Westwood Healthcare And Rehabilitation

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 115601 Department of Health & Human Services Printed: 08/27/2025 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 115601 B. Wing 05/04/2025

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

Westwood Healthcare and Rehabilitation 101 Stockyard Road Statesboro, GA 30458

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36377

Residents Affected - Few Based on observations, resident and staff interviews, record review, and review of the facility policy titled Accident and Supervision, the facility failed to ensure an environment free of accident hazards for three of 25 sampled residents (R) (Resident R21, Resident R25, and Resident R18). This deficient practice had the potential to place Resident R21, Resident R25, and Resident R18 at risk of avoidable accidents.

Findings include:

Review of the facility policy titled Accident and Supervision, dated 4/1/2024, revealed the Policy section stated, The resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes. 1. Identifying hazards (s) and risks(s). 2. Evaluating and analyzing hazards(s) and risk(s) 3. Implementing interventions to reduce hazards and risks. 4. Monitoring for effectiveness and modifying interventions when necessary. The Policy Explanation and Compliance Guidelines included, 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: . ii. Environmental rounds.

1. Review of Resident R21's electronic medical record (EMR) revealed diagnoses including, but not limited to, unspecified osteoarthritis, history of falling, chronic obstructive pulmonary disease, heart failure, and hypertension.

Review of Resident R21's Quarterly Minimum Data Set (MDS) dated [DATE REDACTED], revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) of eight (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented Resident R21 required supervision with ambulation and used

a walker.

Record review revealed Resident R21 resided in room [ROOM NUMBER].

Observation revealed that rooms [ROOM NUMBERS] shared a bathroom.

Observation on 5/2/2025 at 8:36 am revealed that while Resident R21 was exiting the bathroom into her room, she slipped, without falling, and grabbed the sink and her rolling walker. Further observation revealed water around the base of the toilet in the bathroom.

In an interview on 5/2/2025 at 8:36 am, Resident R21 stated that water leaks from the toilet to the floor in the bathroom every time it is flushed. She stated the toilet had leaked for a few months, and she had reported it to staff. She further stated she was afraid of falling because of the water on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 115601 Department of Health & Human Services Printed: 08/27/2025 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 115601 B. Wing 05/04/2025

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

Westwood Healthcare and Rehabilitation 101 Stockyard Road Statesboro, GA 30458

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 0689 2. Review of Resident R25 's EMR revealed diagnoses including, but not limited to, type two diabetes mellitus with hyperglycemia, cerebral ischemia, spinal stenosis, lumbar region with neurogenic age-related osteoporosis. Level of Harm - Minimal harm or potential for actual harm Review of Resident R25's Quarterly MDS, dated [DATE REDACTED], revealed Section C (Cognitive Patterns) documented a Brief

Interview Mental Status (BIMS) of six (indicating severe cognitive impairment). Section GG (Functional Residents Affected - Few Abilities and Goals) documented Resident R25 required supervision with ambulation and did not use an assistive device for ambulation.

Review of Resident R25's Care Plan Report revealed a Focus area initiated 8/6/2023, of being at risk for falls related to poor safety awareness, weakness, lack of coordination, and pain.

Record review revealed Resident R25 resided in room [ROOM NUMBER].

In an interview on 5/2/2025 at 8:45 am, Resident R25 stated that water had been on the bathroom floor for about one month.

3. Review of Resident R18's EMR revealed diagnoses including, but not limited to, Alzheimer's disease, hypertension, glaucoma, history of falling, and repeated falls.

Review of Resident R18's Quarterly MDS, dated [DATE REDACTED], revealed Section C (Cognitive Patterns) documented a Brief

Interview Mental Status (BIMS) of six (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented Resident R18 required supervision with ambulation and did not use an assistive device for ambulation.

Review of Resident R18's Care Plan Report revealed a Focus area initiated 5/15/2024, of being at risk for falls related to history of falls, muscle weakness, pain, difficulty walking, and impaired vision. Interventions included keeping pathways free of clutter and any fall hazards

Record review revealed Resident R18 resided in room [ROOM NUMBER].

In an interview on 5/2/2025 at 8:42 am, Certified Nursing Assistant (CNA) CC verified that Resident R21, Resident R25, and Resident R18 were ambulatory and used the shared bathroom.

During a concurrent observation and interview on 5/2/2025 at 8:18 am, the Maintenance Supervisor and Director of Nursing (DON) confirmed the water on the floor and the leaking toilet in the shared bathroom of rooms [ROOM NUMBERS]. The Maintenance Supervisor reported being unaware of the toilet leaking at the base.

In an interview on 5/4/2025 at 8:18 am, the Administrator reported being unaware of the leaking toilet in the shared bathroom for rooms [ROOM NUMBERS]. She stated that the facility staff conducted environmental rounds, and she would add checking for leaking toilets to the task list.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 115601 Department of Health & Human Services Printed: 08/27/2025 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 115601 B. Wing 05/04/2025

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

Westwood Healthcare and Rehabilitation 101 Stockyard Road Statesboro, GA 30458

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 49675 potential for actual harm Based on observations, staff interviews, record reviews, and review of the facility's policy titled Oxygen Residents Affected - Few Administration, the facility failed to ensure that the physician's order for oxygen administration was followed for one of 10 residents (R) (Resident R13) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Findings include:

Review of the facility's policy titled Oxygen Administration, dated reviewed/revised 4/1/2025, revealed the section titled Policy Explanation and Compliance Guidelines included, 1. Oxygen is administered under the orders of a physician, except in the case of an emergency.

Review of Resident R13's clinical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) (acute) exacerbation and acute respiratory failure with hypoxia.

Review of 13's Quarterly Minimum Data Set (MDS) assessment, dated 4/22/2025, revealed Section J (Health Conditions) documented that the resident exhibited shortness of breath. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen therapy.

Review of Resident R13's Physician Orders revealed an order dated 1/18/2025 for oxygen at three LPM (liters per minute) via nasal canula, continuous.

Observations on 5/2/2025 at 8:18 am, 8:34 am, and 5/3/2025 at 8:34 am and 10:30 am revealed the resident receiving oxygen at a rate set at 2 LPM.

During a concurrent observation and interview on 5/3/2025 at 10:42 am, Licensed Practical Nurse (LPN) AA revealed that she was responsible for making sure the oxygen setting was set on the prescribed rate during morning medication pass. She stated she did not check the rate on 5/2/2025 or 5/3/2025, and she confirmed Resident R13's oxygen was set on two LPM. LPN AA reviewed Resident R13's physician orders and verified that the physician's order was for three LPM.

In an interview on 5/3/2025 at 10:49 am, the Director of Nursing (DON) stated her expectations were for staff to ensure oxygen was administered as ordered by the physician. She stated nurses should check oxygen settings during their medication pass and rounding, since oxygen is a medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 115601 Department of Health & Human Services Printed: 08/27/2025 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 115601 B. Wing 05/04/2025

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

Westwood Healthcare and Rehabilitation 101 Stockyard Road Statesboro, GA 30458

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm 49681

Residents Affected - Few Based on staff interviews, record review, and review of the facility policy titled Behavioral Health Services,

the facility failed to ensure one of 25 sampled residents (R) (Resident R306) received behavioral health services to address behaviors. The deficient practice had the potential to place Resident R306 at risk for medical complications, unmet needs, and a diminished quality of life.

Findings include:

Review of the facility policy titled Behavioral Health Services, reviewed/revised 4/1/2024, revealed the Policy section stated, It is policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being. The Policy Explanation and Compliance Guidelines section included, 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goal for care, while maximizing the residents' dignity, autonomy, privacy, socialization, independence, choice, and safety.

Review of Resident R306's clinical record revealed diagnoses including, but not limited to, unspecified psychosis, dependence on renal dialysis, end-stage renal disease, restlessness and agitation, unspecified dementia, and mood disorder.

Review of Resident R306's Quarterly Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed Section E (Behaviors) documented physical behaviors toward others occurred one to three days, and other behavior symptoms not directed toward others occurred four to six days of the look-back period.

Review of Resident R306's Progress Notes revealed an entry dated 2/27/2025 documenting that the resident was observed in another resident's room with his hands on another resident's neck and head. The Physician, Director of Nursing, Administrator, and responsible parties were notified.

Review of Resident R306's Progress Notes revealed a Social Service Note dated 3/1/2025, of Writer reached out to Psychiatric NP [Nurse Practitioner] for an emergency consult. NP was unavailable and recommended that

the resident be immediately sent out to a behavioral health facility. Writer informed NP that resident is on dialysis and no known behavioral health facility is able to accommodate him. As of writing, writer has not heard back from NP. Writer will monitor and follow up as necessary.

Review of Resident R306's clinical record revealed no documentation of mental health services for the last four months.

In an interview on 5/3/2025 at 8:38 am, the Social Worker stated that Resident R306 had behaviors and sometimes needed redirection. The Social Worker stated that she monitored Resident R306 and there had been no further incidents since 2/27/2025. She confirmed Resident R306 had not been referred for behavioral health services as recommended by the NP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 115601 Department of Health & Human Services Printed: 08/27/2025 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 115601 B. Wing 05/04/2025

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

Westwood Healthcare and Rehabilitation 101 Stockyard Road Statesboro, GA 30458

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 0740 In an interview on 5/3/2025 at 12:22 pm, Registered Nurse (RN) EE stated the NP had recommended Resident R306 to be evaluated by behavioral health services, but Resident R306 had not been evaluated by behavioral health Level of Harm - Minimal harm or services due to Resident R306 was out of the facility for dialysis on the days the behavioral health service provider potential for actual harm was at the facility. RN EE stated the facility should have arranged an appointment for Resident R306 to receive behavioral health services. Residents Affected - Few

In an interview on 5/3/2025 at 12:28 pm, the Director of Nursing (DON) stated Resident R306 should have been seen by the behavioral health services that provided weekly services at the facility. The DON stated the services were provided on Mondays, when Resident R306 was at dialysis, and the facility should have arranged for Resident R306 to be seen on a different day.

In an interview on 5/3/2025 at 12:32 pm, the Administrator stated she was unaware that Resident R306 had not received behavioral health services as recommended by the NP, and stated the services should have been arranged.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 115601