Archway Transitional Care Center

Based on staff interviews, record reviews, and a review of the facility's policy titled Abuse Prohibition-Reporting and Investigating, the facility failed to report an allegation of physical abuse to the State Survey Agency (SSA) in a timely manner involving two Residents (R) (R6 and R7) from a sample of 18 residents.Findings include: Review of a facility policy titled Abuse Prohibition - Reporting and Investigation with a revision date of 12/27/2024. Under the Reporting section of the Guidelines included all allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours.Review of the clinical record for R6 revealed a Nurse's Note dated 12/12/2025 at 7:36 pm that documented the writer was summoned to the dining room regarding an altercation between a resident and another male resident (R7). Witnesses stated that R6 walked up to R7 and started hitting him in the head. Resident was escorted back to his room for assessment. Writer assessed R6 and noted bleeding from the index finger on the right hand from previous injury. Will…

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, staff interviews, and record review, the facility failed to ensure that furniture in resident rooms and the day room on one of four halls, and in the dining room, were maintained in good repair. These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment and a diminished quality of life.Findings include: Observations on 12/9/2025 at 10:30 am on the 300 Hall revealed seven armchairs in use in resident rooms and the day room with missing and torn upholstery. Cushion material was visible on the chairs' seats, arms, and backs. Further observations revealed dressers in resident rooms had broken handles and missing drawer fronts. Observations on 12/9/2025 at 11:54 am in the dining room revealed 55 of 55 chairs in disrepair, with torn or missing upholstery and exposed or missing cushioning on the arms, seats, and backs of chairs. Four of the 55 chairs were missing arm padding/cushioning, leaving sharp metal corners exposed.Review of the email correspondence dated 9/6/2023 between the Central Division…

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, staff interviews, record review, and review of the facility's policies titled Medication Administration-General and Medication Errors, the facility failed to ensure the medication error rate was less than five percent. There were three medication administration errors with 35 opportunities for two of six residents (R) (R37 and R96) observed for a medication error rate of 8.57 percent. This deficient practice had the potential to place R37 and R96 at risk of avoidable medical complications.Findings include:Review of the facility policy titled Medication Administration-General, revised 4/15/2025, revealed the Guideline section included, Associates authorized to administer medications do so only after they have familiarized themselves with the medications. The joint responsibility of the center and the pharmacy is to facilitate accurate medication administration. Prior to medication administration, the Nurse or Certified Medication Aide (CMA): . Reads the administration directions on the MAR [Medication Administration Record] and verifies correct medication, dose,…

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 staff interview, record review, and review of the facility policy titled Abuse Prohibition-Reporting and Investigating, the facility failed to ensure that an allegation of abuse was reported to the state survey agency for one resident (R) (R8) from a total sample of nine residents. Findings include: Review of the facility policy titled Abuse Prohibition-Reporting and Investigating, review date 12/27/2024, revealed the policy included that all allegations of abuse must be reported immediately, but no later than two hours. The Administrator or designee will notify the Complaint Investigation Intake and Referral Unit of the incident and the pending investigation. Review of R8's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, paranoid schizophrenia, generalized anxiety disorder, and hallucinations. Review of the 5/16/2025 Quarterly Minimum Data Set (MDS) assessment revealed that R8 was assessed as being cognitively impaired…

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, staff interviews, and a review of the facility policy titled, Storage Areas, the facility failed to ensure the dumpster area was maintained in sanitary conditions. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms. The facility census was 89 residents. Findings include: A review of the facility policy titled, Storage Areas, dated 12/29/2023, revealed the section titled Dumpster included, Area should be free of trash and debris. Containers should be kept in good condition and covered. Observations on 8/23/2024 at 8:45 am of the facility dumpster area with the Dietary Manager (DM) revealed two of the three dumpster lids were badly damaged and did not allow a secure closure. Further observation revealed broken pallet pieces and large pallets covered with dirt and debris on the ground between two of the dumpsters. During an interview on 8/23/2024 at 10:00 am, the Maintenance Director and DM confirmed the observations. The Maintenance Director reported their vendors deliver supplies, on pallets, to the facility…

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, staff interviews, record review, and review of the facility policy titled, Use of Oxygen Therapy, the facility failed to ensure one of 14 residents (R) (R27) receiving oxygen (O2) therapy was administered O2 in accordance with the physician order. The deficient practice had the potential to place R27 at risk of respiratory complications. Findings include: A review of the facility's policy titled Use of Oxygen Therapy, dated 7/1/2024, revealed the section titled Guideline included, Physician's order for oxygen should be obtained and include oxygen with liter flow as ordered. A review of R27's clinical record revealed a diagnosis of chronic obstructive pulmonary disease (COPD), unspecified. A review of R27's Physician Order Form revealed an order dated 10/2/2023 for O2 via a nasal cannula (NC) at two liters per minute (LPM) as needed for SOB (shortness of breath) or wheezing. Observations on 8/23/2024 at 1:30 pm and 8/24/2024 at 2:00 pm revealed R27 lying in bed receiving O2 via a NC at 2.5 LPM instead of 2.0 LPM. During observation and interview on 8/25/2024 at…

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, staff interviews, and a review of the facilities policies titled, Labeling and Dating Guidelines, Skilled Nursing Services Food Preparation and Distribution, Ready 365 Best Practice Standard of the Week: Thawing, and Skilled Inpatient Services Cleaning and Sanitizing the facility failed to label and date food in the walk-in freezer; failed to properly store stack pans to prevent wet-nesting; failed to properly thaw frozen food items to prevent foodborne illness; and failed to hold food items on the steam table above 135 degrees. The facility census was 77 with 73 residents consuming an oral diet. These failures had the potential of causing bacterial growth associated with foodborne illness. Findings include: 1. Review of the policy titled Labeling and Dating Guidelines revealed upon opening, all items should have an open date and a use by date. Observation on 2/24/2023 at 9:03 a.m. of the walk-in freezer revealed an opened bag of breaded squash with no label or date. Interview on 2/24/2023 at 9:30 a.m. the Certified Dietary Manager (CDM) confirmed that 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.

Based on observations and staff interviews the facility failed to ensure the area behind the dumpsters was properly maintained and free from debris. This failure had the potential to attract pests and transfer microorganisms. Findings include: Observation on 2/25/2023 at 8:40 a.m. of the dumpster area revealed that the facility had three medium sized dumpsters located on the side of the building. The area behind the dumpsters had a wire fence separating the facility campus from a residential home. Between the dumpsters and the wire fence was brush. Continued observation revealed that the area behind the dumpsters in the brush on the ground were multiple Styrofoam cups, two-eight ounce cups, and two-12 ounce cups. The area also had three Styrofoam take-out containers. Further observation revealed paper cloth like trash items that were scattered in the area. Interview on 2/25/2023 at 8:40 a.m. the Certified Dietary Manager (CDM) confirmed that there were multiple trash items on the ground behind the dumpsters. The CDM stated that housekeeping is responsible for the area around 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.

Based on observations, interviews, and review of facility policy titled Medication Administration -General, the facility failed to ensure the proper disposal of expired medication for a centrally located medication storage room and four of five medication carts. Findings include: Observation of medication storage room on 9/1/21 at 1:50 p.m. revealed the following medications to be expired: calcium with vitamin D 500 milligrams (mg) 60 tabs (six bottles) expired 10/2020 and one of the six expired 7/2019; vitamin B-12 1000 mcg (micrograms) 130 tab (two bottles) expired 1/2021, aspirin enteric coated 325 mg 100 tabs expired 10/2020; diphenhydramine hydrochloride (HCL) 25 mg 24 capsules expired 6/2021, Mucinex (children's) stuffy nose and chest congestion 4 fluid ounces (two bottles) expired 10/2020; mineral oil lubricant laxative 16 fluid ounces (two bottles) expired 5/2021, cough syrup 473 milliliters (ml) expired 8/2021, super strength cranberry 450 mg 60 soft gels expired 6/2020, docusate liquid 473 ml (stool softener) (three bottles) expired 6/2021, and antacid (calcium carbonate)…

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.