Prestonwood Rehabilitation & Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for one (Resident #16) of one resident reviewed for discharge assessments. The facility failed to complete and transmit Resident #16's discharge MDS assessment within 14 days of completion. This failure could place the residents at risk of having incomplete records. Findings include: Review of Resident #16's face sheet, dated 04/02/25, reflected Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 12/05/2024. Review of Resident #16's MDS assessments on 04/02/25 revealed Resident #16 did not have a discharge MDS assessment completed. This MDS record was identified as greater than 120 days late on the resident assessment facility task. An interview on 04/02/25 at 09:41 AM with MDS LVN E revealed Resident #16 was discharged from the facility on 12/05/2024. LVN E stated that she…

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 develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 (Resident #32) of 4 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 32's pressure ulcers. This failure could place residents at risk of not having a plan developed to address care needs. Findings include: Record review of Resident #32's MDS assessment dated [DATE] revealed Resident #32 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included Anemia (Lower amount of healthy red blood cells), Hypertension (High blood pressure), Heart Failure, Hyperlipidemia (high lipid levels ) and Respiratory failure (condition in which lungs are unable to perform their primary function: moving…

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 all residents were free of significant medication errors for 1 of 5 residents (Resident #38) reviewed for pharmacy. The facility failed to ensure the medication Lisinopril tablet 2.5 mg, twice a day was given to Resident #38 on 03/29/2025, 03/30/2025 and 03/31/2025. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #38's face sheet dated 04/01/2025 revealed he was an [AGE] year-old male with an admission date of 03/10/2025 with diagnoses of hypertension (high blood pressure) and heart failure. Record review of Resident #38's MDS assessment dated [DATE] revealed he had a BIMS score of 09 indicating moderate cognitive impairment. Resident #38 needed moderate assistance with chair to bed and toilet transfers. Record review of Resident #38's care plan dated 03/13/2025 revealed he had a history of CHF and is 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, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility walk-in freezer were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 03/31/25 at 09:41 AM of the facility walk-in freezer revealed: 1. Frozen ground beef patties inside a cardboard box were not covered and not dated. 2. Frozen oatmeal raisin cookie dough inside a plastic bag in a cardboard box was left open. 3. Frozen meat that looked like Chicken breasts were out of their original packaging and were not dated or labeled. In an interview on 03/31/25 at 09:46 AM Assistant [NAME] F revealed everyone in the kitchen including cooks, dietary aides, and the dietary manager was responsible for covering, dating, and labeling food items in…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #32) of 1 resident reviewed for catheter care. 1. The facility failed to ensure CNA C and CNA D maintained the foley catheter drainage bag below Resident #32's bladder during a mechanical lift transfer. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included: Record review of Resident #32's MDS assessment dated [DATE] reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included coronary artery disease, obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow), and hypertension (elevated blood pressure). He had a BIMS score of 04/15 which indicated severe cognitive impairment, required extensive to total…

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 to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 1 (Nursing Medication cart hall 500 ) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when LVN B did not report a damaged blister pack of Lorazepam 0.5 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings included: Record review of Resident#5's Quarterly MDS assessment, dated 01/26/25, reflected she was an [AGE] year-old female with admission date of 11/30/23. Resident#5's BIMs score was 6/15 which indicated severe cognition impairment. Her diagnoses included diabetes mellitus (elevated blood sugar), dementia (diseases that affect…

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 maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #32 and Resident #222) observed for infection control. The facility failed to ensure CNA C and CNA D used the required PPE for Resident#32 who was on enhanced barrier precautions due to his foley catheter, and wound , while performing a mechanical lift transfer on 04/01/25. The facility failed to ensure CNA C and CNA D used the required PPE for Resident#222 who was on enhanced barrier precautions due to his foley catheter, and wound, while performing a two person assist transfer on 04/02/25. These failures could place the residents at risk of cross-contamination and lapses in infection control. Findings included: 1- Resident #32 Record review of Resident #32's MDS assessment dated [DATE] reflected a…

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, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date food stored in the walk-in refrigerator. 2. The facility failed to date food stored in the walk-in freezer . 3. The facility failed to cover and date food in the dry storage. 4. The facility failed to sanitize the food thermometer while measuring entrée temperatures. These failures could place residents who at risk for food-borne illness and food contamination. Findings included: Observation in facility's kitchen on 02/27/24 at 09:51 AM revealed hard boiled eggs in the walk-in refrigerator were not dated. Observation in facility's kitchen on 02/27/24 at 09:53 AM revealed a bag of frozen mixed vegetables in the walk-in freezer was not dated. Observation in facility's kitchen on 02/27/24 at 09:56 AM revealed a packet of Taco shells was left opened, uncovered, and undated in a box. Observation in facility kitchen on 02/28/2024 at 11:15 AM…

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, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination trough support of resident choice for 4 of 24 residents reviewed for resident rights. The facility failed to ensure residents were informed and provided the right to eat in the dining room. This deficient practice could place residents at risk of having their rights violated, poor self-esteem and socialization and a poor quality of life. Findings include: Interview with CNA K on 02/27/2024 at 11:45 AM revealed all residents ate in their rooms for dinner and were not taken to the dining room. CNA K stated she wasn't sure why and some residents requested to eat in the dining room in the past but she wasn't sure which residents. CNA K stated she would be willing to take the residents to the dining room if the facility chose to serve dinner in the dining room. Interview with RN J on 02/27/2024 at 12:55 PM revealed she was assigned to lunch today and residents often ate in the dining room for lunch. RN J stated…

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 ensure residents had the right to and the facility made prompt efforts to resolve grievances the resident may for 3 of 24 residents (Residents #18, #32, #50) reviewed for resident rights. The facility failed to ensure residents received responses to grievances and concerns. This deficient practice could place residents at risk of having their rights violated, not receive responses to their grievance, a decreased of self-worth and a decline in quality of life. Findings include: 1. Record review of Resident #18's Comprehensive MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included unspecified Dementia, Coronary Artery Disease, Hypertension, Hyperlipidemia and Diabetes Mellitus. Resident #18 had a BIMS score of 10, which indicated moderate cognitive impairment. 2. Record review of Resident #32's Quarterly MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to 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 observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible for three of four residents (Residents #20, #8 and #38) reviewed for incontinence and foley catheter care. 1. CNA N failed to provide adequate perineal care for Resident #20, after an incontinent episode, when she failed to ensure all fecal matter was removed from the resident's perineal area. 2. CNA E failed to provide adequate perineal care for Resident #8, after an incontinent episode, when she failed to ensure all fecal matter was removed from the resident's perineal area and failed to clean the residents' buttocks from front to back. 3. The facility failed to ensure Resident #38's catheter bag did not have contact with the floor. These failures could place residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Resident #11, Resident #113, Resident #42, Resident #114, Resident #20, and Resident # 8) of ten residents observed for infection control. 1. LVN A failed to decontaminate the glucometer which was used to obtain a fingerstick blood sugar on Resident #11 when she failed to allow the glucometer that was sanitized with a germicidal wipe to air dry before returning the glucometer to the medication cart. 2. LVN A failed to prevent cross contamination of Resident #11's insulin and a bottle of test strips, used to obtain glucose levels, when she carried both items into Resident #11's room. 3. LVN D failed to prevent cross contamination of a bottle of test strips, used to obtain glucose levels, when she carried the bottle into…

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #13) reviewed for respiratory care. The facility failed to ensure Resident #13's nasal cannula tubing was labeled or dated. This failure could place residents at risk of respiratory infections. The finding were: Record review of Resident #13's Annual MDS assessment, dated 1/14/2024, reflected Resident #13 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13's relevant diagnoses included Stroke, Chronic Obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), Diabetes mellitus (high blood sugar levels) and Hyperlipidemia (high levels of lipid in blood). Resident #13 was on oxygen therapy. Record review of Resident #13's comprehensive…

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.