Westwood Health And Rehab, Inc

F-F600 indicates, Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing, shoving .The action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions.

A review of the Admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation.

The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently.

A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 - 04/11/2024: Physical aggression received

Level of Harm - Minimal harm or - 04/19/2024: Physical aggression received potential for actual harm - 07/10/2024: Physical aggression received Residents Affected - Some - 08/06/2024: Physical aggression received

- 08/12/2024: Physical aggression received

- 08/21/2024: Physical aggression initiated

- 12/07/2024: Physical aggression received

- 12/20/2024: Physical aggression received

- 12/25/2024: Physical aggression received

- 01/09/2025: Physical aggression received

The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms.

A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident.

On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room . Of all of the reports, only one was reported to the State Agency.

During an interview on 01/31/2025, at approximately 11:00 AM, the Administrator was unaware of the regulation that resident-to-resident altercations had to be reported to the State Agency and stated only interactions that resulted in injury should be reported.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Immediate jeopardy to resident health or 50505 safety Based on observation, record review, and interview, the facility failed to ensure the comprehensive Residents Affected - Few person-centered care plan included an objective for monitoring a resident with wandering behaviors who was at risk for resident-to-resident altercations for 1 (Resident #44) of 3 residents reviewed for abuse. The lack of effective interventions resulted in Resident #44 having resident-to-resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. All of the incidents took place on the locked unit and Resident #44 had been kicked, hit in the face, hit in an unknown area, pushed, punched in the hand, struck in the hand, punched in the stomach, pushed down numerous times, and hit in the head. The last incident resulted in a broken hip.

It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21 (Comprehensive Resident Centered Care Plan) at

a scope and severity of J.

The IJ began on 04/11/2024, when Resident #44 was first pushed down by another resident while residing

on the secure unit.

The Administrator, Director of Nursing, Nurse Consultant, and Director of Operations were notified of the IJ

on 01/29/2025 at 10:28 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/29/2025 at 3:54 PM. The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented.

The findings are:

A review of a policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated the Interdisciplinary Team (IDT) along with the resident and/or resident representative develops and implements

the comprehensive care plan to include measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs. Further review indicated, Care plan interventions are chosen

after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making.

A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse.

A review of the Admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired Level of Harm - Immediate cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed jeopardy to resident health or towards others as well as wandering. Resident #44 was able to ambulate independently. safety

A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a Residents Affected - Few secured/special care neighborhood due to dementia. The following was listed:

- 04/11/2024: Physical aggression received

- 04/19/2024: Physical aggression received

- 07/10/2024: Physical aggression received

- 08/06/2024: Physical aggression received

- 08/12/2024: Physical aggression received

- 08/21/2024: Physical aggression initiated

- 12/07/2024: Physical aggression received

- 12/20/2024: Physical aggression received

- 12/25/2024: Physical aggression received

- 01/09/2025: Physical aggression received

The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms.

A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident.

On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room .

A review of Resident #44 ' s hospital records indicated on 01/09/2025, the resident was admitted to the hospital related to a fall with left hip pain and was diagnosed with a left femur fracture and required surgery.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 01/28/2025 at 2:00 PM, Certified Nursing Assistant (CNA) 13 was in Resident #44 ' s room and stated the resident was not aggressive but at times, the resident takes things that belong to other Level of Harm - Immediate residents, which agitates those residents resulting in pushing Resident #44. jeopardy to resident health or safety During an interview on 01/28/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident #44 was sent to the hospital because the resident was touching another resident who had autism. The DON stated Residents Affected - Few Resident #44 used to be a CNA and likes to pick up things and was trying to pick things up in the other resident ' s room. This resulted in the other resident pushing Resident #44, causing the resident to fall. The DON stated the other resident no longer resided in the facility.

During an interview on 01/29/2025 at 8:20 AM, CNA #2 stated Resident #44 was not aggressive but did go into other resident ' s rooms. CNA #2 stated interventions for Resident #44 included redirecting or distracting

the resident. CNA #2 stated she was aware of an altercation between another resident and Resident #44 and stated the other resident was eating a snack when Resident #44 entered the resident ' s room and tried to grab the snack. This resulted in the other resident pushing Resident #44 to the floor. CNA #2 stated residents on the secure unit are monitored by having at least one staff member on the hall in the middle. CNA #2 stated that during the altercation, both herself and CNA #1 were at the nurse ' s station, monitoring

the cameras. CNA #1 was teaching CNA #2 how to chart in the medical record. CNA #2 stated she looked up at the camera and saw Resident #44 walk towards the other resident and CNA #2 got up and ran from the nurse ' s desk to get Resident #44. This would indicate Resident #44 was not one-on-one per the resident ' s care plan.

During an interview on 01/29/2025 at 8:35 AM, CNA #1 stated Resident #44 was very grabby but did not have aggressive behaviors. CNA #1 stated staff would give Resident #44 towels to fold or give the resident something to do to keep the resident ' s mind busy. CNA #1 stated she was showing CNA #2 how to chart in

the medical record at the nurse ' s station and CNA #2 took off running and that ' s when she looked up at

the camera and saw Resident #44 head towards Resident #9. CNA #1 stated another CNA was supposed to be monitoring the hall but did not know where that CNA went.

During an interview on 01/29/2025 at 11:23 AM, the Administrator stated there were interventions in place to safeguard Resident #44 but was unable to provide them to the surveyor. The Director of Nursing (DON) stated the facility placed a stop sign on another resident ' s door but was removed because the resident did not want it. The DON also stated that there were medication changes for Resident #44 to help with anxiety.

The Administrator stated the facility did monthly in-services regarding behaviors but there was a new staff member completing those in-services and the Administrator could not locate the in-services.

During an interview on 01/29/2025 at 2:00 PM, Licensed Practical Nurse (LPN) 12 stated Resident #44 goes into other resident ' s rooms and staff were to distract the resident. LPN #12 stated CNA #1 and CNA #2 being at the nurse ' s station during the incident between Resident #44 and another resident was not appropriate and they should be charting at the kiosk in the hallway. LPN #12 stated that Resident #44 was trying to get something from another resident and Resident #44 was pushed, making the resident fall and resulted in a broken hip. LPN #12 stated she was not made aware of resident-to-resident interactions except from verbal reports from other shifts and she does not review the resident ' s medical record unless there is

an every-shift requirement to chart. LPN #12 stated the intervention of redirecting Resident #44 was not an appropriate intervention because the resident would just continue with the behavior. LPN #12 stated that an appropriate intervention would have been to remove one of the residents from the neighborhood.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Removal Plan:

Level of Harm - Immediate 1. Resident #44 who received physical aggression placed on observation 1:1 on 01/29/2025 by facility staff. jeopardy to resident health or safety 2. Resident #9 who initiated physical aggression discharged from the facility 01/09/2025

Residents Affected - Few 3. DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors

on 01/29/2025 and continue training staff as they clock in until all staff have been trained.

4. On 1/29/2025, the DON/Designee will initiate in-service related to following care plan interventions for direct care staff currently in facility. Direct care staff not present will be in-serviced prior to the start of their shift. Any newly hired direct care staff will also be in-serviced.

5. DON/Designee will review all care plans for residents residing in the Dementia care unit for appropriate interventions related to behaviors and update the care plans as needed on 1/29/2025.

6. Nurse Consultant/Designee will initiate in-service with the Minimum Data Set (MDS) coordinator and all nurse managers on reviewing and updating care plans and that interventions are appropriate and effective

on 1/29/2025.

Onsite Verification:

The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/30/2025. Resident #9 was verified to have been discharged from the facility on 01/09/2025. Resident #44 had a staff member one on one with the resident as of 01/30/2025. The facility assessed all residents on the unit for signs and symptoms of physical aggression and body audits were completed. A total of 30 staff interviews were conducted with staff from all shifts to verify training had been completed for behavior interventions. The staff interviewed included certified nursing assistants, licensed practical nurses, registered nurses, Administrator, business office staff, laundry staff, kitchen staff, activity staff, housekeeping staff, physical therapy staff, and maintenance staff. The staff interviewed verified they had been trained in handling residents with behaviors and dementia. A review of the in-service sheets provided indicated 45 of 105 had been provided training. Those staff who were not physically present to receive the in-services were to be in-serviced prior to the start of their shift. A total of 6 staff interviews were conducted regarding care plans being updated. The staff interviewed included the DON, the MDS Nurse, the ADON, and three LPNs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 42018 potential for actual harm Based on observation, record review and interview, the facility failed to ensure that the resident received Residents Affected - Some prompt treatment after noticing a change in condition for 1 (Resident #112) of 4 residents reviewed for abuse and/or neglect. Specifically, Resident #112 showed signs of a stroke and was not sent to the emergency room until approximately 4 hours after noticing the change in condition.

The findings are:

A review of an Admission Record indicated Resident #112 had diagnoses of neurocognitive disorder with Lewy bodies, chronic obstructive pulmonary disease, altered mental status, atrial fibrillation (irregular and often rapid heart rhythm that can lead to stroke), cerebrovascular disease (term for conditions that affect blood flow to your brain), cognitive communication deficit.

The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2025 documented the resident scored 00, (0-7 indicates the resident was severely cognitively impaired) on a Brief

Interview for Mental Status (BIMS). Further review indicated the resident ambulated with a walker and was independent with care.

A review of Resident #112 ' s care plan, initiated on 11/27/2023, indicated the resident was on an anticoagulant (blood thinning) medication related to atrial fibrillation. The facility developed interventions to include administering the medication as ordered and monitor for side effects and effectiveness every shift.

The blood thinning medication had a black box warning and premature discontinuation increased the risk of blood clots and to monitor for warning and side effects of the medication. Staff were to monitor, document, and report any adverse reactions of the blood thinner medication.

Review of Resident #112 Progress Notes dated 10/3/2024 at 3:23 PM, staff reported to Licensed Practical Nurse (LPN) #12 that Resident #112 was acting a bit strange during smoke break. When staff spoke to the resident, there was slurred speech and the resident reported to be tired. Resident #112 denied any pain or discomfort and was alert and oriented. Resident #112 was able to ambulate with no difficulty and the resident ' s vital signs were within normal limits for the resident. LPN #12 requested the doctor to see Resident #112

during rounds.

Review of Resident #112 Physician Notes indicated on 10/03/2024 at 7:35 PM, an Advanced Practice Registered Nurse (APRN) provided an interactive audio and visual telecommunication with the resident. The APRN indicated Resident #112 ' s chief complaint was a change in mental status and staff reported slurred speech and left side weakness. The staff reported that this started around 4 hours ago. Resident #112 had significant left sided facial droop on exam, had slurred speech, and complained of back pain. The APRN indicated the resident needed to be sent to the emergency room for an evaluation due to a possible stroke.

The APRN indicated the resident ' s doctor was made aware of the visit and new orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident #112 Progress Notes dated 10/3/2024 at 7:52 PM, Registered Nurse (RN) #14 indicated Resident #112 continued with slurred speech and staff reported she the resident was not acting like Level of Harm - Minimal harm or themselves. The on-call provider was notified and new orders were received to send the resident to potential for actual harm emergency room for evaluation.

Residents Affected - Some Review of Resident #112 Progress Notes showed no physician entries for this resident on 10/03/2024.

A review of Resident #112 ' s Admission H&P [history and physical] notes indicated Resident #112 ' s family member was at the resident ' s bedside at the hospital and told the APRN the resident had stop talking all of their medication approximately 3 months ago. The resident was admitted to the hospital on 10/03/2024 at 8:06 PM. Imaging of the resident ' s head and neck indicated a medium vessel occlusion (most common artery involved in acute stroke) and Resident #112 was not a candidate for intravenous thrombolysis (the use of medication to dissolve blood clots) due to it being outside of the timeframe for administration.

During an interview on 01/29/2024 at 4:48 PM. LPN #12 stated on 10/03/2024, the doctor was doing rounds

in the facility and was notified of the resident ' s change in condition and that the resident needed to be seen by the doctor. LPN #12 stated staff let the resident rest until seen by the doctor.

Review of OLTC Witness Statement Form, dated 01/30/2025 at 9:56 AM the Director of Nursing (DON) indicated On October 3rd, 2024, I received a phone call from the resident ' s Medical Physician (MP). Medical Physician stated that he had seen the resident per [the resident ' s] nurse ' s request. At that time,

the resident did not wish to go to the hospital to be evaluated. The resident was also non-compliant with [the resident ' s] medications, including [a blood thinner]. In light of this, the residents Medical Physician called me on my personal phone and requested that a care plan be scheduled with the resident and [the resident ' s family member] to discuss goals of care and potential comfort care measures. I was on the way home from daycare with children at the time, so the time of call would have been around 5pm. This information provided above is true to the best of my knowledge.

A review of Resident #112 ' s electronic health record did not indicate there was a conversation between Resident #112 ' s MP and the DON on 10/03/2024.

During an interview on 01/30/2025 at 11:08 AM, The MP was asked if he saw the resident on 10/03/2024 while completing rounds on other residents at the facility and the MP stated he did not see the resident and did not have any notes on the resident for that day.

Review of facility policy titled Change in a Resident ' s Condition, which indicated Our facility promptly notifies the resident, his or her primary care provider, and the resident representative of changes in the residents medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 045371 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045371 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Health and Rehab, Inc 802 S West End Street Springdale, AR 72764

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or 42018 potential for actual harm Based on record review and interview, the facility failed to acquire a current Clinical Laboratory Improvement Residents Affected - Some Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, as required, for 1 of 1 facility.

The findings are:

The Centers for Medicare and Medicaid Services (CMS) Guidance at tag

F-F770 documented, .If a facility provides its own laboratory services or performs any laboratory tests directly (e.g. [for example], blood glucose monitoring, etc. [et cetera]) the provisions of 42 CFR [Code of Federal Regulations] Part 493 apply and the facility must have a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility.

On 1/29/25 at 11:52 a.m., Observation of the facility's CLIA certificate documented an expiration date of 1/25/25. The Administrator was asked if the facility had a current CLIA certificate in her office. She stated, I will have to get that for you.

A review of Pay.gov Payment Confirmation: CLIA Laboratory Program indicated the facility paid for the CLIA license on 1:22 PM. The facility was unable to provide a current CLIA certificate.

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