Main West Postacute Care

Inspectors wroteBased on interview and record review, the facility failed to provide Physical Therapy (PT-a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) and Occupational Therapy (OT- a health professional that provides services to increase and/or maintain a person's capability to participate in everyday life activities) for five of five residents (Residents 1, 2, 3, 4 and 5) when Residents 1, 2, 3, 4, and 5 did not receive PT and OT treatments ranging from 1/5/26 to 2/4/26 that had been prescribed by their physician. These failures had the potential to result in a decline in the range of motion, decreased functional status, loss of gains and overall weakness for Residents 1, 2, 3, 4 and 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure discarded items were secured inside of a dumpster. This deficient practice had the potential to affect all 96 residents who resided in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff reported a resident's grievance to the designated Grievance Officer so that an investigation could be initiated for 1 (Resident #66) of 21 sampled residents.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to report allegations of abuse to facility management and to the state survey agency for 2 (Resident #57 and Resident #69) of 3 sampled residents reviewed for abuse. Specifically, facility staff failed to report allegations of abuse after becoming aware of the allegation when a police officer reported to staff that Resident #57 called and said a staff member restrained the resident; and when a police officer reported to staff that Resident #69 called and reported that a certified nursing assistant (CNA) pushed them.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to identify and thoroughly investigate an allegation of abuse for 1 (Resident #69) of 3 sampled residents reviewed for abuse. Specifically, facility staff failed to investigate an allegation of abuse for Resident #69 once they became aware of the allegation when a police officer came to the facility on [DATE] and reported to staff that Resident #69 called and reported that a certified nursing assistant (CNA) pushed them.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to complete a comprehensive assessment at least every 366 days for 4 (Residents #9, #23, #66, and #89) of 22 sampled residents reviewed for resident assessment.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to complete a quarterly Minimum Data Set (MDS) at least every 92 days for 3 (Residents #24, #66, and #93) of 22 sampled residents reviewed for resident assessment.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 1 (Resident #42) of 3 sampled residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 1 (Resident #84) of 3 sampled residents reviewed for PASARR.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses stayed with a resident to ensure all medication was administered as ordered by the physician for 1 (Resident #8) of 21 sampled residents.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to implement the pharmacist's recommendation for 1 (Resident #93) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to address dental needs for 1 (Resident #39) of 1 sampled resident reviewed for dental.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 2 (Resident #93 and Resident #252) of 21 sampled residents.

Inspectors wrote7. Resident #31's electronic medical record revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/23/2025 had a status of Export Ready. The screen did not indicate the assessment completion date. During an interview on 03/06/2025 at 9:38 AM, the MDS Nurse stated Resident #31's quarterly MDS with an ARD of 01/23/2025 was completed on 02/06/2025 and was not submitted until 03/04/2025 (26 days after the assessment completion date). She stated the status of export ready meant the assessment was locked and ready to be submitted but had not yet been sent over or transmitted to CMS. 8. Resident #79's electronic medical record revealed a quarterly MDS with an Assessment Reference Date (ARD) of 01/10/2025 had a status of Export Ready. The screen did not indicate the assessment completion date. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 17 (Rooms 6 through 11 and Rooms 17 through 27) of 43 resident rooms in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the interventions indicated in the plan of care were being provided by the nursing staff for Resident 1 in accordance with professional standards of practice for one of four sampled residents (Resident 1), when Resident 1 ' s splint and finger sleeve was not available for Resident 1. This failure failed to meet the medical needs of Resident 1 and had the potential to contribute to contractures (perment tightenting of joints that casues stifness) Resident 1 ' s right hand.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility for one of one sampled resident (Resident 1) when the facility planned to discharge Resident 1, a [AGE] year-old female with medical and physical needs, to a homeless shelter. This failure resulted in emotional stress, increased anxiety, an increase in antipsychotic medication (used to treat mental health disorders), and near daily episodes of mood swings as evidenced by angry outbursts from Resident 1 and potential for an unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) had an accurate Minimum Data Set Assessment (MDS, a set of comprehensive, standardized assessments), when her MDS assessment dated [DATE] was not accurate. This failure had to potential to affect the care and facility placement of Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the policy and procedure titled, Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) Program for one of three sampled residents (Resident 1) when the facility failed to collaborate with the facility and hospice provider regarding Resident 1 ' s request to receive HIV (human immunodeficiency virus - virus that attacks cells that help the body fight infection) treatment. This failure resulted in Resident 1 not receiving HIV treatment and increasing his chances of weakened immunity (protecting the body against an infectious).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) maintained acceptable parameters of nutritional status when the Registered Dietitian (RD) was not notified of Resident 1's weight loss of 6.8 pounds (9.6%) in 3 weeks and by mouth (PO) intake was 60% to obtain recommendations to prevent unplanned and further weight loss. As a result of this failure, Resident 1's compromised nutritional status was not addressed which had the potential to lead to further medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents environment remained free of accidents and hazards when: 1. Four of 41 residents' rooms (Residents 6, 54, 64 and 73) had unsecured, exposed electrical cable wires and were hanging from the ceiling within arm's reach. 2. Six of 41 residents' rooms (Resident 3, 4, 63, 67, 68 and 71) had water leaking in the bathroom from a clogged swamp cooler line. These failures had the potential to place residents and staff at risk for accident hazards such as electrocution, skin burns, slip and fall, ceiling collapse and avoidable resident and staff injury.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure titled, Hospice Program for eight of eight sampled residents (Residents 25, 26, 47, 54, 55, 81, 85, and 291) when the facility failed to ensure hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures. This failure had the potential to place Residents 25, 26, 47, 54, 55, 81, 85, and 291 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected resident's current status for one of three sampled residents (Resident 64) when MDS assessments failed to accurately code the functional limitations according to the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. This failure had the potential for Residents 64 not being provided with the necessary care and services to meet his healthcare needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental care for one of three sampled residents (Resident 79) according to the facility's policy and procedure titled, Dental Services, when Resident 79 had not been seen for routine dental services since being admitted to the facility on [DATE]. This failure resulted in Resident 79 not having a dental appointment since admission and wanting dentures.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide the correct diet for one of ten sampled residents (Resident 54) during lunch tray assembly when Resident 54 was on a fortified diet (an enrichment of food to increase calorie and protein to sustain or gain weight) and dietary staff did not follow the facility's policy and procedure titled, Fortification of Food: Increasing calories and/or protein in the diet to provide Resident 54 with 1 tablespoon (Tbsp - unit of measurement) of extra tartar sauce (a condiment made of mayonnaise mixed with other ingredients) and 2 teaspoons (tsp - unit of measurement) of extra salad dressing. This failure had the potential to result in Resident 54 to not receive the adequate nutritional requirement to sustain or gain weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food according to the facility's policy and procedure titled, Storage of Food and Supplies, when two of four sampled plastic bin containers with ready to eat dry cereal were labeled with incorrect use by dates (date in which the item must be used). This failure did not meet the professional standards for food safety, had the potential to cause foodborne illness (sickness due to eating contaminated food), and loss of nutritional efficacy (value).

Inspectors wroteBased on observation during the survey period of 8/22/23 to 8/25/23, the facility failed to provide and maintain a minimum of at least 80 square feet of space per resident in 17 resident rooms (Rooms 6, 7, 8, 9, 10, 11, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dietary supervisory supervisor (DSS) possessed the appropriate competencies and skills sets to carry out the functions of the food and nutrition service department in accordance with her job description when: 1. Evaluations of dietary staff competency were not conducted and Dietary Aide (DA)1 and [NAME] 1 were unable to accurately identify the correct level of sanitizer used to sanitize food preparation surfaces, food utensils and dishware; (cross-reference F802) 2. Evaluations of dietary staff competencies were not conducted for [NAME] 1, [NAME] 4 and DA 2 in relation to food service, therapeutic diets and menu compliance and dietary staff were unable to cool down cooked foods and monitor food temperatures according the Food Code standards and the facility policy and procedure; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two dietary staff, Dietary Aide (DA) 1 and [NAME] 3 possessed appropriate competencies and skills sets to perform the duties in the kitchen when DA 1 and [NAME] 3 did not follow manufacturer's guidelines for testing the sanitizer chemical strength used to clean food preparation surfaces and in the 3-compartment dishwashing sink. This failure had the potential to cause food borne illnesses for residents who received meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, sanitize and serve food in accordance with professional standards for food service safety affecting residents who received meals from the kitchen when: 1. Dietary staff were not implementing or accurately documenting safe food cool down methods. 2. The ice machine was not maintained according to manufacturer's cleaning recommendations and contained a pinkish/red residue inside the evaporator next to the ice tray on the inner right side. 3. The vegetable washing sink and ice machine did not have air gaps (is an amount of space that separates a water line from a drain to a sewer). 4. Cooking equipment and plastic ware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze were not discarded. 5. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure safe and sanitary practices were instituted for food brought in to residents by family or visitors from outside the facility when food saved for resident consumption was stored in employee refrigerators without temperature controls. The food stored was unlabeled and undated. This failure could result in consumption of food that is unsafe and cause foodborne illness in residents who received food from outside sources.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively implement their infection control and prevention program when the Director of Staff Development/Infection Preventionist (DSD/IP) had incomplete infection surveillance logs for the monitoring, tracking and trending of facility infections for September 2019, October 2019, and November 2019, for 22 of 22 sampled residents (Resident 4, Resident 22, Resident 39, Resident 45, Resident 49, Resident 52, Resident 63, Resident 76, Resident 78, Resident 83, Resident 85, Resident 334, Resident 384, Resident 486, Resident 487, Resident 488, Resident 489, Resident 490, Resident 491, Resident 492, Resident 493 and Resident 494. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff consistently developed and implemented the comprehensive person focused care plan for three of five sampled residents (Resident 23, Resident 27 and Resident 334) when: 1. Resident 23 was transferred from bed to wheelchair by one Certified Nursing Assistant (CNA) 4 using the mechanical lift instead of two staff members as indicated on the care plan. 2. Resident 27 had known self-feeding difficulties and would spill food on herself. A Comprehensive Care Plan was not developed to optimize Resident 27's self-feeding independence and prevent food spillage. 3. Resident 334's fall prevention care plan interventions were not implemented. These failures placed Resident 23, Resident 334 at risk for falls and injuries and Resident 27 at risk for weight loss and decreased eating independence.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus were followed for residents on fortified diets and No Concentrated Sweets (NCS) diet served on 12/9/19 during the lunch meal service when fortified diets and NCS diets were not served in accordance with residents physician prescribed diet. This failure had the potential to result in residents not receiving the amount of calories and nutrients prescribed by their physician which could lead to unplanned weight loss and further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received a dignified dining experience when Certified Nursing Assistant (CNA) 3 stood while he fed Resident 7, who laid in bed. This failure violated Residents 7's rights to be treated with respect and dignity while receiving assistance with his meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS- assessment of physical and psychological functions and needs) accurately reflected resident's healthcare and functional status for one of three sampled residents (Resident 66) when a diabetic ulcer (a sore that usually forms on the foot of a person who has diabetes - is a disease that causes high blood sugars) was inaccurately coded on Resident's 66's quarterly MDS assessment. This failure had the potential to result in Resident 66's care needs going unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors when Registered Nurse (RN) 1 administered Metoprolol Tartrate (medication use to treat high blood pressure) to Resident 65 without conducting an assessment of Resident 65's heart rate. This failure had the potential for Resident 65 to experience bradycardia (slow than normal heart rate) and an increased risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were labeled with open date in accordance with the facility Administering Medications policy and procedure for two of six sampled residents (Resident 31 and Resident 32) when Resident 31 and Resident 32's Proheal Oral Protein medication bottle was available for use without an opened date labeled on the medication container. This failure had the potential to place Resident 31 and Resident 32 at risk of receiving expired medications which could lead to medication ineffectiveness and experience adverse reactions from potentially expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food appropriate to meet the needs of one of ninety residents (Resident 355) when dietary staff served hard corn bread for Resident 355 on a mechanical soft diet (a diet prescribed to residents by a physician that is soft or mechanically altered food and is easy to chew) on the lunch tray. This failure had the potential to place Resident 355 at risk for choking and possible death.

Inspectors wroteBased on observation during the survey period of 12/9/19 to 12/12/19, the facility failed to provide and maintain a minimum of at least 80 square feet of space per resident in 17 resident rooms (Rooms 6, 7, 8, 9, 10, 11, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This failure had the potential for residents to not have reasonable privacy or adequate space.