Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbors West during CMS and state inspections, most recent first.
Failure to notify residents and representatives of room changes. Three residents with significant cognitive impairment had room changes, but records showed no evidence that the residents or their emergency contacts were informed. Interviews with family members confirmed they were unaware of the moves, and the SW verified the lack of notification.
Failure to Invite Family to Care Conference: The facility did not ensure a resident’s son, listed as the emergency contact, was invited to the resident’s care conference. The resident had dementia, an unspecified mood disorder, depression, and severely impaired cognition. The son said it had been a long time since he had participated in a care conference despite wanting to do so, and the SSW confirmed there was no evidence he was invited.
A resident with COPD, HF, AFib, HTN, and acute kidney failure had multiple scheduled meds left undocumented on the MAR, including statin, antidepressant, beta blocker, acid reducer, diuretic, gabapentin, levothyroxine, and nystatin. The resident’s progress notes also lacked any mention of the missing entries, and the DON confirmed that documentation was missing for many medications during the review period.
A cognitively intact resident with Huntington’s disease and other conditions was participating in chair exercises when a CNA used a personal cellphone to record the resident lifting her leg above her head, without any signed photo release or consent from the resident’s POA. Two other CNAs watched the event and did not report it. Other staff later observed the CNAs laughing and viewing the image on the phone. Review of incident reports, staff statements, and the facility’s social media policy confirmed that the recording was taken in the work area using a personal device and that facility policy prohibits taking or sharing resident photos or videos without prior written permission.
The facility failed to maintain proper hand hygiene during food service, affecting all residents. A staff member contaminated food by using a soiled glove while taking food temperatures. Additionally, a soiled scoop was used during tray line service, contrary to facility policy requiring clean utensils. The facility's policy mandates adherence to federal guidelines for meal service.
The facility failed to maintain clean and safe grounds, with significant litter of cigarette butts observed along the sidewalk to the smoking area. Two residents confirmed the issue, noting that residents did not use the provided dispensing devices. An LPN confirmed the litter and identified potential fire hazards due to piles of debris mixed with cigarette butts. The facility's policy indicated maintenance was responsible for maintaining safe grounds.
The facility failed to conduct interdisciplinary care conferences for three residents, affecting their involvement in care planning. A resident was not invited to any conferences, while another's family was rarely invited. Additionally, a resident's care plan lacked updates for anticoagulant use, despite receiving the medication. These deficiencies were confirmed by staff interviews and record reviews.
The facility failed to timely address pharmacy recommendations for four residents, leading to delays in medication changes. Recommendations for obtaining a TSH level, discontinuing Lorazepam and Megace, and reducing doses of Zoloft and Trazodone were not acted upon promptly. The facility's policy requires timely action on MRR irregularities, which was not followed.
The facility failed to prepare pureed food to the required consistency for residents with dietary needs. A staff member was observed preparing pureed peas, which contained lumps and pieces despite repeated blending. The Regional Dietary Contractor confirmed the improper consistency, which was corrected only after surveyor intervention. The facility's policy mandates a pudding mousse-like consistency for pureed foods.
The facility failed to ensure resident fund authorization forms were properly witnessed, affecting two residents. One resident, cognitively impaired, had an illegible signature without witness signatures, while another, cognitively intact, had a legible signature but also lacked witness signatures. The Business Office Manager was unaware of the requirement for witness signatures, contrary to facility policy.
The facility failed to provide required spenddown notifications to two residents whose account balances exceeded $1800. One resident, with a BIMS score of 4, had balances consistently over the threshold, reaching $3707.29. Another resident, with a BIMS score of 00, had balances over $19,000. Despite the facility's policy requiring notifications when balances reach $1800, these were not consistently provided, as confirmed by the Business Office Manager.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's severe cognitive impairment and multiple diagnoses. Interviews with the DON and a social worker confirmed the absence of a care plan addressing PTSD, contrary to the facility's policy requiring person-centered care plans for all residents.
The facility failed to communicate with the dialysis center for a resident with end-stage renal disease, diabetes, heart failure, and cognitive communication deficit. The LPN confirmed that no documentation was sent to the dialysis center, and the DON acknowledged the lack of communication, as the dialysis center stopped completing their part of the form. The facility's policy required coordination and reporting to the dialysis provider, which was not followed.
A facility failed to provide trauma-informed care for a resident with PTSD, who was severely cognitively impaired and had multiple diagnoses. Despite receiving psychiatric services, the resident's medical record lacked documentation of preferences, trauma triggers, or interventions to prevent re-traumatization. Interviews confirmed the absence of an independent PTSD assessment, as residents were referred to psychiatric services without further facility assessment.
A resident was prescribed Quetiapine Fumarate (Seroquel) for insomnia despite not having a psychotic disorder, which is necessary for such medication. The facility failed to act on a pharmacist's recommendation to discontinue the medication, resulting in its continued use without an appropriate diagnosis.
A medication error occurred when a nurse administered Lisinopril and Propranolol to a resident with a systolic blood pressure of 105 mmHg, despite orders to hold these medications if the systolic blood pressure was below 110 mmHg. The nurse was unaware of the parameters, leading to a medication error rate of 6.45% in the facility.
A resident receiving hospice care had incomplete medical records, with the last hospice note being from a care team meeting. The hospice communication notebook at the nurses' station was also missing visit documentation. Interviews with staff confirmed the absence of hospice notes, affecting the facility's record-keeping for the resident.
A facility failed to prevent contamination during medication administration when an RN handled medications with bare hands before placing them in a medication cup. The RN was unaware of the proper procedure to avoid touching pills directly, which was contrary to the facility's policy requiring medications to be administered in a manner preventing contamination or infection.
A facility failed to follow ordered parameters for blood pressure medication administration for a resident. An RN administered Lisinopril and Propranolol despite the resident's blood pressure being below the prescribed threshold for withholding these medications. The RN was unaware of the hold parameters, contrary to the facility's medication administration policy.
A former LPN misappropriated pain medications from three residents, affecting their prescribed regimens. The facility discovered discrepancies in medication counts and surveillance footage confirmed the LPN's actions. Despite policies requiring controlled substance counts, the misappropriation occurred, impacting resident care.
Two residents experienced significant delays in call light responses, with one resident waiting over an hour for incontinence care and another waiting 20 minutes for assistance with tube feeding. Staff interviews confirmed that long wait times were typical, and observations noted several staff members, including the DON and Unit Manager, walking past activated call lights without responding. Facility policy emphasized the importance of timely responses, highlighting the deficiency in care.
A resident in a LTC facility was observed without a sheet on her mattress over several days, despite being cognitively intact and requiring assistance with daily living activities. After moving rooms, the resident requested a sheet but was denied. Staff confirmed that the bed should have had a sheet, indicating a failure to maintain a homelike environment.
A resident with multiple medical conditions did not receive scheduled showers, resulting in an unkempt appearance. Despite being cognitively intact and requiring assistance, the resident's shower schedule was inconsistently documented, and staff reported frequent refusals and inadequate staffing. The DON was unaware of schedule discrepancies and missing documentation.
A resident with multiple health conditions, including diabetes and respiratory issues, did not receive a full and nutritious meal as per their carb-controlled diet plan. The meal provided was incomplete, missing key components like soup and bread, leading the resident to order additional food. Staff interviews revealed a lack of awareness and adherence to the resident's dietary preferences and facility policy, resulting in non-compliance.
Failure to Notify Residents and Representatives of Room Changes
Penalty
Summary
The facility failed to notify residents, their representatives, or emergency contacts of room changes for three residents. Resident #79 had chronic hepatic failure, unspecified mood disorder, metabolic encephalopathy, generalized anxiety disorder, and delusional disorder, and her BIMS assessment showed moderately impaired cognition. Her record showed a room change on 01/06/26, and although the interdisciplinary team discussed the new room change with her, there was no evidence her daughter, listed as her emergency contact, was notified. Social Service Worker #4 verified there was no evidence the daughter was informed. Resident #9 had metabolic encephalopathy, depression, and anxiety, and his quarterly MDS showed severely impaired cognition. His record showed a room change on 05/07/26, but there was no evidence that he or his spouse, listed as his emergency contact, were notified. Resident #59 had dementia, unspecified mood disorder, and depression, and her quarterly MDS also showed severely impaired cognition. Her record showed a room change on 03/27/26, but there was no evidence that she or her son, listed as her emergency contact, were notified. Interviews with Resident #9's wife and Resident #59's son indicated they were unaware of the room changes, and Social Service Worker #4 verified there was no evidence of notification for either resident.
Failure to Invite Family to Care Conference
Penalty
Summary
The facility failed to ensure a family member was invited to a care conference for Resident #59, whose medical record showed an admission date of 10/25/23 and diagnoses including dementia, unspecified mood disorder, and depression. Her quarterly MDS assessment indicated severely impaired cognition, and her profile listed her son as her emergency contact. Review of the resident’s care conference dated 01/12/26 showed no evidence that her son attended or was invited, and the son stated during interview that it had been a long time since he had participated in a care conference despite wanting to do so. Social Service Worker #4 confirmed there was no evidence the son was invited to the January 2026 care conference and stated he usually liked attending care conferences. The facility policy on comprehensive care plans stated every effort was to be made to schedule care plan meetings at the best time of day for the family and resident.
Missing MAR Documentation for Multiple Scheduled Medications
Penalty
Summary
Failure to provide pharmaceutical services to meet each resident’s needs was identified when Resident #74’s medication administration was not accurately documented on the MAR. Resident #74 was admitted on 08/26/25 and had diagnoses including COPD, acute on chronic respiratory failure with hypoxia, hypertension, heart failure, atrial fibrillation, and acute kidney failure. The resident’s BIMS on 08/27/25 was 14, indicating cognitive intactness. Review of the 08/2025 MAR showed missing documentation for multiple scheduled medications. On 08/27/25, there was no documentation for Atorvastatin 80 mg, Citalopram 40 mg, Carvedilol 6.25 mg, Famotidine 20 mg, Furosemide 40 mg, Gabapentin 300 mg, and Nystatin powder. On 08/28/25, there was no documentation for Levothyroxine 100 mcg, Gabapentin 300 mg at two scheduled times, and Nystatin powder at two scheduled times. The resident’s progress notes also did not contain documentation regarding the missing MAR entries, and the DON confirmed that documentation was missing for many medications during those two days. The facility policy required licensed nurses or other authorized staff to sign the MAR after administration and to correct discrepancies and report them to the nurse manager.
Unauthorized Cellphone Recording of Resident Without Consent
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of a resident’s personal and medical information when a CNA used a personal cellphone to record the resident without consent. The resident, admitted with diagnoses including Huntington’s disease, anxiety, and protein calorie malnutrition, was cognitively intact with a BIMS score of 13 and required one-person assistance with ADLs. During a chair exercise activity in the dining room, the CNA observed the resident lifting her leg above her head and took out her cellphone to take a picture/video of the resident. Two other CNAs stood nearby, watched the resident performing the exercises, and witnessed the recording being made but did not report it. The resident’s POA later confirmed that she had not given authorization for any photos or videos to be taken of the resident. Multiple staff interviews and document reviews corroborated that the recording occurred and that it involved the resident’s image being captured without prior authorization. The Activities Director and Business Office Manager both observed the three CNAs outside the dining room laughing and looking at a cellphone image of the resident with her leg pointed straight up. Review of the incident reports and staff statements confirmed that the recording was made on a personal cellphone in the work area. The Admissions Coordinator verified that there was no signed photo release authorization for the resident, and review of the facility’s Social Media Policy showed that employees are prohibited from using personal electronic devices in the work area without written approval and from taking or sharing resident photos or videos without prior written permission from the resident or authorized agent. Observation of the video by the Administrator and DON further confirmed that the resident had been recorded without authorization, constituting a breach of confidentiality and privacy.
Failure to Maintain Proper Hand Hygiene During Food Service
Penalty
Summary
The facility failed to maintain proper hand hygiene during food service, which had the potential to affect all residents. During an observation, a staff member was seen taking temperatures of food items and inadvertently contaminating the food. The staff member placed a thermometer in mashed potatoes, getting a piece of potato on her thumb and pointer finger. Without changing gloves, she submerged her soiled fingers into the gravy, confirming that her dirty glove was in the gravy mixture. In another instance, a staff member was observed scooping augratin potatoes when the scooper fell into the pan and became soiled. Despite this, a Regional Dietary Contractor picked up the soiled scoop and continued to use it for tray line service, handling other food items with it. The staff member acknowledged that if a scoop or service item falls into the food, it should be replaced with a clean one. The facility's policy on meal distribution and infection control, dated February 2023, mandates that meal service should follow federal guidelines.
Facility Grounds Littered with Cigarette Butts
Penalty
Summary
The facility failed to maintain the grounds in a clean and safe manner, specifically regarding the accumulation of cigarette butts on the property. Observations on two separate occasions revealed significant litter of cigarette butts along the sidewalk from the east hall exit to the designated smoking area, with hundreds of cigarette butts visible. Interviews with two residents confirmed that the smoking area, sidewalk, and grass area outside the fence were littered with cigarette butts, as residents did not use the dispensing devices provided and instead tossed their cigarette butts anywhere. An LPN confirmed the presence of hundreds of cigarette butts along the sidewalk and behind the fence, noting that the yard company was responsible for picking up trash and cigarette butts. The LPN also identified piles of dead plant debris mixed with cigarette butts, which could pose a fire hazard next to the wooden fence. The facility's policy on Preventative Maintenance indicated that maintenance was responsible for ensuring the building and grounds were maintained in a safe and operable manner.
Deficiencies in Care Conferences and Care Plan Updates
Penalty
Summary
The facility failed to ensure that interdisciplinary quarterly care conferences were completed for three residents, affecting their involvement in care planning. Resident #7, who was cognitively intact, reported not being invited to any care conferences in the previous year, despite documentation indicating a conference was held. Similarly, Resident #9's family expressed that they were only invited to a care conference once in the last year, although the facility's records showed a conference was held. Interviews with regional staff confirmed the lack of evidence for completed care conferences for these residents. Resident #36, who was moderately cognitively impaired, also did not have documented care conferences. The resident expressed a desire to be more involved in their care, but the facility only documented a quarterly mood evaluation by the social worker without a summary of care discussions or participant details. The social worker confirmed the absence of documented care plan meetings, indicating that the resident's care discussions were informal and not part of a structured conference. Additionally, the facility failed to update the care plan for former Resident #51 regarding the use of an anticoagulant medication. Despite receiving Eliquis for embolism and thrombosis, the resident's care plan lacked focus, goals, or interventions related to the medication. The Director of Nursing confirmed this oversight, which was inconsistent with the facility's policy to develop comprehensive care plans that address residents' medical needs.
Delayed Response to Medication Regimen Reviews
Penalty
Summary
The facility failed to timely respond to monthly medication regimen reviews (MRR) for four residents, leading to deficiencies in addressing pharmacy recommendations. For Resident #53, the pharmacist recommended obtaining a thyroid stimulating hormone (TSH) level on 02/05/25, but the provider did not address this until 03/18/25, with the TSH level ordered on 03/25/25. The Director of Nursing (DON) confirmed that the expectation is for recommendations to be addressed by the provider on the next visit, which occurs at least weekly. Resident #62's MRR on 02/05/25 included recommendations to discontinue Lorazepam and reduce doses of Zoloft and Trazodone. The provider agreed to these changes on 03/18/25, but the interdisciplinary team did not meet to review these recommendations until 03/25/25, delaying the implementation of the medication changes. Similarly, for Resident #73, a recommendation to discontinue Megace due to the risk of deep vein thrombosis was made on 02/05/25, but the provider did not respond until 03/18/25, and the medication was not discontinued until 03/25/25. Resident #32's MRR on 02/05/25 recommended discontinuing Seroquel, which was being used for sleep in a patient with dementia. The physician agreed to discontinue the medication on 03/18/25, but it was not acted upon until 03/24/25. The facility's policy requires MRR irregularities to be reported and acted upon within 10 working days, but this was not adhered to, resulting in delayed responses to pharmacy recommendations for these residents.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the proper consistency, as required for residents with specific dietary needs. During an observation, a staff member was seen preparing pureed peas by adding broth to the mixture in a roboku blender. Despite repeated blending and tasting, the mixture contained significant amounts of food on the sides, including visible lumps and pieces of peas. The Regional Dietary Contractor confirmed the presence of chunks and full skins of peas in the mixture. The facility's policy requires pureed foods to be made to a pudding mousse-like consistency, which was not achieved until after surveyor intervention.
Failure to Witness Resident Fund Authorizations
Penalty
Summary
The facility failed to ensure that resident fund authorization forms were properly witnessed, affecting two residents out of seven authorizations reviewed. Resident #12, who was cognitively impaired with a BIMS score of six, had an authorization form dated 04/24/24 with an illegible signature and no witness signatures. Resident #36, who was cognitively intact with a BIMS score of 12, had an authorization form dated 04/20/23 with a legible signature but also lacked witness signatures. The facility's policy requires that authorization forms be signed by the resident or responsible party and witnessed by an individual not associated with the facility when required by the state. During an interview, the Business Office Manager (BOM) confirmed that the authorizations for both residents were not witnessed. The BOM was unaware that witness signatures were necessary, believing they were only required if the resident was unable to sign. This oversight indicates a lack of adherence to the facility's policy regarding resident fund authorizations, which mandates witness signatures to ensure the proper management of residents' financial affairs.
Failure to Provide Spenddown Notifications
Penalty
Summary
The facility failed to provide spenddown notifications to residents when their account balances exceeded $1800, as required by their policy. This deficiency affected two residents, both of whom had account balances over the threshold. Resident #17, who was cognitively impaired with a BIMS score of 4, had a personal fund balance that consistently exceeded $1800 from January 2024 to March 2025, reaching as high as $3707.29. Despite the high balances, spenddown letters were not consistently provided monthly, as required. Resident #43, also cognitively impaired with a BIMS score of 00, had a personal fund balance that significantly exceeded the threshold, with balances over $19,000 for several months in 2024. The resident's balance remained above the $1800 threshold into 2025, yet spenddown notifications were not provided monthly. The facility's policy required that residents be notified when their account balance reached $1800, but this was not adhered to. An interview with the Business Office Manager confirmed that spenddown letters were not provided monthly for residents who were over-resourced. The facility's policy, dated February 2018, stated that residents should be notified when their account balance reaches $1800, but this was not consistently followed, leading to the deficiency.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop an accurate and comprehensive care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD, was found to have no documented care plan addressing PTSD or potential triggers. The annual minimum data set (MDS) indicated severe cognitive impairment and psychiatric/mood disorders, yet the care plan lacked specific interventions for PTSD. Interviews with the Director of Nursing (DON) and a social worker confirmed the absence of a care plan for the resident's PTSD. The facility's policy mandates the development of a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to address medical, nursing, and psychosocial needs identified in the resident's comprehensive assessment. However, this policy was not adhered to in the case of the resident with PTSD, as evidenced by the lack of a care plan for this specific condition.
Failure to Communicate with Dialysis Center for Resident Care
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident requiring dialysis services. This deficiency affected a resident with end-stage renal disease, diabetes, heart failure, and cognitive communication deficit. The medical record review revealed that the facility did not maintain a dialysis communication binder, and all documentation was located in the electronic medical record. The Licensed Practical Nurse (LPN) confirmed that the facility did not send any documentation to the dialysis center and believed the center did not have access to the facility's medical records. The Director of Nursing (DON) confirmed the lack of communication with the dialysis center, stating that the center had stopped completing their part of the communication form, leading the facility to cease sending it. The pre and post-dialysis assessments in the electronic record were not specific to dialysis sessions, as they were based on vitals taken every 12 hours rather than immediately before and after dialysis. The facility's policy required coordination between the facility and the dialysis provider, including providing a report to the dialysis provider on each treatment day, which was not adhered to in this case.
Lack of Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide individualized trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD, was found to be severely cognitively impaired with a BIMS score of five out of 15. Despite receiving psychiatric services and medications for depression and PTSD, the medical record lacked documentation of the resident's preferences, trauma triggers, or interventions to prevent re-traumatization. Interviews with the Director of Nursing and a social worker confirmed the absence of an independent PTSD assessment, as residents with PTSD were referred to psychiatric services without further facility assessment.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis for the use of an antipsychotic medication, specifically Quetiapine Fumarate (Seroquel). The resident, who was admitted with diagnoses including malnutrition, Alzheimer's disease, heart failure, muscle weakness, and atrial fibrillation, was prescribed Seroquel for insomnia. However, the resident did not have a psychotic disorder, which is necessary for the use of such medication. Despite recommendations from a pharmacist to evaluate and discontinue the medication due to the lack of an appropriate diagnosis, the medication was continued until it was eventually discontinued on 03/25/25. The Director of Nursing confirmed that the medication regime review was not acted upon in a timely manner, and the resident continued to receive Seroquel without a warranted diagnosis. The facility's policy states that psychotropic drugs should only be administered when necessary to treat a specific condition, as diagnosed and documented in the clinical record. The failure to adhere to this policy resulted in the unnecessary administration of an antipsychotic medication to a resident without a proper diagnosis.
Medication Administration Error Due to Unawareness of Parameters
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.45%. This deficiency affected one resident out of three observed for medication administration. During an observation, a registered nurse prepared and administered seven medications to a resident, including Lisinopril and Propranolol, both of which were to be held if the resident's systolic blood pressure was less than 110 mmHg. The resident's blood pressure was recorded at 105/69, yet the medications were administered. The nurse confirmed she was unaware of the parameters to hold the medication, despite the facility's policy requiring the person administering medications to obtain and record vital signs and hold medications for vital signs outside the physician's prescribed parameters.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who was receiving hospice services. The resident, who had multiple diagnoses including dementia and chronic kidney disease, was unable to be interviewed due to communication difficulties. The review of the resident's electronic medical record showed that the last hospice note was from an interdisciplinary team meeting, and there were no subsequent hospice notes uploaded. Additionally, the hospice communication notebook at the nurses' station, which should have contained visit documentation, was found to be incomplete with only an admission face sheet and blank sections for hospice team communication. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of hospice communication notes in the hospice binder. The Director of Nursing acknowledged that the nursing staff relied on the binder for hospice communication and verified that the last note in the electronic medical record was from the care team meeting. This deficiency affected the facility's ability to maintain accurate and complete records for the resident receiving hospice care.
Medication Administration Deficiency Due to Improper Handling
Penalty
Summary
The facility failed to ensure medications were administered in a manner to prevent contamination or infection, affecting one resident during medication administration observations. On the morning of March 26, 2025, a Registered Nurse (RN) prepared seven medications for a resident using a unit dose dispensing system. The RN removed each medication from its package and placed it into her ungloved hand before dropping it into a medication cup. During an interview, the RN confirmed that she was unaware that she should not touch the pills with her bare hands and should either place the pills directly into the cup or wear gloves. A review of the facility's Medication Administration policy, last reviewed on January 17, 2023, confirmed that medications are to be administered as prescribed by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to the ordered parameters for administering blood pressure medications to Resident #240. During an observation, RN #136 prepared and administered seven medications, including Lisinopril and Propranolol, to the resident. The resident's blood pressure was recorded at 105/69, which was below the prescribed threshold of 110 mmHg for withholding these medications. Despite this, RN #136 administered the medications, later confirming she was unaware of the hold parameters. The facility's medication administration policy, last reviewed on 01/17/23, requires staff to obtain and record vital signs and hold medications if vital signs fall outside the physician's prescribed parameters.
Medication Misappropriation by LPN
Penalty
Summary
The facility failed to protect three residents from misappropriation of their pain medications by a former Licensed Practical Nurse (LPN). The residents involved had various medical conditions requiring pain management, including multiple sclerosis, chronic obstructive pulmonary disease, and paraplegia. The care plans for these residents included administering medications as ordered and monitoring their effectiveness. However, discrepancies in medication counts were discovered, indicating that the prescribed Gabapentin was not administered as documented. The incident came to light when the Director of Nursing noticed inaccuracies in the medication counts for the affected residents. Surveillance footage revealed that the former LPN diverted medication by removing pills from blister packs and placing them into a generic container. This misappropriation was confirmed when the LPN admitted to the missing medications during an inquiry by the facility's administrator. The facility's policy required controlled substances to be counted at the end of each shift, with discrepancies reported immediately. Despite this policy, the misappropriation occurred, affecting the residents' medication regimens. The facility's failure to adhere to its own procedures allowed the LPN to misappropriate medications, impacting the care of the residents under her supervision.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner, affecting two residents. Resident #35, who was cognitively intact and required assistance with various activities of daily living, had her call light activated for incontinence care from approximately 8:00 A.M. until 9:25 A.M. on the day of observation. Interviews with the resident and CNAs revealed that long wait times for call light responses were typical, with staff often too busy to respond promptly. The resident reported that requests for showers or incontinence care were often delayed by one to two hours, or staff would not return after initially acknowledging the request. Resident #49, who was also cognitively intact and had a feeding tube, experienced a delay in response to his call light, which had been activated for about 20 minutes due to concerns about his tube feeding. Observations noted several staff members, including nursing staff, CNAs, the DON, and the Unit Manager, walking past the room without responding to the call light. An LPN confirmed that the call light had been on for a long time and acknowledged that all staff were responsible for answering call lights, with an expectation of a response within about five minutes. The facility's policy and protocol emphasized the importance of timely responses to call lights, indicating that failure to do so could be considered neglect.
Failure to Provide Linens for Resident's Bed
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for Resident #35 by not providing linens on her bed. Resident #35, who was cognitively intact and required assistance with various activities of daily living, was observed multiple times over three days without a sheet on her mattress. Instead, she had only one sheet/blanket covering her while she slept. This lack of proper bedding was confirmed through observations and interviews with the resident and staff. Resident #35 had recently moved rooms, and it was noted by Certified Nursing Aides that she had a sheet on her bed in her previous room. However, since the move, the mattress on her bed had been without sheets. The resident had requested a sheet, but her request was denied. A Licensed Practical Nurse confirmed that the type of bed and mattress used by the resident should have a sheet, and acknowledged that staff should have placed a sheet on the mattress.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled, affecting one resident out of three reviewed for Activities of Daily Living (ADLs). The resident, who was cognitively intact, required assistance with showering and personal hygiene due to multiple medical conditions, including diabetes, spinal muscular atrophy, and functional quadriplegia. Despite being scheduled for showers on specific days, records showed inconsistencies in documentation, with several instances where showers were not recorded as provided or refused. Observations revealed the resident appeared unkempt, with greasy hair and dirty nails, indicating a lack of proper hygiene care. Interviews with the resident and staff revealed discrepancies in the shower schedule and a lack of adequate staffing to provide the necessary care. The resident expressed a preference for bed baths and reported receiving showers less frequently than scheduled. Staff confirmed the resident's disheveled appearance and noted frequent refusals of ADL care. The Director of Nursing was unaware of the discrepancies in the shower schedule and acknowledged missing documentation for several shower instances. This deficiency was investigated under multiple complaint numbers.
Failure to Provide Nutritious Meal to Resident
Penalty
Summary
The facility failed to provide a full and nutritious meal to a resident, identified as Resident #35, who was part of a group reviewed for nutritious meals. Resident #35, who was cognitively intact and required setup assistance for eating, had a medical history that included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. The resident was on a carb-controlled diet, and the menu for the dinner meal included lentil soup, whole wheat crackers, tuna salad on wheat bread, marinated tomato salad, and a half slice of dessert. However, the resident received a meal consisting only of shredded lettuce with tomato and onion salad and two slices of lunch meat, missing several components of the planned meal. Interviews with staff revealed discrepancies in meal preparation and delivery. A CNA confirmed the resident received an incomplete meal, and the Director of Nursing was unaware of the missing items. The Kitchen Manager acknowledged the resident's preferences and confirmed that the resident was not given half of her meal, which led to the resident frequently ordering food from DoorDash. The resident expressed a preference for wraps instead of open-faced sandwiches and confirmed ordering additional food due to insufficient meals. The facility's policy on menus and adequate nutrition was not followed, as the resident's nutritional needs were not met, leading to non-compliance under a complaint investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Jefferson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurels Of West Columbus, The | 7.2 mi | ★★★★★ | 11 | 1 |
| Columbus Healthcare Center | 9 mi | ★★★★★ | 25 | 0 |
| London Health & Rehab Center | 9.5 mi | ★★★★★ | 1 | 0 |
| Norwich Springs Health Campus | 9.7 mi | ★★★★★ | 3 | 0 |
| Darby Glenn Nursing And Rehabilitation Center | 10 mi | ★★★★★ | 4 | 0 |
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