Living Center West

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide written bed hold notices at the time of hospital transfer for 1 of 1 residents reviewed for hospitalization (Resident #68). The facility reported a census of 67 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to utilize Enhanced [NAME] Precaution (EBP) for high contact resident care for one of four residents reviewed (Resident #2). The facility reported a census of 67 residents.

Inspectors wroteBased on interviews, clinical record review, facility investigation, and facility policy review, the facility failed to protect resident's right to privacy for 1 of 3 residents reviewed for resident rights when staff took video of a resident and posted it to social media (Resident #1). The facility reported a census of 70 residents.

Inspectors wroteBased on interviews, facility investigation review, and facility policy review, the facility failed to report to the state agency within 2 hours of knowledge of an abuse allegation for 1 of 3 residents reviewed for resident's rights (Resident #1). The facility reported a census of 70 residents.

Inspectors wroteBased on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 66 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview the facility failed to maintain accurate advance directive records based on resident preference for 1 of 8 residents reviewed (Resident #4). The facility reported a census of 66 residents.

Inspectors wroteBased on record review, resident and staff interviews, and policy review the facility failed to address the resident's goals for discharge for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 66 residents.

Inspectors wroteBased on record review, staff and resident interviews, and policy review the facility failed to implement its policy to ensure the safety of both smoking and non-smoking residents (Resident #65). The facility reported a census of 66 residents.

Inspectors wroteBased on interviews, clinical record review, and facility policy review the facility failed to complete pre and post dialysis assessments that included site assessment for 1 of 1 dialysis residents reviewed (Resident #16). The facility reported a census of 66 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to prevent sexual exploitation for 1 of 1 resident reviewed for abuse (Resident #10). After a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room, they left the room leaving the two of them alone in the room. No one reported the witnessed event to members of administration until several weeks later and the facility didn't terminate Staff A until 6/17/24. In addition, the facility learned on 2/29/24 that Resident #10 stated he and Staff A kissed and she locked the door of the activity room so they could be alone. The facility failed to have documentation of an investigation into the situation, nor did they separate Staff A from Resident #10 or the other residents after 2/29/24. [...]

Inspectors wroteBased on observation, clinical record review, policy review, staff, and resident interviews, the facility failed to report an allegation of sexual exploitation for 1 of 1 resident reviewed for abuse (Resident #10). On 5/7/24 a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room. No one reported the witnessed event to members of administration until 6/10/24. The facility suspended Staff A on 6/10/24 and terminated her on 6/17/24. The deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 74 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/25/24 at 9:30 AM The IJ began on 2/29/24. The facility staff removed the immediacy on 6/10/24 through the following actions: a. [...]

Inspectors wroteBased on observation, clinical record review, policy review, staff, and resident interviews, the facility failed to investigate an allegation of sexual exploitation and separate an alleged perpetrator of sexual exploitation from other residents for 1 of 1 resident reviewed for abuse (Resident #10). When a staff member observed Staff A, Activities Director, and Resident #10 kissing in the activity room. No one reported the witnessed event to members of administration until several weeks later. At that time, the facility suspended Staff A and then terminated her employment on 6/17/24. In addition, the facility learned Resident #10 reported on 2/29/24 he and Staff A kissed and she locked the door of the activity room so they could be alone. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure privacy by leaving a resident exposed for several minutes during incontinence cares for 1 of 7 residents reviewed for dignity (Resident #6). The facility reported a census of 74 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to follow the care plan to provide a pressure reducing cushion for 1 of 3 residents reviewed with a pressure ulcer (Resident #11). The facility reported a census of 74 residents.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and act to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 74 residents.

Inspectors wroteBased on observation, staff interview, resident interview, clinical record review, and policy review the facility failed to treat residents with dignity and respect while providing cares for 5 of 7 residents reviewed for resident rights (Residents #3, #6, #7, #8, #9). The facility reported a census of 83 residents.

Inspectors wroteBased on clinical record review, observations, interviews, and policy review the facility failed to accurately and thoroughly assess patterns in fluid intake, voiding patterns, cleaning care, or symptoms associated with long term catheter use for 3 of 3 residents reviewed for catheters and for 12 of 12 residents in the facility using catheters as part of their care. The facility reported a census of 83 residents.

Inspectors wroteBased on observation, record review, and interviews the facility failed to maintain an adequate number of supplies to provide for the daily needs of all residents in the facility. The facility reported a census of 83 residents.

Inspectors wroteBased on clinical record review, interviews, and policy review the facility failed to ensure catheter care orders were in place for 1 of 3 residents reviewed for catheter care (Resident #1). The facility reported a census of 83 residents.

Inspectors wroteBased on clinical record review, interviews, and policy review the facility failed to provide wound care as ordered for 1 of 3 residents (Resident #2) In addition, the facility failed to complete skin assessments for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 83 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, observations, and facility policy review, the facility failed to identify impaired skin for residents at high risk to develop pressure sores for 2 of 6 resident's reviewed (Residents #5 and #6). The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to notify 1 of 3 resident's family/guardian in a timely manner when the resident had a change in condition (Resident #2). The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, observation, facility policy review, staff and resident interviews, the facility failed to provide appropriate skin assessment and interventions for 2 of 6 residents reviewed (Residents #1 & #2). The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, staff, resident, family member and Medical Director interviews, and facility policy review, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed for abuse, when a direct care worker indicated they intentionally pressed on a resident's knee to cause pain and to avoid providing the resident care (Resident #32). The facility reported a census of 73 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 11/15/23, revealed Resident #32 with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicative of moderate cognitive impairment. Resident #32 dependent on staff for transfers, toileting, and toileting hygiene and required substantial/maximal assistance of staff for bed mobility. Resident #32 utilized antipsychotic, antidepressant, and opioid (pain) medications. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to follow sanitary practice when transporting clean linen uncovered through hallways for 2 of 2 linen carts observed. The facility reported a census of 73 residents. Findings Include: On 1/07/24 at 1:55 PM, Staff G, Laundry Staff grabbed clean resident clothing from an uncovered rolling linen cart, located in the hallway, and swung the clothes underneath left arm, the resident clothing then held against Staff G's uniform, and more resident clothing grabbed with right hand before Staff G entered a resident's room. The uncovered clean linen cart left unattended in hallway with various staff and residents passing by the area. [...]

Inspectors wrote2. The MDS dated [DATE] for Resident #4 documented diagnoses to include debility, cardiorespiratory conditions, coronary artery disease, heart failure and renal insufficiency. The MDS documented a BIMS score of 15 out of 15, indicating intact cognition status. The MDS further documented under Section GG for functional abilities and goals for toileting hygiene: The Resident dependent on the assistance of 2 or more helpers is required. The Care Plan for Resident #4, with a revision date of 12/1/23, under the Focus Area for bladder documented resident experienced occasional bladder incontinence related to impaired mobility, type II diabetes mellitus, physical deconditioning, and weakness. [...]

Inspectors wroteBased on clinical record review, resident, family and staff interviews, and facility policy review, the facility failed to assure residents had the right to choose their own schedule for 1 of 1 residents reviewed for choices and self-determination (Resident #20). The facility reported a census of 73 residents. Finding Include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 documented diagnoses to include fractures and other multiple trauma, heart failure, peripheral vascular disease, renal insufficiency, anxiety disorder and depression. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition status. Review of the Baseline Care Plan, with a completion date of 8/21/23, on page 3, titled Resident's Daily Routine and Preferences Section, noted the section left blank. [...]

Inspectors wroteBased on clinical record review, observations, and staff interviews, the facility failed to ensure safe wheelchair transfers when pedals were omitted on wheelchairs for 2 of 2 residents observed during wheelchair transportation (Residents #34 and #47). The facility reported a census of 73 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment, dated 1/10/24, documented Resident #34 with impairment to one side, for both upper and lower extremities, and required staff dependence for transfers. Resident #34 utilized a manual wheelchair for mobility. Diagnoses included: non-Alzheimer's dementia, Peripheral Vascular Disease, Spondylolysis of the lumbar region, and polyneuropathy. [...]

Inspectors wroteBased on clinical record review, staff interview, Advanced Registered Nurse Practitioner (ARNP) interview, and facility policy review, the facility failed to assure residents who require Dialysis receive services consistent with professional standards of practice by not following Physician Orders for 1 of 1 residents reviewed for Dialysis (Resident #227). The facility reported a census of 73 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] documented Resident #227 with a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating intact cognition. The MDS further documented the resident's diagnoses to include non-traumatic brain dysfunction, heart failure, hypertension, and end-stage renal disease. [...]

Inspectors wroteBased on clinical record review, staff, resident, and family interviews, and review of the Resident Council Meeting Minutes, the facility failed to have sufficient nursing staff, including Nurse Aides, to meet the needs of the residents for three of five residents reviewed for sufficient staffing and call light response time (Residents #4, #18 and #20). The facility reported a census of 73 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses to include debility, cardiorespiratory conditions, coronary artery disease, heart failure and renal insufficiency. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition status. The MDS further documented under Section GG for functional abilities and goals for toileting hygiene: [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to secure medications by leaving the medication cart unlocked and unattended for 3 of 3 medication storage observations. The facility reported a census of 73 residents. Findings Include: On 1/08/24 at 3:15 PM, the medication cart located on the 200 hallway, parked between rooms [ROOM NUMBERS], observed with the lock in the up position and drawers able to be opened without a key, no staff present in this area. Staff C, Licensed Practical Nurse (LPN), returned to medication cart at 3:17 PM from a resident's room. On 1/08/24 at 3:18 PM, Staff C prepared medications and walked away from medication cart into a resident's room, medication cart remained unlocked with residents present in the area but no staff to attend the medication cart. [...]

Inspectors wroteBased on clinical record review, staff and Physician interviews, observations, and facility policy review, the facility failed to assess 1 of 7 residents who had reports of pain (Resident #3). The facility reported a census of 81. Findings Include: According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had diagnoses which included dementia, vascular dementia, stroke, diabetes type 2, kidney disease, above the knee left leg amputation and osteoarthritis. The resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated the resident had moderate cognitive ability. The resident required extensive assistance of 2 staff for transfers, dressing, toileting and total dependence on staff for hygiene needs. The resident did not walk or bear weight. [...]

Inspectors wroteBased on clinical record review, observations, staff and resident interviews, and facility policy review, the facility failed to provide appropriate supervision to keep residents safe during a transfer for two of seven residents reviewed. (Residents #1 and #3). The facility reported a census of 81 residents. Findings Include: 1. According to the MDS (Minimum Data Set) dated 8/16/2023, Resident #1 had no cognitive impairment, transferred from one surface to another with extensive assistance of two staff, had a fall with a major injury since the prior assessment and diagnoses including end stage renal disease, diabetes, and heart failure. The Care Card dated 6/9/2023 revealed the resident required the assistance of two staff and a gait belt to stand pivot transfer. [...]