Westbury Center of Conyers for Nursing and Healing

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policies titled Infection Prevention and Control Program Description and Hand Hygiene, the facility failed to practice hand hygiene between glove changes for one of four residents (R) (R4), sampled for incontinence care. This deficient practice had the potential to place R4 at risk of infections due to cross-contamination.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure one of 75 sampled residents (R) (R7) was provided with a call device suitable for the resident's use. This deficient practice had the potential to place R7 at risk of unmet needs and a diminished quality of life.

Inspectors wroteBased on resident representative and staff interviews, record review, and review of the facility's policy titled Bed Hold Prior to Transfer, the facility failed to ensure one of two residents (R) (R4) reviewed for hospitalization was provided with a written bed hold notice or reason for transfer at the time of transfer. This deficient practice had the potential to place R4 or the resident representatives at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility. The sample size was 75.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the medication error rate was less than 5 percent. The medication error rate was 7.69 percent, with two errors from 26 opportunities for two of four residents (R) (R89 and R77) observed for medication administration. This deficient practice had the potential to place R89 and R77 at risk of adverse effects or a lack of desired effects from the medications.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled Pain Management, the facility failed to ensure that pain management was provided to one of six residents (R) R117 who required such service and was reviewed for pain management. Actual Harm was identified on 5/6/2024 when R117 was exhibiting physical signs and symptoms of pain and distress. Facility staff failed to assess R117's condition and only provided her with Tylenol tablets for pain when she had an active order for a stronger pain medication available. The resident requested to be sent to the hospital and was admitted on [DATE] with a diagnosis of colitis.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Medication Administration, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications were administered as ordered by the physician. A total of 27 medication opportunities were observed, with three errors, for one of five residents (R) R124, for a medication error rate of 11.11%.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled Residents Rights Regarding Treatment and Advanced Directives, the facility failed to have the code status for one of 65 sampled residents (R) R111 available to staff who cared for this resident. This failure had the potential to affect all residents in this facility.

Inspectors wroteBased on observations, record review, and interviews, and review of the policy titled Activities of Daily Living, the facility failed to provide activities of daily living (ADL) care for one resident (R) R4 with contracted hands, resulting in inadequate nail care and hand hygiene. Five residents were reviewed for ADL care.

Inspectors wroteBased on interview, review of facility documentation, and review of the policy titled Ostomy Care-Colostomy, Urostomy, and Ileostomy, the facility failed to ensure urostomy care was provided consistent with professional standards of practice for one of two sampled residents (R) R262. Specifically, the facility sent R262 to an outside appointment without a urostomy bag. The deficient practice had the potential to cause infection.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of policies entitled Oxygen Administration and Medication Administration, the facility failed to follow standard infection control practices to prevent the spread of infections by not ensuring respiratory equipment was bagged when not in use for one of two sampled residents; and during medication observations, one of five Licensed Practical Nurses (LPNs), LPN KK, handled medications with her bare hands during medication administration. The census was 148.

Inspectors wroteBased on observations, interviews, and review of the policy titled Storage of Medications, the facility failed to ensure that two of four medication carts were locked and secured when the carts were out of view of the nurse. The census was 151.

Inspectors wroteBased on observations, staff interview, and review of the policies titled Food Receiving and Storage and Sanitation, the facility failed to ensure opened food items were properly dated and labeled in the dry food pantry. In addition, the facility failed to ensure the oven and the ventilation hood were cleaned, by due date of 9/22. The census on was 151 Residents. Findings Include: 1. Review of the undated policy titled Food Receiving and Storage revealed policy interpretation and implementation number 6. dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by) date. Such foods will be rotated using a first in - first out system. Number 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by) date. Observation on 10/3/22 at 9:45 a.m. [...]

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to follow the care plan related to weekly weights for two residents (R) (R#201 and R#21) and activities of daily living for one resident (R#79). The sample size was 51.

Inspectors wroteBased on record review, interviews and review of policy titled, Residents' Rights Regarding Treatment and Advanced Directives, the facility failed to ensure code status was consistently documented accurately throughout the clinical record for one of 35 sampled residents (R) (R#97) after a Physician Orders for Life-Sustaining Treatment (POLST) was obtained on 8/14/22.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide activities of daily living (ADL) care for one dependent resident (R) (R#79) related to oral care and shaving. The sample size was 35.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to weigh two residents (R) (R#201 and R#21) weekly as ordered, after significant weight loss. The sample size is 51.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Oxygen Administration, the facility failed to follow the Physician Order (PO) and ensure humidification was provided for one resident of seven residents (R) (R#51) receiving continuous oxygen therapy.

Inspectors wroteBased on observations, record review, staff interviews, and review of policy titled Dialysis: Hemodialysis (HD)-Communication and Documentation, the facility failed to maintain consistent communication forms with the dialysis center to coordinate care for one resident (R) (#41) of eight residents receiving dialysis.