West River Health Campus

Inspectors wroteBased on the interview and record review, the facility failed to complete a physician's order to obtain a urine sample timely for 1 of 3 residents reviewed for urinary tract infections (UTIs). A urine sample was not obtained for five (5) days, with two documented attempts to obtain the sample before the physician was notified, and an order to obtain the sample via catheterization was received. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with medications observed at bedside during 2 random observations had a self-administration of medication assessment, physician orders, and a care plan for self-administration of medication. (Resident 27)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's plan of care was followed by providing assistance during transfers for 1 of 1 residents reviewed for falls. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe environment free of pests based on 2 random observations of ants in the resident bathroom and air conditioner during the survey. (Resident 27)

Inspectors wroteBased on interview and record review, the facility failed to complete the required discharge documentation. Transfer/Discharge documentation was left blank and incomplete. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided to a resident with an indwelling urinary catheter to prevent the development of infection for 1 of 1 resident reviewed for a catheter-associated urinary tract infection (CAUTI). (Resident 32) This deficient practice resulted in Resident 32 developing a CAUTI with septic shock and pneumonia. Resident 32 required artificial ventilation and treatment at a hospital-based intensive care unit. (Resident 32)

Inspectors wrote4. On 8/12/24 at 11:21 A.M., Resident 6 indicated she was supposed to get showers every other day but didn't get them very often. She indicated if she refused a shower, she was not offered a bed bath as an alternative. At that time, white flakes of skin were observed on Resident 6's blanket and chair. On 8/13/24 at 1:04 P.M., Resident 6's clinical record was reviewed. Resident 6 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, hypertensive heart disease, major depressive disorder, and urge incontinence. The most current admission Minimal Data Set (MDS) Assessment, dated 7/8/24, indicated Resident 6 was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen and 1 of 1 observations of unit refrigerators. Food was not labeled, floors were soiled, and equipment was soiled. (Kitchen, Certified Locked Dementia Unit)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff performed proper hand hygiene and sanitation practices while providing care for 3 of 3 residents observed receiving care and 1 of 1 residents observed receiving blood glucose level checks. (Resident 11, Resident 19, Resident 32, Resident 9)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had supervision and interventions in place to prevent accidents for 2 of 2 residents reviewed for Accidents. A resident's fall intervention was out of place, care plans were not updated with new interventions, and a resident's diet orders were not followed or supervised during a group activity. (Resident 30 and Resident 32)

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure a resident's decline in nutritional status was addressed and recommendations were followed for 1 of 1 residents reviewed for significant weight loss. (Resident 32)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order for 1 of 3 residents reviewed for respiratory care. (Resident 6)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective supervision was provided to a cognitively impaired, dependent resident to prevent falls and failed to ensure the bed was in low position with a fall mat in accordance with the plan of care to prevent injury for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident B experiencing an unwitnessed fall from the bed, landing on the floor, and sustaining a left clavicle fracture. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician medication orders were put in place for 1 of 3 residents reviewed. A medication dosage increase was not done. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications for 2 of 2 medication carts and 2 of 2 medication storage rooms observed. Loose pills were observed in the medication cart drawers, and temperature logs were not completely filled out for the refrigerator in the medication rooms (200 Hall, 300 Hall).

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored appropriately and dishwasher temperatures were within range and completed for 1 of 1 kitchen observations. Food was not labeled correctly, left open to air, and expired food was not disposed of from the refrigerator and the freezer. Dishwasher final wash temperatures documented in logs were not at an appropriate level. (Kitchen)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's as needed anti-anxiety medication was ordered for greater than 14 days (Resident 10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 6 residents (Resident 14, Resident 238)observed during medication pass. 2 medication errors were observed during 25 opportunities for error in medication administration. This resulted in a medication error rate of 8%. A resident choked and was unable to swallow large portion of unidentified partially crushed medication and the incorrect dose of an ordered medication was given to a resident.