Woodard Creek Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, report and thoroughly investigate allegation of abuse/neglect for 5 of 8 sample residents (Resident 78, 37, 94, 100, & 131) reviewed for abuse and 20 supplemental residents (Resident 25, 53, 143, 4, 144, 150, 31, 45, 86, 80, 148, 149, 112, 99, 110, 69, 116, 10, 44, & 38) whose reported allegations of potential abuse and neglect were identified upon review of the facility's grievance log. The allegations identified included verbal abuse, rough handling, residents being fearful of staff, lack of incontinence care, not responding to call lights for multiple hours or turning call lights off and leaving without providing the requested care, and failure to provide help with bathing and hygiene for up to a week. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to prevent the development of avoidable pressure ulcers (PU), and to promote wound healing and prevent further decline of existing PUs for 2 of 3 residents (Residents 11 and 14) reviewed for pressure injuries. Specifically, the facility failed to thoroughly assess resident specific risk factors, develop and implement preventative measures, and timely identify, assess, monitor, treat, and notify the provider of newly developed PUs that direct care staff had knowledge of. These failures placed residents at risk for unidentified wound development and/or deterioration, delayed treatment, and intervention. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 8 residents (Resident 78, 131, 94 & 37) reviewed for abuse and neglect were free from verbal abuse or neglect. The facility failed to ensure there was adequate supervision and sufficient staff to meet the care needs of the residents. The facility's investigations substantiated verbal abuse involving Resident 78 and substantiated neglect involving Residents 131, 94, and 37. These failures subjected Resident 78 to potential psychosocial harm and resulted in delayed provision of necessary care and services for Residents 131, 94, and 37.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a federally mandated program requiring all individuals to be screened for mental illness or intellectual disabilities before being admitted to a nursing facility) assessments were accurately completed upon or during admission to the facility for 3 of 6 residents (11, 40 & 130) reviewed for PASRR. This failure had the potential to place residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 8 of 24 sampled residents (Residents 10, 11, 78, 24, 7, 1, 2 & 100) reviewed. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs related to activities of daily living, advanced directives, vision, self-medication/medications at bedside, oxygen services/respiratory care, and fluid restrictions, placed residents at risk of unmet care needs and potential negative health outcomes. Findings Included . Resident 10Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's comprehensive care plan, initiated 11/08/2025, showed there was no direction to staff to assist the resident with nail care, or identification of who was responsible to provide it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure incontinent (episodes of uncontrolled urination or bowel movements) residents were reviewed to evaluate if they were candidates for bowel or bladder retraining for continence, and/or provided appropriate incontinent care for 3 of 3 residents (Resident 37, 94, & 100) reviewed for bowel and bladder incontinence. This failure placed residents at risk for neglect, lack of dignity, skin impairment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status by following orders for weights, closely monitoring resident's with weight loss identified prior to admission/accurately identifying weight loss, accurately documenting meal monitors and supplemental shake intake, and/or following consistent implementation of required meal assistance for 2 of 3 residents (Residents 100 & 94) reviewed for nutrition. This failure placed residents at risk for continued significant weight loss, malnutrition, impaired skin integrity, unidentified/unmonitored care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for 3 of 3 residents (Residents 11, 131 & 1) reviewed for oxygen therapy when facility staff failed to ensure oxygen-related treatments and services were implemented in accordance with physician orders and resident needs. This failure placed residents at risk for dry nares, nose bleeds, scabbing and/or decreased oxygen saturation levels and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff were available to meet residents' needs and provide care and services in a timely manner for residents residing on 4 of 4 units reviewed for sufficient staffing. Evidence of insufficient staffing included resident and family reports of excessive wait times for assistance and care, staff reports of insufficient time to complete assigned duties, facility records demonstrating prolonged response times to resident requests for assistance, and a pattern of resident grievances, including allegations of neglect related to delayed or unmet care needs. These failures resulted in delays in care and services and placed residents at risk for unmet needs, complications of medical conditions, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received non-pharmacological interventions (NPI) for pain management prior to receiving as needed pain medications for 6 of 24 sampled residents (Resident 24, 138, 2, 37, 100, and 11) reviewed for pain. This failure placed residents at risk for potential side effects, increased pain, and medication reliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident (Resident 2) reviewed for dialysis. This failure placed residents at risk of medical complications, risk for falls, discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent cross contamination during meal preparation services for 1 of 1 kitchen, reviewed for food service safety. The failure to prevent cross contamination placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the Administration failed to provide oversight and monitoring of facility personnel, systems and practices related to Abuse/Neglect and failed to ensure compliance for identifying, reporting, protecting and thoroughly investigating allegations of abuse/neglect. These failures resulted in residents experiencing verbal abuse and neglect and placed other residents at risk of unidentified abuse/neglect and resulted in an Immediate Jeopardy (IJ) situation related to CFR 483.12(2)-(4) F610, alleged violations-Investigate/Prevent/Correct.

Inspectors wroteBased on interview and record review, the facility failed to ask residents if they had an Advanced Directives (AD) and attempt to obtain a copy or failed to notify residents of their right to formulate one for 1 of 3 residents (Resident 11) reviewed for ADs. This failure detracted from the resident's ability to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their medical preferences and choices honored regarding emergent and end-of-life care.

Inspectors wroteBased on record review and interview, the facility failed to initiate grievances for 1 of 1 month, April 2026, that included sampled residents (Resident 139, 47, 25 & 80) reviewed for grievances. This failure placed the residents at risk of unmet needs, personal loss and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to accurately assess 4 of 24 residents' Minimum Data Sets (MDS, an assessment tool) reviewed. Failure to ensure accurate assessments for Preadmission Screening and Resident Review (PASRR, a federally mandated program requiring all individuals to be screened for mental illness or intellectual disabilities before being admitted to a nursing facility) (Resident 4), weight loss (Resident 100), urinary incontinence (Resident 94), cognitive pattern assessments and formal pressure injury prediction tools (Resident 17) placed residents at risk for unidentified and or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 24 sampled residents (Residents 17, 10, 11, & 119) reviewed. The failure to obtain, follow and/or clarify physicians' orders when indicated, only sign for those tasks completed, and to notify the physician/pharmacy of missed doses due to unavailable medications, resulted in medication errors and placed residents at risk for adverse side effects, ineffective treatment and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dependent resident's activities of daily living (ADLs) were followed related to nutrition and/or hygiene for 1 of 5 residents (Resident 100) reviewed for ADLs and 1 of 2 residents (Resident 30) reviewed for choices. These failures placed residents at risk for nutritional concerns, lack of dignity, poor hygiene, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure non-pressure skin conditions were assessed, monitored and treated, in accordance with physician orders, and as needed bowel care was provided for 3 of 8 residents (Residents 17, 78 & 10) reviewed for non-pressure skin and/or bowel management. The failure to initiate bowel care in accordance with physician's orders, and to assess, monitor and implement ordered treatments for non-pressure skin conditions, placed residents at risk for pain/discomfort, delayed wound healing, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary foot care and treatment in accordance with professional standards, including provision of nail care and podiatry services for 3 of 7 (Resident 78, 11 & 10) residents reviewed for activities of daily living. Failure to provide timely toenail care placed the residents at risk for negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure falls were investigated and/or investigated thoroughly for 1 of 1 resident (Resident 2) reviewed for hospitalization related to falls, or to ensure residents with mobility bars (a form of a side rail, used to assist residents with mobility while in bed) had the required components necessary to determine if they were safe and also assess to determine they were not being used as a restraint for 3 of 3 residents (Resident 100, 37, & 50) reviewed for bed rails/restraints. These failures placed residents at risk of falls, medical complications, injury, restraint, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to coordinate and manage dialysis (a procedure that filters the blood) care for 1 of 1 (Resident 2) reviewed for dialysis. The facility failed to maintain complete dialysis records, communicate essential dialysis information between the facility and dialysis center, update dialysis related care planning to reflect the resident's current treatment needs, monitor fluid restriction compliance, and assess and respond to abnormal blood pressure trends. As a result, Resident 2 experienced ongoing fluid management concerns, including presentation to dialysis treatments above prescribe dry weight and the need for additional dialysis treatments, placing the resident at risk for fluid overload, cardiovascular complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a diagnosis of dementia received appropriate care and services for 1 of 1 resident (Resident 100) reviewed for dementia care. This failure placed residents at risk of unmet or unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety for 1 of 1 resident (Resident 24) reviewed for medications at the bedside and expired influenza vaccinations were properly disposed of for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. This failure placed residents at risk of receiving compromised or ineffective medications, accidental ingestion of medication, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete, accurate and readily accessible and that residents personal identifiable information was protected for 1 of 1 resident (Resident 17) reviewed for Hospice services, 1 of 1 resident (Resident 2) reviewed for dialysis services, and 1 of 1 resident (Resident 142) reviewed for identifiable personal health information. These failures placed residents at risk for a loss of privacy, poor/impaired communication and coordination of care with Hospice and Dialysis center staff, and unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 1 residents (Resident 17) reviewed for hospice services. The facility failed to designate a member of their inter-disciplinary team (IDT) to be the liaison with hospice staff, to obtain and maintain a current copy of the coordinated hospice plan of care, and to have a system/documentation of what hospice staff had visited (e,g,, registered nurse, chaplain, certified nursing assistant, massage therapist), when they visited, and what care they provided. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who fell were assessed/evaluated for increased supervision and/or that a resident-specific fall prevention care plan was implemented for 1 of 3 residents (3) reviewed for falls. These failures put residents at risk for further injury, pain, and a decreased quality of life. Resident 3, who was assessed as a known high fall risk, was on blood thinning medication and had severe cognitive impairment, experienced harm when they had an unwitnessed and unsupervised fall, sustained a left hip fracture and experienced extreme pain as evidenced by the resident's grimacing and yelping when rolled to their left side.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%, by having an error rate of 23.5%, with 8 errors of 34 medication administration opportunities observed. This failure placed residents at risk of medication complications and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure resident records were complete, accurate, readily accessible, and systematically organized for 3 of 4 sampled residents (1, 3, & 4), reviewed for quality of care. This failure placed residents at risk of having an incomplete medical record, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (5) reviewed for care conferences. This failure placed residents at risk for weight loss, pain, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan that guided staff in providing care for 1 of 13 sampled residents (1) reviewed for care plans. The failure to establish care plans that were individualized placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the efficacy for use of an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) for 2 of 3 sampled residents (6 & 11), reviewed for catheter use. This failure placed the residents at increased risk of catheter associated urinary tract infections, pain, and urethral trauma.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered as ordered, resulting in repeated medication omissions that constituted significant medication error for 1 of 5 residents (Resident 1) reviewed for medication administration. This failure placed residents at risk for injury and adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff donned (putting on) appropriate PPE (Personal Protective Equipment) when entering enhanced barrier precaution (EBP) rooms, failed to sanitize equipment used in the EBP rooms, failed to have PPE readily accessible to rooms that required additional PPE to enter, and failed to promptly dispose of dirty linen and trash for 2 of 3 halls (Hall A and Hall B) observed. The facility also failed to implement a respiratory protection program (a key component of infection control interventions intended to mitigate the risk of spreading infection) when the facility failed to provide fit testing of N95 respirator masks, as part of their respiratory protection program, in a timely manner for 21 of 21 newly hired employees reviewed for infection prevention and control. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received assistance with meals for intake for 2 of 5 residents (1 & 7) reviewed for nutrition and hydration. The facility failed to promptly identify weight loss and implement interventions to prevent further weight loss for 2 of 4 residents (5 & 7) sampled for weight loss. This failure placed residents at risk for impaired nutrition, impaired hydration, and a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure results of allegations/investigations were reported to the State Agency Hotline within 5 working days for 3 of 3 residents (2, 3, & 4) reviewed for abuse and neglect. This failure placed residents at risk for potential unmet needs and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and intervene upon a change in the resident's respiratory status in accordance with standards of practice for 1 of 9 residents (2) reviewed for care and services. This failure placed residents at risk of unmet care needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations involving abuse were immediately reported, within two hours, to Law Enforcement for 1 of 1 sampled resident (4) reviewed for abuse. The facility failed to ensure residents leaving against medical advice (AMA) were logged and/or reported to the Adult Protective Services (APS) and/or the State Agency for 3 of 6 sampled residents (3, 5, & 6) reviewed for discharge. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate interventions to prevent elopements or act on an elopement for 2 of 3 residents (1, 5) reviewed for elopement. The facility failed to ensure discharges Against Medical Advice (AMA) were safe for 2 of 4 residents (3 & 6) reviewed for AMA discharges. This failure placed residents at risk of unmet needs, diminished quality of life, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure signs of psychosocial outcome related to allegations of abuse were monitored for 1 of 4 sampled residents (4) reviewed for abuse. This failure placed residents at risk of abuse, neglect and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents with discharge needs to ensure a timely discharge for 1 of 3 residents (1) reviewed for discharge planning. The facility failed to ensure discharge planning reflected the resident's discharge status for 1 of 3 residents (3) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, risk for re-hospitalization, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (2) reviewed for discharge planning. The facility failed to provide written bed hold notices at the time of a therapeutic leave for 1 of 1 sampled resident (3) reviewed for therapeutic leaves. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed, protection of resident rights during transfers, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 13 sampled residents (2 & 4) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 5 sampled agency and facility (Staff I, J, K, L, M) reviewed for competency with mechanical lifts showed proficiency with the operation of mechanical lift transfers. This failure placed the residents at risk for falls and their associated injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 5 sampled residents (6, 8, 9, 10) reviewed for infection control practices, received vaccinations for influenza and pneumonia. This failure placed the residents at risk of contracting pneumonia and influenza and potential complications associated with those illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was provided for 3 of 5 residents (6, 8, 10), reviewed for immunizations. The failure to provide the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications.

Inspectors wroteBased on record review and interview, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored, documented on, had associated non-pharmacological interventions (non-medication interventions), that as needed psychotropic medications had end dates and limited to 14 days, and/or monthly pharmacist recommendations were acted upon timely, for 5 of 7 residents (Residents 9, 354, 91, 88 & 66) reviewed for unnecessary medication or hospice. This failure placed residents at risk of unnecessary medication usage, increase in side effects without intervention, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to transmit required Minimum Data Set (MDS, an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion as required for 8 of 9 residents (Residents 75, 36, 7, 31, 6, 62, 74 & 19) reviewed for resident assessment. The failure to ensure MDS assessment and tracking records were completed and transmitted timely as required, placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, implement and/or ensure residents' comprehensive care plans accurately reflected care needs for 12 of 24 (Residents 9, 29, 33, 37, 90, 66, 57, 30, 79, 94, 91, & 88) residents reviewed. These failures placed residents at risk for unidentified and/or unmet care needs, medical complications and a diminished quality of life.

Inspectors wrote2) Resident 37 was admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was cognitively impaired and received greater than 51% of their calories via tube feeding. Review if the electronic health record (EHR) showed a 06/02/2025 order for nurses to change, date and initial Resident 37's tubefeeding syringe daily. Observation on 06/17/2025 at 9:34 AM, 06/23/2025 at 1:53 PM, and 06/24/2025 at 10:49 AM, showed Resident 37 had an undated /initialed 60 cubic centimeter (cc) syringe at bedside. Review of the June 2025 MAR showed the night shift nurse signed that the task was completed daily from 06/02/2025 - 06/23/2025. During an interview on 06/24/2025 at 10:57 AM, Staff B, DNS, observed Resident 37's 60 cc syrnge at bedside and confirmed it was undated/initialed. Staff B said it was the expectation that nurses only sign for tasks they completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of accidents or hazards by creating a plan of care and implementing preventative measures and/or assessments for 3 of 4 residents (Residents 18, 91 & 94) reviewed for accident hazards. This failure placed residents at risk for falls, injuries, medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to provide care in a timely manner and complete activities of daily living (ADLs) as evidenced by information provided during resident interview for 16 of 38 residents (Residents 28, 55, 30, 79, 16, 87, 10, 66, 1, 39, 56, 254, 154, 33, 62, & 28) and 2 of 7 staff (Staff R & U) interviewed for sufficient staffing or resident council, for 3 of 3 resident council monthly meeting notes (March 2025, April 2025, & May 2025) reviewed, and review of 1 of 3 grievance logs (May 2025). These failures placed residents at risk for unmet care needs, negative outcomes and a diminished quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate less than 5%, by having an error rate of 15.38%, with 4 errors of 26 medication administration opportunities observed. This failure placed residents at risk of medication complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored or covered to prevent cross-contamination, that outdated or unlabled food was discarded, and/or refridgerator temperature logs were filled out and monitored for 1 of 1 kitchen reviewed and from resident accessible refrigerators for 2 of 4 dining rooms (Country Kitchen & Bistro) reviewed. These failures placed residents at risk of eating expired/outdated food and/or food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a dignified manner for 2 of 3 residents (Residents 9 & 90) reviewed for dignity. Failure to ensure staff to residents interaction occured in a respectful and dignified manner, residents clothing was changed daily and residents were assisted out of their day clothes prior to bed, placed residents at risk for diminished self-worth and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure they informed and provided written information to residents on their right to formulate an advance directive (written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney (POA) for health care) for 2 of 3 residents (Residents 91 & 94) reviewed for advance directives. This failure placed residents at risk for not having their choice of who to care for them when incapacitated, not having their health care wishes honored, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 1 of 3 sampled residents (Resident 22) reviewed for Beneficiary Notices. This failure placed residents and/or their representatives at risk for not having adequate information to make financial decisions related to the residents' stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours for 1 of 2 sampled residents (Resident 39) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation to rule out abuse or neglect for 1 of 3 residents (Resident 91) reviewed for falls. Failure to conduct a thorough investigation placed the residents at risk for unidentified abuse or neglect, poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assisted with activities of daily living (ADLs) for 4 of 6 sampled residents (Residents 9, 33, 54 & 79) reviewed for ADLs and choices. Failure to provide assistance with nail care and/or bathing to residents who were dependent on staff for provision of such care, placed the residents at risk for poor hygiene, embarrassment, diminished self-image, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their person-centered plan of care for 4 of 9 residents (Resident 90, 29, 33, and 88) reviewed for bowel management, and 1 of 2 residents (Resident 29) reviewed for fluid volume status. The failure to obtain and evaluate daily weights and ensure the provision of bowel care in accordance with physicians' orders and/or the facility bowel protocol, placed residents at risk for fluid volume overload, delays in treatment, unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ongoing assessment, monitoring, and documentation of identified pressure injuries (PIs/ injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) for 1 of 2 residents (Resident 9) reviewed for pressure injuries. The failure to routinely assess and monitor PI wound characteristics with measurements, wound bed tissue type, details of drainage, wound edges, peri-wound (area of skin surrounding the wound) and response to treatment, impaired staffs' ability to determine if the wound was responding to treatment and determine if it was improving or declining. This failure placed residents at risk for unidentified wound decline, delays in treatment, prolonged wound healing, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to maintain range of motion for 2 of 4 residents (Resident 18 and 54) reviewed for positioning and mobility. These failures placed the residents at risk for decreased mobility, pain, discomfort and a decreased quality of life. <Resident 18> Review of the electronic health record (EHR) showed Resident 18 admitted to the facility on [DATE] with diagnoses of stroke (when a portion of the brain is without blood flow for a period), hemiplegia (paralysis of one side of the body) and contracture of the right hand. The resident was able to make needs known. During an observation on 06/16/2025 at 2:45 PM, Resident 18 was laying in bed, the resident was unable to move their right arm/hand and had a washcloth positioned in their right palm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure significant weight loss was identified, the physician was notified, and nutritional interventions were evaluated for effectiveness for 1 of 1 sampled resident (Residents 28) reviewed for nutrition. These failures placed the resident at risk for continued weight loss, malnutrition, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 3 of 3 residents (Resident 29, 10, & 91) reviewed. The facility failed to ensure continuous positive airway (CPAP, a form of non-invasive ventilation therapy used to facilitate breathing) orders were complete and in place, to include the prescribed pressure settings, checking, refilling and cleaning of the humidifier reservoir, and identifying what solution was to be used in the humidifier. Additionally, staff failed to ensure oxygen (O2) was administered in accordance with physicians' orders, and portable oxygen tanks were refilled and periodically checked to ensure they were not empty. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary medications for 2 of 5 sampled residents (Residents 62 & 91) when reviewed for unnecessary medications. The facility failed to ensure residents were provided non-pharmacological interventions (NPIs, treatments or strategies used to prevent, reduce, or manage symptoms without the use of medications) prior to the use of as needed pain medications. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure medication carts were locked/secured in the absence of a nurse for 1 of 5 carts observed (A wing medication cart), and proper labeling and storing of medications and expired medications/equipment were discarded timely for 3 of 3 carts reviewed (carts #2, #3, #5). These failures placed residents at risk for receiving compromised or inaccurate medications, medication diversion and potential harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a manner that conserved nutritive value and palatability for 4 of 4 residents (Resident 9, 71, 156 and 157) with pureed diet textures, to honor residents' preferences for 3 of 5 residents (Residents 158, 356, and 46) observed with identified preferences, and to ensure meals/beverages were appetizing and served at appropriate temperatures as evidenced by 7 resident interviews and test tray results. These failures placed resident at risk of dissatisfaction with meals, decreased intake, weight loss, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents hearing needs were addressed and they had access to bariatric (treatment of obesity) equipment for 1 of 1 sampled resident (Resident 1) reviewed for accommodation of needs. These failures placed resident at risk of diminished independent functioning and a loss of comfort.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive plan of care for urinary care and urinary tract infection (UTI, an infection of the urine) for 1 of 4 sampled residents (Residents 1) reviewed for care plans. The failure to establish individualized care plans, that accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to accurately determine and identify the resources needed for the facility residents who needed bariatric (treatment of residents' who experience morbid obesity) care. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure possible allegations of abuse were thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigations. This failure placed residents at risk for unidentified abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately report to the state agency potential financial exploitation for 1 of 1 resident (Resident 1) reviewed for allegations of misappropriation. Failure to immediately report alleged abuse and/or neglect placed residents at risk for potential unidentified mistreatment and a poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a personalized discharge plan based on each resident's identified needs, goals and preferences and implement it timely for 1 of 3 residents (Resident 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 3 residents (Resident 1) reviewed for mood and behavior. This failed practice placed residents at risk for unidentified triggers, re-traumatization and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 5 of 26 sampled residents (Residents 90, 88, 62, 34 and 427) of 20 reviewed for medication management. The failure to follow, obtain, and/or clarify incomplete physician's orders when indicated, to sign for medication(s) that were administered, to document the reason and notify the provider when medications were held, placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs.

Inspectors wrote2) Resident 161 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed Resident 161 was dependent on staff for bathing and decisions about bathing were Very important. On 05/21/2024 at 1:20 PM, Resident 161 said staff did not come on the days they were supposed to provide showers. The resident reported the previous Friday staff informed her they couldn't provide their shower because a nursing assistant called off. An ADL care plan (CP), dated 05/07/2024, showed Resident 161 was to be showered twice weekly. Review of Resident 161's March 2024 bathing record showed from 05/07/2024 - 05/29/2024 (23 days), no bathing was offered/provided. On 05/29/2024 at 12:11 PM, when asked how many baths/showers had been offered/provided to Resident 161 from 05/07/2024 - 05/29/2024, Staff B, stated, I don't see any. 3) Resident 93 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 9 of 11 residents (Residents 49, 62, 20, 76, 93, 90, 23, 34, and 50) reviewed for bowel management and 1 of 2 residents (Resident 88) reviewed for positioning. The failure to initiate bowel care in accordance with physician's orders, address changes in bowel habbits and to reposition residents at the frequency they were assessed to require, placed residents at risk for pain/discomfort, skin breakdown and unmet bowel care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure timely acquiring, receiving, and administering of all drugs) to meet the needs of each resident for 2 of 2 sampled residents (Residents 90 & 76) reviewed for pharmacy services. Failure to ensure timely receipt and administration of ordered medications, resulted in residents missing several doses of ordered medications and placed them at risk for inadequate and/or ineffective treatment of underlying medical conditions, and other negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to maintain a kitchen environment which allowed each resident to receive nourishing, palatable, and well-balanced meals without cross contamination when reviewed for kitchen. This failure placed residents at risk of lack of nutritional intake, avoidable weight loss, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to obtain dishwasher temperatures logs and maintain the temperature in required range, failed to discard expired or no Use By Date (UBD) food and beverages items, and failed to maintain and document refrigerator temperature logs for 8 of 8 facility refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate records for 7 of 7 sampled residents (Residents 93, 61, 161, 90, 22, 81 & 50) reviewed for activities of daily living and choices. The failure to identify and correct a system issue with the facility's Point of Care (a computer program) charting, caused staff to falsely document bathing and/or resident refusal of bathing that did not occur. These failures resulted resident medical records containing inaccurate documentation of bathing that was not provided and/or refusal of care that did not occur. This detracted from staffs' ability to investigate resident complaints about not receiving showers and placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff compliance with current infection control guidelines and standards of practice for correctly donning/doffing (to put on/to take off) personal protective equipment (PPE) for 2 of 2 dining observations reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of illness), transmission of diseases and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a manner that promoted the resident's dignity and quality of life when personal grooming was not provided for 2 of 6 sampled residents (Resident 61 & 88) reviewed for dignity. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure visual impaired/legally blind residents received reasonable accommodations for 1 of 1 sampled residents (Resident 61) reviewed for accommodation of needs. This failure placed residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (ADs) for 1 of 4 sampled residents (Resident 42) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a visually impaired/legally blind resident's room was maintained in a safe and accommodating manor for 1 of 7 sampled residents (Resident 61) reviewed for environment. This failure placed residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of concerns during resident council for 5 of 9 months (June 2023, August 2023, September 2023, October 2023 and November 2023) of resident council minutes reviewed. The failure to identify the initiate, log, investigate and timely resolve reported complaints/concerns, and inform residents of the findings and actions taken to correct the issues, placed residents at risk of feelings of frustration, unimportance, diminished self-worth, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an assessment for 1 of 2 sampled residents (Resident 42) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Sets (MDS- an assessment tool) accurately reflected residents' health status and/or care needs for 3 of 29 sample residents (Residents 62, 76 and 88) reviewed for assessments. The failure to accurately assess whether residents' had a terminal diagnosis, were on a physician ordered planned weight loss program, and accuaretley code dental issues, placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services] was completed accurately for 1 of 5 sampled residents (Resident 42), reviewed for unnecessary medication review. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses for 1 of 5 sampled residents (Resident 20) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental health needs.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide pressure ulcer treatment and services in accordance with professional standards for 1 of 6 sampled residents (Resident 45) reviewed for pressure ulcers. This failure placed residents at risk for untreated pressure ulcers, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Intravenous (IV) access devices were assessed, and maintained/monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 90 & 88) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care as ordered, to include changing needleless injection caps, weekly dressing changes and measuring of arm circumference and PICC external length. Additionally, the facility failed to ensure maintenance flushes and ongoing monitoring of a peripheral IV access sites. These failures placed residents at risk for loss of vascular access, infection, and other complications and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 2 sampled residents (Resident 76) reviewed for hospice services. The facility failed to designate a member of their inter-disciplinary team (IDT) to be the liaison with hospice staff, to obtain and maintain a current copy of the coordinated hospice plan of care, and to have a system/ documentation of what hospice staff had visited (e,g,, registered nurse, chaplain, certified nursing assistant, massage therapist), when they visited, and what care they provided. [...]

Inspectors wroteBased on interview and record review, the facility failed to log allegations of abuse and neglect, mistreatment by staff, untimely incontinence care, and misappropriation of property on the reporting log within five working days for 5 of 5 investigations involving 9 residents (1, 2, 3, 4, 5, 6, 7, 8 & 9) reviewed for reporting of alleged violations. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of neglect and misappropriation of property for 4 of 6 sampled residents (1, 2, 3 & 4) reviewed for investigating alleged violations. This failure placed residents at risk for not identifying corrective actions to prevent further neglect, misappropriation, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being when a resident was not monitored and timely interventions were not implemented after experiencing end of life and death of a roommate for 3 of 4 sampled residents (1, 2 & 3)) reviewed for medically related social services. This failure placed residents at risk of having unmet social service needs, psychosocial decline and a diminished quality of life.