West Side House LTC Facility

Inspectors wroteBased on observation, and interview, the facility failed to follow professional standards of practice for food safety in the main kitchen to prevent the potential spread of foodborne illnesses to residents who are at high risk. Specifically, the facility failed to ensure food temperatures were taken and documented prior to meal service in the facility's main kitchen to ensure the food temperatures were within acceptable parameters for food safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right of residents to be free from physical restraints for one Resident (#2) out of a total sample of 14 residents. Specifically, for Resident #2, the facility failed to: -appropriately assess and re-assess the use and the need for a wheelchair seat belt used as a restraint when the Resident was seated in the wheelchair. -obtain informed consent and review the risk/benefits with the Resident's Representative for the use of the wheelchair seat belt, which was used to prevent Resident #2 from sliding off the wheelchair, increasing the potential risk of accidental falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards of practice during a bolus feeding (a method of tube feeding administering a dose of the formula through a feeding tube using a catheter syringe [syringe without a needle]) procedure for one Resident (#51) out of a total sample of 14 residents. Specifically, for Resident #51, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other residents within the facility. [...]

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for one Resident (#19) out of a total sample of 14 residents. Specifically, for Resident #19, the facility staff failed to accurately code the use of an antipsychotic medication on one MDS Assessment.

Inspectors wroteBased on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2), who were severely cognitively impaired and had court ordered legal guardianships in place, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when, on 10/17/24, although Nurse #1 and Nurse #2 were made aware of an allegation of abuse, that Resident #1 was at Resident #2's bedside engaged in a sexual act, neither of them reported the allegation to the Director of Nursing or Administrator, and as a result, they were not made aware until more than 12 hours later, when Nurse #3 became aware and reported the allegation.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to maintain professional standards for safe and sanitary food storage in the main kitchen and in two out of two kitchenettes.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%). Specifically, the medication error rate was observed to be 31.03%, for two Residents (#34 and #18), out of three applicable residents, out of 29 opportunities. 1. For Resident #34, medication errors occurred relative to the administration of medications not given within the required timeframe. 2. For Resident #18, medication errors occurred relative to the administration of medications not given within the required timeframe and omitting a prescribed medication.

Inspectors wroteBased on interviews and records reviewed for three Residents (#30, #17, and #4) out of five sampled residents for immunizations, the facility failed to offer or provide Pneumococcal Vaccinations as required. Specifically, the facility staff failed to: 1. Provide a Pneumococcal Vaccination for one Resident (#30) after the Resident's Representative requested the vaccination. 2. Provide education, assess for eligibility, and offer Pneumococcal Vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations to two Residents (#17 and #4) and/or their Representatives.

Inspectors wroteBased on interview and records reviewed for one Resident (#7) out of a total sample of 13 residents, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment within the required 14 days.

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#23) out of a total sample of 13 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #23.

Inspectors wroteBased on observations, interviews and records reviewed for two residents (Residents #26 and #30) out of a total sample of 13 residents, the facility failed to ensure recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed timely and implemented as required. Specifically, 1. For Resident #26, the facility staff failed to implement recommendations for medication dosage adjustment and obtain lab work to monitor lipid levels and liver function timely. 2. For Resident #30, the facility staff failed to obtain lab work to monitor lipid levels timely.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure that medications were stored in a safe and secure manner and medication storage rooms were maintained in a sanitary manner. Specifically, facility staff: -stored Heparin flushes in an unlocked drawer of a resident's nightstand with availability to any resident having access to the room. - were using and storing personal food containers in the medication storage room, with risk of spilled contents and contamination.

Inspectors wroteBased on interview and records reviewed for one Resident (#23) out of a total sample of 13 residents, the facility failed to ensure an accurate medical record was maintained relative to Physician's orders for the care and services of a Foley urinary catheter (tubing inserted into the bladder to that allows urine to drain outside the body).