents at risk of having their gastric tubes clogged.

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 infections for 1 of 5 residents (Resident #38) reviewed for infection control. CNA A and CNA B failed to wear the appropriate PPE while they transferred Resident #38, who was on Enhanced Barrier Precautions, to her bed. This failure could place residents at risk of being infected by staff in contact with other residents with infections.

Inspectors wroteBased on interview, observation, and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's physical or mental status or need to alter treatment significantly for one (Resident #1) of eight residents reviewed for change of condition. The facility failed to notify Resident #1's physician and responsible party when the resident's blood pressure was 216/114 on 01/24/25. An Immediate Jeopardy (IJ) was identified on 02/14/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 2/14/25 at 05:04 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eight residents reviewed for quality of care. The facility failed to follow protocols for abnormal vital signs when MA C did not notify the nurse after Resident #1's blood pressure was 216/114 and there was no re-check to ensure accuracy to determine if further treatment was needed. An Immediate Jeopardy (IJ) was identified on 02/14/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 2/14/25 at 05:04 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Resident #47) reviewed for abuse. The facility failed to ensure Resident #47 was free from abuse when LVN F sent the resident a mentally/emotionally abusive text message, which caused the resident to experience fear for her personal safety. The noncompliance was identified as PNC. The IJ began on 01/16/24 and ended on 01/17/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 2 of 18 residents (Residents #15 and #59) of residents and one of two halls (Station 1) reviewed for safe clean homelike environment. 1. The facility failed to properly clean and maintain a sanitary and comfortable environment free of foul odors on Station 1. 2. The facility failed to ensure Resident #15 and #59 had a clean privacy curtain. 3. The facility failed to maintain resident's wheelchairs in a sanitary and safe operating condition according to 4 residents who attended the confidential group interview. These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on two of three medication carts (Station 1) and 1 of 1 (Resident #4) reviewed for pharmacy services. 1. The facility failed to ensure the station 1 south nurses medication cart contained accurate narcotic record for Residents #4 . 2. The facility failed to ensure a bottle of Aspirin 81mgs tablets that was expired was removed from the station 1 Hall nurse's medication cart. This failure could place residents at risk for drug diversion, delay in medication administration, and at risk of receiving medications that were ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on three of three medication carts (station 1 south side, and station three) reviewed for pharmacy services. The facility failed to ensure insulin pens that were opened from station 1 South and station 3 nurse's medication cart were dated with an opening date. This failure could place residents at at risk of receiving insulins that were ineffective.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received proper treatment and assisted the resident in making appointments for 1 of 29 residents (Resident #74) whose records were reviewed for vision services. LVN E failed to ensure that Resident #74 was scheduled for an ophthalmologist appointment since February 2024. This failure could affect residents and contribute to a decline in vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary treatment and services to promote healing for 1 of 3 residents (Resident #86) reviewed for pressure ulcers. The facility failed to ensure Resident #86's Stage 4 pressure ulcer was covered with a dressing. This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 2 (Resident #69 and #92) of 4 residents reviewed for dialysis. 1. The facility failed to ensure post-dialysis assessments were completed for Resident #69 after return from dialysis treatment. 2. The facility failed to ensure post-dialysis assessments were completed for Resident #92 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for one resident (Resident #77) of three residents reviewed for (DRR) Drug Regimen Review. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #77's psychotropic medication (Cymbalta [Duloxetine HCL]) GDR that was due. This deficient practice could place residents at risk of receiving unnecessary medications and dosages.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 of 90 residents (Residents #56) reviewed for call lights. The facility did not adequately equip Resident #56 with a call light to allow the resident to call for assistance. This failure could place residents who rely on the call light system to have a delayed response or no way contact staff to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of five residents reviewed for residents rights. 1. The facility failed to maintain a resident's wheelchair in a sanitary and safe operating condition for Resident #1 who had dried vomit on her wheelchair. 2. The facility failed to maintain a homelike environment for Resident #1 who had a large portion of wood missing from her headboard. These failures could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents. The facility failed to safely transfer Resident #1 and prevent and injury during the use of the mechanical Hoyer lift, which resulted in the resident sustaining neck and back pain. This failure could place resident at risk for accidents, injuries, and hospitalization.