Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 West Rest Haven during CMS and state inspections, most recent first.
Two residents with moderate cognitive impairment and significant ADL deficits did not receive needed assistance after activating their call lights. In one case, a resident dependent on staff for toileting requested help to use the restroom; a CNA entered, turned off the call light, stated they would return, and left without providing toileting care. In the other case, a resident requiring 1-person assist for transfers requested to be moved from a wheelchair to a recliner; an RN entered, turned off the call light, said they needed to collect meal trays first, and left, after which the resident reactivated the call light and a CNA again turned it off and exited without completing the requested transfer.
A resident with metabolic encephalopathy, PVD, AKI, diabetes, and a history of multiple prior falls was care-planned as needing set-up/touching assistance for transfers and identified as a moderate fall risk, with interventions such as nonskid socks, adequate lighting, and a bedside fall mat if allowed. Despite this, the resident, who often attempted to do things independently and disliked the fall mat due to wheelchair mobility issues, experienced an unwitnessed fall from bed, was found on the floor near the doorway with blood noted by the bed and on the remote, and was later diagnosed with a head laceration requiring staples and a trace subarachnoid hemorrhage. Staff reported rounding practices and a fall prevention policy that included routine checks and use of floor mats when appropriate, but the resident’s repeated falls and this unwitnessed fall with serious head injury demonstrated that the environment and supervision were not adequate to prevent the accident.
A resident with dementia and mobility deficits, care planned for two-person mechanical lift transfers, was improperly transferred by a CNA using a gait belt and without a second staff member, resulting in a femur fracture. The CNA did not review the assignment sheet indicating the required assistance level, and staff interviews confirmed the resident's need for mechanical lift transfers with two staff at all times.
A registered nurse administered an antibiotic injection to a resident without obtaining a physician's order, acting outside her scope of practice and against facility policy. The resident had a history of UTIs and moderate cognitive impairment, and lab results indicated a possible infection, but further testing was pending. The nurse assumed the medication would be appropriate and documented the administration without physician authorization. The incident was identified when the DON reviewed the order and confirmed with the medical director that no order had been given.
A registered nurse administered an antibiotic injection to a resident without obtaining a physician's order, despite facility policy requiring such authorization. The resident, who had moderate cognitive impairment and a history of UTIs, received the medication based solely on the nurse's judgment after lab results suggested a possible infection.
Multiple residents did not have individualized, comprehensive care plans addressing their specific medical, nursing, and psychosocial needs, including lack of clear transfer instructions, contracture management, PTSD interventions, and infection management. Staff often failed to use required assistive devices or document care, and care plans were not updated to reflect residents' current conditions, as confirmed by observations, interviews, and record reviews.
Several residents did not receive proper supervision or use of assistive devices during transfers, resulting in one resident sustaining multiple fractures and a scalp laceration after a fall, and others experiencing bruising or unsafe transfer practices. Staff failed to consistently use gait belts and did not address hazards such as missing protective caps on equipment, despite care plans and facility policies requiring these safety measures.
Several residents with various psychiatric and neurological diagnoses were administered psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents, without documented informed consent. Despite care plans indicating the need for education on medication risks and benefits, required consents were not found in the medical records. Nursing staff and the DON confirmed that the process for obtaining and filing consents was not consistently followed, resulting in medications being given without proper authorization.
Surveyors found multiple deficiencies in medication labeling and storage, including an undated and unlabeled bottle of Systane eye drops, loose unidentified pills in several medication carts, and an expired bottle of magnesium oxide. Staff interviews confirmed that these practices did not align with facility policy or professional standards.
A resident with multiple chronic conditions reported her hearing aids missing to a social worker and an LVN, but neither initiated the required grievance process or documented the complaint. Staff interviews revealed confusion about grievance procedures, and the facility's grievance log showed no record of the incident, despite policy requiring prompt reporting and written documentation of grievances.
A resident with multiple health conditions and requiring substantial assistance with transfers suffered a witnessed fall resulting in serious injuries while being assisted by a CNA who did not use a gait belt or provide hands-on support. The incident was not reported to the State Agency within the required timeframe, and staff did not initially recognize the event as potential neglect. The facility did not obtain hospital records promptly or restrict the CNA from resident care immediately after the incident.
A resident with dementia and Alzheimer's disease expired in the facility, but the required discharge MDS assessment was not completed or transmitted within the mandated timeframe. The last MDS submitted was the admission assessment, and the discharge assessment was found to be significantly overdue, with staff interviews confirming the lapse was due to the absence of an MDS coordinator.
A resident's MDS assessment inaccurately indicated no dental issues, despite documentation and observation of broken natural teeth. The resident's care plan and psychosocial notes reflected her refusal of dental care, and staff confirmed ongoing oral care. The discrepancy between the MDS and actual oral status was identified through record review, interviews, and observation.
A resident with documented diagnoses of psychotic disorder, major depressive disorder, and anxiety disorder was admitted without these mental illnesses being accurately reflected on the PASRR Level 1 Screening. The screening form was incorrectly marked as negative for mental illness, despite medical records and care plans indicating otherwise. Facility leadership acknowledged the error and the expectation for accurate and timely PASRR completion.
A resident with multiple diagnoses and memory impairment required extensive assistance and a mechanical lift for transfers, but the care plan was not updated to reflect these needs. Documentation and staff interviews confirmed the resident's increased dependence, yet the care plan continued to indicate only limited assistance was necessary, contrary to facility policy requiring timely care plan revisions by the IDT.
A resident with hemiplegia and a left-hand contracture did not receive appropriate contracture management, as her care plan lacked specific interventions, therapy devices were not used, and staff were unclear about responsibility for ongoing care. The resident was not receiving restorative services or documented contracture management, and her hand hygiene needs were not consistently addressed.
A resident with PTSD did not have specific trauma triggers identified in her care plan, despite staff awareness of her diagnosis and the importance of such information. The care plan included only general interventions, and staff interviews confirmed that no trauma assessment or trigger identification had been completed or documented.
A resident with a history of UTIs and moderate cognitive impairment was given Keflex as a prophylactic antibiotic without adequate indication or care plan documentation. Staff interviews revealed that antibiotic use was not properly monitored or reviewed, and facility policies for infection surveillance and antibiotic stewardship were not followed in practice.
The facility did not maintain proper temperature logs or ensure safe refrigeration in one nourishment room, and failed to label and date food items in another. Staff interviews revealed unclear responsibilities for monitoring and reporting, and the facility's policy requiring labeling of outside food was not consistently followed.
A resident received prophylactic antibiotics without written justification or proper care plan documentation, and the facility did not use established criteria to determine the need for antibiotic therapy. Staff interviews revealed a lack of symptom tracking and inconsistent pharmacy review of antibiotic use, despite facility policies requiring standardized assessment and oversight.
Staff Turned Off Call Lights Without Providing Requested Care
Penalty
Summary
The deficiency involves staff failing to provide treatment and care in accordance with professional standards and residents’ care plans by not responding appropriately to call lights and not meeting residents’ stated needs. For Resident #1, an older female with multiple diagnoses including aftercare following joint replacement surgery, B-cell lymphoma, osteoarthritis, kidney disease, a history of falls, and dementia with a BIMs score of 9 indicating moderate cognitive impairment, the care plan documented that she was dependent on staff for toileting. On 4/28/2026 at 9:15 a.m., her call light was observed to be on. CNA A entered the room and exited about a minute later, and the call light was turned off. At 9:17 a.m., Resident #1 reported she had activated the call light because she needed to use the restroom, and that the aide had turned the call light off and said she would be right back, without providing the requested toileting assistance at that time. For Resident #2, an older female with diagnoses including type 2 diabetes, cataracts, repeated falls, dementia, muscle weakness, lack of coordination, and high blood pressure, with a BIMs score of 11 indicating moderate cognitive impairment, the care plan indicated she required assistance of one staff member for transfers between surfaces. On 4/28/2026 at 9:24 a.m., her call light was observed to be on. Nurse B entered the room at 9:30 a.m., the call light was turned off, and Nurse B exited. At 9:31 a.m., Resident #2 stated she had requested transfer from her wheelchair to her recliner, and that Nurse B told her they needed to collect lunch trays first and would return. Resident #2 then reactivated her call light. At 9:32 a.m., the call light was again observed to be on; CNA A entered the room, the light was turned off, and CNA A exited, with the report indicating that CNA A failed to provide the requested care before leaving the room. These observed actions and interviews show that staff turned off call lights and left both residents’ rooms without meeting their expressed care needs.
Failure to Prevent Fall and Head Injury in Known Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s environment free from accident hazards and to provide adequate supervision and fall interventions, resulting in a fall with head laceration and a trace subarachnoid hemorrhage. The resident was an adult male with diagnoses including metabolic encephalopathy, peripheral vascular disease, acute kidney injury, and diabetes. His most recent MDS showed a BIMS score of 14, indicating he was cognitively intact, with no functional limitation in lower extremity range of motion, and he required only set-up or clean-up assistance for transfers and sit-to-stand. His care plan identified an ADL self-care performance deficit related to mild cognitive impairment and metabolic encephalopathy, and documented that he required set-up to touching assistance with transfers by one staff member. The resident had a documented history of multiple prior falls, including falls while attempting to self-transfer, falls in his room and restroom, and a fall with a head laceration that led to transfer to the hospital. His care plan for actual falls related to unsteady gait listed multiple fall events with dates and noted that he had a goal to resume usual activities without further incident. Interventions on the care plan included encouraging the resident to wear nonskid socks, ensuring adequate lighting, and using a fall mat at bedside if the resident allowed. Physician orders also included floor mats at bedside if the resident allowed, and a Morse Fall Scale assessment identified him as at moderate risk for falls. On the day of the incident, the resident reported that he believed he had been asleep and fell out of bed, striking his head and causing bleeding, but he could not recall what he was doing before the fall or how it occurred. Staff interviews indicated that the CNA assigned to the hall was making rounds room to room and had been in the room next door to the resident when she saw what she initially thought were socks on the floor, then realized it was the resident’s feet. She found the resident on the floor near the doorway, alert and responsive, with blood noted by the bed. The LVN reported she had not been down the hall for about 30 minutes but knew the CNA was rounding; when called, she assessed the resident, noted a bleeding head wound, and observed blood on the remote hanging off the bed and on the floor by the head of the bed. The resident was later diagnosed at the hospital with a laceration to the back of the head requiring 12 staples and a trace subarachnoid hemorrhage of the anterior interhemispheric fissure. The facility’s fall prevention policy required evaluation of fall risk, routine visits to check on residents, use of bedside floor mats when appropriate, and documentation of interventions, but the resident’s repeated falls and the circumstances of this unwitnessed fall demonstrated that the environment and supervision were not sufficient to prevent this accident. The resident expressed that he did not like the fall mat by his bed because it made wheelchair mobility more difficult, and family and staff interviews confirmed he frequently attempted to do things on his own and did not consistently use the call light. The DON and ADM stated that staff were expected to round on residents at least every two hours, with some staff reporting they rounded more frequently, such as every 30 minutes to an hour. Despite these stated practices and the resident’s known fall history and moderate fall risk, the fall occurred unwitnessed between staff checks, with the resident found on the floor by the door and evidence of blood near the bed and on the remote. The combination of the resident’s established fall risk, prior falls while self-transferring, care-planned need for assistance with transfers, and the unwitnessed nature of the fall with serious head injury formed the basis for the cited deficiency in providing an environment free from accident hazards and adequate supervision to prevent accidents.
Failure to Provide Required Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments was not provided the required level of assistance during a transfer. The resident, who had diagnoses including dementia, muscle weakness, abnormal gait, and a history of femur fracture, was care planned to require a mechanical lift with two staff for all transfers. Despite this, a CNA transferred the resident from bed to wheelchair by holding onto the resident's pants and using a gait belt, without the assistance of a second staff member or the mechanical lift as required. The CNA did not consult the assignment sheet at the start of her shift, which would have indicated the resident's transfer needs. Interviews with facility staff, including the DON, RN, LVN, and multiple CNAs, confirmed that the expectation and policy were for the resident to be transferred with a mechanical lift and two staff at all times. Assignment sheets detailing each resident's transfer requirements were available at each nurse's station, and staff were expected to review these at the beginning of each shift. The incident report and hospital records indicated that the resident sustained an acute, slightly displaced fracture of the left greater trochanter as a result of the improper transfer. The resident was subsequently hospitalized and returned to the facility with pain management orders. The investigation found that the CNA involved had not followed established procedures for reviewing assignment sheets or adhering to the resident's care plan. The resident's inability to recall the incident or report pain was consistent with her documented cognitive impairment. Other staff interviews confirmed knowledge of the correct transfer procedures and the location of assignment sheets, but the failure to follow these protocols in this instance led directly to the resident's injury.
RN Administers Antibiotic Without Physician Order
Penalty
Summary
A registered nurse (RN) administered an antibiotic injection to a resident without obtaining a physician's order, which is outside the RN's scope of practice and contrary to facility policy. The resident, who had a history of anxiety, unspecified psychosis, urinary tract infection (UTI), and nausea, was admitted with moderate cognitive impairment and required moderate assistance with activities of daily living. Lab results indicated a possible UTI, and further testing was pending to determine the appropriate antibiotic. Despite this, the RN ordered and administered Ceftriaxone from the emergency kit, documenting the action as a preventive measure against sepsis or worsening condition, but without physician authorization. The incident was discovered when the Director of Nursing (DON) reviewed the order and confirmed with the medical director that no order had been given for the antibiotic. The RN admitted to not contacting the physician and stated she assumed the medication would be appropriate based on the resident's history and symptoms. The facility's pharmacy policy requires that no medication be administered without a written physician's order. The medical director confirmed he was not contacted and did not authorize the medication. The resident did not experience any negative outcomes as a result of the unauthorized administration.
Medication Administered Without Physician Order
Penalty
Summary
A registered nurse (RN) administered Ceftriaxone, an antibiotic, intramuscularly to a resident without obtaining a physician's order. The resident had been admitted with diagnoses including anxiety, unspecified psychosis, urinary tract infection (UTI), and nausea. Laboratory results indicated a possible UTI, but further testing was required to determine the appropriate antibiotic. Despite this, the RN wrote and signed an order for Ceftriaxone and administered the medication from the emergency kit, without consulting or receiving authorization from the resident's physician. The medication administration record and nursing progress notes confirmed that the RN acted independently, and the physician later confirmed that no order had been given for the antibiotic. The resident in question had moderate cognitive impairment and required moderate assistance with activities of daily living. The incident was discovered when the Director of Nursing (DON) reviewed the order and found discrepancies, leading to confirmation that the physician had not been contacted. The facility's policy clearly states that no medication should be administered without a written physician's order. The RN admitted to administering the medication based on her own judgment, citing the resident's previous history with Ceftriaxone and the timing of the lab results.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans did not include individualized, measurable objectives and timeframes to address residents' medical, nursing, and psychosocial needs identified in their assessments. For several residents, care plans lacked specific instructions regarding transfer methods, such as the use of gait belts, mechanical lifts, or stand aids, despite documented needs for substantial or maximal assistance. Observations and interviews revealed that staff often did not use gait belts during transfers, and care plans did not specify the required level of assistance, leading to unsafe transfer practices. In one instance, a resident fell and sustained a laceration during a transfer when staff failed to provide hands-on assistance or use a gait belt, as required by her condition and facility expectations. Another resident with a left-hand contracture did not have a comprehensive care plan addressing contracture management, despite observable limitations and the presence of therapy devices in her room. Interviews with staff and therapy personnel indicated that there was no written plan or documentation for the use of contracture management devices, and restorative care for the contracture had been discontinued without a formal plan or communication to nursing staff. The resident reported that staff rarely assisted with her contracture devices or nail care, and observations confirmed the lack of consistent intervention. Additionally, a resident with a diagnosis of PTSD did not have a care plan that identified her specific triggers or individualized interventions, despite her mental health history and the facility's process for collecting trauma histories. The social worker responsible for trauma-related care plans was unaware of the resident's PTSD diagnosis and had not documented any triggers or interventions. Another resident with recurrent UTIs and prophylactic antibiotic use did not have a care plan addressing infection management or monitoring for side effects, even though she had multiple documented infections and ongoing antibiotic therapy. These deficiencies were identified through observation, interview, and record review, and were confirmed by facility leadership.
Failure to Provide Adequate Supervision and Assistive Devices During Resident Transfers
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, as evidenced by multiple incidents involving four residents. One resident, who had a history of fractures, repeated falls, osteoporosis, and mild cognitive impairment, required substantial to maximal assistance for transfers according to her care plan and therapy evaluation. However, during a sit-to-stand transfer, the assigned CNA did not provide contact guard assistance or use a gait belt, instead standing by and holding the wheelchair while the resident attempted to transfer herself. This resulted in the resident falling headfirst into a wall, causing multiple rib fractures, a cervical vertebra fracture, a compression fracture, and a scalp laceration. Other residents also experienced deficiencies in supervision and use of assistive devices. One resident, with a history of osteoporosis, muscle weakness, and falls, reported bruising on her arm from contact with an exposed metal nut on the stand aid device, which was missing its protective plastic cap. Staff interviews revealed that the issue had been verbally reported to a nurse, but no maintenance request had been made, and maintenance staff were not routinely checking for missing caps. Another resident, who was hemiplegic and at high risk for falls, reported that staff often did not use a gait belt during transfers and sometimes pulled on his clothing instead. Observations confirmed that staff did not always use gait belts as required by policy and care plans. Additionally, a resident with arthritis, cataracts, and legal blindness was observed being transferred with a stand aid without a gait belt and while wearing non-slip-resistant socks. The CNA involved admitted to forgetting the gait belt and recognized the risk of falls without proper equipment. Review of facility policies indicated that staff were expected to use gait belts and follow individualized care plans for transfers, but these protocols were not consistently followed, leading to actual harm and the identification of Immediate Jeopardy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for multiple residents. For one resident with diagnoses including acute respiratory failure, PTSD, schizoaffective disorder, and low back pain, there was no signed consent for Depakote Sprinkles, despite the medication being administered as ordered. The resident had moderately impaired cognition and was receiving several psychotropic medications, but neither the electronic nor paper medical records contained the required consent documentation. Another resident with unspecified dementia, depression, anxiety disorder, and psychosis, and who had severely impaired cognition, was administered Seroquel without a signed consent. The medication was given as ordered except for a few refusals, but no documentation of informed consent was found in the records. Similarly, a third resident with anxiety disorder, dementia, and mood disorder, and who also had severely impaired cognition, was administered Sertraline and Seroquel without any signed consents present in the medical records. A fourth resident, who was cognitively intact and had diagnoses including psychotic disorder with delusions, hemiplegia, and hemiparesis, was administered Duloxetine, Depakote, Xanax, and Risperdal without signed consents. The care plans for these residents included interventions to educate about risks, benefits, and side effects, but the required consents were not obtained or documented. Interviews with nursing staff and the DON confirmed that the process for obtaining and filing consents was not consistently followed, and that the lack of consents could result in residents receiving medications that they or their families did not want.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices across four medication carts. An undated and unlabeled bottle of Systane eye drops was found in the Station 1 south-hall medication cart, with no resident name or label to identify ownership. Additionally, three loose, unidentified pills were found in the Station 1 east-hall medication cart, one loose pill in the Station 2 south-hall cart, and eighteen loose, unidentified pills in the Station 2 north-hall cart. An expired bottle of magnesium oxide, labeled with a best by date of 02/2025, was also found in the Station 2 north-hall cart. Staff interviews confirmed that nurses were responsible for maintaining the order and cleanliness of the medication carts, and that medications should be dated when opened and stored in their original containers. Despite these expectations, the observations revealed that medication carts were not consistently maintained according to facility policy and professional standards. Staff members acknowledged that loose pills should not be present in the carts and that dropped pills should be removed immediately. The Director of Nursing and Assistant Administrator both stated that the findings did not meet their expectations for medication storage. Review of the facility's procedure for medication storage confirmed that drugs should be stored in an orderly manner and in their originally received containers, which was not followed in these instances.
Failure to Initiate and Document Grievance Process for Lost Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that prompt efforts were made to resolve those grievances. Specifically, a resident with a history of diabetes, chronic kidney disease, uterine cancer, major depressive disorder, hypertension, and heart failure reported the loss of her hearing aids, which were routinely collected by nursing staff for charging. The resident communicated the loss to the social worker (SW), who acknowledged being told about the missing hearing aids but did not initiate the facility's grievance process as required by policy. The SW attempted to find a replacement provider but did not document or formally report the grievance. Additionally, a Licensed Vocational Nurse (LVN) was made aware of the missing hearing aids but did not initiate the grievance process or report the issue to her supervisor until prompted by the surveyor. The LVN supervisor and assistant administrator both confirmed that they were not informed of the missing hearing aids until much later, and the facility's grievance log showed no record of a grievance being filed for this incident. Interviews revealed that staff were unclear about the proper procedures for reporting and documenting grievances, despite the facility's policy requiring any employee to report grievances to their department head or charge nurse and for a written report to be initiated. The facility's grievance policy states that residents or their representatives have the right to file grievances orally or in writing and expect a written decision within seven working days. However, in this case, the process was not followed, and the resident's concern about her missing hearing aids was not formally addressed through the established grievance system. This failure was identified through interviews and record reviews, which showed a lack of documentation and appropriate response to the resident's complaint.
Failure to Timely Report Serious Resident Injury Following Fall
Penalty
Summary
The facility failed to immediately report an incident involving a resident who experienced a witnessed fall resulting in multiple serious injuries, including rib fractures, a cervical spine fracture, a thoracic compression fracture, and a scalp laceration. The fall occurred while the resident, who had a history of heart failure, osteoporosis, depression, mild cognitive impairment, and required substantial to maximal assistance with transfers, was being assisted by a CNA. The CNA did not use a gait belt and was not physically assisting the resident during the transfer, contrary to the resident's care plan and functional assessment, which indicated the need for moderate assistance. Following the fall, the resident was transported to the hospital, where her injuries were confirmed. Despite the severity of the injuries and the witnessed nature of the fall, the facility did not report the incident to the State Agency within the required two-hour timeframe. The DON and nurse supervisor did not initially recognize the incident as potential neglect or abuse, and the extent of the resident's injuries was not known to the facility until hospital records were received upon the resident's re-admittance. The facility's investigation did not include obtaining hospital records at the time of the incident, and the CNA involved was not suspended or restricted from resident care immediately following the event. Interviews with staff revealed a lack of clarity regarding reporting requirements and the appropriate response to such incidents. The nurse supervisor viewed the event as a failure in transfer technique rather than a potential case of neglect, and the DON was unaware of the need to report the injuries to the State Agency. The facility's policies required immediate reporting of suspected abuse, neglect, or misappropriation of resident property, but these procedures were not followed in this case.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for a resident who expired in the facility. The resident, an elderly female with dementia and Alzheimer's disease, was admitted and later transitioned to palliative care before passing away. Review of her records showed that her last transmitted MDS was the admission assessment, and the required discharge MDS was not completed or submitted within the mandated timeframe. The MDS transmission system indicated that the discharge assessment was 141 days overdue. Interviews with facility staff revealed that the absence of an MDS coordinator contributed to the missed assessment. The Director of Nursing acknowledged responsibility for the oversight and confirmed that the discharge MDS should have been completed and transmitted. The facility's policy and the RAI Manual require timely completion and submission of MDS assessments, including discharge assessments, but these procedures were not followed in this instance.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected her oral and dental status. Specifically, the MDS assessment indicated that the resident had no dental issues, as the box for 'None of the above were present' was checked in Section L - Oral/Dental Status. However, record review and interviews revealed that the resident had broken natural teeth, which was documented in a psychosocial note and observed during an interview. The resident herself acknowledged having broken teeth, though she stated they did not cause her pain and she did not wish to have them fixed. Further review showed that the resident's care plan noted her refusal of dental care, and staff interviews confirmed that oral care was being provided and any changes were reported to nursing staff. The Director of Nursing acknowledged that the MDS should be coded as accurately as possible and that inaccuracies could affect the overall assessment and care provided. The facility's policy requires resident information to be as accurate and truthful as possible, but this was not followed in the case of the resident's dental status.
Inaccurate PASRR Level 1 Screening for Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I assessment for one resident. The PASRR Level I Screening, completed prior to admission, did not indicate a diagnosis of mental illness, despite the resident having documented diagnoses of psychotic disorder with hallucinations, major depressive disorder, and anxiety disorder upon admission. The resident's face sheet and quarterly MDS assessment confirmed these mental health diagnoses, and the care plan included interventions for major depressive disorder. However, the PASRR Level I Screening form incorrectly reflected that the resident did not have a primary diagnosis of mental illness. Interviews with the DON revealed that the PASRR screening should have been positive due to the resident's mental illness diagnosis, but was incorrectly marked negative. The DON acknowledged responsibility for PASRRs and stated that a corrected screening should have been completed and sent to the local authority for evaluation. The facility's PASRR policy was requested but not provided prior to the survey exit. The Assistant Administrator also confirmed the expectation that PASRR Level 1 Screenings are completed accurately upon admission and corrected immediately if errors are found.
Failure to Update Care Plan for Resident Requiring Extensive Transfer Assistance
Penalty
Summary
The facility failed to review and revise the comprehensive, person-centered care plan for one resident who required assistance with transfers. Despite documentation and staff interviews indicating that the resident had progressed to needing extensive assistance and the use of a mechanical lift for transfers, the care plan continued to state that only limited assistance by one staff member was required. Observations confirmed the resident was using a mechanical lift with a blue sling and required two staff for transfers, as corroborated by a CNA who reported that the resident had not used the Stand Aid for several weeks. The resident's medical record reflected multiple diagnoses, including muscle weakness, difficulty walking, and unsteadiness, and the most recent MDS assessment showed memory impairment and a need for partial to moderate assistance with transfers. However, transfer documentation over a one-month period showed the resident required extensive assistance or was totally dependent for most transfers. The facility's policy required care plans to be updated by an interdisciplinary team after each assessment, but this was not done in this case, resulting in an inaccurate care plan that did not reflect the resident's current needs.
Failure to Provide Contracture Management for Resident with Limited ROM
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis was admitted with functional limitations in range of motion (ROM) on one side, specifically affecting her left upper extremity. The resident's care plan noted contractures of the left upper extremity and included interventions for skin care, but did not address specific management for her left-hand contracture. There were no physician orders or occupational therapy treatment plans targeting the left-hand contracture, and the occupational therapy evaluation did not provide a specific plan for this issue. Observations revealed the resident had a left-hand contracture with fingers fixed in a closed position and lacked any palm guard or device in place. Therapy carrots, intended for contracture management, were found unused in the resident's room. The resident reported that staff rarely assisted with her hand or trimmed her fingernails, and that the therapy devices were seldom used. Interviews with staff indicated that the resident was not currently receiving restorative care for her contracture, and there was no documentation or plan for contracture management in her medical record. Staff were unclear about responsibility for ongoing contracture care after discharge from restorative services. Further review showed that although a restorative hand program had previously been in place, it was not active at the time of the survey, and the interventions outlined in the program were not being implemented. The DON confirmed that the resident was not receiving restorative care for her contracture and that contracture management was not included in her current care plan. The administrator stated that residents with contractures should remain on restorative care or receive treatment from floor staff, and that failure to do so could result in worsening of the contracture.
Failure to Identify Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of post-traumatic stress disorder (PTSD) received trauma-informed, culturally competent care in accordance with professional standards. Record review showed that the resident's care plan acknowledged a history of trauma and included general interventions such as approaching the resident calmly and avoiding startling her. However, the care plan did not identify any specific triggers related to the resident's trauma, despite her documented PTSD diagnosis. The resident's social history and psychiatric assessments also lacked documentation of trauma triggers, and there was no evidence of a trauma assessment being completed after regulatory changes. Interviews with facility staff, including the Social Worker, DON, and Assistant Administrator, revealed that staff were aware of the importance of identifying trauma triggers but could not confirm that this had been done for the resident in question. The Social Worker stated she did not recall assessing the resident for trauma or identifying triggers, and the DON and Assistant Administrator both indicated that care plans should include specific triggers to prevent re-traumatization. A policy for trauma-informed care was requested by surveyors but was not provided before the survey exit.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically by administering Keflex as a prophylactic antibiotic without adequate indication. The resident, a female with a history of urinary tract infections (UTIs) and moderate cognitive impairment, was prescribed Keflex 500mg at bedtime for prevention, despite not having current symptoms or a documented infection at the time. The resident's care plan did not include entries related to UTIs or antibiotic use, and her medical records showed she had been diagnosed with UTIs on three separate occasions, each treated with different antibiotics based on culture results. Interviews with facility staff revealed gaps in monitoring and documentation practices. The Assistant Director of Nursing/Infection Preventionist (ADON IP) stated that the only form used for antibiotics was the infection surveillance report and that there was no other system in place to document symptoms or track infections. The Director of Nursing (DON) indicated that the family had requested ongoing antibiotics and believed the pharmacist was reviewing antibiotic use, but acknowledged the absence of a standardized form for tracking UTI symptoms. The Medical Director and Pharmacy Consultant both confirmed that prophylactic antibiotic use was not being routinely reviewed or monitored, and recommendations regarding ongoing antibiotic therapy were not being communicated to the prescribing physician. Facility policies referenced the use of McGeer Criteria for infection surveillance and outlined expectations for antibiotic stewardship, including assessment, documentation of indication, dose, and duration, and periodic review of antibiotic use. However, these protocols were not followed in practice, as evidenced by the lack of care planning, inadequate monitoring, and absence of documentation supporting the ongoing use of prophylactic antibiotics for the resident.
Deficient Food Storage and Labeling in Nourishment Room Refrigerators
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the management of nourishment room refrigerators in two stations. At station #2, the temperature log for the nourishment refrigerator was not maintained after a certain date, and the refrigerator was observed to be operating at 52 degrees, which is above the recommended temperature for safe food storage. Several nutritional shakes inside the refrigerator were noted to be only slightly cooler than room temperature. Additionally, the staff interviews revealed confusion regarding responsibilities for maintaining the temperature log and monitoring refrigerator conditions. At station #1, the refrigerator contained multiple food items that were not labeled or dated, including a container of cut watermelon, a container with an unknown substance, and a carton of almond milk. Although a sign instructed family members to label and date all food items, these instructions were not followed. Housekeeping staff reported that they were responsible for ensuring items were labeled and dated, and would report non-compliance to their supervisor, who would then inform nursing. The facility's policy required all refrigerated food or drink brought in for residents to be labeled with the resident's name, date, and product name, but this was not consistently implemented.
Failure to Ensure Appropriate Antibiotic Stewardship and Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring the appropriate use of antibiotic therapy and not providing written rationale from the provider when an antibiotic was used outside of established criteria. For one resident, there was no documentation that established and accepted criteria, such as the McGeer or CDC criteria, were used to determine if her urinary tract infection (UTI) met the requirements for antibiotic use. Additionally, the resident was receiving a prophylactic antibiotic (Keflex) without written justification for its use, and her care plan did not include entries related to UTIs or antibiotic use. Record reviews showed that the resident had been diagnosed with UTIs on three separate occasions, with symptoms documented as altered mental status, increased confusion, and not feeling well, but without comprehensive symptom tracking or documentation of other required criteria. The infection surveillance reports did not consistently document all necessary symptoms, and the facility did not have a standardized form to track symptoms at the onset of UTI symptoms. Interviews with staff revealed that there was no system in place to track symptoms, and the only form used was the infection surveillance report. The pharmacy consultant was not reviewing residents on prophylactic antibiotics or sending recommendations to the medical director, and the pharmacist's review of antibiotics was inconsistent and did not include ongoing prophylactic use. Facility policies referenced the use of McGeer criteria and the importance of antibiotic stewardship, including assessment using standardized tools, specifying dose, duration, and indication, and periodic review of antibiotic prescriptions. However, these policies were not followed in practice, as evidenced by the lack of documentation, symptom tracking, and oversight of antibiotic use for the resident in question.
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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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town Hall Estates | 13.5 mi | ★★★★★ | 13 | 2 |
| Avir At Hillsboro | 13.7 mi | ★★★★★ | 15 | 0 |
| Crestview Healthcare Residence | 16.2 mi | ★★★★★ | 1 | 0 |
| Whitney Nursing And Rehabilitation Center | 16.3 mi | ★★★★★ | 2 | 0 |
| Lakeshore Village Nursing And Rehabilitation | 16.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.