West View Nursing Home, Inc

Inspectors wroteBased on clinical record review and resident and staff interviews, the facility failed to ensure services were provided in accordance with professional standards for 1 of 1 resident reviewed, Resident ID #1. Specifically, the facility failed to implement physician's orders for prescribed medications following two separate hospital discharges, including a hydrocortisone enema (a medication prescribed to treat rectal inflammation) and Veltassa (a potassium binder prescribed to treat elevated potassium levels). These repeated failures resulted in the resident missing multiple doses of hydrocortisone enemas, experiencing worsening pain, and suffering a relapse of symptoms requiring rehospitalization. The resident also missed two doses of prescribed Veltassa following the second hospital discharge despite having a critically elevated potassium level of 6.1 documented on 7/16/2026.

Inspectors wroteBased on clinical record review and staff interview, the facility failed provide services that meet professional standards relating to following the prescribed physical therapy treatment plan for 1 of 2 Residents reviewed, ID #1. Resident ID #1 sustained a left femoral (the long bone of the upper leg) fracture when a Physical Therapy Assistant (PTA) performed rotational exercises of the resident's left hip that were not included in the resident's therapy treatment plan. The facility's investigation determined that the PTA failed to follow the established treatment plan and performed interventions outside the scope of the treatment directives. [...]

Inspectors wroteBased on clinical record review, and staff interview, the facility failed to ensure care and services were provided in accordance with professional standards of clinical practice for 1 of 3 residents reviewed receiving insulin therapy for diabetes mellitus, Resident ID #1. Specifically, the facility failed to ensure a complete and clinically appropriate insulin order was obtained, accurately transcribed, and safely administered, resulting in the resident receiving rapid-acting insulin during overnight hours without meal intake, causing severe hypoglycemia requiring emergent hospital transfer.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide respiratory care in accordance with professional standards of practice for 1 of 1 resident reviewed. Emergency Medical Services (EMS) observed Resident ID #1 receiving oxygen at 5 liters per minute (LPM) via a non-rebreather mask, a delivery method that requires a minimum flow rate of 10 LPM to maintain proper reservoir inflation and effective oxygen delivery. The use of a non-rebreather mask below the required flow rate rendered the device ineffective, resulting in inadequate oxygenation and placing the resident at immediate and significant risk for respiratory failure, hypoxia, and cardiopulmonary decompensation. [...]

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and the satellite kitchenette.

Inspectors wroteBased on clinical record review, and staff and resident interviews, the facility failed to allow a resident to participate in his or her treatment for 1 of 2 residents reviewed, relative to the resident requesting a hospital transfer, Resident ID #25.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 2 residents observed for wound care, Resident ID #4.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented for 1 of 1 resident reviewed for hemodialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly), Resident ID #39.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to ensure that the food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the cleanliness of the dishes, the stove, and the flat top grill in the main kitchen.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 2 residents reviewed with non-pressure wounds, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing for 1 of 4 residents reviewed who is at risk for skin breakdown, Resident ID #1, and for 1 of 2 residents reviewed with actual pressure ulcers (a localized injury to the skin and/or underlying skin usually over a bony prominence), Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for an actual restraint, as the resident was observed in bed with a bed sheet tied across him/her, Resident ID #1.

Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 7 residents reviewed, Resident ID #7.

Inspectors wroteBased on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to provide and prepare food in a form designed to meet individual needs for 3 of 4 residents reviewed with a physician's order for thickened consistency fluids, including mildly thick (nectar) and moderately thick (honey) consistencies, Resident ID #s 7, 26, and 98.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with a suprapubic catheter (SP catheter- a device inserted through the abdomen into the bladder to drain urine), Resident ID #16.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to 1 of 1 resident reviewed for safe food temperatures, Resident ID #45, and 3 of 3 ice machines without an air gap (gap between the water supply inlet and the flood level rim of the plumbing fixture).

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents reviewed for pressure ulcers, Resident ID #s 65 and 84.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents receive proper foot care and treatment in accordance with professional standards of practice for 1 of 1 resident reviewed, Resident ID #29.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 5 of 6 medication carts observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities) for 2 of 3 residents reviewed during the infection control task, Resident ID #s 84 and 458.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to promote and facilitate self-determination through support of a resident choice, relative to weekly showers for 1 of 1 resident reviewed, Resident ID #29.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with parameters to treat low blood pressure, Resident ID #74.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to assist residents in obtaining routine and emergency dental care for 1 of 1 resident reviewed, Resident ID #62.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status such a usual body weight or desirable body weight and are offered sufficient fluid intake to maintain proper hydration for 3 of 7 residents reviewed, Resident ID #s 81, 202 and 304. Additionally, the facility failed to offer a therapeutic diet when there is a nutritional problem for 1 of 7 residents reviewed, Resident ID #303.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 2 residents reviewed for a change in condition, Resident ID #202.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 2 residents reviewed who expired in the facility, Resident ID #202.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents, for 1 of 2 residents reviewed for supervision with eating, Resident ID #81.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) System within 14 days of completion for 9 of 10 residents reviewed for assessments due in October of 2023, Resident ID #s 2, 8, 9, 15, 39, 42, 58, 63, and 80.