Winfield Rehab & Nursing

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months reviewed. (July 2025 and August 2025)The facility did not have RN coverage for 2 days in July 2025 (7/26/2025 and 7/27/2025). The facility did not have RN coverage for 2 days in August 2025 (8/02/2025 and 8/03/2025). This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2025 for the fourth quarter July 2025 to September 2025). The facility failed to submit accurate RN hours for:07/01 (TU); 07/02 (WE); 07/03 (TH); 07/04 (FR); 07/05 (SA); 07/06 (SU); 07/07 (MO); 07/08 (TU); 07/09 (WE); 07/10 (TH); 07/11 (FR); 07/12 (SA); 07/13 (SU); 07/14 (MO); 07/15 (TU); 07/16 (WE); 07/17 (TH);07/18 (FR); 07/19 (SA); 07/20 (SU); 07/21 (MO); 07/22 (TU); 07/23 (WE); 07/24 (TH); 07/25 (FR); 07/26 (SA); 07/27 (SU); 07/30 (WE); 07/31 (TH) 08/02 (SA); 08/03 (SU); 08/04 (MO); 08/05 (TU); 08/07 (TH); 08/08 (FR); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that:The facility failed to ensure the dish machine reached recommended minimal 50-100 parts-per-million, (PPM), of hypochlorite (chlorine) during the final rinse cycle of the facility dish machine on 12/8/2025. This failure could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove reviewed for food service in that:The facility did not ensure the gas stove was in working order. Two of six gas stove burners (left front and left back) did not light properly when the knob was turned. This failure could place residents who eat out of the kitchen at risk of injury and undercooked food.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to incorporate recommendations from a PASARR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for 2 of 9 (Resident # 7 and Resident #9) residents reviewed for PASARR services. The facility failed to submit a complete and accurate request for NF specialized services in the LTC online portal within 20 business days after the date of the Interdisciplinary Team (IDT) meeting on [DATE]. This failure could place residents at risk of not receiving specialized PASARR services which would enhance their highest level of functioning and could contribute to residents' decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 2 of 12 residents (Resident #16 and #29) reviewed for ADL care.1. The facility failed to ensure Resident #16 did not have a thick, black substance under his nails on 12/8/2025 and 12/9/2025. 2. The facility failed to ensure Resident #29 had clean clothing on 12/08/2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.

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 for 1 of 3 medication carts (nurse cart for 300 hallway) reviewed for pharmacy services. The facility failed to dispose of expired insulin pens from the nurse medication cart for the 300 hall. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart for 300 hallway) reviewed for labeling and storage. The facility did not document when insulin was opened from the nurse medication cart for the 300 hallway. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 4 resident's personal refrigerators reviewed for food safety (Resident #59). The facility failed to ensure the refrigerator for Resident #59 did not contain a bottle of Miracle Whip that expired on 9/23/2025. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, 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 6 residents (Resident #59) reviewed for infection control. The facility failed to ensure staff did not place dirty towels on the floor of Resident #59's bathroom from 12/8/2025 to 12/9/2025. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased 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 one (Resident #1) of six residents reviewed for pharmaceutical services. The facility failed to ensure an unknown staff did not leave Resident #1's medications inside the resident's room for the resident to take unsupervised which resulted in her dropping one Colace pill and one Amlodipine pill on an unknown date. This failure could place the residents at risk of not receiving medications as ordered by the physician for 1 of 6 residents (Resident #1) reviewed for pharmaceutical services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free from physical and chemical restraints imposed for purposes of discipline or convenience and were not required to treat the resident's medical symptoms for 1 of 11 residents (Resident #8) reviewed for restraints. The facility failed to ensure Resident #8 was free from physical restraint when CNA A physically restrained him during incontinence care on 4/27/25. An Immediate Jeopardy (IJ) situation was determined to have existed between 4/27/2025 to 4/28/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for physical restraint.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 11 residents (Resident #1) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 4/24/2025 when she followed a visitor out of the facility. An Immediate Jeopardy (IJ) situation was determined to have begun on 4/24/2025 and ended on 4/28/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for serious injury and accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility did not implement their policy to report to HHSC within 24 hours when a fall incident to Resident #1 occurred on 3/04/2025. This failure could place residents at risk of injuries, abuse, and/or neglect.

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 and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #1) residents reviewed for abuse and neglect. The facility did not report to the state agency within 24 hours when NA B dropped Resident #1 during a mechanical lift transfer on 3/4/25. These failures could place residents at risk for serious injury and accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1). The facility failed to properly secure Resident #1 during a mechanical lift transfer on 3/4/25 when she fell out of the mechanical lift and there was a potential for severe injury due to the neglectful actions of NA B. These failures could place residents at risk for serious injury and accidents. The noncompliance was determined to be past noncompliance (PNC). The past noncompliance began on 3/4/25 and ended on 3/7/25. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 24 residents reviewed for accidents. (Resident #20) The facility failed to properly secure Resident #20 during a mechanical lift transfer on 8/30/2024 when she fell out of the mechanical lift and hit her head and left shoulder on the door in her room resulting in a subdural hematoma and a left shoulder separation. On 9/10/2024 at 10:00 AM an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 9/10/2024 at 3:53 PM, the facility remained out of compliance at a potential for harm with a scope identified as isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on observations, interviews, 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 4 of 10 staff (CNA F, Medication Aide H, Medication Aide M, and ADON L) observed for compliance to infection control standards during meal and medication pass. 1. The facility failed to ensure CNA F washed or sanitized her hands before and after resident contact when passing out meal trays to residents on Hall 100. 2. The facility failed to ensure Medication Aide H washed or sanitized before and after resident contact during medication pass. 3. The facility failed to ensure Medication Aide M washed or sanitized before and after resident contact during medication pass. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 3 of 24 residents (Resident #7, Resident #65, and Resident #38) reviewed for call lights. The facility failed to ensure Resident #7, #65, and #38's emergency call light string in the bathroom were not tied in knots or wrapped around the grab bar on 9/9/2024-9/11/2024. These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to develop, implement, and maintain an effective training program for 3 of 17 employees (Interim DON, Dietary Manager, and CNA S) new and existing staff reviewed for training. The facility failed to ensure the Interim DON was trained on HIV, dementia, and restraint reduction on hire. The facility failed to ensure the Dietary Manager was trained on dementia annually. The facility failed to ensure CNA S was trained on HIV, dementia, and restraint reduction on hire. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 3 of 17 employees (Interim DON, Dietary Manager, and CNA S) reviewed for orientation and annual training. The facility did not ensure QAPI training was completed by the Interim DON, the Dietary Manager, and CNA S during their orientation. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interviews and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 3 of 17 employees (Interim DON, Dietary Manager, and CNA S) new and existing staff reviewed for training. The facility failed to ensure the Interim DON was trained on an infection prevention and control program on hire. The facility failed to ensure Dietary Manager was trained on an infection prevention and control program annually. The facility failed to ensure CNA S was trained on an infection prevention and control program on hire. This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure training on Compliance and Ethics was completed for 3 of 17 employees (Interim DON, Dietary Manager, and CNA S) reviewed for training. The facility failed to ensure the Interim DON was trained on compliance and ethics on hire. The facility failed to ensure Dietary Manager was trained on compliance and ethics annually. The facility failed to ensure CNA S was trained on compliance and ethics on hire. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on interviews and record review, the facility failed to provide mandatory effective behavioral health training for 2 of 15 employees (Interim DON and CNA S) reviewed for training. The facility failed to ensure effective behavioral health training was provided to the Interim DON and CNA S on hire. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 8 residents (Resident #20) reviewed for neglect. The facility did not report to the state agency within 2 hours when an allegation of neglect occurred on 8/30/2024 that involved Resident #20 who had a fall from a mechanical lift and sustained a right subdural hematoma (brain bleed) and a left shoulder joint separation. This failure could place vulnerable residents at risk of harm due to delays in reporting an allegation of neglect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 of 8 resident (Resident #15) reviewed for smoking. The facility failed to follow their policy on smoking when Resident #15 had smoking materials that included a lighter in his possession from 9/9/2024-9/11/2024. These failures could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure employees received the required training effective communications for 2 of 17 new employees (Interim DON and CNA S) reviewed for training. The facility did not ensure an effective communication training was completed by the Contract Interim DON and CNA S during orientation. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 2 of 17 employees (Interim DON and CNA S) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by the Interim DON and CNA S during orientation. These failures could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interviews and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation and dementia management training for 2 of 17 (Interim DON and CNA S) reviewed for training. The facility did not ensure Abuse, Neglect, and Exploitation and dementia management training was completed by the Interim DON and CNA S during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure CNAs completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 1 of 5 CNAs (CNA S) reviewed for training. The facility did not ensure ANE, and dementia management trainings were completed by CNA S during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.

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 11 of 18 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) reviewed for abuse and neglect. The facility failed to protect Resident #1 from verbal abuse from Housekeeper A on 10/25/23 when Housekeeper A called Resident #1 a Nasty MF. The facility failed to protect Resident #1 from abuse from Resident #3 on 12/19/23 when Resident #3 hit Resident #1 on the arm. The facility failed to protect Resident #1 from abuse from Resident #6 on 8/6/23 when Resident #6 hit Resident #1 on her back. The facility failed to protect Resident #2 from abuse from Resident #3 on 2/4/24 when Resident #3 hit Resident #2 on her left shoulder. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 18 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) reviewed for abuse policies. The facility failed to protect Resident #1 from verbal abuse from Housekeeper A on 10/25/23 when Housekeeper A called Resident #1 a Nasty MF. The facility failed to protect Resident #1 from abuse from Resident #6 on 8/6/23 when Resident #6 hit Resident #1 on her back. The facility failed to protect Resident #1 from abuse from Resident #3 on 12/19/23 when Resident #3 hit Resident #1 on the arm. The facility failed to protect Resident #2 from abuse from Resident #3 on 2/4/24 when Resident #3 hit Resident #2 on her left shoulder. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 3 of 4 Residents (Resident #13, Resident #14 and Resident #15) reviewed for pressure injuries. The facility failed to implement interventions to prevent pressure ulcer or injury development for Resident #13 and Resident #14. The facility failed to provide ongoing skin assessments causing undiscovered wounds for Resident #13 and Resident #14 to go untreated. The facility failed to implement the wound care physicians' recommendations for Resident #13. The facility failed to identify and treat wound to Resident #13's right outer ankle. The facility failed to identify and treat wound to Resident #14's left heel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 14 residents (Resident #12) reviewed for accidents. The facility failed to properly secure Resident #12 during transport in the facility van on 3/2/2024 when he fell out of his wheelchair into the facility van. On 4/4/2024 his wheelchair lifted off the floor from defective floor straps. An Immediate Jeopardy (IJ) situation was identified on 6/26/2024 at 2:40 PM. While the IJ was removed on 6/27/2024 at 1:35 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. [...]

Inspectors wroteBased on observation and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 4 of 4 resident shower rooms (Halls 100, 200, 300 and 400) observed for resident environment. The facility failed to ensure the shower rooms in the facility were clean. There was a black substance on the bathroom tiles and baseboards on 6/24/2024 and 6/25/2024. This failure could place residents at risk for an unsafe and unsanitary environment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure 6 of 11 (NA H, NA K, NA L, NA M, NA O, NA P) staff were not working in the facility longer than four months without having completed a nurse aide competency evaluation program. The facility failed to ensure NA H, NA K, NA L, NA M, NA O, NA P became certified within four months of hire as full-time staff. This deficient practice place residents at risk for receiving care from an individual whose skill level was not known.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 2 of 15 residents reviewed for abuse and neglect. (Residents #8 and #9) The Administrator failed to report an allegation of abuse on 12/30/2023 when Resident #8 was observed in the room of Resident #9 with his hands under the covers by staff feeling of Resident #9's breasts. This failure could place residents at risk for further abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify and consult with the resident's physician when there was a need to alter treatment for 1 of 8 residents (Resident #1) reviewed for notification of changes. The facility failed to ensure the physician was notified of a change in condition when Resident #1 did not have a bowel movement for 14 days. Resident #1 had contained fecal perforation in her rectum and expired at the hospital on 6/8/2024. The noncompliance was identified as PNC. The IJ began on 06/04/2024 and ended on 06/06/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate medical treatments, deterioration of health, hospitalization, and death.

Inspectors wroteBased on interviews and record reviews the facility failed to provide residents treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 8 residents reviewed for quality of care. (Resident #1) The facility failed to monitor Resident #1's significant change of no bowel movements for 14 days between 05/19/2024 through 06/02/2024. Resident #1 was sent to the emergency room on [DATE] and x-ray showed she had a contained fecal perforation in her rectum and expired at the hospital on 6/8/2024. The noncompliance was identified as PNC. The IJ began on 06/04/2024 and ended on 06/06/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for deterioration of health, hospitalization, or death.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 3 of 16 staff (Licensed Social Worker, Activity Director, and Food Service Supervisor) reviewed for develop and implement abuse policies. The facility failed to ensure the Human Resource (HR) Coordinator implemented the facility's abuse/neglect policy and procedure when she failed to complete training to prevent abuse, neglect, and exploitation upon hire and annually for the Licensed Social Worker, Activity Director, and annually for the Food Service Supervisor. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication storage room and 1 of 2 medication carts (100/400 medication aide cart) reviewed for pharmacy services. The facility failed to remove expired influenza vaccines, hepatitis B vaccine, and Tuberculin PPD (purified protein derivative) from the refrigerator located inside the medication storage room. The facility failed to remove expired Latanoprost eye drops from the medication cart 100/400 for Resident #3. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. The floor underneath the dish machine was dirty with a slimy, black mold looking substance. There was a pink sticky substance spilled in the bottom of the three-door refrigerator. These failures could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurate, in accordance with accepted professional standards and practices for 4 of 10 residents (Residents #10, #13, #26, and #217) reviewed for accurate records. The facility failed to ensure Resident #10, Resident #13, Resident #26, and Resident #217's progress notes in the medical record were updated accordingly when physician notifications were made per facility policy. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and risk to safety.

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 3 of 16 direct care staff (LVN M, Activity Director, and Licensed Social Worker) reviewed for training. The facility failed to ensure effective communication training was provided to LVN M, Activity Director, and Licensed Social Worker. This failure could affect residents and place them at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 5 of 17 employees (Activity Director, ADON N, DON, Food Service Supervisor, and LVN M) reviewed for training, in that: The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted with the Activity Director, ADON N, DON, Food Service Supervisor and LVN M This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual or new hire Abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention. for 3 of 16 employees (Licensed Social Worker, Activity Director, and Food Service Supervisor) reviewed for training. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 17 employees (Activity Director, ADON N, ADON O, the DON, CNA L, Licensed Social Worker, LVN B, and LVN M) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the Activity Director, ADON N, ADON O, the DON, CNA L, Licensed Social Worker, LVN B, and LVN M. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 16 residents (Residents # 4 & # 44) reviewed for resident rights. The facility failed to ensure Residents # 4 & # 44 were assisted with eating in a dignified manner. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.