WESTWOOD HEALTH AND REHAB, INC
For profit - Corporation
85 Beds
ANTHONY & BRYAN ADAMS
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
9/100
#182 of 218 in AR
Photo by Google Maps
Photo by Westwood Health And Rehab Inc
Photo by Britteny Freeman
Photo by Britteny Freeman
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Westwood Health and Rehab, Inc. has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. They rank #182 out of 218 in Arkansas, placing them in the bottom half of state facilities, and #10 out of 12 in Washington County, meaning only two local options are worse. The facility has a stable trend with 8 issues reported in both 2024 and 2025. Staffing is a relative strength with a 4 out of 5-star rating, although their turnover rate at 56% is average. However, they have concerning fines totaling $13,871, which is higher than 82% of Arkansas facilities, and serious incidents have occurred, including multiple instances of resident-to-resident abuse that led to a resident suffering a fractured hip due to inadequate monitoring and care planning. While they demonstrate good quality measures, the critical findings highlight serious deficiencies in resident safety and food hygiene practices, indicating a need for improvement in overall care.
- Trust Score
- F
- In Arkansas
- #182/218
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $13,871 in fines. Higher than 61% of Arkansas facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
9/100
Bottom 17%
Review needed
8 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Arkansas average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 56%
10pts above Arkansas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $13,871
Below median ($33,413)
Minor penalties assessed
Chain: ANTHONY & BRYAN ADAMS
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Arkansas average of 48%
The Ugly 20 deficiencies on record
2 life-threatening
Jan 2025
8 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure a resident was free from resident-to-resident abuse for 1 (Resident #44) of 3 sampled residents reviewed for abuse. ...
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Based on observations, interviews, and record review, the facility failed to ensure a resident was free from resident-to-resident abuse for 1 (Resident #44) of 3 sampled residents reviewed for abuse. The lack of effective behavior monitoring resulted in Resident #44 having resident to resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. Of those incidents, Resident #9 was the physical aggressor for 3 instances. On 12/07/2024, Resident #9 hit Resident #44 in the stomach. On 12/20/24, Resident #9 pushed resident #44, resulting in the resident falling. On 01/08/2025, Resident #9 pushed Resident #44, resulting in the resident falling. Resident #44 was sent to the emergency room and was found to have a fractured hip. All of the other incidents were completed by other residents on the locked unit and Resident #44 had been kicked, hit in the face, hit in an unknown area, pushed, punched in the hand, struck in the hand, and hit in the head.
It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J.
The IJ began on 12/07/2024 at 10:59 PM, when Resident #44 was punched in the stomach by Resident #9.
The Administrator, Director of Nursing, Nurse Consultant, and Director of Operations were notified of the IJ on 01/29/2025 at 10:28 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/29/2025 at 3:54 PM. The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented.
The findings are:
A review of the facility Abuse Prevention, revised 11/16/2017 revealed during abuse investigations, Allegations involving residents will require assessment and appropriate interventions to protect the victim and other residents. lnterventions may include temporary one-on-one supervision, transfer to another level of care or discharge to a family member/responsible party.
A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse.
A review of State Operations Manual Appendix PP, F600 indicates, Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing, shoving .The action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm . Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions.
A review of the admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently.
A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed:
- 04/11/2024: Physical aggression received
- 04/19/2024: Physical aggression received
- 07/10/2024: Physical aggression received
- 08/06/2024: Physical aggression received
- 08/12/2024: Physical aggression received
- 08/21/2024: Physical aggression initiated
- 12/07/2024: Physical aggression received
- 12/20/2024: Physical aggression received
- 12/25/2024: Physical aggression received
- 01/09/2025: Physical aggression received
The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms.
A review of the admission Record, indicated the facility admitted Resident #9 with diagnoses that included dementia, autistic disorder, psychosis, cognitive communication deficit, and schizophrenia.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. Resident #9 was not documented as having physical or verbal behavior symptoms directed toward others. Resident #9 had no impairments to upper or lower extremities and was able to independently ambulate.
A review of Resident #9 ' s Care Plan initiated on 10/26/2024, revealed the resident needed a secured/special care neighborhood. Interventions included: administering and monitoring the effectiveness and side effects of medications as ordered, medication review with antidepressant increased, kept one-on-one observation until discharge, and to support resident ' s needs to spend time in room in self-direct pursuits.
A review of facility incident and accident reports for the last twelve months for Resident #9 indicated on 12/7/2024, Resident #9 punched another resident in the stomach. On 12/20/2024, another resident wandered into Resident #9 ' s room, resulting in Resident #9 pushing the other resident, making the resident fall to the floor. On 1/8/2025, Resident #9 pushed another resident.
A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident. On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room.
A review of Resident #44 ' s hospital records indicated on 01/09/2025, the resident was admitted to the hospital related to a fall with left hip pain and was diagnosed with a left femur fracture and required surgery.
During an interview on 01/28/2025 at 2:00 PM, Certified Nursing Assistant (CNA) #13 was in Resident #44 ' s room and stated the resident was not aggressive but at times, the resident takes things that belong to other residents, which agitates those residents resulting in pushing Resident #44. CNA #13 stated Resident #44 did fall and break their hip and did not walk anymore and uses a wheelchair for mobility.
During an interview on 01/28/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident #44 was sent to the hospital because the resident was touching another resident who had autism. The DON stated Resident #44 used to be a CNA and likes to pick up things and was trying to pick things up in the other resident ' s room. This resulted in the other resident pushing Resident #44, causing the resident to fall. The DON stated the other resident no longer resided in the facility.
During an interview on 01/29/2025 at 8:20 AM, CNA #2 stated Resident #44 was not aggressive but did go into other resident ' s rooms. CNA #2 stated that Resident #9 got aggressive easily and the resident would make fists and grumble, even if no one was bothering the resident. CNA #2 stated that staff remove other residents out of Resident #9 ' s way when the resident was upset or overwhelmed. CNA #2 stated she was aware of an altercation between Resident #9 and Resident #44 and stated Resident #9 was eating a snack when Resident #44 entered the resident ' s room and tried to grab the snack. This resulted in Resident #9 pushing Resident #44 to the floor. CNA #2 stated residents on the secure unit are monitored by having at least one staff member on the hall in the middle. CNA #2 stated that during the altercation, both herself and CNA #1 were at the nurse ' s station, monitoring the cameras. CNA #1 was teaching CNA #2 how to chart in the medical record. CNA #2 stated she looked up at the camera and saw Resident #44 walk towards Resident #9 and CNA #2 got up and ran from the nurse ' s desk to get Resident #44.
During an interview on 01/29/2025 at 8:35 AM, CNA #1 stated when Resident #9 charges at you, staff were told to get out of the way and when Resident #9 was frustrated, the resident would hit the air or themselves. CNA #1 stated staff were advised to get the residents away from Resident #9. CNA #1 stated Resident #44 was very grabby but did not have aggressive behaviors. CNA #1 stated that Resident #9 had behaviors, and the facility had to move Resident #9 ' s roommate to a different room. CNA #1 stated that Resident #9 was autistic with mixed personalities and would freak out. CNA #1 stated she was showing CNA #2 how to chart in the medical record at the nurse ' s station and CNA #2 took off running and that ' s when she looked up at the camera and saw Resident #44 head towards Resident #9. CNA #1 stated another CNA was supposed to be monitoring the hall but did not know where that CNA went.
During an interview on 01/29/2025 at 11:23 AM, the Administrator stated there were interventions in place to safeguard Resident #44 but was unable to provide them to the surveyor. The Director of Nursing (DON) stated the facility placed a stop sign on Resident #9 ' s door but was removed because Resident #9 did not want it. The DON also stated that there were medication changes for Resident #44 to help with anxiety. The Administrator stated the facility did monthly in-services regarding behaviors but there was a new staff member completing those in-services and the Administrator could not locate the in-services.
During an interview on 01/29/2025 at 2:00 PM, Licensed Practical Nurse (LPN) #12 stated Resident #44 goes into other resident ' s rooms and staff were to distract the resident. LPN #12 stated CNA #1 and CNA #2 being at the nurse ' s station during the incident between Resident #44 and Resident #9 was not appropriate and they should be charting at the kiosk in the hallway. LPN #12 stated that Resident #44 was trying to get something from Resident #9 and Resident #44 was pushed, making the resident fall and resulted in a broken hip. LPN #12 stated she was not made aware of resident-to-resident interactions except from verbal reports from other shifts and she does not review the resident ' s medical record unless there is an every-shift requirement to chart.
Removal Plan:
1. Resident #44 who received physical aggression placed 1:1 observation on 01/29/2025 by facility staff.
2. Resident #9 who initiated physical aggression discharged facility 01/09/2025.
3. Licensed nurse will assess all residents currently on secured unit for signs and symptoms of physical aggression as well as assess for signs of trauma and physical abuse by skin audits on 01/29/2025.
4. DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors as well as Dementia training on 1/29/2025. Staff not present will be in-serviced prior to the start of their shift.
Onsite Verification:
The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/30/2025. Resident #9 was verified to have been discharged from the facility on 01/09/2025. Resident #44 had a staff member one on one with the resident as of 01/30/2025. The facility assessed all residents on the unit for signs and symptoms of physical aggression and body audits were completed. A total of 30 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included certified nursing assistants, licensed practical nurses, registered nurses, Administrator, business office staff, laundry staff, kitchen staff, activity staff, housekeeping staff, physical therapy staff, and maintenance staff. The staff interviewed verified they had been trained in handling residents with behaviors and dementia. A review of the in-service sheets provided indicated 45 of 105 had been provided training. Those staff who were not physically present to receive the in-services were to be in-serviced prior to the start of their shift.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Comprehensive Care Plan
(Tag F0656)
Someone could have died · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the comprehensive person-centered care plan included an objective for monitoring a resident with wandering behaviors w...
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Based on observation, record review, and interview, the facility failed to ensure the comprehensive person-centered care plan included an objective for monitoring a resident with wandering behaviors who was at risk for resident-to-resident altercations for 1 (Resident #44) of 3 residents reviewed for abuse. The lack of effective interventions resulted in Resident #44 having resident-to-resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. All of the incidents took place on the locked unit and Resident #44 had been kicked, hit in the face, hit in an unknown area, pushed, punched in the hand, struck in the hand, punched in the stomach, pushed down numerous times, and hit in the head. The last incident resulted in a broken hip.
It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21 (Comprehensive Resident Centered Care Plan) at a scope and severity of J.
The IJ began on 04/11/2024, when Resident #44 was first pushed down by another resident while residing on the secure unit.
The Administrator, Director of Nursing, Nurse Consultant, and Director of Operations were notified of the IJ on 01/29/2025 at 10:28 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/29/2025 at 3:54 PM. The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented.
The findings are:
A review of a policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated the Interdisciplinary Team (IDT) along with the resident and/or resident representative develops and implements the comprehensive care plan to include measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs. Further review indicated, Care plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making.
A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse.
A review of the admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently.
A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed:
- 04/11/2024: Physical aggression received
- 04/19/2024: Physical aggression received
- 07/10/2024: Physical aggression received
- 08/06/2024: Physical aggression received
- 08/12/2024: Physical aggression received
- 08/21/2024: Physical aggression initiated
- 12/07/2024: Physical aggression received
- 12/20/2024: Physical aggression received
- 12/25/2024: Physical aggression received
- 01/09/2025: Physical aggression received
The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms.
A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident. On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room.
A review of Resident #44 ' s hospital records indicated on 01/09/2025, the resident was admitted to the hospital related to a fall with left hip pain and was diagnosed with a left femur fracture and required surgery.
During an interview on 01/28/2025 at 2:00 PM, Certified Nursing Assistant (CNA) 13 was in Resident #44 ' s room and stated the resident was not aggressive but at times, the resident takes things that belong to other residents, which agitates those residents resulting in pushing Resident #44.
During an interview on 01/28/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident #44 was sent to the hospital because the resident was touching another resident who had autism. The DON stated Resident #44 used to be a CNA and likes to pick up things and was trying to pick things up in the other resident ' s room. This resulted in the other resident pushing Resident #44, causing the resident to fall. The DON stated the other resident no longer resided in the facility.
During an interview on 01/29/2025 at 8:20 AM, CNA #2 stated Resident #44 was not aggressive but did go into other resident ' s rooms. CNA #2 stated interventions for Resident #44 included redirecting or distracting the resident. CNA #2 stated she was aware of an altercation between another resident and Resident #44 and stated the other resident was eating a snack when Resident #44 entered the resident ' s room and tried to grab the snack. This resulted in the other resident pushing Resident #44 to the floor. CNA #2 stated residents on the secure unit are monitored by having at least one staff member on the hall in the middle. CNA #2 stated that during the altercation, both herself and CNA #1 were at the nurse ' s station, monitoring the cameras. CNA #1 was teaching CNA #2 how to chart in the medical record. CNA #2 stated she looked up at the camera and saw Resident #44 walk towards the other resident and CNA #2 got up and ran from the nurse ' s desk to get Resident #44. This would indicate Resident #44 was not one-on-one per the resident ' s care plan.
During an interview on 01/29/2025 at 8:35 AM, CNA #1 stated Resident #44 was very grabby but did not have aggressive behaviors. CNA #1 stated staff would give Resident #44 towels to fold or give the resident something to do to keep the resident ' s mind busy. CNA #1 stated she was showing CNA #2 how to chart in the medical record at the nurse ' s station and CNA #2 took off running and that ' s when she looked up at the camera and saw Resident #44 head towards Resident #9. CNA #1 stated another CNA was supposed to be monitoring the hall but did not know where that CNA went.
During an interview on 01/29/2025 at 11:23 AM, the Administrator stated there were interventions in place to safeguard Resident #44 but was unable to provide them to the surveyor. The Director of Nursing (DON) stated the facility placed a stop sign on another resident ' s door but was removed because the resident did not want it. The DON also stated that there were medication changes for Resident #44 to help with anxiety. The Administrator stated the facility did monthly in-services regarding behaviors but there was a new staff member completing those in-services and the Administrator could not locate the in-services.
During an interview on 01/29/2025 at 2:00 PM, Licensed Practical Nurse (LPN) 12 stated Resident #44 goes into other resident ' s rooms and staff were to distract the resident. LPN #12 stated CNA #1 and CNA #2 being at the nurse ' s station during the incident between Resident #44 and another resident was not appropriate and they should be charting at the kiosk in the hallway. LPN #12 stated that Resident #44 was trying to get something from another resident and Resident #44 was pushed, making the resident fall and resulted in a broken hip. LPN #12 stated she was not made aware of resident-to-resident interactions except from verbal reports from other shifts and she does not review the resident ' s medical record unless there is an every-shift requirement to chart. LPN #12 stated the intervention of redirecting Resident #44 was not an appropriate intervention because the resident would just continue with the behavior. LPN #12 stated that an appropriate intervention would have been to remove one of the residents from the neighborhood.
Removal Plan:
1. Resident #44 who received physical aggression placed on observation 1:1 on 01/29/2025 by facility staff.
2. Resident #9 who initiated physical aggression discharged from the facility 01/09/2025
3. DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors on 01/29/2025 and continue training staff as they clock in until all staff have been trained.
4. On 1/29/2025, the DON/Designee will initiate in-service related to following care plan interventions for direct care staff currently in facility. Direct care staff not present will be in-serviced prior to the start of their shift. Any newly hired direct care staff will also be in-serviced.
5. DON/Designee will review all care plans for residents residing in the Dementia care unit for appropriate interventions related to behaviors and update the care plans as needed on 1/29/2025.
6. Nurse Consultant/Designee will initiate in-service with the Minimum Data Set (MDS) coordinator and all nurse managers on reviewing and updating care plans and that interventions are appropriate and effective on 1/29/2025.
Onsite Verification:
The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/30/2025. Resident #9 was verified to have been discharged from the facility on 01/09/2025. Resident #44 had a staff member one on one with the resident as of 01/30/2025. The facility assessed all residents on the unit for signs and symptoms of physical aggression and body audits were completed. A total of 30 staff interviews were conducted with staff from all shifts to verify training had been completed for behavior interventions. The staff interviewed included certified nursing assistants, licensed practical nurses, registered nurses, Administrator, business office staff, laundry staff, kitchen staff, activity staff, housekeeping staff, physical therapy staff, and maintenance staff. The staff interviewed verified they had been trained in handling residents with behaviors and dementia. A review of the in-service sheets provided indicated 45 of 105 had been provided training. Those staff who were not physically present to receive the in-services were to be in-serviced prior to the start of their shift. A total of 6 staff interviews were conducted regarding care plans being updated. The staff interviewed included the DON, the MDS Nurse, the ADON, and three LPNs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure hand hygiene was performed during one of one me...
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Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure hand hygiene was performed during one of one meal service observed.
Findings include:
A review of a facility policy titled, Handwashing/Hand Hygiene, revised October 2023, indicated, handwashing was the primary means to prevent the spread of infections and stated that hand hygiene is indicated immediately before touching a resident, after contact with contaminated surfaces and after touching a resident or the resident ' s environment.
During an observation on 01/27/2025 at 12:38 PM, Nursing Assistant (NA) #9 rubbed their hands on their shirt, then placed their hands in their lap, then picked up a spoon and started feeding a resident without sanitizing hands. After feeding the bite, NA #9 placed their hands back in between their knees, then grabbed a spoon to feed the resident, without sanitizing hands. NA #9 reached across another second resident and adjusted the resident, then picked up a glass and offered the first resident a drink without sanitizing hands.
During an interview on 01/27/2025 at 1:40 PM, NA #9 stated it was a bad habit that hands were placed in between the knees and confirmed that hands should have been sanitized prior to feeding the residents after touching clothes or between the residents.
During an interview on 01/31/2025 at 8:50 AM, the Director of Nursing (DON) confirmed that it is not right to hold hands between the legs and then go to assist one resident and then to move to another resident to feed without hand sanitizing in between.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on interviews and record review, it was determined that the facility failed to ensure that resident to resident events were reported within 24 hours even if no serious bodily injury occurred for...
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Based on interviews and record review, it was determined that the facility failed to ensure that resident to resident events were reported within 24 hours even if no serious bodily injury occurred for 1 (Resident #9) of three residents reviewed for abuse and neglect.
Findings include:
A review of the facility policy, Abuse Prevention, revised 11/16/2017 revealed that all reports of resident abuse, neglect, injuries of an unknown source, resident-to-resident abuse and resident-to-staff abuse are promptly and thoroughly investigated by facility management, and that when an alleged or suspected abuse is reported, the facility administrator or his/her designee, would notify the following:
1.
The State licensing/certification agency
2.
The resident ' s representative
3.
Law enforcement
4.
The resident ' s attending physician.
A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse.
A review of State Operations Manual Appendix PP, F600 indicates, Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing, shoving .The action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions.
A review of the admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently.
A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed:
- 04/11/2024: Physical aggression received
- 04/19/2024: Physical aggression received
- 07/10/2024: Physical aggression received
- 08/06/2024: Physical aggression received
- 08/12/2024: Physical aggression received
- 08/21/2024: Physical aggression initiated
- 12/07/2024: Physical aggression received
- 12/20/2024: Physical aggression received
- 12/25/2024: Physical aggression received
- 01/09/2025: Physical aggression received
The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms.
A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident. On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room. Of all of the reports, only one was reported to the State Agency.
During an interview on 01/31/2025, at approximately 11:00 AM, the Administrator was unaware of the regulation that resident-to-resident altercations had to be reported to the State Agency and stated only interactions that resulted in injury should be reported.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that the resident received prompt treatment aft...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that the resident received prompt treatment after noticing a change in condition for 1 (Resident #112) of 4 residents reviewed for abuse and/or neglect. Specifically, Resident #112 showed signs of a stroke and was not sent to the emergency room until approximately 4 hours after noticing the change in condition.
The findings are:
A review of an admission Record indicated Resident #112 had diagnoses of neurocognitive disorder with Lewy bodies, chronic obstructive pulmonary disease, altered mental status, atrial fibrillation (irregular and often rapid heart rhythm that can lead to stroke), cerebrovascular disease (term for conditions that affect blood flow to your brain), cognitive communication deficit.
The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2025 documented the resident scored 00, (0-7 indicates the resident was severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). Further review indicated the resident ambulated with a walker and was independent with care.
A review of Resident #112 ' s care plan, initiated on 11/27/2023, indicated the resident was on an anticoagulant (blood thinning) medication related to atrial fibrillation. The facility developed interventions to include administering the medication as ordered and monitor for side effects and effectiveness every shift. The blood thinning medication had a black box warning and premature discontinuation increased the risk of blood clots and to monitor for warning and side effects of the medication. Staff were to monitor, document, and report any adverse reactions of the blood thinner medication.
Review of Resident #112 Progress Notes dated 10/3/2024 at 3:23 PM, staff reported to Licensed Practical Nurse (LPN) #12 that Resident #112 was acting a bit strange during smoke break. When staff spoke to the resident, there was slurred speech and the resident reported to be tired. Resident #112 denied any pain or discomfort and was alert and oriented. Resident #112 was able to ambulate with no difficulty and the resident ' s vital signs were within normal limits for the resident. LPN #12 requested the doctor to see Resident #112 during rounds.
Review of Resident #112 Physician Notes indicated on 10/03/2024 at 7:35 PM, an Advanced Practice Registered Nurse (APRN) provided an interactive audio and visual telecommunication with the resident. The APRN indicated Resident #112 ' s chief complaint was a change in mental status and staff reported slurred speech and left side weakness. The staff reported that this started around 4 hours ago. Resident #112 had significant left sided facial droop on exam, had slurred speech, and complained of back pain. The APRN indicated the resident needed to be sent to the emergency room for an evaluation due to a possible stroke. The APRN indicated the resident ' s doctor was made aware of the visit and new orders.
Review of Resident #112 Progress Notes dated 10/3/2024 at 7:52 PM, Registered Nurse (RN) #14 indicated Resident #112 continued with slurred speech and staff reported she the resident was not acting like themselves. The on-call provider was notified and new orders were received to send the resident to emergency room for evaluation.
Review of Resident #112 Progress Notes showed no physician entries for this resident on 10/03/2024.
A review of Resident #112 ' s admission H&P [history and physical] notes indicated Resident #112 ' s family member was at the resident ' s bedside at the hospital and told the APRN the resident had stop talking all of their medication approximately 3 months ago. The resident was admitted to the hospital on [DATE] at 8:06 PM. Imaging of the resident ' s head and neck indicated a medium vessel occlusion (most common artery involved in acute stroke) and Resident #112 was not a candidate for intravenous thrombolysis (the use of medication to dissolve blood clots) due to it being outside of the timeframe for administration.
During an interview on 01/29/2024 at 4:48 PM. LPN #12 stated on 10/03/2024, the doctor was doing rounds in the facility and was notified of the resident ' s change in condition and that the resident needed to be seen by the doctor. LPN #12 stated staff let the resident rest until seen by the doctor.
Review of OLTC Witness Statement Form, dated 01/30/2025 at 9:56 AM the Director of Nursing (DON) indicated On October 3rd, 2024, I received a phone call from the resident ' s Medical Physician (MP). Medical Physician stated that he had seen the resident per [the resident ' s] nurse ' s request. At that time, the resident did not wish to go to the hospital to be evaluated. The resident was also non-compliant with [the resident ' s] medications, including [a blood thinner]. In light of this, the residents Medical Physician called me on my personal phone and requested that a care plan be scheduled with the resident and [the resident ' s family member] to discuss goals of care and potential comfort care measures. I was on the way home from daycare with children at the time, so the time of call would have been around 5pm. This information provided above is true to the best of my knowledge.
A review of Resident #112 ' s electronic health record did not indicate there was a conversation between Resident #112 ' s MP and the DON on 10/03/2024.
During an interview on 01/30/2025 at 11:08 AM, The MP was asked if he saw the resident on 10/03/2024 while completing rounds on other residents at the facility and the MP stated he did not see the resident and did not have any notes on the resident for that day.
Review of facility policy titled Change in a Resident ' s Condition, which indicated Our facility promptly notifies the resident, his or her primary care provider, and the resident representative of changes in the residents medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to (1) properly transfer 1 (Resident #41) of 9 residents reviewed for accidents; (2) ensure keys were not left in the janitor...
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Based on observations, interviews, and record reviews, the facility failed to (1) properly transfer 1 (Resident #41) of 9 residents reviewed for accidents; (2) ensure keys were not left in the janitor closet door unattended where chemicals were stored for 1 (100 hall) of 4 halls observed; (3) ensure the rear casters/wheels of the mechanical lift were in the unlocked position when raising and lowering residents affecting 1 (Resident #8) of 9 residents reviewed for accidents; (4) ensure the beauty shop on the secured unit was locked when not in use or when there were no staff present.
The findings are:
1. A review of an Order Summary Report revealed Resident #41 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis after a stroke) affecting the dominant side.
The quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2024 revealed Resident #41 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review indicated the resident had upper and lower extremity range of motion impairment to one side. Resident #41 was able to transfer from the bed to the chair independently.
A care plan with a revision date 1/30/2025 indicated that Resident #41 was a risk for falls related to balance problems. The facility developed interventions that included staff were to ensure the resident was wearing appropriate footwear when ambulating in the wheelchair and to have non-skid strips at the bedside. Resident #41 also had an activity of daily living (ADL) self-care performance deficit and was able to move between surfaces independently.
During an observation on 1/28/25 8:45AM the staff were informed that Resident #41 was on the floor in their bedroom. Certified Nurse Assistant (CNA) #11 and the Medical Records Coordinator put a gait belt around Resident #41's waist. When the two staff went to pick up the resident, they placed their hands under the resident ' s arms and lifted the resident up without using the gait belt.
A review of Resident #41's Incident Note dated 1/28/25 indicated that Resident #41 went to transfer themselves to a wheelchair to use the bathroom. Resident #41 did not have on proper footwear, missed the wheelchair, and went to the floor. There were no injuries. A sock was placed on the resident's foot, and non-skid strips were at the resident's bedside. Interventions included non-skid sock, non-skid strips placed on bedside, and neuro checks.
During an interview on 1/29/25 at 3:56 PM the Medical Records Coordinator indicated that she and CNA #11 picked Resident #41 up off the floor when the fell on 1/28/25. Medical Records Coordinator indicated that she was not sure why she picked Resident #41 up with her hand positioned under the resident's arm pits. Medical Records Coordinator indicated that Resident #41 could have received a shoulder injury by being picked up improperly. Medical Records Coordinator indicated that a lift was not used because Resident #41 transfers on their own.
During an interview on 1/31/2025 the Director of Nurse (DON) indicated that staff should use a gait belt when picking a resident up from the floor after a fall. The DON indicated that a resident should never be picked up by staff placing their hands under a resident's arm pit. The DON indicated that if the staff does not use a gait belt that the resident or the staff could be injured.
A review of facility policy, Falls - Clinical Protocol, with a revision date of 03/2018 did not indicate how residents should be transferred after a fall.
2. A review of a facility policy titled, Hazardous Areas, Devices, and Equipment revised July 2017, indicated that a hazard is defined as anything in the environment that has the potential to cause injury. Further review indicated, The Safety Committee will recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility (locks, alarms, supervision, etc.).
On 1/27/2025 at 2:39 PM, the Housekeeping Supervisor went into the tub room on the 100 halls, left the keys to the janitor's closet in the door, and shut the door behind them. At 2:41 PM the Housekeeping Supervisor walked out of the janitor ' s closet on the 100 hall and began to walk down the hall. She was informed by the surveyor that she had left her keys in the janitor closet door. At 2:44 PM, the Housekeeping Supervisor indicated that she did not realize that she had left her keys in the door. She indicated that a resident could have gone into the closet where chemicals are stored. At 2:46 PM, the Housekeeping Supervisor opened the door to the janitor's closet. There was a gallon of glass cleaner, a gallon of bathroom cleaner, a gallon of odor solution, a gallon of sanitizer, and a container of urine cleaner in the closet.
3. A review of Medical Diagnosis revealed Resident #8 had diagnoses of dementia, heart failure, and schizoaffective disorder.
A review of Resident #8 ' s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2024 indicated a Staff Assessment for Mental Status (SAMS) was completed, which indicated the resident was moderately impaired for cognitive skills for daily decision making. Further review indicated the resident required a manual or electric wheelchair, and the resident required total care for eating, bathing, dressing, personal care, transfers, and toileting.
A review of Resident #8 ' s care plan revealed a self-care performance deficit related to disease processes, requiring two staff members to transfer Resident #8 with a mechanical lift.
During an observation on 01/28/2025 at 9:31 AM, Certified Nursing Assistant (CNA) #7 assisted CNA #8 were in Resident #8 ' s room to transfer the resident using a mechanical lift. Both CNAs positioned the open legs of the mechanical lift around Resident 8 ' s specialty chair. CNA #8 was observed locking the rear casters/wheels of the lift and raising Resident #8 up with the mechanical lift and sling from the chair to transfer to the bed. The CNAs positioned the lift over the resident ' s bed. With the legs open under the bed, the right rear caster/wheel of the lift was locked, and the left caster was left unlocked and resident was lowered to the bed.
During an interview on 01/28/2025 at 9:34 AM, CNA #8 stated when they transferred Resident #8 using the mechanical lift, the legs of the mechanical lift were open for stability, and the rear casters/wheels were locked so the mechanical lift would not move when raising and lowering Resident #8. CNA #7 and CNA #8 both stated they have been in-serviced on using a mechanical lift.
A review of Batter Powered Patient Lift User Manual, dated 2018, revealed on page 6 that it was not recommended to lock the rear casters/wheels of the mechanical lift when lifting a resident, because it could cause the lift to tip and endanger the resident and assistants. On page 12, a warning label revealed, DO NOT lock the casters of the Patient Lift when lifting an individual. [NAME] MUST be left unlocked to allow Patient Lift to stabilize during lifting procedures.
During an interview on 01/29/2025 at 9:35 AM, the Director of Nursing (DON) stated during a transfer, the legs of the mechanical lift were to remain open to provide stabilizing and the rear casters/wheels were left unlocked. The DON stated leaving the rear wheels unlocked would prevent the mechanical lift from tipping. The DON stated if the weight shifts when a resident was being raised, the base of the lift would shift with the resident to prevent tipping. The DON stated it would not be appropriate to lift a resident with the rear casters locked, and stated she does not know why staff would lock the right wheel and leave the left wheel or rear caster unlocked when lowering the resident to the bed.
A review of facility policy titled Lifting Machine, Using a Mechanical, revised July 2017, and it did not indicate locking the rear casters/wheels when lifting a resident with a mechanical lift. The policy did indicate that lift designs and operations may vary depending on the manufacture and staff must be trained and demonstrate competency using the lift.
A review of Competency Assessment Lifting Machine, Using a Mechanical indicated a competency and/or return demonstration of using a mechanical lift. The checklist was verbatim of the above facility policy and did not indicate the rear casters should be locked.
4. During an interview on 01/31/2025 at 10:00 AM, the Administrator stated the facility did not have a policy for the beauty shop.
During an observation on 01/29/2025 at 2:01 PM, while making rounds on the secure unit, the beauty shop door was noted to be open, and no staff were present. Three residents on the secured unit were wandering the hallway. One resident was in a wheelchair and two residents were ambulatory. Inside of the beauty shop was a floor scrubber and a 2-wheeled dolly, shampoos, 2 spray bottles with clear liquid (unlabeled), vinegar, hair products and a can of clipper cleaning spray. Electrical supplies (clippers and a curling iron) were plugged in and ready for use.
During an observation on 01/29/2025 at 2:06 PM, the beautician returned to the beauty shop with a resident from the main facility, while this surveyor remained beside the open door to the beauty shop.
During an interview on 01/29/2025 at 2:12 PM, the beautician confirmed that the door was left ajar due to not having a key to get in after getting another resident to do the resident ' s hair. The beautician stated that the door to the beauty shop should be shut and locked when not in use or if no one is present.
During an interview on 01/30/2025 at 3:15 PM, the Administrator confirmed that the beauty shop should not have been left open and was not aware that the beautician did not have a key, stating, I ' m going to make it where it has a code to get in. The Administrator stated the beautician had been working for the facility for approximately one month as a full-time certified nursing assistant and did the beauty shop 2-3 times a month.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to acquire a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the fa...
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Based on record review and interview, the facility failed to acquire a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, as required, for 1 of 1 facility.
The findings are:
The Centers for Medicare and Medicaid Services (CMS) Guidance at tag F770 documented, .If a facility provides its own laboratory services or performs any laboratory tests directly (e.g. [for example], blood glucose monitoring, etc. [et cetera]) the provisions of 42 CFR [Code of Federal Regulations] Part 493 apply and the facility must have a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility.
On 1/29/25 at 11:52 a.m., Observation of the facility's CLIA certificate documented an expiration date of 1/25/25. The Administrator was asked if the facility had a current CLIA certificate in her office. She stated, I will have to get that for you.
A review of Pay.gov Payment Confirmation: CLIA Laboratory Program indicated the facility paid for the CLIA license on 1:22 PM. The facility was unable to provide a current CLIA certificate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to ensure garbage and refuse was disposed of properly for one of one dumpster observed.
The findings are:
During an observatio...
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Based on observations, interviews, and record review, the facility failed to ensure garbage and refuse was disposed of properly for one of one dumpster observed.
The findings are:
During an observation on 01/28/2025 at 3:00 PM, the trash dumpster gates were opened, exposing the trash dumpster and the trash inside. Sitting directly next to the dumpster was a used recliner and broken wooden fencing.
A. The trash dumpster door was left open, exposing trash bags containing briefs, gloves, and other waste items inside.
B. The fence around the dumpster had a large section of the fence missing, exposing a large black trash bag lying on the ground beside the dumpster that contained unknown debris and a dirty recliner sitting beside the dumpster. The black trash bag was torn open in several places. Items that had spilled out of the black trash bag included an empty sugar bag, several foam containers, plastic lids, a stack of white cups, plastic bags, used plastic gloves and an empty bottle of thickened water. [NAME] bags, used gloves, paper and other debris were on the grounds around the fencing and dumpster.
C. A white bag of used rolled baby diapers was tossed on the ground along the fence that ran along the back of the facility grounds.
D. Several tree limbs and brush were piled up between the fencing around the dumpster and the fencing along the backside of the grounds with a white plastic bag on the ground, a snicker bar wrapper, used gloves, and other debris under the limbs.
E. Approximately 3 feet behind the trash bin fence was a pair of used gloves. There were several plastic bags lying along the fence row along the back yard of the facility. A white bag with rolled used briefs was observed lying on the ground along the fence of the back yard.
F. A large screw, approximately 2 inches long with a sharp point, was protruding out the side of the fence post, eye level with the surveyor.
2. During an interview on 01/29/2025 at 8:15 AM, the Administrator stated the dietary department was responsible for cleaning the dumpster area.
3. During an interview on 01/29/2025 at 8:30 AM, the Dietary Manager (DM) stated she checked the dumpster three times a week to ensure the bags were picked up. The DM stated she removed the black trash bag that was on the ground yesterday (01/28/2025), and stated the bag had been there since last week.
4. During a concurrent observation and interview on 01/29/2025, at 8:37 AM, the DM and Surveyor observed the dumpster area and noted the dumpster gates surrounding the dumpster were open. The DM stated the gates were always left open. The dumpster door was noted to be opened. The DM stated the dumpster door should be closed and she closed the dumpster door. The DM stated the gloves could be a danger to a resident if the resident got the gloves because the gloves could have infectious things on them and cross contaminate the resident with whatever is on the glove. The DM stated the brush and tree limbs between the dumpster fence and the backyard fencing could be a danger to a resident if the resident walked back there and
got hung up in the branches and maybe even pass away if no one thought to look back there. The DM identified a clear white plastic cup lying on the ground as being one the nurse ' s use. The DM stated the fencing had been broken and missing pieces for about a month. The DM stated the recliner was put next to the dumpster over the weekend. The DM stated she tells her staff to pick up the trash around the dumpster when they take the trash out and to make sure the door is closed to the dumpster.
5. During an observation on 01/29/2025 at 8:52 AM, the black trash bag was lying on the ground and hanging from under the dumpster, the sugar bag was hanging on the back corner of the dumpster, the glove behind the dumpster fencing was lying on the ground, the trash was under the brush and limbs, a pair of used gloves was lying on the ground beside the fencing, the bag of diapers was still lying on the ground beside the fence, two used masks were lying on the concrete just outside the dietary department.
6. During an interview on 01/29/2025 at 9:23 AM, the DM stated she did not have any training documentation and/or in-services to indicate training had been provided to dietary employees related to the disposal of refuse/garbage and/or the facility dumpster.
7. A review of facility policy Food-Related Garbage and Refuse Disposal revised 10/2017, indicated Garbage and reuse containing food wastes will be stored in a manner that is inaccessible to pests .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.
Jan 2024
8 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure 1 (Resident #13) of 1 sampled resident was provided a weighted cup for fluids to prevent dehydration. The findings are:
Resident #13 h...
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Based on observation and interview, the facility failed to ensure 1 (Resident #13) of 1 sampled resident was provided a weighted cup for fluids to prevent dehydration. The findings are:
Resident #13 had a diagnosis of covid 19 and unspecified severe protein-calorie malnutrition. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/24 documented the resident scored 07 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS).
A Care Plan dated 10/23/23 documented, .Weighted Cups .Encourage good nutrition and hydration in order to promote healthier skin .
On 1/22/24 at 2:42 PM, Resident #13 had a pitcher and a styrofoam cup in his room. Both were empty.
On 1/24/24 at 2:56 PM, Resident #13 was in bed drinking liquid out of a white styrofoam cup.
On 1/25/24 at 9:36 AM, there were no drinking cups in Resident #13's room.
On 1/25/24 at 9:45 AM, the Activity Director walked into Resident #13's room. She was asked, Does [Resident #13] have any water or a weighted cup in his room. She stated, No, he doesn't.
On 1/25/24 at 9:47 AM, the Social Worker walked down to Resident #13's room and passed a cup to the Activity Director.
On 1/25/24 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was asked, Can you tell me why [Resident #13] didn't have water, or his weighted cup in his room. She stated, He wasted the water on him at breakfast, and we were going to bring him more when we brought out the snacks. She was asked, Should [Resident #13] have his weighted cup with water available at all times? She stated, Yes ma'am.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0575
(Tag F0575)
Could have caused harm · This affected multiple residents
Based on observation, interview, and policy review the facility failed to post, in a form and manner accessible and understandable to residents, contact information for pertinent State agencies and ad...
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Based on observation, interview, and policy review the facility failed to post, in a form and manner accessible and understandable to residents, contact information for pertinent State agencies and advocacy groups for 15 residents residing in the facility's Secure Unit. The findings are:
On 01/22/2024 at 02:40 PM, observed the contact information for State agencies and the Ombudsman was not posted in the secure unit. The doorways into the secure unit were closed and secured to prevent residents from exiting and observing contact information posted in other parts of the facility.
On 01/23/2024 at 08:30 AM, observed the contact information for State agencies and the Ombudsman was not posted in the secure unit.
On 01/24/2024 at 08:00 AM, observed the contact information for State agencies and the Ombudsman was not posted in the secure unit.
On 01/24/2024 at 01:35 PM, the Director of Nursing (DON) reported they were not aware that the contact information for State agencies and the Ombudsman was required to be posted in the secure unit. The DON confirmed that the contact information should be available to all residents.
On 01/24/2024 at 01:45 PM, the Administrator confirmed that contact information for State agencies and the Ombudsman was required to be posted in the manner that it was accessible to all residents.
On 01/24/2024 at 04:00 PM, the Administrator reported that the facility did not have a policy on posting required information and that state regulations were followed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the resident rooms in a safe, functional, ho...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the resident rooms in a safe, functional, homelike manner for 3 (Rooms 114, 119, 121) rooms, as evidenced by trim disconnected from the walls and built in drawers failed to open and close safely. The findings are:
On 01/24/24 at 10:08 AM, during environmental rounds the following observations were made:
a. Standing in the entrance of room [ROOM NUMBER], inside the bathroom, on the left side of the floor, the trim was disconnected from the wall 2 inches.
b. Standing in the entrance of room [ROOM NUMBER], the lower section of the built in 2-door closet had upper and lower drawers. The upper drawer toward the outside window could not be opened and safely closed.
c. Standing in the entrance of room [ROOM NUMBER], the lower section of the built in 2-door closet had upper and lower drawers. The upper and lower drawers toward the bathroom could not be opened and safely closed. In addition, the floor trim on the wall from the bathroom entrance extending to the built in closet door was disconnected from the wall 1 inch.
On 01/24/24 at 04:03 PM, during a tour with Maintenance Supervisor #1, in response to the question, Are you aware that the floor trim in the bathroom of room [ROOM NUMBER], is disconnected from the wall? The Maintenance Supervisor stated, I was not aware, but this will be repaired. In addition, in response to the question, Are you aware that the built in drawers in room [ROOM NUMBER] and 121 cannot be opened and closed safely, and the trim is disconnected in room [ROOM NUMBER]? The Maintenance Supervisor tried to open and close the drawers in both rooms. He stated, I will have these drawers repaired and will repair the wall trim.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 2 (Residents #32 and #34) of 15 ...
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Based on observation, interview and record review, the facility failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 2 (Residents #32 and #34) of 15 (Residents #2, #3, #4, #8, #13, #21, #31, #32, #35, #38, #43, #45, #48, #105, and #106) sampled residents who were dependent on staff for fingernail care and facial hair was removed from 1 (Resident #105) of 10 (Residents #50, #105, #13, #45, #35, #41, #32, #38, #5, and #8) sampled residents who were dependent on staff for personal hygiene. The findings are:
1. Resident #32 had a diagnosis of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/02/23 documented the resident scored 06 (0-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required partial/moderate assistance with Activities of Daily Living (ADL's).
The Comprehensive Care Plan with a revision date of 12/23/23 included the need for assistance with ADLs with an intervention noted Resident #32 was able to perform personal hygiene care independently following staff set up and resident required total dependence on staff for bathing.
On 01/22/2023 at 2:30 PM, Resident #32 was sitting in his wheelchair in his room. A dark substance, brown in color, was observed under his fingernails. His lunch tray was in his room lying on his bed.
On 01/23/24 at 09:04 AM, Resident #32 was sitting in his wheelchair in his room, with his breakfast tray on his bed. A dark substance, brown in color, remained under his fingernails.
On 01/23/24 at 03:48 PM, Resident #32 was sitting in his wheelchair in his room, with his lunch tray lying on his bed. A dark substance, brown in color, was observed under his fingernails.
On 01/24/24 at 09:02 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to the resident's room and observed the dark brown substance under his nails. In response to the question, How does the facility clean under his nails and when should his nails be cleaned? LPN #1 stated, His nails should be cleaned, we use a small wooden stick to clean under his nails. The Surveyor asked when the hands and nails are looked at, to know when care should be preformed? LPN #1 stated, Nails should be cleaned before meals, and after using the bathroom.
On 01/25/24 at 07:50 AM, in an interview with the Director of Nursing (DON), in response to the question, Are you aware that Resident #32 has dark residue under his nails? The DON responded, I will follow-up and nails should have been cleaned.
2. Resident #34 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Quarterly MDS with an ARD on 12/02/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS.
Resident #34's Care Plan with a revision date of 01/01/24 noted Resident #34 required substantial/maximal staff assistance to
perform personal hygiene.
On 1/23/24 at 9:01 AM, Resident #34's fingernails were 1/2 inch long with a thick black substance underneath his nails. Resident #34 raised his hands up, then he stated, They're still dirty.
On 1/24/24 at 9:03 AM, the Surveyor asked Resident #34, How often do the staff cut your nails? He stated, They don't never cut them. He was asked, Would you like them cut? He stated, I would love to have them cut and trimmed. His nails were 1/2 inches long with a thick black substance underneath.
On 1/25/24 at 9:03 AM, the Surveyor asked Resident #34, Did you get your nails cut? He stated, Not yet. His nails were 1/2 inch long with a thick black substance underneath.
#3. Resident #105 had a diagnosis of malignant neoplasm of extrahepatic bile duct. The admission MDS with an ARD on 1/03/24 documented the resident scored 14 (cognitively) on a BIMS and required staff setup or clean up assistance with personal hygiene including shaving.
On 1/22/24 at 2:26 PM, Resident #105's beard was 1 inch long. Resident #105 was asked, How often do you get a shave? He stated, They don't ever ask me. He was asked, Would you like to be shaved? He stated, I would from time to time.
On 1/24/24 at 3:27 PM, Resident #105 beard was 1 inch long. Resident #105 was asked, How long have you been living in this facility? He stated, A few weeks, almost a month. He was asked, When was the last time you had a shave? He stated, I was shaved at the place I was at before I came here. No one has shaved me here. I would like a nice trim.
On 1/22/24 at 9:19 AM, Resident #105 was in bed. His beard was 1 inch long.
On 1/25/24 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was asked, How often does [Resident #105] get a shave? She stated, Usually when they ask for it, but we try to ask them on shower days. The Surveyor asked, Can you tell me why [Resident #105] hasn't been shaved? She stated, We haven't asked him if he wants one.
On 01/24/24 at 4:02 PM, the Administrator provided a policy titled, Activities of Daily Living (ADLs) (Revised March 2018), that read in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities for 15 residents in the facility's Secure Unit. The findings are:
On 01/22/2024 at 0...
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Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities for 15 residents in the facility's Secure Unit. The findings are:
On 01/22/2024 at 02:15 PM, Resident #28 was asked if they were encouraged to participate in activities. Resident #28 denied being invited to join in activities.
On 01/22/2024 at 02:39 PM, a bulletin board labeled, Activities of the Week was observed in the secure unit. It documented the activities planned for the week.
On 01/22/2024 at 04:00 PM, a Music Social was scheduled. It did not take place.
On 01/23/2024 at 11:00 AM, a game of Zingo was planned. It did not take place.
On 01/23/2024 at 04:00 PM, a game of Ball Toss was planned. It did not take place.
On 01/24/2024 at 11:00 AM, Creativity Art was planned. It did not take place.
On 01/24/2024 at 01:27 PM, the Director of Activities was asked if residents in the secure unit had a program of activities that was being followed. The Director of Activities confirmed that a program was in place and was posted on that unit. The Director of Activities was asked who was responsible for ensuring those activities took place. The Director of Activities confirmed that they were responsible for planning the activities, and that staff working in the secure unit were responsible for carrying out the program. The Director of Activities confirmed that it was important for residents residing on the secure unit to have an ongoing program of activities.
On 01/24/2024 at 02:30 PM, the Administrator acknowledged the importance of residents residing on the secure unit to have an ongoing program of activities.
On 01/24/2024 at 04:00 PM, a Policy titled, Activity Programs was provided by the Administrator. It documented, Activity programs are designed to meet the needs and interests of and support the physical, mental, and psychosocial well-being of each resident.5. Activities are scheduled 7 (seven) days a week .Resident's activity participation is documented in the resident's individual medical record .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that hazardous fluids were stored in a safe ma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that hazardous fluids were stored in a safe manner in 3 (rooms [ROOM NUMBER]) resident rooms located in the facility's secure unit. This failed practice had the potential to affect 10 residents identified as ambulatory by a list provided by the Administrator on 01/24/2024 at 04:00 PM. The findings are:
1. On 01/22/2024 at 02:03 PM, rooms [ROOM NUMBERS] were observed to share a bathroom. In the bathroom was an opened bottle of Perineal and Skin Cleanser. The label documented, Caution: For external use only. Avoid contact with eyes. In case of eye irritation, flush with water and contact a physician . Keep out of reach of children.
a. On 01/23/2024 at 08:45 AM, the bottle of skin cleanser was observed in the bathroom for rooms [ROOM NUMBERS].
b. On 01/24/2024 at 09:00 AM, the bottle of skin cleanser was observed in the bathroom for rooms [ROOM NUMBERS].
2. On 01/22/2024 at 02:15 PM, an opened bottle of Lens Cleaner was observed in the bathroom of room [ROOM NUMBER]. The label documented, Caution: Do not spray near eyes. Not for contact lens use. Keep out of reach of children.
a. On 01/23/2024 at 08:50 AM, the bottle of lens cleaner was observed in the bathroom for room [ROOM NUMBER].
b. On 01/24/2024 at 09:05 AM, the bottle of lens cleaner was observed in the bathroom for room [ROOM NUMBER].
3. On 01/24/2024 at 01:35 PM, the Director of Nursing (DON) confirmed that liquids such as cleansers should not be stored in resident rooms on the secured unit.
4. On 01/24/2024 at 01:45 PM, the Administrator confirmed that liquids such as cleansers should not be stored in resident rooms on the secured unit.
5. On 01/24/2024 at 03:30 PM, the Administrator provided a document titled, Acknowledgement of Prohibition of Potential Hazards. It documented, .Hazards include the following: .Personal care and other items with warnings such as Keep out of reach of children Chemicals or plants that would be poisonous if ingested .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure 1 (Resident #13) of 12 (Residents #50, #105, #13, #3, #45, #106, #35, #5, # 4, #8, #31, and #48) sampled residents who were dependent ...
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Based on observation and interview, the facility failed to ensure 1 (Resident #13) of 12 (Residents #50, #105, #13, #3, #45, #106, #35, #5, # 4, #8, #31, and #48) sampled residents who were dependent on staff for hydration always had fluids available. The findings are:
Resident #13 had a diagnosis of covid 19, and unspecified severe protein-calorie malnutrition. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 10/26/24 documented the resident scored 07 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS).
A January 2024 Physicians Order documented, .Nectar consistency .
A Care Plan dated 10/23/23 documented, .Weighted Cups .Encourage good nutrition and hydration in order to promote healthier skin .
On 1/22/24 at 2:42 PM, Resident #13 had a pitcher and a styrofoam cup in his room. Both were empty.
On 1/24/24 at 2:56 PM, Resident #13 was in bed drinking a liquid out of a white styrofoam cup.
On 1/25/24 at 9:36 AM, there were no drinking cups in Resident #13's room.
On 1/25/24 at 9:45 AM, the Activity Director walked into Resident #13's room. She was asked, Does [Resident #13] have any water or cups in his room. She stated, No, he doesn't.
On 1/25/24 at 9:47 AM, the Social Worker walked down to Resident #13's room and passed a cup to the Activity Director.
On 1/25/24 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was asked, Can you tell me why [Resident #13] didn't have water, or his weighted cup in his room. She stated, He wasted the water on him at breakfast, and we were going to bring him more when we brought out the snacks. She was asked, Should [Resident #13] have his weighted cup with water available at all times?' She stated, Yes ma'am.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure the oxygen tubing, humidifier mask, and/or an oxygen water bottle were dated for 2 (Residents #3 and #13) of 6 (Residen...
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Based on observation, record review and interview, the facility failed to ensure the oxygen tubing, humidifier mask, and/or an oxygen water bottle were dated for 2 (Residents #3 and #13) of 6 (Residents #3, #13, #28, #50, #105, and #106) sampled residents who had a physician's order for oxygen. The findings are:
1. Resident #3 had a diagnosis of covid 19, pneumonia, unspecified organism, and acute cough. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 1/07/24 documented the resident scored 07 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS).
A Physicians Order for Resident #3 dated 11/14/23 documented, .Change and date O2 [oxygen] tubing and water bottle q [every] week and clean filter and initial portable o2 tubing changed weekly as well, ensure bag is in place, and tubing is inside bag when not being used every night shift every Mon [Monday] . O2 @ [at] 2L/min [liters per minute] via [by] nasal cannula ***MAY REMOVE FOR ADL'S [activities of daily living]***as needed for shortness of breath.
On 1/22/24 at 1:45 PM, the oxygen tubing and water bottle were not dated. The oxygen tubing on the portable oxygen concentrator was not dated or bagged.
On 1/22/24 at 2:58 PM, the oxygen tubing and water bottle were not dated. The oxygen tubing on the portable oxygen concentrator was not dated or bagged.
On 1/22/24 at 8:30 AM, the oxygen tubing and water bottle were not dated. The oxygen tubing on the portable oxygen concentrator was not dated or bagged.
On 1/24/23 at 10:08 AM, Licensed Practical Nurse (LPN) #1 was asked, When should the oxygen tubing be dated. She stated, Every time we change the tubing. She was asked, What should you do with the oxygen tubing when it's not in use? She stated, Put it in the bag.
2. Resident #13 had a diagnosis of covid 19, and unspecified severe protein-calorie malnutrition. The Medicare 5-Day MDS with an ARD on 10/26/24 documented the resident scored 07 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS).
A Care Plan with an initiated date of 10/19/23 did not indicate that Resident #13 was on oxygen.
A Physicians Order dated 01/12/24 noted Resident #13 was to have the oxygen tubing and water bottle changed and dated every week and initialed and portable oxygen tubing replaced and put in a bag and the bag replaced every night shift every Monday.
On 1/22/24 at 2:42 PM, Resident #13's oxygen tubing, humidifier mask, and water bottle were not dated. The resident was receiving oxygen by nasal cannula at 6 liters per minute.
On 1/23/24 at 2:56 PM, Resident #13's oxygen tubing, humidifier mask, and water bottle were not dated.
On 1/24/24 at 10:15 AM, Resident #13's humidifier mask was on the bedside table, not in a storage bag.
On 1/25/24 at 9:25 AM, Resident #13's oxygen concentrator was at the end of his bed. The oxygen tubing attached to the concentrator was on the floor. The humidifier mask was on the bedside table, not in a storage bag.
On 1/25/23 at 10:04 AM, Licensed Practical Nurse (LPN) #1 was asked, How often is [Resident #13] ordered to have on his oxygen. She stated, It's as needed, but he has been wearing it continuously. She was asked, When the oxygen and the humidifier mask is not in use where should the tubing and humidifier mask be stored? She stated, The clear plastic bags that's in the room. She was asked, Does [Resident #13] ambulate? She stated, No he doesn't.
Dec 2022
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure 2 (Resident #3, and R #4) of 6 (R #1, R #2, R #3, R #4, R #5, R #6) sampled residents were provided with adaptive equi...
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Based on observation, record review, and interview, the facility failed to ensure 2 (Resident #3, and R #4) of 6 (R #1, R #2, R #3, R #4, R #5, R #6) sampled residents were provided with adaptive equipment during meals to ensure residents achieved and or maintained their highest practicable level of eating/drinking independence. The findings are:
1.Resident #3 (R #3) had diagnoses of Dementia, Alzheimer's disease, and muscle wasting and atrophy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/2022 documented the resident scored 2 (0-7 indicated severe impairment) on the Brief Interview for Mental Status (BIMS), required limited assist for most all activities of daily living (ADLs).
a. A Care Plan with a revision date of 9/29/2022 documented .The resident has an Activity of Daily Living (ADL) self-care performance deficit r/t (related to) dementia .the resident can feed self independently following tray set up .
b. On 12/13/2022 at 12:20 p.m. Certified Nursing Assistant (CNA) #1 was setting up R #3 meal tray in the dining room on the secure unit. CNA #1 served R #3 8 ounces of tea in a regular cup with no lid. CNA #1 served R #3 8 ounces of milk in a regular cup with no lid.
c. On 12/13/2022 at 12:23 p.m., review of R #3 meal tray card documented .Standing orders .8 fl (fluid) oz (ounces) iced tea .put in large cup with lid .8 fl. oz. milk .put in large cup with lid .
2. Resident #4 (R #4) had diagnoses of Dementia, Alzheimer's Disease, and lack of coordination. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/2022 documented the resident scored 3 (0-7 indicated severe impairment) on the Brief Interview Mental Status (BIMS), required extensive assistance with most all ADL's.
a.A Care Plan with a revision date of 5/23/2022 documented .The resident has an ADL self-care performance deficit r/t dementia .the resident feeds self independently following staff set up .
b. On 12/13/2022 at 12:24 p.m. CNA #1 was setting up R #4 meal tray in the dining room on the secure unit. CNA #1 served R #4 8 ounces of tea in a regular cup with no lid. CNA #1 then served R #4 8 ounces of coffee in a regular cup with no lid.
c. On 12/13/2022 at 12:26 p.m., review of R#4 meal tray card documented .Standing orders .8 fl. oz. coffee .cup with lid .8 fl. oz. iced tea .cup with lid .
3. The following interview were conducted with facility staff:
a. On 12/13/2022 at 12:37 p.m., The Surveyor asked CNA #1, Why weren't R#3 and R#4 served drinks in cups with lids? CNA #1 stated, I don't know.
b. On 12/13/2022 at 12:59 p.m., The Surveyor asked CNA #1, Who is responsible for ensuring meal cards are followed? CNA #1 stated, everybody.
c. On 12/13/2022 at 5:01 p.m., The Surveyor asked the Dietary Manager (DM) #1, Why are R #3 and R #4 drinks not in cups with lids today? The DM #1 stated, They should be, R #3 got shaky and sometimes he spills his drinks, I got all over her, one of my girls, for not putting the cups with lids out.
d. On 12/15/2022 at 10:29 a.m., The Surveyor asked CNA #2, Who is responsible for ensuring the tray cards are followed? CNA #2 stated, CNA's, whoever passes the trays. The Surveyor asked CNA #2, If a resident's tray card states, Serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? CNA #2 stated, It should be. The Surveyor asked CNA #2, Why would a resident's tray card state, Serve liquids in a cup with a lid? CNA #2 stated, To keep them from taking big drinks, and keep from spilling.
e. On 12/15/2022 at 11:05 a.m., The Surveyor asked CNA #3, Who is responsible for ensuring the tray cards are followed? CNA #3 stated, The kitchen, but whoever delivers the tray is responsible for ensuring the diet and equipment is right. The Surveyor asked CNA #3, If a resident's tray card states, Serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? CNA #3 stated, It should be. The Surveyor asked CNA #3, Why would a resident's tray card state, Serve liquids in a cup with a lid? CNA #3 stated, He might have trouble with spilling it.
f. On 12/15/2022 at 11:23 a.m., The Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for ensuring the tray cards are followed? LPN #1 stated, It starts in the kitchen, then the CNA's, whoever has access to the tray. The Surveyor asked LPN #1, if a resident's tray card states, Serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? LPN #1 stated, it should be. The Surveyor asked LPN #1, Why would a resident's tray card state, Serve liquids in a cup with a lid? LPN #1 stated, Probably because they have an issue with spilling, and to prevent it from spilling.
g. On 12/15/2022 at 11:47 a.m., The Surveyor asked Dietary #2, who is responsible for ensuring the tray cards are followed. Dietary #2 stated, It's our job, the Dietary Manager, it's our responsibility as it goes out the kitchen. The Surveyor asked Dietary #2, If a resident's tray card states, Serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? Dietary #2 stated, they should be.
h. On 12/15/2022 at 12:00 p.m., The Surveyor asked Dietary #3, Who is responsible for ensuring the tray cards are followed? Dietary #3 stated, The cook and the assistants. The Surveyor asked Dietary #3, If a resident's tray card states, serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? Dietary #3 stated, that would be me too.
i. On 12/15/2022 at 12:20 p.m., The Surveyor asked the Dietary Manager #1, Who is responsible for ensuring the tray cards are followed? Dietary Manager #1 stated, The ones who's serving out the line. The Surveyor asked Dietary Manager #1, If a resident's tray card states, Serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? Dietary Manager #1 stated, It should be the person doing the drinks.
j. On 12/15/2022 at 12:37 p.m., The Surveyor asked the Director of Nursing (DON), Who is responsible for ensuring the tray cards are followed? The DON stated, dietary and nursing. The Surveyor asked the DON, If a resident's tray card states, Serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? The DON stated, only if he refused.
k. On 12/15/2022 at 12:38 p.m., The Surveyor asked the Administrator, Who is responsible for ensuring the tray cards are followed. The Administrator stated, dietary and nursing. The Surveyor asked the Administrator, If a resident's tray card states, serve liquids in a cup with a lid, should the resident's liquids be served in a cup with a lid? The Administrator stated, it should be served.
4. A policy provided by the Administrator on 12/15/2022 at 11:02 a.m. documented .Adaptive Eating Devices .adaptive eating devices will be used as necessary to ensure that residents can achieve or maintain their highest practicable level or eating independence .DM (Dietary Manager) ensures that the resident tray card states the specific adaptive device needed .dietary department .places the devices on the resident's tray as needed .
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered or sealed and dated, failed to ensure expired milk items were promptly ...
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Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered or sealed and dated, failed to ensure expired milk items were promptly removed/discarded by the expiration or use by dates, failed to ensure foods left out on the kitchen table were covered; and failed to ensure dry goods were labeled and dated to prevent potential for food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 65 residents who received meals/trays from the kitchen according to a list provided by the Director of Nursing (DON) on 12/15/2022 at 10:41 a.m. The findings are:
1. On 12/13/2022 at 10:31 a.m. a metal bowl of uncooked chicken thighs was on the kitchen table, uncovered. A metal bowl of egg batter mix was on the kitchen table, uncovered. A metal bowl of corn flake batter mixture was on the kitchen table, uncovered.
a. On 12/13/2022 at 10:33 a.m., the Surveyor asked the Dietary Manager (DM), what is in the bowls? The DM stated, Chicken thighs, egg batter, and corn flakes. The Surveyor asked the DM, Should it be covered? The DM stated, yes, it should be covered while the other is cooking.
2. On 12/13/2022, the following were in the refrigerator:
a. At 10:40 a.m., a clear plastic bag that contained lettuce and slices of tomatoes had no label and was not dated.
b. At 10:42 a.m., a clear plastic container that contained 6 hardboiled eggs had no label and was not dated.
On 12/13/2022 at 10:45 a.m., the Surveyor asked the DM, Who is responsible for ensuring food is labeled and dated? The DM stated, Absolutely everybody.
c. At 10:51 a.m., a half-gallon of buttermilk with a use by date of December 12, 2022.
3. On 12/13/2022 at 10:46 a.m., the following were on a metal cart next to the stove:
a. 3 clear plastic bags of potato chips with no date and no label
b. a rice [named snack] wrapped in clear [named] wrap with no label and no date
c. 3 clear bags that contained 1 chocolate chip cookie each, with no label and no date
4. A policy provided by the Administrator on 12/14/2022 at 10:23 a.m. documented .Food Receiving and Storage .Foods shall be received and stored in a manner that complies with safe food handling practices .all foods stored in the refrigerator or freezer will be covered, labeled and dated .dry foods that are stored in bins will be removed from original packaging, labeled and dated .such foods will be rotated using a first in - first out system .beverages must be dated when opened and discarded per expiration or per manufacturers guidelines .other opened containers must be dated and sealed or covered during storage .
5. On 12/15/2022 the following interviews were conducted:
a. At 11:47 a.m., the Surveyor asked Dietary #2, why should food in the refrigerator be labeled and dated? Dietary #2 stated, so you're not serving residents food that is bad. The Surveyor asked Dietary #2, why should expired milk be removed from the refrigerator? Dietary #2 stated, it can make you sick if served. The Surveyor asked Dietary #2, why should food be covered when sitting out in the kitchen? Dietary #2 stated, because we do have flies, and they could land on the food, and cause diseases. The Surveyor asked Dietary #2, who is responsible for ensuring food is labeled and dated? Dietary #2 stated, everybody is. The Surveyor asked Dietary #2, who is responsible for ensuring food is covered like chicken thighs, cornflake mix, and egg batter when sitting out? Dietary #2 stated, the cook is responsible, if your cooking, it's your responsibility. The Surveyor asked Dietary #2, who is responsible for ensuring expired food is not stored in the kitchen? Dietary #2 stated, everybody. The Surveyor asked Dietary #2, have you been trained on storage and handling of food? Dietary #2 stated, yes.
b. At 12:00 p.m., the Surveyor asked Dietary #3, why should food in the refrigerator be labeled and dated? Dietary #3 stated, so we know what day we put it in. The Surveyor asked Dietary #3, why should expired milk be removed from the refrigerator. Dietary #3 stated, it goes bad. The Surveyor asked Dietary #3, why should food be covered when sitting out in the kitchen? Dietary #3 stated, from cross contamination. The Surveyor asked Dietary #3, who is responsible for ensuring food is labeled and dated? Dietary #3 stated, whoever uses it or puts it up. The Surveyor asked Dietary #3, who is responsible for ensuring food is covered like chicken thighs, cornflake mix, and egg batter when sitting out? Dietary #3 stated, the cook, but the assistants too, basically everybody. The Surveyor asked Dietary #3, who is responsible for ensuring expired food is not stored in the kitchen? Dietary #3 stated, everybody. The Surveyor asked Dietary #3, have you been trained on storage and handling of food? Dietary #3 stated, yes.
c. At 12:20 p.m., the Surveyor asked the DM, why should food in the refrigerator be labeled and dated. The DM stated, so you know what it is and how long it's been in there. The Surveyor asked the DM, why should expired milk be removed from the refrigerator. The DM stated, it could make someone sick. The Surveyor asked the DM, why should food be covered when sitting out in the kitchen? The DM stated, In case there's any bugs or something gets in it. The Surveyor asked the DM, who is responsible for ensuring food is labeled and dated? The DM stated, everybody. The Surveyor asked the DM, who is responsible for ensuring food is covered like chicken thighs, cornflake mix, and egg batter when sitting out? The DM stated, the cook, whoever is dealing with that, it's their responsibility. The Surveyor asked the DM, who is responsible for ensuring expired food is not stored in the kitchen? The DM stated, everybody. The Surveyor asked the DM, Have you been trained on storage and handling of food? The DM stated, yes. The Surveyor asked the DM, what are your expectations from your staff regarding following the facility policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to food storage and handling. The DM stated, I got high expectations.
d. At 12:38 p.m., the Surveyor asked the Administrator, Why should food in the refrigerator be labeled and dated? The Administrator stated, so you know it's not bad. The Surveyor asked the Administrator, why should expired milk be removed from the refrigerator? The Administrator stated, it's expired. The Surveyor asked the Administrator, why should food be covered when sitting out in the kitchen? The Administrator stated, sanitary, to keep warm, it shouldn't be left uncovered. The Surveyor asked the Administrator, who is responsible for ensuring food is labeled and dated? The Administrator stated, dietary. The Surveyor asked the Administrator, who is responsible for ensuring food is covered like chicken thighs, cornflake mix, and egg batter when sitting out? The Administrator stated, dietary. The Surveyor asked the Administrator, who is responsible for ensuring expired food is not stored in the kitchen? The Administrator stated, dietary. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facility policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to food storage and handling? The Administrator stated, with education and them understanding, we expect them to do things right.
Oct 2022
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure a resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 (Resident #17) o...
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Based on observation, record review, and interview, the facility failed to ensure a resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 (Resident #17) of 7 (Residents #2, #17, #27, #36, #43, #46 and #59) sampled residents who were dependent for nail care. The findings are:
Resident #17 had diagnoses of Type II Diabetes Mellitus and Dementia. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was totally dependent of one person physical assistance for bathing and required extensive physical assistance of one person for personal hygiene.
a. The Physician's order dated 7/26/22 documented, Cut/file finger/toe nails every day shift every Tue [Tuesday] .
b. The Care Plan dated 8/18/22 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Dementia . BATHING/SHOWERING: Resident requires total dependence x [times] 1 staff for showering . PERSONAL HYGIENE: Resident requires extensive assist x 1 staff for personal hygiene . The resident is resistant to care r/t dementia . Resident often times refuses finger/toe-nail care .
c. On 10/17/22 at 12:22 PM, Resident #17 was sitting in his recliner, his fingernails on the left hand were approximately 1/4 inch long, thick, and jagged with a thick brownish substance under his nails.
d. On 10/18/22 at 8:35 AM, Resident #17 was lying in bed, his fingernails on the left hand were approximately ¼ inch long, thick, and jagged with a thick brownish substance under his nails. The Surveyor asked Resident #17 if he would like his nails trimmed. The resident stated Do you have some cutters? I don't see any cutters
e. On 10/18/22 at 8:48 AM, Certified Nurse Assistant (CNA) #1 accompanied the Surveyor to the resident's room. The Surveyor asked CNA #1 to describe the resident's nails. CNA #1 looked at the resident's nails and stated, Oh we definitely will get that taken care of. The Surveyor asked, Who is responsible for the resident's nail care? He stated, The CNAs, if they aren't diabetic, the nurses trim the diabetic residents. I'm not sure if he is diabetic, but I can check on that The Surveyor asked CNA #1, When is nail care completed? He stated, Usually on bath days
f. On 10/18/22 at 8:58 AM, Licensed Practical Nurse (LPN) #1 went into Resident #17's room with fingernail clippers and a file. LPN#1 asked the resident if she could trim his nails, the resident agreed. LPN #1 went to the resident's bedside and performed nail care on the resident's left hand.
g. On 10/18/22 at 10:40 AM, the Surveyor asked LPN #1, Who is responsible for nail care? LPN #1 stated, The CNAs are, unless they are diabetic, then the nurses do it. The Surveyor asked, When is nail care done on the residents? LPN #1 stated, Some have it done twice a week, or at least once a week. The Surveyor asked, What is that brown, thick substance under [Resident #17's] nails? LPN #1 stated, It's a fungus, and his nails get thick and are hard to properly trim. The Surveyor asked, What could happen if his nails are not trimmed and filed? She stated, He could scratch himself and cause injury. The Surveyor asked, Who is responsible to ensure nail care is being completed as needed on the residents? LPN #1 stated, The nurses.
h. On 10/20/22 at 9:17 AM, during a telephone interview with LPN #1, the Surveyor asked, What was that brown substance under the resident's nails? LPN #1 stated, It was a buildup of skin. The Surveyor asked, How often is nail care performed on the resident. LPN #1 stated, Every Tuesday. The Surveyor asked, Does the resident refuse nail care? LPN #1 stated, Yes, but not often. The Surveyor asked, If the resident refuses nail care what do you do? LPN #1 stated, Reattempt, if he still refuses, document the refusal in the nurse's note.
i. The October 2022 Nurse's Notes contained no documentation the resident refused nail care.
j. The Policy of Activities of Daily Living received on 10/20/22 at 10:38 AM from the Administrator documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain . grooming and personal . hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .Hygiene (bathing . grooming .)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items and expired food items were promptly removed/discarded ...
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Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items and expired food items were promptly removed/discarded by the expiration or use by dates to prevent potential for food bone illness. These failed practices had the potential to affect 66 residents who received meals from the kitchen and 21 residents who received snacks from the unit (total census: 66), as documented on a list provided by the Dietary Supervisor on 10/19/2022. The findings are:
1. On 10/19/22 at 8:20 AM, a half-gallon of sweet and sour sauce was on a shelf in the storage room with an expiration date of 5/3/2022.
2. On 10/19/22 at 11:29 AM, Dietary Employee (DE) #1 used a rag to wipe off the counter. She did not was her hands, she picked up plates and placed them on the counter with her fingers touching the interior surfaces of the plates. She then removed gloves from the glove box and placed them on her hands and contaminated the gloves. She removed the plastic covering or seal from the pie, did not change gloves or wash her hands. She used a knife to slice the pie. She used a spatula to scoop up slices of pie from the pan and used her contaminated gloved hand to push slices pie onto individual plates. At 1:59 PM, the Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.
3. On 10/19/22 at 11:55 AM, DE #2 pushed a cart that contained clean dishes towards the food preparation counter. Without washing her hands, she picked up plates, with her fingers touching the interior surfaces of the plate. She picked up glasses by the rims and stacked them in an opened cabinet.
4. On 10/19/22 at 11:57 AM, DE #2 pulled her pants up. Without washing her hands, she picked up a pan with her fingers touching the inner surfaces of the pan as she placed the pan on the shelf. At 11:59 AM, the Surveyor asked DE #2, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.
5. On 10/19/22 at 1:59 PM, the Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.
6. On 10/20/22 at 10:17 AM, the following food items were on a shelf in the Unit Medication Room:
a. A packet of mini powered donuts with an expiration date of 9/28/2022.
b. Two boxes of fall party cakes with 10 snack cakes in each box. The date on the boxes showed, Best if used by 10/17/2022.
7. The facility Policy for Hand Washing provided by the Dietary Supervisor on 10/20/2022 at 10:20 AM documented, Dietary department employees are required to wash their hands on the occasions listed below: Before beginning shift, after handling dirty dishes and any other time deemed necessary.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s). Review inspection reports carefully.
- • 20 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $13,871 in fines. Above average for Arkansas. Some compliance problems on record.
- • Grade F (9/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Westwood Health And Rehab, Inc's CMS Rating?
CMS assigns WESTWOOD HEALTH AND REHAB, INC an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Arkansas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Westwood Health And Rehab, Inc Staffed?
CMS rates WESTWOOD HEALTH AND REHAB, INC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Arkansas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Westwood Health And Rehab, Inc?
State health inspectors documented 20 deficiencies at WESTWOOD HEALTH AND REHAB, INC during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 18 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Westwood Health And Rehab, Inc?
WESTWOOD HEALTH AND REHAB, INC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ANTHONY & BRYAN ADAMS, a chain that manages multiple nursing homes. With 85 certified beds and approximately 54 residents (about 64% occupancy), it is a smaller facility located in SPRINGDALE, Arkansas.
How Does Westwood Health And Rehab, Inc Compare to Other Arkansas Nursing Homes?
Compared to the 100 nursing homes in Arkansas, WESTWOOD HEALTH AND REHAB, INC's overall rating (2 stars) is below the state average of 3.1, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Westwood Health And Rehab, Inc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the facility's high staff turnover rate.
Is Westwood Health And Rehab, Inc Safe?
Based on CMS inspection data, WESTWOOD HEALTH AND REHAB, INC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Arkansas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Westwood Health And Rehab, Inc Stick Around?
Staff turnover at WESTWOOD HEALTH AND REHAB, INC is high. At 56%, the facility is 10 percentage points above the Arkansas average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Westwood Health And Rehab, Inc Ever Fined?
WESTWOOD HEALTH AND REHAB, INC has been fined $13,871 across 1 penalty action. This is below the Arkansas average of $33,218. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Westwood Health And Rehab, Inc on Any Federal Watch List?
WESTWOOD HEALTH AND REHAB, INC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.