West Side Campus of Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure that eight 64-ounce pitchers of dark brown liquid were labeled and dated. 2. The facility failed to ensure that four 4-ounce canned food items were free of dents. These failures had the potential to affect residents by placing them at risk for cross-contamination and foodborne intoxication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 medication carts reviewed for medical waste and for 2 of 3 halls reviewed. 1. The facility failed to perform appropriate disposal of medical waste. 2. The facility failed to ensure medical waste container was covered on the medication cart located on secure unit These failures could place residents at risk of cross-contamination, increased risk of infection, and the spread of infection.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #179) of 6 residents reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #179 within 48 hours of admission. This failure had the potential to place newly admitted residents at risk of not receiving effective, person-centered care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate resident's allergies for 1 of 6 (Resident #180) residents reviewed for food allergies. The facility failed to ensure Resident #180 did not receive two ketchup packets on his lunch tray which were listed as a food allergy in his medical record. This failure could cause an allergic reaction, a decrease in resident choices, and a diminished interest in meals placing him at risk for contributing to poor intake and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Residents #1) of 6 residents reviewed for dignity. CNA A failed to ensure Resident #1 was provided with a dignified dining experience, when she stood over him as she was assisting him in eating his lunch in the dining room on 12/11/25. This failure could affect the residents by placing them at risk of not having a home-like dining experience and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to be free from abuse for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to ensure that Resident #1 was free from physical abuse when he alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. Resident #1 was transported to the local hospital on 4/30/25 and diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure. An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to implement the abuse and neglect policy and procedures to ensure that Resident #1 was free from physical abuse when he alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. Resident #1 was transported to the local hospital on 4/30/25 and diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure. An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one resident (Residents #2) of six residents reviewed for respiratory care in that: -The facility failed to ensure that Residents #2, who required continuous oxygen therapy, continued to receive adequate oxygen when her portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 4/28/2025. Resident #2 was sent to the local hospital by the clinic after running out of oxygen and complaining of SOB and chest pain. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 05/07/25 at 2:57 PM. The Immediate Jeopardy began on 04/28/25 and ended on 04/28/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime, abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the suspicion or allegation was made, to a law enforcement entity or State Agency in accordance with State law through established procedures, for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to report to law enforcement and the State Agency when Resident #1 alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. This failure could place residents at risk for continued abuse due to unreported allegations of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to implement their abuse, neglect, and exploitation policy and investigate suspected or alleged abuse when Resident #1 alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. This failure could place all residents at an increased risk for abuse and neglect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 4 of 6 residents reviewed for clinical records (Resident #41, Resident #59, Resident #76, and Resident #121) in that: The facility failed to ensure that Resident #41, Resident #59, Resident #76, and Resident #121 use of bed rails/grab bars/mobility bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team had determined that self-administration of medications by a resident was clinically appropriate for 1 of 4 (Resident #118) residents reviewed for resident rights, in that: The facility failed to assess, obtain physician orders, and interdisciplinary team approval for Resident #118 to self-administer his G-tube medications and feedings. LVN B allowed the resident to self-administer his own medications via g-tube on 01/15/25. This failure placed the resident at risk of not receiving the proper medication or the therapeutic benefits of medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident dignity for 1 of 4 residents reviewed for dignity (Resident #114). Resident #114 did not receive his personal clothing for two days (01/11/25 and 01/12/25) which caused him to remain in bed and not engage in preferred activities during the week. This failure could place the resident who required assistance with dressing at risk of feeling disrespected.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for two (Resident #111 and Resident #118) of the four residents reviewed for enteral tube feeding, in that: 1. LVN A failed to check G-tube residual to verify G-tube placement verification before administering medication and feedings for Resident #111 on 01/15/25. 2. LVN B failed to check G-tube residual to verify G-tube placement before administering medication and feedings to Resident #118 on 01/15/25. These failures could place residents with G-tubes at risk of aspiration pneumonia, discomfort, malnutrition and a decline in the resident's health. 1 Record review of Resident #111 admission record dated 1/15/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with an initial admission date of 04/15/22. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for one of eight residents (Resident #370) reviewed for storage of medication. The facility failed to ensure two medications/suppliments Complete mineral complex dietary supplement for professional use only and Advanced multivitamins were not stored on Resident #370's bedside table and failed to ensure they were secured in the medication cart or medication room. This failure could place residents at risk of medication misuse and supplements could interfere with prescribed medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 1 (Resident # 165) residents reviewed for resident call system. The facility failed to ensure Resident #165's bathroom call light was functioning outside the Resident's room. On 01/14/2025 when the bathroom light was activated, the call light did not turn on in the hallway above Resident #165's door. This failure could place residents at risk of not getting assistance and not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 of 2 shower rooms reviewed for environment. The facility failed to ensure station 2's second shower room was clean and free of a black substance on the ceiling and tiles on the wall. This could place residents at risk for respiratory infections and a decrease in quality of life.

Inspectors wroteBased on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #25) of 3 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #25 attempted to leave the facility on 01/30/24. This failure could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and home like environment, for daily living for seven showers viewed for environmental concerns. The facility failed to ensure that the residents' showers were ready resident use. The deficient practice could place residents at risk for diminished quality of life and a diminished clean and homelike environment.

Inspectors wroteBased on observation, interview and record 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 transmission of communicable diseases and infections for 2 (Residents #2, #71) of 11 residents observed for infection control. The facility failed to ensure RN A sanitized her hands after feeding Resident # 2, before starting to feed resident #71. The facility failed to ensure RN A washed her hands after cleaning a spill on Resident #71 table. The facility failed to ensure RN A performed standard hand hygiene after touching and pushing Resident #2 wheelchair. The facility failed to ensure RN A performed hand hygiene after she removed and discarded gloves. These failures could place residents at risk of contamination and infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one (outside of kitchen) of one dumpster reviewed for garbage disposal. 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest and failed to ensure garbage receptacles were covered after being removed from the kitchen area to dumpster . This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents.

Inspectors wroteBased on observation, interview and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 of 8 residents (Resident #93) reviewed for physical environment. The facility failed to ensure Resident #93's call light was functioning. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision. 1. On 09/28/23 the facility failed to ensure adequate supervision and services were provided to Resident #1, when she was allowed to sign herself out of the facility even though it was known she had impaired cognitive function, impaired thought process, and potential for delirium or acute episodes of confusion, due to dementia. 2. On 09/28/23 the facility failed to notify Resident #1's RP/POA she signed out of the facility, which caused the RP/POA not to know Resident #1's location and if she was safe for approximately 5 hours. Resident #1 was located at a nearby fast-food restaurant in a high-traffic area with a sunburn. An IJ was identified on 10/04/23 at 5:08 PM. [...]