Wrights Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to check the temperature of food items and use proper hand hygiene during meal preparation and meal-plating service. Finding Included: During an observation on 1/19/26 at 10:26 a.m., Staff B, [NAME] was preparing raw meat wearing blue gloves, he grabbed a black notebook, opened it, placed the notebook back on the rack and continued preparing the raw meat. During an observation on 1/19/26 at 10:36 a.m., A three compartment sink with soiled dishes in all three compartments was next to a tan rack with a silver pan, a sliver metal lid and multiple other clean dishes were observed on the clean side of the dish area. During an observation on 1/20/26 at 12:05 p.m. Staff B was wearing a black hooded shirt that had two strings hanging down to his mid chest area. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure an accurate PASRR screening was completed for four residents (#4, 5, 34, and 40) of five residents reviewed for PASRR. 1. Review of the admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, and dementia. Review of Resident #40's level I Preadmission Screening and Resident Review (PASRR) dated 12/2/25 revealed a level II PASRR evaluation not required was marked. During an interview on 1/30/25 at 10:50 a.m. with the Director of Nursing (DON), and the Minimum Data Set (MDS) nurse the MDS nurse said she does not consider bipolar disorder to be a serious mental illness. She said based on her understanding options in PASRR Level I Section B - Intellectual Disability (ID) or suspected ID must be selected to trigger a Level II referral. [...]

Inspectors wroteBased on observations, record reviews and interviews the facility failed to develop and implement a comprehensive, person-centered care plans for two residents (#5 and #39) out of two reviewed. Findings Included:Review Resident #5's admission record showed admission to the facility on [DATE] with diagnoses to include parkinsonism-11/4/25, opioid dependence-11/24/25, anxiety-11//24/25, post-traumatic stress disorder (PTSD)-11/24/25, psychosis-11/24/25 and major depressive disorder-11/24/25. Resident #5's care plan did not address PTSD diagnosis, triggers and interventions to decrease expressions or indications of distress. Review of Resident #5's order summary report, dated 1/22/26 revealed orders including the following medications: Clonazepam 0.5mg daily for anxiety, Sertraline 150 mg for depression and Wellbutrin XL 150 mg for major depressive disorder. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the residents' right to be free from abuse by an agency staff member, for one resident (#1) out of 3 residents sampled for abuse. On 11/04/2024 a physical altercation was witnessed to occur between Staff A, Agency Certified Nursing Assistant and Resident #1. Resident #1 suffered injuries to include: purple discoloration of the left eye on the eye lid and under the eyebrow, purplish discoloration along his left jaw line, and a swollen right forearm with redness near his elbow extending down to his mid forearm. Resident #1 was transferred to a higher level of care for evaluation and treatment as a result of the altercation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review and failed to correct the document for two (Residents #6, and #12) of twenty-eight sampled residents. Findings Included: 1. A review of Resident #6's admission Record revealed the resident was admitted on [DATE] with unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and unspecified single episode major depressive disorder. The Preadmission Screening and Resident Review (PASRR), dated 8/3/23, for Resident #6 did not include any Mental Illness diagnoses. Section IV of the screening revealed that the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASRR evaluation was not required. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety related to labeling and dating foods, discarding expired foods, and using appropriate hand hygiene.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure two (Resident #103 and #13) of twenty-two sampled residents were assessed for the self-administration of medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to protect the Private Healthcare Information and personal data for three (Residents #55, #46, and #54) of 28 sampled residents as evidence by conversations held at the receptionist desk with a visitor standing nearby and with resident documents left unattended at the receptionist desk.

Inspectors wroteBased on record review, interview, and observation, the facility failed to assess and develop a comprehensive care plan related to side rails for two (Residents #12 and #18) out of twenty-eight sampled residents. Findings Included: 1. On 9/18/23 at 1:33 p.m., an observation was conducted of Resident #12's bed. The observation showed a mattress that was bolstered at the head of bed (HOB) and end of bed (EOB) with 1/4 rails lowered in a manner that produced a 1/2 rail covering the distance in between the two bolsters. A review of Resident #12's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Post-Traumatic Stress Disorder (PTSD), and Parkinson's Disease. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise the care plan with appropriate interventions following a fall on 04/20/23 for one resident (Resident #37) out of the sampled twenty-eight residents. The resident had a second fall on 04/23/23 in the same location and around the same time. Resident #37 was discharged to the hospital on [DATE] and was found to have a fractured cervical spine (C1).

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure one (Resident #14) of twenty-eight sampled residents received on-going nursing assessments following a change in condition during 2 of 3 days of survey.

Inspectors wroteBased on interview and record review, the facility did not ensure grievances were addressed in a timely manner for resident council members with the potential to affect a census of 50 residents.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure each resident was provided with dignity related residents exposed body and confidentiality regarding resident's bodily functions for 2 (#30 and #39) of 27 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound care orders and consistent treatment were in place for one Resident (#40) of three residents reviewed. Findings Included: During an interview and observation of Resident #40 on 9/8/21 at 10:52 a.m. she stated she had a fall recently and sustained a skin tear to the left arm and left lower leg. The resident stated someone changed the dressing and pulled up her left sleeve which revealed an oval shaped white dressing with illegible writing on her left arm and left leg. During an interview with Staff Member E, Licensed Practical Nurse (LPN) on 9/9/21 at 3:49 p.m. she stated the resident had a fall a few weeks ago and scraped her left arm and left leg. [NAME] said a dressing was applied for pressure and protection as the scrapes were scabbed over. [...]