Alliance Health at West Acres

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for two of two test trays.

Inspectors wroteBased on observation, document review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure emergency water supply was discarded and replenished prior to the expiration date.2. Maintain safe and clean equipment in three out of three kitchenettes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure quality of care was provided, according to the plan of care and professional standards of practice for one Resident (#14), out of 23 total sampled residents. Specifically, the facility failed for Resident #14, to ensure wound care treatments to a right heel diabetic wound were reflective of recommendations from the Physician Wound Consultant.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory (lab) services were obtained for one Resident (#5), out of a total sample of 23 residents. Specifically, the facility failed to follow the physician's telephone order (T.O.) to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), and BMP (Basic Metabolic Panel) for Resident #5 who was on a blood thinner and experiencing nose bleeds.

Inspectors wroteBased on observation, interview, and document 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 potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to: 1. Perform a COVID-19 related investigation and conduct contact tracing for a single new resident case to prevent, to the extent possible, the onset and spread of infection and ensure staff and resident COVID-19 surveillance line listings were maintained; 2. Ensure proper COVID-19 outbreak testing procedures were implemented for four of four facility staff members reviewed representing two (Station 1 Unit and Station 3 Unit, both COVID-19 affected units) out of three units; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for one Resident (#49), out of a sample of 23 residents. Specifically, the facility failed to ensure a medication to increase blood pressure was administered to the Resident as ordered by the physician.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement care plans for three Residents (#7, #55, and #8), out of a sample of 25 residents. Specifically, the facility failed: 1. For Resident #7, to implement a nose picking behavior care plan; 2. For Resident #55, to apply Geri-sleeves (a device that helps protect extremities from abrasion, bruises, and skin tears), as ordered; and 3. For Resident #8, a. to apply Geri-sleeves, and b. to implement a fall mat (a device used to reduce risk of injury from impact) on the floor as ordered and ensure the Resident's bed was in a low position.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure four Residents (#60, #7, #37, and #312), out of a sample of 25 residents received care consistent with professional standards of practice. Specifically, the facility failed: 1. For Resident #60, to implement a physician's order not to have straws; 2. For Resident #7, to document weekly skin checks accurately; 3. For Resident #37, to ensure nursing implemented new physician's orders and implemented the physician's order review policy as required; and 4. For Resident #312, to implement a physician's order for an ace wrap.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 4 errors out of 33 opportunities resulting in a medication error rate of 12.12%. Those errors impacted two Residents (#68 and #53), out of three residents observed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were stored (refrigerated), and dated once opened, according to manufacturer's guidelines in 2 out of 3 medication carts. 1. On 7/25/23 at 1:00 P.M., the surveyor and Nurse #1 made the following observations of the Station 2, B medication cart: - one bottle of Latanoprost Ophthalmic eye drops, opened and undated - one bottle of Dorzolamide / Timolol eye drops, opened and undated - one bottle of Timolol Ophthalmic eye drops, opened and undated - one bottle of Latanoprost Ophthalmic eye drops, unopened and undated. Review of the packaging indicated keep refrigerated until opened. During an interview on 7/25/23 at 1:07 P.M., Nurse #1 said that the eye drops should be dated once opened and the eye drops should have been stored in the refrigerator until opened. 2. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store and handle food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure a dignified dining experience for one Resident (#11), out of a total sample of 25 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete a restraints assessment for one Resident (#94), out of a sample of 25 residents. Specifically, the facility failed to assess therapeutic devices (two pillows and two block floor mats) as restraints.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to provide supervision during meals for one Resident (#8), out of a total sample of 25 residents.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure for one Resident (#312), who required dialysis, he/she received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 25 sampled residents. Specifically, the facility failed to ensure nursing implemented a physician's order for emergency equipment at the Resident's bedside (pressure dressing and clamp).

Inspectors wroteBased on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one Resident (#97), out of a total sample of 25 residents. Specifically, for Resident #97, the facility failed to ensure that staff coded the use of Oxygen on the Minimum Data Set (MDS) assessment.