Woodway Nursing & Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 5 (CR #1) reviewed for laboratory services. The facility failed to obtain CR #1's lipid panel (a blood test used to measure fats to assess cardiovascular health and the risk of heart disease, stroke, and other heart-related conditions) as ordered by the physician to be drawn on 05/26/26. This failure could place residents at risk of not receiving timely services ordered by the physician and a decline in health status. Record review of CR #1's face sheet dated 07/02/26 revealed a [AGE] year-old admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a base-line person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (CR #1) reviewed for base-line care plans. The facility failed to provide CR #1 with a base-line personal-centered care that addressed, monitored, and managed the development of wounds to CR #1's posterior area. This failure places residents at risk for appropriate care, treatment, monitoring, and timely assessment for the development of infections, resulting in hospitalization, a decline in health, or death.

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 (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 4 residents (CR #1) reviewed for ADLs. The facility failed to ensure CR #1, a resident with wounds, was provided with personal grooming, showers, and bed baths on the 2:00 p.m. to 10:00 p.m. shift. These failures could place residents at risk for skin breakdown, offensive odors, or infections, resulting in a decline in health, hospitalization, or dealth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 9 residents (CR #1) reviewed. The facility failed to ensure CR #1, received orders, monitoring, and interventions to an existing wound and development of new wounds resulting in the lack of wound care management and hospitalization. These failures could place residents at risk of developing, reopening and worsening of pressure ulcers

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure resident environment remained as free of accident hazards as was possible for 1 of 4 shower rooms (A Hall shower room) reviewed for accidents. The facility failed to ensure the A Hall shower room was locked and sharps in the shower room were secured and not accessible to residents on 06/02/2026 and on 06/03/2026. This failure could place residents at risk of entering the shower room that and could harm themselves due to the presence of unsecured sharp items. During observations on 06/02/2026 at 10:02 a.m., and on 06/03/2026 at 3:10 p.m., the A Hall shower room door was ajar and accessible to residents. No residents or staff were in the hallway or inside the shower room at that time. [...]

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), to meet the needs of each resident 1 of 1 medical supply reviewed for medication storage and labeling. The facility failed to ensure the medication cart was free from expired medical supplies on 06/05/2026. This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition and could cause infections due to compromised sterile equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 5 residents reviewed for wound prevention. The facility failed to provide Resident #1 wound care every day shift as ordered on 2/23/26, 2/24/26, and 2/25/26 for his 6 documented wounds. Pressure wound on Resident #1's left hip developed a strong odor with moderate serosanguinous fluid. Wound Care Doctor (WCD) diagnosed the wound as infected on 2/27/26. An IJ was identified on 03/01/256. The IJ template was provided to the facility on [DATE] at 3:30 p.m. [...]

Inspectors wroteBased on interview, and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders for 1 (CR#1) of 45esidents reviewed for advanced directives. CR #1 was found unresponsive on [DATE]. LVN A failed to perform CPR on resident or contact Hospice A for further instruction. CR#1 was pronounced deceased on [DATE] at 6:20 p.m. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. The failure could place residents at risk of experiencing a diminished quality of life and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records or safeguard medical record information against loss, destruction, or unauthorized use for 1 (Hall C) of 2 halls observed for privacy and failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is to the individual, or their resident representative where permitted by applicable law or required by law for 1 (CR#1) of 1 residents reviewed for medical records. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its residents are free of any significant medication errors for 1 (Resident #1) of 4 residents reviewed for medication administration. RN B failed to call the hospital, ADON, and Administrator on 11/04/25 when she did not receive report from the hospital when Resident #1 returned to the facility from the hospital on [DATE]. The facility failed to administer Resident #1's IV Vancomycin 1gm evening dose on 11/04/25 and morning dose on 11/5/25. The facility failed to administer Resident #1's IV Meropenem 500mg every 4 hours when he returned to the NF on 11/04/25 from the hospital. The facility did not initiate the medication until 11/05/25 at 8:00PM. Resident #1 missed a total of 4 doses. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety for 1 (Resident #1) of 4 residents observed for cleanliness of rooms. Housekeeping failed to clean Resident #1's room prior to being admitted from the hospital to facility on 11/04/25. This failure placed residents at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 4 residents (Resident # 2,) reviewed for infection control in that: CNA D failed to don (to put on) disposable gown when providing direct care for Resident #2 who was on Enhanced Barrier Precautions on 11/05/25. This failure could place residents at risk for cross-contamination and unwanted infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the entire facility which included: 2 residents who experienced abuse (Resident #113 & Resident #114), 3 residents who experienced problems with services for treatment and services for mental and psychosocial concerns (Resident #30, Resident #42 & Resident #52); 2 resident who experienced repeated G-tube dislodgement (Resident #18 & Resident #33); 2 residents who experience problems with ADL care (Resident #28 & Resident #109), 3 residents who experienced significant medication errors and problems with quality of care (Resident #161, Resident #162, Resident #163); [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for two residents (Resident #111, #113 and #114) out of seven reviewed for abuse. The facility failed to protect Resident #113 and #114 from a physical altercation on 3/23/25. Resident #114 sustained redness and pain to the left eye and sent to the ER. The facility failed to address Resident # 114's continued threatening and aggressive behavior towards residents and staff. The facility failed to address Resident #113's inappropriate sexual behavior on 5/03/2024 towards an unknown female resident as documented in the medical records. An Immediate Jeopardy (IJ) was identified on 05/03/2025. The IJ template was provided to the facility on [DATE] at 1:58 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 Residents (Resident #18, Resident #28, Resident #30, Resident #33 , Resident #52, Resident #113 & Resident #114 ) reviewed for care plans. - The facility failed to develop and implement a care plan that addressed Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in the resident pulling out her G-tube in 11/12/24, 03/28/25 and 04/15/25 which required hospitalization to place a new tube. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 ( Resident #161) residents and 2 out of 2 Crash Carts in that: - RN D failed to use the AED when providing CPR to Resident #161 when he was found unresponsive on [DATE]. - The facility failed to ensure the facility had pads for use with the AED in case a resident was in need of CPR. - The facility failed to ensure the facility crash carts had oxygen available. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 02:12 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 3 of 9 residents (Resident #161, Resident #162 and Resident #163) reviewed for quality of care. - LVN T failed to enter orders for potassium to treat Resident #161's critically low potassium of 2.7 correctly which resulted in Resident #161 receiving his first dose of potassium over 12 hours after the lab notified LVN T of the critical lab result and Resident #162 receiving 2 doses of Potassium in error. - RN E failed to notify Resident #163's physician of his critically high BUN of 93 correctly by sending a picture to the incorrect provider after hours instead of notifying the on-call physician and failed to conduct a CIC evaluation for the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #18 and Resident #33 ) of 7 residents reviewed for enteral nutrition. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in: the resident pulling out her G-tube on 2 occasions (11/12/24 and 04/15/25) which required hospitalization to place a new tube; and on 1 occasion (03/27/25) the resident pulling on her G-tube and an IV pole falling on her head on. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 3 of 8 residents (Resident # 30, Resident #42 Resident #52) reviewed for treatment and services for mental and psychosocial concerns. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #30's escalating behaviors which resulted in a suicide attempt on 04/13/25 and the resident attempting to draw a police officer's firearm when she had to be forcefully restrained and removed from the facility. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free of significant medication error for 3 of 7 residents (Resident #31, Resident #161, and Resident #162) reviewed for significant medication errors. - The facility failed to administer Potassium 40 mEq immediately to Resident #161 after he had a critical potassium lab value of 2.7. - The facility failed to ensure Resident #162 was not administered Potassium 40 mEq in error. -The facility failed to administer Resident #31's seizure medications (Lacosamide and Clonazepam) and IV antibiotic (Meropenem) after he readmitted to the facility from a short-term hospital stay even though the medication was in the facility. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 out of 1 laundry rooms reviewed for . - The facility failed to ensure the resident's laundry was washed and returned. There were 4 big barrels of dirty clothes in the laundry room that were not able to get washed and returned to the residents. This deficient practice could place residents at risk of missing clothes, and not having clean clothes to wear which could lead to a decreased quality of life.

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 6 of 7 months (October 2024, November 2024, December 2024, January 2025, February 2025, March 2025) reviewed for nursing services. The facility failed to ensure a registered nurse worked on 2 out of 31 days in October of 2024. The facility failed to ensure a registered nurse worked on 4 out of 30 days in November of 2024. The facility failed to ensure a registered nurse worked on 9 out of 31 days in December of 2024. The facility failed to ensure a registered nurse worked on 4 out of 31 days in January of 2025. The facility failed to ensure a registered nurse worked on 2 out of 28 days in February of 2025. The facility failed to ensure a registered nurse worked on 3 out of 31 days in March of 2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 2 (the left dryer) dryers reviewed for safe operating conditions. - The facility failed to clean the lint filter in a timely manner resulting in a thick layer of lint on the filter, around it, and below it. This failure could place residents at risk of injury, hospitalization, or death due to a fire. In an observation and interview on 4/17/25 at 10:30am with the Laundry Tech, he pulled out the lint filter for the dryer. There was a thick layer of lint on the filter, around the filter, and below the filter. He said he checked the filter when he got to work at 6am, again at 10:00am, and then before he left at 5:00pm. He said if there was a buildup of lint it could cause a fire. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options if he or she preferred for 7 of 8 residents ( Resident #11, Resident #42, Resident #45, Resident #52, Resident #54, Resident #159 and Resident #160) reviewed for resident rights. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 5 of 8 residents (Resident #18, Resident #30, Resident #33, Resident #45 and Resident #52) reviewed for accuracy of assessments . - The facility failed to accurately assess Resident #30's behaviors which included calling 911 on a frequent basis, yelling, screaming, and cursing out staff which escalated until the resident attempted suicide and had to be physically restrained by police officers when she attempted to pull their firearm. - The facility failed to accurately assess Resident #52's behaviors which included yelling, screaming, and cursing out staff which escalated until the resident made threats of suicide and was forcefully removed from the facility by EMS under physical restraints. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that, for a resident who is unable to carry out activities of daily living, provide the necessary services to maintain grooming and personal care for 2 of 8 residents (Resident #28 and Resident #109) reviewed for ADL care. -The facility failed to provide nail care to Resident #28, leaving the nail on his left thumb long, dirty, thick, and discolored. The facility failed to ensure Resident #109 was provided personal grooming (long fingernails and brown substance under the fingernails) and oral hygiene (bad breath) by facility staff. This failure could place residents at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life.

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 administrating of all drugs and biologicals, to meet the needs of each resident for 2 of 2 Med Rooms ( A&B Med Room and C&D Med Room) reviewed for pharmacy services. -The facility failed to ensure the A & B Hall Med Room did not contain expired IV Antibiotics -The facility failed to ensure the C & D Hall Med Room did not contain expired IV Antibiotics and expired insulin. This failure could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 3 of 5 medication carts (Hall A Nursing Cart, Hall A & B Nurse Cart and RT Cart ) reviewed for medication storage . - The facility failed to ensure the Hall A & B Nursing Cart did not contain loose pills. - The facility failed to ensure the Hall A Nurse Cart did not contain open and in-use insulin pens with no open date. - The facility failed to ensure the RT Cart was not left unlocked when unattended. These failures could place residents at risk of adverse reactions to medications, misappropriation of medications, and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 2 of 5 residents (Resident #18 and #109) and one of one laundry room reviewed for infection control. LVN J failed to wear a PPE (personal protective equipment) gown during administration of medications via Resident #18's indwelling PEG tube (percutaneous endoscopic gastrostomy - an endoscopic medical procedure in which a tube is passed into a patient's stomach allowing nutrition to be received through the stomach when oral intake is contraindicated). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Halls C and D) of 4 halls reviewed for environmental concerns. The facility failed to repair loose and damaged floor tiles on Hall C, secure a loose toilet in room [ROOM NUMBER] on Hall C, and secure a loose sink in room [ROOM NUMBER] on Hall D. This deficient practice could place residents at risk of falls, injuries, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of four shower rooms, (Shower on Hall C), the nurse's stations (Station C & D), and on a towel on a Resident in Room D11 . The facility had live gnats in areas of the facility including the shower room on Hall C and on a towel on a Resident in Room D11. The facility had live roaches at station C & D Hall nursing station. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to have evidence that the alleged violation was thoroughly investigated for (Resident #113 and Resident #114) reviewed for freedom from abuse and neglect. The previous Administrator failed to have evidence that the alleged violation was thoroughly investigated by indicating whether the Ombudsman or Law Enforcement were notified and include witness statements from staff members when a resident-to-resident altercation between Resident #113 and #114 occurred on 3/23/25. This failure could place residents at risk for abuse from altercations and could place the residents at risk of harm.

Inspectors wroteBased on interview, observation, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 3 of 12 residents (Resident #58, Resident #109, and Resident #112) reviewed for baseline care plan. - The facility failed to ensure baseline care plans werewithin 48 hours of admission that addressed services that were to be provided to Resident #58, Resident #109, and Resident #112 This failure could place newly admitted residents at risk of not having their individual, medical, functional, and psychosocial needs identified, and services provided with could cause a physical or psychosocial decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to post the daily nursing staffing information on 04/15/25, 04/19/25 & 04/20/25. - The facility failed to include the facility name and census of the daily nursing staffing information post on 04/16/25, 04/17/25, 04/18/25 & 04/21/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 04/15/25 at 11:38 AM revealed, the facility Daily Staffing posting on the top of a pony wall located behind the receptionist desk that read Today's Date 04-14-25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 18 of 18 residents reviewed (CR #1, Resident #2, #3, #4, #5, #6, #7, #10, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 4 of 4 Halls (A, B, C & D Halls) reviewed for clean, comfortable, homelike environment, and clean bed and bath linens. - The facility failed to maintain a clean and homelike environment for all residents across the facility. - The facility failed to provide adequate clean linens (towels & Sheets) to meet the needs of all residents across all units which resulted in residents (CR#1, Resident #2, #7, #5, #3) who reported they stuck to their mattress, felt cold, unclean, dirty, worthless, neglected, and left CR #1 in tears. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were free from neglect for 18 of 18 residents (CR #1, Resident #2, #3, #4, #5, #6, #7, #10, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 4 of 4 Halls (A, B, C & D Halls) reviewed for neglect. - The facility failed to provide adequate clean linens (towels & Sheets) to meet the needs of all residents across all units which resulted in residents (CR#1, Resident #2, #7, #5, #3) who reported they stuck to their mattress, felt cold, unclean, dirty, worthless, neglected, and left CR #1 in tears. - The facility failed to provide adequate clean linens as Residents #6, #10, #21, #22, #24, #25, #26, #27, #28, #29 & #30 were observed laying on bare mattresses. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 1of 1 resident (Resident #6) reviewed for professional standards. - The facility failed to follow Resident #6's care plan by not applying a hand roll to his contracted left hand. This failure could place residents at risk of worsening of contractures, pain and deterioration of health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 1 resident (Resident #6) reviewed for quality of care. - The facility failed to provide follow up care to Resident #6's left hand middle finger after an injury involving staff resulted in bleeding and pain. This failure could place residents at risk of pain and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess each resident's status for 1 of 1 resident (Resident #6) reviewed for accuracy of assessments. -The facility failed to document Resident #6's upper extremity impairment in the resident's quarterly MDS or care plan. This could place residents at risk of not having accurate assessments, which could compromise their plan of care. Record review of Resident #6's face sheet dated 03/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that, for a resident who is unable to carry out activities of daily living, provide the necessary services to maintain grooming and personal care for 1 of 1 residents (Resident #6) reviewed for ADL care. -The facility failed to provide nail care to Resident #6, leaving him with long dirty nails that snagged on his clothing resulting in pain, injury and bleeding. This failure could place resident at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life.

Inspectors wroteBased on observations, interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. - The sinks and toilets were loose in residents' bathrooms (C-6, C-7, C-8, D-1, and D-9). - The outside trash dumpster area had trash bags, boxes, and other debris on the ground. The trash bin was too full to shut the cover. - The facility failed to maintain hot water in multiple resident rooms across multiple units. - The window screen for resident room C-16 had been cut open leaving jagged edges. The windowpanes were held in place with duct tape. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 1 resident (Resident #6) whose records were reviewed for accuracy and completeness. - The facility failed to document Resident #6's injury to his left middle finger in the resident's chart. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident #1) received adequate supervision and that the resident environment remained as free of accident hazards as is possible, in that: The facility failed to ensure Resident #1 was served coffee at a safe temperature which resulted in a burn to her left hand. The facility failed to ensure a temperature log was kept to document temperatures of coffee prior to distribution and service to residents. An immediate jeopardy of past non-compliance was identified on 11/13/2024 at 1:30PM. The IJ template was provided to the facility Administrator on 11/13/2024 at 2:50PM. The Immediate Jeopardy was determined to have existed from 10/20/24 to 10/22/2024 due to the facility's implemented actions that corrected the non-compliance prior to survey entry. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for two (Residents #4 and #10) of five residents reviewed for accidents and hazards. The facility failed to ensure Resident #4 had a fall mat in place at the bedside as indicated in her care plan. The facility failed to provide adequate supervision to Resident #10 when he fell from his wheelchair in his room. This failure could place residents at risk of falls with injury and hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents received proper treatment and care to maintain mobility and good foot health, and failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 (Resident #1) of 5 residents reviewed for foot care. The facility failed to ensure Resident #1 had his toenails trimmed by a podiatrist. This failure could place residents at risk of discomfort, poor foot hygiene, or a decline in residents' physical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored and prepared under sanitary conditions in one of one kitchens, in that: - Multiple foods were stored without labels or dates. - Dietary Aide A was observed not performing hand hygiene in between tasks and not properly washing dishes. - The Dietary Manager was observed washing dishes using the dishwasher temperature below the required temperature. the failures placed residents at risk of acquiring a food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environmen, including but not limited to receiving treatment and supports for daily living safely for 1 room (Room B14) of 9 resident rooms on Hall B and 1 of 4 halls (Hall C), reviewed for environment. The facility failed to ensure the window in resident room B14 was intact and windowpanes were properly attached to the window frame to prevent cold air from entering the room. The facility failed to ensure the wood laminate flooring on Hall C was not loose . This failure could place residents at risk of a diminished quality of life due to an unsafe, unmaintained, and uncomfortable environment.

Inspectors wroteBased on interview and record review the facility failed to refer 1 of 3 residents (Resident #14), reviewed for PASRR screening and evaluations, with a newly evident mental disorder or a related condition for a level II PASRR review, in that: Resident #14 was not referred to the state-designated authority for a PASRR evaluation upon evidence of new diagnoses of schizoaffective disorder, bipolar type, dated 01/09/2023. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards of practice for 2 (Resident #121 and Resident #128) of 5 residents reviewed for respiratory care. Resident #121 had no date on her oxygen tubing and the nebulizer face mask was found in a drawer with no bag covering. Resident #128's oxygen was in use, her humidified water was dated 12/22/2023 and her oxygen tubing had no date on it . This failure placed residents who received oxygen at risk for respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 30 of 30 days reviewed for staffing, in that: There was no proof of RN coverage for 30 days, 09/01/2023 - 09/30/2023. This failure places all residents at risk of not receiving adequate medical care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate treatment and services for care of 2 (Resident #135 and Resident #136) 0f 4 residents reviewed for urinary catheters. Resident #135's Suprapubic catheter (Catheter coming directly from the bladder) bag was on the floor. Resident #136's Foley catheter bag was found on the floor, and there was no device to hang it on the bed. This failure placed residents who had foley catheters at risk for urinary tract stress and urinary tract infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs, for 3 (Resident #1, #2, #3) of 5 residents reviewed for accommodation of needs. 1. The facility failed to ensure there was a sustainable amount of incontinent care supplies for residents. 2. Residents #1, #2, and #3 were placed in the incorrect sized adult briefs after incontinent care. These findings could cause resident discomfort and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 (Resident #2) of 6 residents reviewed for resident call systems. The facility failed to ensure Resident #2's call light was working properly. When the call light button was activated, the light did not light up over her door nor beep at the nurses' station. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for 1 (Resident #1) of 3 residents reviewed for notification of changes. -The facility failed to notify the primary doctor (MD B) of Resident #1's pressure ulcers that were observed 10/6/23 to11/16/23 resulting in Stage. An Immediate Jeopardy (IJ) was identified on 12/7/2023. The IJ template was provided to the facility on [DATE] at 4:03 pm. While the IJ was removed on 12/8/2023 at 3:45 pm, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 7 residents reviewed for pressure ulcers. -The facility failed to turn/re-position Resident #1 and Resident #2 every 2 hours who were completely dependent and bed bound to prevent Pressure Ulcer development. -The facility failed to perform accurate skin assessments for Resident #1 (10/13/23 to 10/27/23) and Resident #2 (11/7/23 to 12/4/23) for Pressure Ulcers. -The facility failed to treat Resident #1's facility acquired pressure ulcers for over a month after being identified by Wound Care Nurse on 10/6/23 (sacrum, knee, buttocks, bilateral heels) . [...]