James L. West Center for Dementia Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of two residents (Residents #47 and #73) reviewed for catheter care. The facility failed to ensure both Resident #47 and Resident #73 had a physician's order for an indwelling catheter. This failure could place residents who had incontinence at risk for infections and improper treatment. Findings included: Record review of Resident #47's face sheet dated 06/12/25, revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #47's Comprehensive MDS assessment dated [DATE] reflected Resident #47 had a BIMS score of 05 indicating Resident #47 had a severe cognitive impairment with diagnoses including Depression (persistent feeling of sadness), Anxiety Disorder (mental health conditions of excessive fear, worry, dread that interferes with daily life),…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for two of six residents (Resident #21 and Resident #38) reviewed for medication administration. 1. LVN G failed to administer Timolol Maleate Ophthalmic Solution 0.5 % (Timolol Maleate (Ophth) (a prescription medicine used to treat glaucoma) to Residents #21 and #38 as ordered by the physician. 2. LVN A failed to order Timolol maleate Ophthalmic solution 0.5% (Timolol Maleate (Ophth) (a prescription medicine used to treat glaucoma) for Residnet#21 and #38 after administering the last dose on 06/10/25. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included: 1. Record review of Resident #21's quarterly MDS assessment, dated 04/13/25, revealed an [AGE] year-old…

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 that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6.25% based on 2 errors out of 32 opportunities, which involved two of six residents (Resident #21 and Resident #38) reviewed for medication errors. LVN G Failed to administer Timolol Maleate Ophthalmic Solution 0.5 % (Timolol Maleate (Ophth) (a prescription medicine used to treat glaucoma ) to Residents #21 and #38 as ordered by the physician. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included: 1. Record review of Resident #21's quarterly MDS assessment, dated 04/13/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident's cognition was severely impaired with a BIMS of 7. The resident had diagnosis which included acute angle-closure glaucoma,…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for two of five residents (Residents #22 and #54) completed and accurate records. 1. The facility failed to ensure Resident #22's ordered Buspirone medication included an indication for use in his physician's orders. 2. The facility failed to ensure Resident #54's ordered Cymbalta medication included an indication for use in her physician's orders. The facility failures could place residents at risk of having inaccurate medical records. Findings included: 1. Record review of Resident #22's admission Record, dated 06/12/25, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #22's Annual MDS Assessment, dated 04/06/25, reflected he had a BIMS score of 06,…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately to the State survey Agency in accordance with State law through( established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report an abuse allegation made by Resident #1's RP's on 08/06/24 when it was alleged CNA B was rough and continued providing care to Resident #1 even though he refused leaving red marks to Resident #1's face. This failure could place residents at risk for abuse and/or neglect . Findings included: Record review of the facility's Abuse and Neglect- Clinical Protocol policy, revised March 2018, reflected: 1. 'Abuse' is defined at [symbol]483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or…

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 revise and review the care plan for 2 of 5 residents (Residents #2 and #74) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident # 2's care plan after he was unable to use the call light system to call for help. 2. The facility failed to revise and review Resident #74's care plan after admission to include Hospice in a timely manner. 3. The facility failed to revise and review Resident #74's use of suprapubic catheter. These failures could lead to the residents not receiving the care they require, resulting in injuries. Findings included: Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, muscle weakness, and repeated falls. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he was severely cognitively impaired. His Functional Status indicted…

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 and interview, the facility failed to ensure at the time residents were admitted they had physician orders for the resident's immediate care for 1 (Resident #74) of 5 residents reviewed for admission orders. The facility failed to enter physician's orders for Resident #74's hospice and catheter care. This failure could cause the residents to have incomplete care with hospice and improper incontinent care and urinary tract infections. Findings included: Review of Resident #74's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Dementia, Type 2 Diabetes (high blood sugar), Hypothyroidism (lack of thyroid hormones), Hypertension (high blood pressure). Review of Resident #74's MDS, dated [DATE], revealed Resident #74 had a BIMS of 14 indicating cognition was intact. Resident #74 required use of indwelling suprapubic catheter. The MDS did not indicate Resident #74 entered the facility on hospice or was on…

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 revise and review the care plan for 1 of 5 residents (Resident #74) reviewed accuracy of assessments. The facility failed to indicate on Resident #74's Minimum Data Set that he entered the facility on Hospice care. These failures could lead to the residents not receiving the care they require, resulting in injuries. Findings included: Review of Resident #74's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Dementia, Type 2 Diabetes (high blood sugar), Hypothyroidism (lack of thyroid hormones), Hypertension (high blood pressure). Review of Resident #74's MDS dated [DATE], revealed Resident #74 had a BIMS of 14 indicating cognition was intact. MDS did not indicate Resident #74 entered the facility on Hospice or was on Hospice during his stay. Review of Resident #74's baseline care plan, dated 02/27/24, indicated Resident #74 was admitted with no…

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 the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents hazards. The facility failed to ensure that Resident #1 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer. This failure could place residents at risk of falls or injuries. Findings included: Review of Resident #1's electronic face sheet dated 02/21/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities), Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS dated [DATE], revealed…

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.