Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Park Care Center Llc during CMS and state inspections, most recent first.
Missed Scheduled Bathing and Incomplete Documentation: A cognitively intact resident who required extensive assistance with bathing reported not receiving showers or baths regularly as planned or per preference. Staff said residents were assigned twice-weekly bath days and could receive additional bathing if needed, but the shower log showed no bathing for part of the month and no explanation for missed care, with some entries marked not applicable and no supporting nursing notes or documentation.
A resident with aphasia, functional quadriplegia, adult FTT, and protein-calorie malnutrition did not have ordered monthly weights completed and documented for two months. The chart also showed a large weight discrepancy that was not promptly reweighed, and dietary staff later noted the higher weight was likely inaccurate based on the resident’s trend. The RD verified the missing weights and lack of documentation showing refusal, and the NA confirmed no timely reweigh was done after the discrepant weight.
A resident with a PEG tube, severe cognitive impairment, dysphagia, and prior cerebral infarction had tube feeding formula and the administration set in use without the required name, date, time, or nurse initials. Ordered PEG site care was also not documented as completed on multiple shifts, including cleansing, application of medicated powder, and split gauze dressing per the MAR/TAR and staff verification.
Two residents received oxygen at flow rates that did not match prescriber orders. One resident with emphysema, CHF, and dementia had an order for 4 to 6 LPM but was observed on 8 LPM, and another resident with lupus, COPD, and vascular dementia had an order for 1 LPM but was observed on 2 LPM. An LPN confirmed both incorrect settings, and the facility policy required staff to verify orders and set the unit to the desired flow rate.
A resident with severe cognitive impairment and difficulty swallowing was observed approaching the nurse's station with a cup of pills after med pass. An RN cut the pills in half and returned them to the resident, who then took them, while the RN stated she had left the meds with him because he said he would take them. The record showed no assessment confirming the resident could self-administer meds, and facility policy required direct observation during med pass.
A resident with dementia, CKD, and type 2 DM with diabetic neuropathy received a significant med error when an LPN administered Lantus from an insulin pen without priming it first. The LPN attached a new needle tip and dialed directly to the ordered 5-unit dose without priming through the new tip, and later confirmed not being aware of the priming requirement. The facility policy required insulin pens to be primed before each use.
Unlabeled and Undated Medications Stored on Medication Carts: Surveyors found an insulin pen and multiple inhalers stored on medication carts without required open dates or storage dates. An RN and an LPN confirmed the items were open and not labeled, and manufacturer directions for the insulin and inhalers specified time limits after opening or removal from protective packaging.
A facility failed to ensure adequate nutritional care for two residents at risk of malnutrition and dehydration. One resident experienced significant weight loss, leading to hospitalization and PEG tube placement, while another resident's weight was not monitored as required, resulting in an inability to accurately assess weight loss post-amputation. The facility's lack of timely nutritional assessments and interventions contributed to these deficiencies.
A resident with vascular dementia and anxiety disorder experienced hallucinations and behavioral issues, fearing people were entering her room to harm her. Despite recommendations to investigate these claims, the facility did not take action, and the resident's care plan lacked interventions to address her fears. The facility's investigation into her claims was unsubstantiated, and no new interventions were implemented. The resident's guardian was informed that the facility could not meet her needs, leading to her discharge.
The facility did not secure a surety bond sufficient to cover all resident funds, managing $158,125 with a bond of only $50,000. Interviews with the Administrator and DON confirmed the lack of evidence for an adequate bond increase.
The facility failed to maintain hot water temperatures below 120°F, affecting multiple residents, and did not document or investigate a fall involving a resident with cognitive impairments. The Maintenance Director confirmed the elevated temperatures, and the DON acknowledged the lack of documentation for the fall.
A resident with multiple health conditions was observed wearing a hospital gown on two occasions, despite having personal clothing available. The resident's care plan required staff to encourage participation in dressing, but this was not followed, as confirmed by a CNA. The facility's policy emphasized treating residents with dignity, which was not upheld in this instance.
A facility failed to notify a resident's PCP of a significant weight gain, which was outside the physician-ordered parameters. The resident had multiple diagnoses, including congestive heart failure and morbid obesity, and specific orders for weight monitoring. Despite a weight increase exceeding the threshold, the PCP was not informed, as confirmed by staff interviews and record reviews.
A resident with severe cognitive impairment and a stage II pressure ulcer on the right heel had their care plan inadequately revised. Despite multiple instances of care rejection, the care plan lacked necessary interventions. The resident was hospitalized due to the ulcer's decline and returned after a below-the-knee amputation. The DON confirmed the absence of required interventions, contrary to the facility's guidelines.
A resident with multiple medical conditions did not receive routine showers as per their care plan, receiving only one shower since admission. Despite being scheduled for showers twice a week, the resident had to repeatedly request assistance for personal hygiene. A CNA confirmed the resident's requests and provided a shower outside the scheduled day, highlighting a failure to adhere to the facility's shower policy.
A facility failed to implement physician orders for three residents, including daily weights for a resident with heart failure, a fluid restriction for a resident with multiple diagnoses, and lymphedema wraps for a resident. The deficiencies were confirmed by the DON and were not documented as per facility policy.
A facility failed to address a resident's leaking nephrostomy tube and did not document the resident's transfer to the ER for replacement. The resident, with multiple health issues, was found with a leaking collection bag wrapped in a towel and trash bag. The RN was unaware of the leak, and despite contacting urology, the NP ordered an ER visit. The DON confirmed the lack of documentation, violating facility policy.
A facility failed to store respiratory equipment properly, affecting a resident with multiple health conditions including emphysema. The resident's nebulizer was found in a dresser drawer without a protective bag, as confirmed by an RN.
A facility failed to administer medications as ordered, resulting in a medication error rate of 10.71%, exceeding the acceptable 5% threshold. A resident with multiple health conditions, including dementia and chronic kidney disease, received incorrect forms of medications during a medication pass. The RN administered Aspirin EC, Oyster shell calcium without vitamin D, and Senna instead of the prescribed medications. The facility's policy required accurate medication administration, which was not followed.
A resident was found with an Albuterol inhaler on their bedside stand without a physician's order or self-administration evaluation, contrary to the facility's policy requiring medications to be stored in locked compartments. This affected one of 18 residents observed for medication storage.
A facility failed to maintain hospice communication notes for a resident receiving hospice services. The resident had multiple medical conditions and was admitted with a requirement for hospice care. Despite the hospice contract stipulating communication through written records, the hospice binder lacked these notes. Staff interviews confirmed the absence of notes, which were only provided after surveyor intervention.
Missed Scheduled Bathing and Incomplete Documentation
Penalty
Summary
The facility failed to ensure Resident #62 received adequate bathing in accordance with the resident’s needs, preferences, and schedule. Resident #62 was admitted with diagnoses including muscle weakness, unspecified atrial fibrillation, and lymphedema. The annual MDS showed the resident was cognitively intact and required maximal assistance with showers and bathing, as well as partial to moderate assistance with transfers to and from the shower or bath. During interview, the resident stated there were multiple instances when showers or baths were not received regularly as planned or at a frequency consistent with the resident’s preferences. Facility staff stated residents were assigned bath or shower days twice weekly based on room number, and additional showers or baths could be provided if requested or needed. However, the shower log for April 2026 showed no evidence that Resident #62 received any showers or baths from 04/01/26 through 04/15/26, and there was no explanation for the missed care. The log also documented bathing as “not applicable” on 04/16/26 and 04/20/26 without explanation. Nursing progress notes contained no documentation explaining why the resident did not receive scheduled bathing. The facility’s shower and ADL policies stated residents would receive showers per request and facility schedule based on preference and safety, and that care provided should be documented in the medical record.
Failure to Obtain Ordered Monthly Weights
Penalty
Summary
The facility failed to obtain and document monthly weight measurements as ordered for a resident admitted with aphasia, functional quadriplegia, adult failure to thrive, and unspecified protein-calorie malnutrition. The resident’s quarterly MDS noted cognitive intactness and significant weight loss in the facility while not on a prescribed weight loss program. Physician orders directed monthly weights on the first day of each month, but the record showed missing weight measurements for January 2026 and May 2026. The resident’s documented weights included 125 lbs., then 142 lbs. obtained in a wheelchair, followed by weights around 121 lbs. obtained with a Hoyer lift. Dietary staff later noted the 142-lb. weight was likely inaccurate based on the resident’s weight trend before and after that measurement. The regional dietitian verified that weights were not completed and/or documented per physician orders for the missing months and stated there was no documentation showing the resident refused weights during those times. The dietitian also stated residents should be weighed at least monthly and reweighed when there is a notable change, while the nutrition associate confirmed no timely reweigh was obtained after the large discrepancy in December 2025 and that the inaccurate weight was not documented as such until a dietary progress note entered several months later.
PEG Tube Care and Tube Feeding Labeling Not Completed as Ordered
Penalty
Summary
Enteral nutrition products in use were not properly marked as ordered for Resident #7, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, and gastrostomy status. The resident’s quarterly MDS showed severe cognitive impairment, use of a PEG tube for nutritional intake, and a need for maximal assistance with eating/nutritional intake. Physician orders required each bottle of tube feeding formula and each tube feeding administration set to be labeled with the resident’s name, date, time, and nurse’s initials, but observation on 07/06/26 at 3:35 P.M. showed the tube feeding bottle had no date, start time, or nurse initials, and the administration set was also not labeled. An LPN later verified that both items were in use and were not date marked as ordered. The resident’s PEG tube site care was also not completed as ordered. Physician orders directed the PEG site to be cleansed with soap and water, patted dry, and covered with split gauze, and another order required cleansing with soap and water, patting dry, applying medicated powder, and covering with split gauze every shift for 14 days. Review of the April 2026 TAR showed no evidence that the PEG site was cleaned on day shift for 04/08/26 or 04/10/26, and no evidence that medicated powder was applied on day shift for 04/03/26, 04/08/26, or 04/10/26. An RRN verified there was no evidence in the medical record that the ordered PEG tube site care was completed on those dates.
Oxygen Flow Rates Not Set Per Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by administering oxygen at flow rates that did not match prescriber orders for two residents. Resident #1 had diagnoses including emphysema, congestive heart failure, and unspecified dementia, and the MDS indicated severe cognitive impairment and use of oxygen therapy. The resident had an order for continuous oxygen via nasal cannula at 4 to 6 LPM, but during observation the oxygen concentrator was set at 8 LPM, which was confirmed by an LPN. Resident #69 had diagnoses including lupus, COPD, and vascular dementia, and the MDS indicated moderate cognitive impairment and use of oxygen therapy. The resident had an order for continuous oxygen via nasal cannula at 1 LPM, but during observation the oxygen concentrator was set at 2 LPM, which was also confirmed by the LPN. The facility policy titled Oxygen Administration stated staff were to verify physician's orders and turn the unit on to the desired flow rate.
Medication Left With Resident After Administration
Penalty
Summary
The facility failed to ensure staff followed established procedures for pharmaceutical services for one resident observed with possession of medications after administration. Resident #84 was admitted with diagnoses including unspecified symptoms and signs involving cognitive functions and awareness, acute hematogenous osteomyelitis of the right ankle and foot, secondary polycythemia, and hypertension. The MDS assessment indicated severe cognitive impairment and pain or difficulty swallowing. Physician orders also allowed medications to be crushed together and administered in preferred food or in bolus form. During observation and interview, Resident #84 approached the nurse's station with a small cup containing eight pills and asked RN #209 to cut the pills in half to make them easier to swallow. RN #209 cut the pills in half and handed them back to the resident, who then took the medications. RN #209 stated she had completed medication pass around 10:00 A.M. and left the medications with the resident because he said he would take them. Review of the MAR showed the resident received allopurinol, aspirin, cholecalciferol, nifedipine ER, senna, and ascorbic acid. The record also showed no assessments confirming the resident was able to self-administer medications. The facility policy stated that during medication pass, all medications must be under the direct observation of the person who administered them.
Insulin Pen Not Primed Before Administration
Penalty
Summary
A significant medication error occurred when insulin was not administered as ordered for Resident #74. The resident was admitted with diagnoses including unspecified dementia, hypertensive chronic kidney disease, and type two diabetes mellitus with diabetic neuropathy, and the most recent MDS assessment indicated moderate cognitive impairment. Physician orders directed that 5 units of long-acting insulin (Lantus) be injected once daily from a 100 units/mL Lantus insulin pen. During observation, an LPN removed the resident’s insulin pen from the medication cart, attached a new needle tip, and dialed the pen directly to 5 units without first priming the pen. The LPN then administered the injection to the resident. In interview, the LPN confirmed not being aware that the insulin pen needed to be primed before dialing to the ordered dose and administering it, and stated that a new needle-tip cap was placed on the pen before each administration but the pen was not primed through the new tip. The facility policy titled Medication- Insulin Administration required insulin pens to be primed prior to each use to avoid collection of air in the insulin reservoir.
Unlabeled and Undated Medications Stored on Medication Carts
Penalty
Summary
The facility failed to ensure medications were properly labeled and dated for storage. During observation of the front hallway medication carts, surveyors found a baggie labeled for a resident that contained a Lantus insulin glargine prefilled pen that was stored at room temperature without an opened date or room temperature storage date. The resident had diagnoses including type II diabetes mellitus, congestive heart failure, and chronic kidney disease, and the MDS indicated the resident was cognitively intact and used insulin. An RN confirmed the pen was stored in a room temperature cart and was not labeled with an open date or date for room temperature storage, and manufacturer information stated the pen has a 28-day expiration when stored at room temperature. Surveyors also found multiple inhalers stored open and unlabeled for two residents. One resident had COPD, unspecified dementia, and rheumatoid arthritis, and an opened fluticasone propionate and salmeterol inhalation powder inhaler was outside the moisture-protective foil pouch without an opened or expiration date; an LPN confirmed it was open and unlabeled. Another resident had COPD, unspecified heart failure, and chronic kidney disease, and an opened fluticasone propionate and salmeterol inhalation powder inhaler and an opened umeclidinium inhaler were both outside their moisture-protective packaging without opened or expiration dates. An RN confirmed both inhalers were open and not labeled with open dates. Manufacturer information stated the fluticasone propionate and salmeterol inhaler should remain in the unopened foil pouch until initial use and be discarded one month after opening, and the umeclidinium inhaler should remain in the unopened foil tray until initial use and be discarded six weeks after opening.
Failure to Monitor and Address Nutritional Needs Leads to Harm
Penalty
Summary
The facility failed to ensure adequate nutritional care for a resident identified at risk of malnutrition and dehydration, leading to significant weight loss and hospitalization. Resident #52, who had a history of cerebral infarction, protein calorie malnutrition, and other conditions, experienced a 5.1% weight loss over four weeks and a severe 13.6% weight loss over less than three months. Despite these significant changes, the facility did not conduct timely nutritional assessments or implement new interventions. The resident's meal intake records showed consistent consumption of less than 50% of meals, yet no adjustments were made to address this issue. The lack of permanent dietitian coverage in October 2024 contributed to the oversight of the resident's weight loss. Resident #52's condition deteriorated, resulting in hospitalization for failure to thrive and the placement of a PEG tube for enteral nutrition support. The hospital records indicated dehydration, with elevated serum sodium, BUN, and creatinine levels. Upon readmission to the facility, the resident was placed on continuous enteral feeding and a pureed diet with nectar thickened liquids. Despite these interventions, the resident was later admitted to hospice care with a terminal diagnosis of cerebral infarction, compounded by severe weight loss. Additionally, the facility failed to complete required weight monitoring for another resident, Resident #81, who was also at nutritional risk. The facility did not obtain weekly weights for the first four weeks after admission, nor did they document weights upon the resident's readmission following a below-the-knee amputation. This oversight resulted in an inability to accurately assess the resident's weight loss, which was significantly more than expected post-amputation. The facility's policy required weekly weights for new admissions, but this was not adhered to, placing the resident at risk for more than minimal harm.
Failure to Address Behavioral Health Needs Leads to Resident Discharge
Penalty
Summary
The facility failed to investigate and implement psychiatric recommendations for a resident with vascular dementia, anxiety disorder, and other conditions, who experienced hallucinations and behavioral issues. The resident, who had moderately impaired cognition, reported fears of people entering her room to harm her. Despite recommendations from a Nurse Practitioner to investigate these claims, the facility did not take action to clarify or address the resident's statements. The resident's care plan lacked interventions to address her fears, and there was no evidence of a root cause analysis to understand her continued allegations. The facility's investigation into the resident's claims of being attacked was deemed unsubstantiated, and no new interventions were implemented to alleviate her fears. The Director of Nursing confirmed that no further investigations were conducted, and the facility did not monitor the resident's behaviors or validate her allegations. The resident's guardian was informed that the facility could not meet her needs, leading to her discharge. The guardian confirmed that no interventions were made to address the resident's hallucinations, and she was unaware of any investigation into the validity of the resident's claims.
Inadequate Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to secure a surety bond that adequately covered all resident funds managed by the facility. A review of the financial records for 42 residents revealed that the total amount of funds managed by the facility was $158,125. However, the surety bond, dated 05/31/24, was only increased from $40,000 to $50,000, which was insufficient to cover the total amount of resident funds. Interviews with the Administrator and the Director of Nursing confirmed that there was no evidence of further increases to the surety bond to meet the required coverage for the resident funds.
Failure to Maintain Safe Water Temperatures and Document Resident Fall
Penalty
Summary
The facility failed to maintain hot water temperatures below the maximum allowable limit of 120 degrees Fahrenheit, as observed in multiple resident rooms. Specifically, water temperatures were recorded at 124.5, 122.4, 121.3, 123.8, and 122.4 degrees Fahrenheit in various rooms, exceeding the facility's policy range of 105 to 120 degrees Fahrenheit. This oversight had the potential to affect 37 residents residing on the specified hallway. The Maintenance Director confirmed the elevated temperatures, indicating a lapse in adherence to the facility's water temperature policy. Additionally, the facility did not document or investigate a fall incident involving a resident with multiple diagnoses, including cerebral infarction and vascular dementia. The resident, who had a BIMS score indicating moderately impaired cognition, experienced a fall on a specified date, but the clinical record lacked documentation or investigation of the event. The Director of Nursing confirmed the absence of documentation and investigation, which was contrary to the facility's Fall Management Guidelines that require a fall risk evaluation and documentation in the resident's medical record after a fall.
Failure to Maintain Resident Dignity in Dressing
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by the observations and interviews conducted. The resident, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and dementia, was observed on two separate occasions wearing a hospital gown despite having personal clothing available. The resident's care plan indicated that they required assistance with activities of daily living and that staff should encourage participation to the fullest extent possible, including dressing in preferred clothing. The facility's policy on dignity emphasized that residents should be cared for in a manner that promotes their well-being and self-esteem, including supporting their rights to dress in their preferred clothing. However, the resident remained in a hospital gown, which was confirmed by a CNA, indicating a failure to adhere to the facility's policy and the resident's care plan. This deficiency affected the resident's dignity and self-worth, as outlined in the facility's policy.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify a resident's primary care physician of a significant weight gain, which was outside the physician-ordered parameters. The resident, who was admitted with multiple diagnoses including congestive heart failure and morbid obesity, had specific physician orders for a fluid restriction and daily weight monitoring. The orders required notifying the physician if the resident experienced a weight gain of more than two pounds per day over two days or five pounds in a week. On one occasion, the resident's weight increased by more than two pounds in a single day, but there was no documented evidence that the primary care physician was informed of this change. The deficiency was confirmed through a review of the resident's medical records, staff interviews, and facility policy review. The facility's policy on change in condition notification mandates that the nurse must inform the resident, the physician, and the resident's designated representative of any significant changes in the resident's status. However, an interview with a registered nurse confirmed that the physician was not notified of the weight gain as required by the physician's orders. This oversight affected one resident out of five reviewed for unnecessary medications, within a facility census of 84.
Failure to Revise Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to adequately revise the care plan for a resident who was admitted with multiple diagnoses, including a severe cognitive impairment and a stage II pressure ulcer on the right heel. Despite the resident's behavior logs indicating 24 instances of care rejection, including treatment for the pressure ulcer, the care plan was not updated with appropriate interventions. The resident was admitted to the hospital due to a declining condition of the pressure ulcer and later returned to the facility after a below-the-knee amputation. The care plan for changes in mood and behavior, as well as the care plan for skin integrity, were updated to include areas of concern such as refusal of treatment and non-compliance with dressing changes. However, no specific interventions were added to address these issues. The Director of Nursing confirmed that the care plans lacked necessary interventions, which should have been included according to the facility's Skin and Wound Guidelines. These guidelines emphasize the need for individualized interventions to manage pressure injuries and skin alterations.
Failure to Provide Routine Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident received routine showers as per their care plan and facility policy. Resident #140, who was admitted with multiple medical conditions including amyloidosis, congestive heart failure, and diabetes, was scheduled to receive showers every Wednesday and Saturday. However, since admission, the resident had only received one shower, which was not in accordance with the scheduled routine. This lack of adherence to the shower schedule was confirmed through record reviews and interviews with the resident and staff. Observations and interviews revealed that Resident #140 had to repeatedly request a shower and clothing change from multiple staff members, including therapy, before receiving assistance. The resident was observed wearing clothing with dried food stains, indicating a lack of personal hygiene care. A Certified Nursing Assistant confirmed that the resident had been asking for a shower and that she provided one despite it not being the scheduled day. The facility's policy stated that showers should be provided per request and schedule, but this was not followed, leading to the deficiency.
Failure to Implement Physician Orders for Three Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences for three residents. Resident #5, who had multiple medical diagnoses including chronic heart failure and dementia, did not have daily weights recorded as ordered from 02/11/25 to 02/13/25, with no documentation explaining the omission. The Director of Nursing confirmed the failure to obtain the weights as required by the facility's policy. Resident #140, diagnosed with conditions such as congestive heart failure and diabetes, had a physician-ordered fluid restriction of 1800 ml that was not implemented. The facility's policy required collaboration between nursing and dietary departments to manage fluid restrictions, but there was no evidence of this coordination. Additionally, Resident #48, who had lymphedema, was not wearing the prescribed Circaid Reduction Kit and tubi-grips as ordered, which was confirmed by the Director of Nursing during an observation.
Failure to Address and Document Nephrostomy Tube Leak
Penalty
Summary
The facility failed to timely address a resident's leaking nephrostomy tube and accurately document the resident's hospitalization and subsequent nephrostomy tube replacement. The resident, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and obstructive uropathy, was observed with a leaking nephrostomy collection bag wrapped in a towel and placed inside a trash bag. The registered nurse was unaware of the leak until it was pointed out, and the facility delayed contacting the urology office regarding the issue. Despite obtaining an appointment for the resident with urology, the nurse practitioner ordered the resident to be sent to the emergency room for replacement of the leaking nephrostomy collection bag. However, there was no documentation in the medical record of the resident being transferred to the ER or the nephrostomy tube being replaced. The Director of Nursing confirmed the lack of documentation, which was against the facility's policy that required timely and factual documentation of care services.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored in a sanitary manner, affecting a resident who required respiratory care. Resident #143, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and panlobular emphysema, was observed to have their nebulizer delivery system improperly stored. The nebulizer was found lying in the top drawer of the resident's dresser without a protective bag, which was confirmed by a registered nurse during an interview. This deficiency was identified during an observation conducted on February 24, 2025.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication administration error rate of 10.71%, which is above the acceptable threshold of 5%. This error rate was determined from three errors out of 28 observed opportunities during a medication pass. The errors affected one resident, who was observed during the medication administration process. The resident had a medical history that included dementia, chronic kidney disease, diabetes mellitus, lymphedema, hypertension, obstructive sleep apnea, insomnia, hyperlipidemia, and constipation. The resident's care plan included specific interventions for managing constipation, such as administering medications like stool softeners and laxatives as ordered. During the medication pass, a registered nurse administered the wrong forms of medications to the resident. Instead of the prescribed Aspirin 81 mg chewable tablet, Oyster shell calcium with vitamin D 500-5 mg/mcg, and Sennosides-Docusate Sodium 8.6-50 mg tablet, the nurse administered Aspirin enteric coated 81 mg tablet, Oyster shell calcium 500 mg tablet, and Senna 8.6 mg tablet. The facility's policy on medication administration emphasized the importance of preparing and administering medications accurately according to physician orders and professional standards, which was not adhered to in this instance.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medication was properly secured, as required by their policy. Specifically, Resident #143, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and dementia, was observed to have an Albuterol Sulfate inhaler on their bedside stand. This observation was made without a physician's order permitting the inhaler to be kept at the bedside or an evaluation to determine the resident's ability to self-administer the medication. The facility's policy mandates that all medications and biologicals be stored in locked compartments. However, during an interview, RN #250 confirmed that there was no physician's order or self-administration evaluation for Resident #143 to have the inhaler at the bedside. This oversight in medication storage affected one of the 18 residents observed for medication storage, highlighting a lapse in adherence to the facility's medication and treatment storage policy.
Lack of Hospice Communication Notes for Resident
Penalty
Summary
The facility failed to ensure that hospice communication notes were readily available for a resident receiving hospice services. The resident, who was admitted on 04/07/22, had multiple medical diagnoses including frontal lobe and executive function deficit following cerebral infarction, type two diabetes mellitus with diabetic retinopathy, hemiplegia and hemiparesis, chronic hepatitis, and syncope. The hospice contract required communication between the hospice and the facility through various means, including written communication in the resident's medical record. However, upon review, it was found that the hospice binder at the nurse's station only contained three skin grids, a hospice election of service form, and a DNR order, with no hospice communication notes present. Interviews with nursing staff confirmed the absence of hospice communication notes in the hospice binder for the resident. An Agency Registered Nurse and a Registered Nurse both acknowledged that the notes were not on-site at the facility until they were faxed over from the hospice provider following surveyor intervention. This deficiency affected the resident's care as the necessary hospice communication was not readily accessible to the facility staff.
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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 Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Woodview | 0 mi | ★★★★★ | 32 | 0 |
| Columbus Healthcare Center | 2.3 mi | ★★★★★ | 27 | 0 |
| Monterey Care Center | 2.7 mi | ★★★★★ | 13 | 0 |
| Scioto Pointe | 2.9 mi | ★★★★★ | 22 | 0 |
| Majestic Care Of Columbus Llc | 3.5 mi | ★★★★★ | 6 | 0 |
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