Walker Methodist Westwood Ridge II

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate monitoring and documentation related to psychotropic medication use to include side effect monitoring and resident-specific target behaviors for 3 of 5 residents (R3, R25 and R42) reviewed for unnecessary medications. R3's face sheet dated 4/16/26, indicated R5 was admitted to the facility on [DATE]. R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact and had diagnoses of schizophrenia and anxiety. R3's Order Summary Report dated 4/16/26, included the following orders: Buspirone (antianxiety medication) HCL 5 milligrams (mg), take 2 tablets, three times a day for schizoaffective disorder. Risperidone (an antipsychotic used to treat schizophrenia) 0.5 mg, take 1 tablet twice a day po for schizophrenia. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure written discharge/transfer notices were given as soon as practicable for 1 of 1 residents (R35) reviewed for hospitalization and 1 of 2 residents (R2) reviewed for discharge. In addition, the facility failed to ensure the written notice of transfer included a statement of the resident's appeal rights and the name, address, and telephone number of the entity that receives appeal requests for 1 of 1 residents (R35) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure baseline care plans were in place for 2 of 5 residents (R25, R50) reviewed for baseline care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision during meals for 1 of 1 residents (R42) with a known swallowing impairment who had a physician order for supervision related to holding food in the oral cavity (pocketing), and who was left unsupervised during meals despite documented risks.

Inspectors wroteBased on interview and record review, the facility failed to ensure implementation of medication side effect monitoring for 1 of 1 resident (R42) reviewed for anticoagulant use with a known risk of bleeding.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement and ensure adherence to infection prevention and control practices, including appropriate use of personal protective equipment (PPE) and proper cleaning and disinfection of shared equipment for residents on contact precautions. This deficient practice placed 2 of 2 residents (R49 and R50) observed on contact precautions at increased risk for the transmission of infectious organisms.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) use for 1 of 3 residents (R4) on enhanced barrier precautions (EBP) reviewed for proper PPE use during survey. In addition, the facility failed to ensure a comprehensive Infection Prevention and Control Program (IPCP) was maintained to include an ongoing analysis of collected data to help identify and reduce the risk of infection spread and outbreak. This had potential to affect all 30 residents, staff, and visitors.

Inspectors wroteBased on interview and document review, the facility failed to implement an antibiotic stewardship program which included development of protocols and a system to monitor appropriateness of antibiotic use to prevent antibiotic resistance and help prevent the spread of infectious diseases. This had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the acting infection preventionist had completed specialized training in infection prevention and control. This had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure private and confidential resident information was secure and not visible to residents and visitors when multiple care sheets were left out in public view. This had the ability to affect eleven residents on the 400 hallway including R4.

Inspectors wroteBased on interview and document review, the facility failed to ensure 5 of the 6 residents (R5, R9, R26, R28, and R133) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). In addition, the facility failed to ensure 1 of the 5 residents (R26) was offered and/or provided the influenza vaccination as recommended by the CDC.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident choices for bathing preferences were assessed and honored for 1 of 1 residents (R5) reviewed for choices.

Inspectors wroteBased on interview and document review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) and/or Notice of Medicare Non-Coverage (NOMNOC; CMS-10123) upon the termination of Medicare A coverage for 3 of 4 residents (R26, R187, and R188) reviewed.

Inspectors wroteBased on interview and document review the facility failed to provide a copy of the resident's base line care plan for 1 of 2 resident (R26) reviewed for baseline care plans.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 5 residents (R29) reviewed for comprehensive care plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences were conducted upon admission for 1 of 2 residents (R5) reviewed for care conferences.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization that affected 1 of 1 residents (R5) reviewed for hospice services.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively reassess and demonstrate adequate justification for the continued use of an indwelling catheter for 1 of 2 residents (R4) reviewed who used a catheter. Further, the facility failed to develop a comprehensive plan of care to monitor and assess residents with indwelling catheters for 1 of 2 residents (R4) reviewed who used a catheter. The facility further failed to ensure a resident who was continent of bowel received services to maintain bowel continence for 1 of 2 residents (R5) reviewed for bowel and bladder.

Inspectors wroteBased on interview, and document review, the facility failed to ensure a resident that was prescribed psychotropic medications was monitored for side effects, for 1 of 2 residents (R283) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 (R1) resident had parameters of an as needed (PRN) antipsychotic medication (medication used for a variety of mental health disorders) used for sleep.

Inspectors wroteBased on interview and document review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) in accordance with resident wishes and physician orders for full code status of CPR to 1 of 3 residents (R1) reviewed. This deficient practice resulted in an immediate jeopardy (IJ) situation when R1 was found not breathing, had no pulse, CPR was not initiated timely, and R1 passed away at the facility. The IJ began on 8/29/24, at 12:30 a.m. when R1 was noted to have no respirations or pulse, and no immediate action was taken by Registered Nurse (RN)-A, including CPR, which resulted in a missed opportunity to resuscitate R1, resulting in certain death. On 9/6/24, at 5:15 p.m. the administrator and director of nursing (DON) were notified of the IJ. [...]

Inspectors wroteBased on interview, and document review the facility failed to notify the physician timely for 1 of 1 resident (R1) who was recovering from neoplasm (growth of abnormal cells) bladder surgery, had pulled out their indwelling catheter and had specific orders to contact physician with change of condition.

Inspectors wroteBased on interview and record review, the facility failed to immediately report to the state agency (SA) when a provider orders for life sustaining treatment (POLST) and cardiopulmonary resuscitation was not initiated timely, as per the resident wishes for 1 of 1 resident (R1) reviewed for neglect.

Inspectors wroteBased on interview, and document review, the facility failed to provide the necessary care and services for 1 of 3 residents who was recovering from bladder surgery, had pulled out their indwelling catheter and the provider was not contacted timely, provider orders to replace catheter or send to Emergency Department were not followed and ongoing assessment and monitoring for bladder retention, bleeding, or change of condition were not completed.

Inspectors wroteBased on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure 3 of 3 medication carts were free of expired facility stock medications. The findings had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess, monitor, and document for 2 of 2 residents (R89, R90) reviewed for appropriate self-administration of medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a fast-acting insulin Flexpen, and newly attached needle was primed and administered in accordance with manufacturer instructions to facilitate complete dosing of the medication for 1 of 2 resident (R122) observed to receive insulin. This had potential to deliver an incorrect dose of insulin and constituted a significant medication error.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 1 of 5 residents (R2) over [AGE] years old whose vaccinations histories were reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of misappropriation of property were reported within 24 hours to the State Agency (SA) for 1 of 5 residents (R1) reviewed for allegations of misappropriation of property. R1's discharge Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact and had almost constant pain that occasionally affected her sleep with an average pain rating of 6/10 (Pain scale where 0 is no pain and 10 is the worst pain imaginable) R1's Provider Orders included oxycodone (narcotic pain medication) 10 milligram (mg) tablet by mouth every 4 hours as needed (PRN) for pain level 8-10/10 and Ambien (sedative) 5 mg by mouth every 24 hours as needed for sleep. [...]