West View Healthy Living

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure isolation precautions were followed for Resident #7 and #25, and failed to properly monitor Resident #74's stools to ensure proper precautions were in place for Clostridioides Difficile. This affected three residents (Resident #7, Resident #25, and Resident #74) and had the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received interest on resident funds greater than 100 dollars. This affected seven (Residents #5, #13, #20, #26, #30, #38 and #187) of seven residents reviewed for personal funds with the potential to affect all 16 residents whose funds were managed by the facility. The facility census was 87.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure oxygen tubing was dated and changed as required. This affected three residents (Residents #38, #59, and #71) out of five residents on respiratory care. The facility census was 87.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure staff implemented proper infection control practices related to hand hygiene. This affected two residents (Resident #14 and Resident #28) who were reviewed for incontinence care. The facility census was 84.

Inspectors wroteBased on review of the infection control tracking log and staff interview the facility failed to ensure monthly completion of the infection control tracking log. This had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to ensure advance directives matched in the electronic health record and paper medical record. This affected one resident (#65) of 18 residents reviewed for advance directives.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #177's physician and the dietitian were notified of significant weight changes. This affected one resident (#177) of three residents reviewed for nutrition.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a Preadmission Screening and Review Review (PASARR) assessment was resubmitted for review after a new mental health diagnosis was added for Resident #14. This affected one resident (#14) of one resident reviewed for PASARR assessments.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure proper infection control practices were followed during Resident #53's dressing change to prevent a wound infection. This affected one resident (#53) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #65, who had a gastrostomy tube with enteral feeding, was provided water flushes as ordered by the physician. This affected one resident (#65) of one resident reviewed for enteral feedings.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to obtain physician's orders for hemodialysis treatments for Resident #177 and failed to ensure the resident's hemodialysis access site was monitored/assessed for patency and/or complications. This affected one resident (#177) of one resident reviewed for hemodialysis.

Inspectors wroteBased on observation, facility policy and procedure review and interview the facility failed to properly dispose of garbage and refuse in outside dumpsters. This had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on review of personnel files, review of the facility new hire list, review of the facility abuse policy, and staff interview, the facility failed to effectively implement their abuse policy and procedure to ensure all potential staff hires were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This affected 15 dietary personnel, three Housekeeping personnel, one Maintenance personnel, one Life Enrichment Director, one Medical Records Coordinator and one Director of Dietary Services and had the potential to affect all 69 residents residing in the facility. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide a dignified dining experience for Resident #2, Resident #6 and Resident #49. This affected three residents (#2, #6 and #49) of 11 residents who were identified to eat in the Tuscan dining room. Findings Include: An observation on 09/16/19 at 5:20 P.M. revealed State Tested Nursing Assistant (STNA) #758 was assisting Resident #2, Resident #6 and Resident #49 with the dinner meal. STNA #758 was standing at the table, walking around the table giving each resident a bite of food then moving on the next resident. STNA #758 never sat down to feed a specific resident. During an interview on 09/16/19 at 5:30 P.M. STNA #785 verified she had been standing while feeding Resident #2, Resident #6 and Resident #49. An interview on 09/16/19 at 5:40 P.M. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #48 was comprehensively assessed for the use of a seatbelt restraint in a motorized wheelchair. This affected one resident (#48) of one resident reviewed for restraints. Findings Include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, paraplegia, diabetes, foot drop and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderately impaired cognition, required staff extensive assistance with bed mobility and toilet use and required total assistance from staff for transfer. The assessment revealed the resident did not have a restraint. Observations on 09/17/19 at 9:15 A.M., 1:45 P.M., 4:20 P.M. and on 09/18/19 at 9:00 A.M. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure adequate and ongoing monitoring and comprehensive assessments were completed of skin impairments identified by the facility to be non-pressure related for Resident #120. This affected one resident (#120) of two residents reviewed for non-pressure skin concerns. Findings Include: Review of Resident #120's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic non-pressure ulcers to bilateral lower legs, and cellulitis of bilateral legs. Review of progress note dated 09/12/19 at 9:55 P.M. revealed Resident #120's dressings to bilateral lower legs were changed. A scant amount of serosanguineous (mixture of blood and serum) drainage was noted from the left leg. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to adequately assess and monitor pressure ulcers for Resident #27 #120 and #22. This affected three residents (#27, #120 and #22) of three residents reviewed for pressure ulcers. Findings Include: 1. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included displaced fracture of third cervical, venous insufficiency, and pressure ulcer of sacral region. A progress note dated 02/12/19 at 4:20 P.M. revealed Resident #27's bottom was reddened and had shearing. Resident #27 was admitted to the facility with a Mepilex (foam dressing) to the buttocks for protection. Further review of February 2019 progress notes revealed no mention of a wound or Resident #27 rejecting care. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #55 received nutritional supplements and thickened liquids as ordered, the amount of supplement consumed was documented and re-weights were obtained to ensure the resident maintained adequate parameters of nutrition. This affected one resident (#55) of two residents reviewed for nutrition. Findings Include: Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, tremor, abdominal aortic aneurysm, and dysphagia. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the attending physician provided rationale for continued use of psychotropic medications for Resident #31 and failed to ensure the physician addressed a gradual dose reduction for Resident #46. This affected two residents (#31 and #46) of five residents reviewed for unnecessary medication use Findings Include: 1. Review of a consultation report, dated 09/12/18 revealed a pharmacist recommendation to the attending physician for Resident #31. The recommendation stated Resident #31 had been receiving Diazepam at 5 mg three times a day as needed for anxiety, agitation and restlessness. The order was written on 03/03/18. If the as needed (PRN) use was to continue, the physician must document indication, duration and rationale for an extended time frame. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #31 was prescribed an antipsychotic medication with a clinical indication for use. This affected one resident (#31) of five residents reviewed for unnecessary medication use. Findings Include: Review of a note to the attending physician dated 03/06/19 and the consultant pharmacist's medication regimen review dated 03/06/19 revealed Resident #31 had been receiving Quetiapine (Seroquel) 50 milligrams (mg) twice a day since December 2018 for anxiety, agitation and restlessness. Record review revealed Resident #31 had an order dated 04/01/19 for Quetiapine (Seroquel) 50 milligrams (mg) twice a day for dementia with Lewy bodies. [...]