Wrights Healthcare And Rehabilitation Center

Based on observation, interview and record review the facility failed to check the temperature of food items and use proper hand hygiene during meal preparation and meal-plating service.Finding Included: During an observation on 1/19/26 at 10:26 a.m., Staff B, [NAME] was preparing raw meat wearing blue gloves, he grabbed a black notebook, opened it, placed the notebook back on the rack and continued preparing the raw meat. During an observation on 1/19/26 at 10:36 a.m., A three compartment sink with soiled dishes in all three compartments was next to a tan rack with a silver pan, a sliver metal lid and multiple other clean dishes were observed on the clean side of the dish area. During an observation on 1/20/26 at 12:05 p.m. Staff B was wearing a black hooded shirt that had two strings hanging down to his mid chest area. The strings were touching the resident's food as Staff B was putting the food trays together. Staff E, Cook, microwaved a soup and did not take the temperature prior to putting it on a resident's tray. During an observation on 1/21/26 at 10:13 a.m. no temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an accurate PASRR screening was completed for four residents (#4, 5, 34, and 40) of five residents reviewed for PASRR. 1. Review of the admission record showed Resident #40 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, and dementia. Review of Resident #40's level I Preadmission Screening and Resident Review (PASRR) dated 12/2/25 revealed a level II PASRR evaluation not required was marked. During an interview on 1/30/25 at 10:50 a.m. with the Director of Nursing (DON), and the Minimum Data Set (MDS) nurse the MDS nurse said she does not consider bipolar disorder to be a serious mental illness. She said based on her understanding options in PASRR Level I Section B – Intellectual Disability (ID) or suspected ID must be selected to trigger a Level II referral. In further reviewing Resident #40's PASRR Level 1 the MDS nurse said that on the PASRR Section II question six which the answer is selected as no, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility failed to develop and implement a comprehensive, person-centered care plans for two residents (#5 and #39) out of two reviewed.Findings Included:Review Resident #5's admission record showed admission to the facility on [DATE] with diagnoses to include parkinsonism-11/4/25, opioid dependence-11/24/25, anxiety-11//24/25, post-traumatic stress disorder (PTSD)-11/24/25, psychosis-11/24/25 and major depressive disorder-11/24/25.Resident #5's care plan did not address PTSD diagnosis, triggers and interventions to decrease expressions or indications of distress.Review of Resident #5's order summary report, dated 1/22/26 revealed orders including the following medications: Clonazepam 0.5mg daily for anxiety, Sertraline 150 mg for depression and Wellbutrin XL 150 mg for major depressive disorder.Review Resident #5's psychiatry and psychology note dated 1/8/25 revealed PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety related to labeling and dating foods, discarding expired foods, and using appropriate hand hygiene. Findings included: On 09/18/23 at 9:58 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The following concerns were observed: the wall in the kitchen was ripped and missing tiles; a box of bruised, cut, and sprouted potatoes; two opened bags of blueberries, one opened bag of strawberries, one opened bag of pineapple chunks, one opened bag of cauliflower florets, one opened bag of broccoli, and one opened bag of egg patties was observed in the reach in freezer undated; an opened bag of hotdog buns and one opened container of garlic parmesan wing sauce was observed in the dry storage room undated; one opened 16 oz bottle of water was observed in the dry storage room; two bottles of heavy-duty degreaser and two containers of sanitizers were observed sitting on the top of boxes of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure two (Resident #103 and #13) of twenty-two sampled residents were assessed for the self-administration of medications. Findings included: 1. An observation and interview was conducted on 9/18/23 at 11:29 a.m., with Resident #103. An over-bed table was positioned in front of the resident and a medication cup containing two white round tablets was within reach of the resident. The resident identified the tablets as Xanax then said they were a name brand pain reliever/anti-inflammatory. A review of Resident #103's New admission Evaluation, dated 9/14/23 at 3:45 p.m., revealed the resident had not expressed a desire to self-administer medications. The review of the resident's evaluations on 9/18/23 at 12:53 p.m. showed the resident had not been evaluated for self-administration of medications. (Photographic Evidence Obtained) The Order Summary Report, active as of 9/19/23 at 7:37 p.m., for Resident #103 did not include a physician order allowing the resident to self-administer any medications. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to protect the Private Healthcare Information and personal data for three (Residents #55, #46, and #54) of 28 sampled residents as evidence by conversations held at the receptionist desk with a visitor standing nearby and with resident documents left unattended at the receptionist desk. Findings included: On 9/18/23 at 2:50 p.m., Staff D, Executive Assistant/Receptionist, was talking on the telephone at the reception desk making an appointment for a walker to be delivered to an unknown resident's home address. The name, date of birth , and home address of the resident was given to the recipient of the phone call. This information was overheard by this writer as well as other team members from the conference room across the hallway, approximately 12 feet, from the receptionist's desk. On 9/19/23 at 10:45 a.m., Staff D was sitting at the receptionist's desk while a female visitor was standing directly in front of the desk. The staff member was speaking to an unknown person on the telephone and provided the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to assess and develop a comprehensive care plan related to side rails for two (Residents #12 and #18) out of twenty-eight sampled residents. Findings Included: 1. On 9/18/23 at 1:33 p.m., an observation was conducted of Resident #12's bed. The observation showed a mattress that was bolstered at the head of bed (HOB) and end of bed (EOB) with 1/4 rails lowered in a manner that produced a 1/2 rail covering the distance in between the two bolsters. A review of Resident #12's admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Post-Traumatic Stress Disorder (PTSD), and Parkinson's Disease. A review of the annual comprehensive assessment, dated 7/22/23, showed Resident #12 had a Brief Interview of Mental Status score of 4, indicative of severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to revise the care plan with appropriate interventions following a fall on 04/20/23 for one resident (Resident #37) out of the sampled twenty-eight residents. The resident had a second fall on 04/23/23 in the same location and around the same time. Resident #37 was discharged to the hospital on [DATE] and was found to have a fractured cervical spine (C1). Findings included: On 09/18/23 at 11:43 a.m., Resident #37 was observed sitting in the main dining room in a wheelchair and wearing a neck brace. On 09/19/23 at 10:27 a.m., Resident #37 was observed sitting in the dining room in a wheelchair and wearing a neck brace. The admission Record showed Resident #37 was admitted to the facility on [DATE] with diagnoses to include progressive supranuclear ophthalmoplegia, unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure one (Resident #14) of twenty-eight sampled residents received on-going nursing assessments following a change in condition during 2 of 3 days of survey. Findings included: Review of an undated facility policy titled, Resident Right-Notification of Change, showed it is the policy of the facility to inform the resident and or their legal representative of changes in the resident's condition or plan of care in such a manner to acknowledge and respect resident rights. A need to alter treatment significantly means a need to stop a form of treatment . or commence a new form of treatment to deal with a problem. On 09/18/23 at 12:30 p.m., Resident #14 was observed sleeping in her bed all morning. The resident did not eat lunch. The resident did not respond to the interview. A review of an admission record for Resident #14 showed she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. On 09/18/23 at 12:34…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure grievances were addressed in a timely manner for resident council members with the potential to affect a census of 50 residents. Findings included: A review of an undated document titled, Nursing Home Resident's Rights, showed each resident shall have the right to present grievances and recommend changes in policies and services free from restraint, interference, coercion, discrimination, or reprisal. A review of the facility's grievance logs dated May 2023 to September 2023 showed the facility did not have any grievances recorded. The review showed no documentation related to any concerns/complaints the residents may have had. A review of Resident council meeting minutes revealed on-going grievances reported as follows: On 08/31/23 at 2:00 p.m., a resident council meeting was held attended by 7 residents. The residents reported concerns with, increased bugs sightings. Call lights responses still longer than they would appreciate. Nurses and CNAs (certified Nursing assistants) on personal phone calls and using earbuds…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure each resident was provided with dignity related residents exposed body and confidentiality regarding resident's bodily functions for 2 (#30 and #39) of 27 sampled residents. Findings included: 1. Observations on 9/09/21 at 7:46 AM from the hallway outside the resident's room, Resident#30 was noted to be in her room moving around organizing her closet. The resident was noted to be wearing a hospital gown that was open in the back exposing her bare back and her incontinent brief. It was also noted the curtain to the window that looks out to the enclosed patio was open about 2 feet and a staff member was noted to be walking back and forth on the patio repeatedly passing the resident's window. Continued observation at this time revealed that Staff A, Certified Nursing Assistant (CNA) was standing in the hallway and said good morning to the resident from the hallway and explained to this surveyor that the resident was going home today.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure wound care orders and consistent treatment were in place for one Resident (#40) of three residents reviewed. Findings Included: During an interview and observation of Resident #40 on 9/8/21 at 10:52 a.m. she stated she had a fall recently and sustained a skin tear to the left arm and left lower leg. The resident stated someone changed the dressing and pulled up her left sleeve which revealed an oval shaped white dressing with illegible writing on her left arm and left leg. During an interview with Staff Member E, Licensed Practical Nurse (LPN) on 9/9/21 at 3:49 p.m. she stated the resident had a fall a few weeks ago and scraped her left arm and left leg. [NAME] said a dressing was applied for pressure and protection as the scrapes were scabbed over. Staff Member E, LPN stated she did not document what the wounds looked like and called them 'scabs.' Staff Member E, LPN stated she did not get an order for wound care as she probably…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.