Westchester House, the

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' personal possessions were kept safe from loss or theft and failed to maintain inventory sheets for four sampled residents (Residents #1, #8, #9 and #10). The census was 90. Review of the facility's Inventory of Personal Belongings policy, dated [DATE], showed: -The facility will reduce the potential for lost clothing and ensure that residents receive all of their personal clothing once it has been laundered; -The Laundry Department will be notified of each new resident admission, take the resident's clothing, mark it and account for each item on an inventory sheet, with description for each article of clothing; -The same procedure will be done each time new clothing is brought into the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete weekly skin assessments and to identify an open wound caused by cellulitis (a serious bacterial infection) for one resident (Resident #1) and failed to notify the resident's physician of the wound and obtain orders for the wound care. The facility also failed to discontinue wound care orders for the resident's right medial distal thigh and documented falsely in the resident's Treatment Administration Record (TAR). The sample size was four. The census was 90. Review of the facility's Skin Integrity and Pressure Ulcer/Prevention and Management Policy, dated 7/9/24, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete weekly skin assessments and to identify a Stage II (partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (non-viable, dark brown or black tissue). May also present as an intact or open/ruptured blister) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one resident (Resident #1) and failed to notify the resident's physician of the pressure ulcer and obtain orders for the wound care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a significant weight loss was provided appropriate mealtime assistance resulting in a 9.43% weight loss within a 30 day time frame (Resident #36). In addition, the facility failed to notify the physician and Registered Dietician (RD) when a resident experienced a weight loss for one resident (Resident #31) and failed to ensure nutritional supplements and double portions were provided for one resident at risk for weight loss (Residents #22). The sample size was 18. The census was 78. Review of the facility's Hydration and Nutrition policy, revised 8/24/23, showed: -Each resident receives a sufficient amount of food and fluids to maintain acceptable parameters of nutritional and hydration status; -Federal Regulations; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with food that was palatable and at a safe and appetizing temperature for 7 of 18 sampled residents (Residents #80, #38, #292, #81, #54, #36 and #79). The census was 87. Review of the facility Safe Food Handling Policy, dated 10/7/19, and revised on 4/16/23 and reviewed on 5/1/2024, showed: -All food purchased, stored and distributed is handled with accepted food-handling practices, and per federal, state and local requirements; -Danger Zone-means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause food borne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or the resident's responsible party (RP) were invited to participate in all aspects of person-centered care planning for six of 18 sampled residents (Residents #66, #80, #292, #50, #62 and #54). The census was 78. Review of the facility's Comprehensive Care Plans and Revisions policy, reviewed 8/22/23, showed: -Policy: The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; -Procedure; [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify, in a timely manner, the family/resident representative of three residents' change of room assignment after they tested positive of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) (Residents #62, #31, and #14). The facility census was 78. Review of the facility's COVID-19 Policy, reviewed on 7/12/24, showed: -Place a resident with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The resident should have a dedicated bathroom; -The facility could consider designating entire units within the facility, with dedicated healthcare provided, to care for residents with SARS-CoV-2 infection when the number of residents with SARS-CoV-2 infection is high; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of three of 18 sampled residents. (Residents #36, #79, and #292) . The census was 78. Review of the facility's Comprehensive Care Plans and Revisions policy, reviewed 8/22/23, showed: -Policy: The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; -Procedure; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who received activities of daily living (ADL) received personal care in accordance with their personal needs for three of 18 sampled residents (Residents #36, #79 and #50). The census was 78. Review of the facility's Activities of Daily Living (ADLs), revised 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse; -Federal Regulations: F677 A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an on-going activity program based on resident preferences to support residents in their choice of activities and meet the needs of residents. The resident council meeting participants reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program for eight of 18 sampled residents (Residents #54, #26, #50, #62, #44, #55, #22 and #36). The census was 78. Review of the facility's Therapeutic Activities Program, dated reviewed 9/21/23, showed: -Activities -refers to any endeavor, other than routine activities of daily living (ADLs), in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physicians' orders for respiratory evaluation and treatments were followed for five residents out of 18 sampled residents (Residents #50, #62, #31, #14, and #44). The facility census was 78. Review of the facility policy binder, showed no policies regarding respiratory illness/infections. 1. Review of Resident #50's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/24 showed; -Cognitively moderately impaired; -Diagnoses included kidney failure, dementia, arthritis, malnutrition and depression. Review of the resident's nurse's progress notes, showed on 8/12/24 at 3:55 P.M., the resident was diagnosed positive for COVID-19, respiratory precautions in place. Review of the resident's physician's orders, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 33 opportunities, for errors, four errors occurred, resulting in a 12.12% medication error rate (Residents #242, #30, #23 and #29). The census was 78. Review of the facility's Administration of Medication Policy, dated 8/24/23, showed: -Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; -Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: -Right Drug: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, medical device care or use, and wound care) with residents on enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (an umbrella term for bacteria and other microorganisms that are resistant to antibiotics and other drugs designed to kill them) that employs targeted gown and glove use during high contact resident care activities) for five residents (Residents #79, #74, #19, #242 and #36). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary was completed, including a recapitulation of the resident's stay and final summary of the resident's status at the time of discharge, for two of three residents investigated for discharge (Residents #54 and #89). The census was 78. 1. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/24 showed; -Cognitively intact; -Diagnoses included heart failure, kidney failure, diabetes and high blood pressure. Review of the resident's progress notes, showed; -On 3/17/2024 at 9:29 A.M., Note Text: Resident requested that Social Services send referral for possible transfer, will follow up on referral; -On 3/29/2024 at 4:16 P.M., Note Text: Resident does not want to transfer to another facility anymore. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow the wound treatment order, resulting in an untreated non-pressure wound, for one sampled resident (Resident #292). The sample was 18. The census was 78. Review of the facility's Wound Care Policy, revised on 7/12/24, showed: -Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the residents' choices; -The skin care program developed by the facility is interdisciplinary and implemented using a team approach; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with wounds received necessary treatments. and services to promote healing (Resident #31). The sample size was 18. The census was 78. Review of the facility's Skin Integrity & Pressure Ulcer/Injury Prevention and Management Policy, dated revised: 7/9/2024, showed: -Skin observations also occur throughout points of care provided by Certified Nurse Aide's (CNA) during Activities of Daily Living (ADL) care (bathing, dressing, incontinent care, etc.). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when the facility failed to administer medications as ordered for two of six sampled residents (Resident #1 and Resident #3). The census was 83. The administrator was notified on [DATE] of the past non-compliance. The facility had already began an investigation, counted the medication carts, added a corrected count to all controlled substance logs, interviewed staff and residents, notified the police, the resident's physician and family, in-serviced staff on abuse and misappropriation of resident property (including drug diversion) and terminated Licensed Practical Nurse (LPN) A. The deficiency was corrected on [DATE]. Review of the facility's Administration of Medications policy, reviewed [DATE], included: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when a staff member misappropriated $13,300 of resident's money from their personal account, without the resident's consent. This affected one of eight sampled residents (Resident #8). The census was 75. Review of the facility's Abuse, Neglect and Exploitation policy dated 7/18/23, showed the following: -It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs by not providing baths/showers for three residents (Residents #1, #2 and #3). The sample size was four. The census was 75. Review of the facility's Activities of Daily Living (ADLs) policy, revised on 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse; -A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/23, showed: [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to allow resident access to personal funds on an ongoing basis. This practice affected 39 residents with personal funds accounts out of a census of 58 residents.

Inspectors wroteBased on observations, interviews, facility policy, and document review, the facility failed to store and prepare food in accordance with professional standards for food service safety in the kitchen which had the potential to affect 56 of 58 residents who received food from the kitchen. Specifically, the facility failed to ensure food in the dry storage area was sealed and dated when opened; ensure temperature logs on the refrigerators and freezers were complete; ensure meal temperature logs were completed and logged before each meal; and monitor and clean the nourishment room refrigerator.

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for nine of 23 sampled employees hired since the last survey. The facility hired at least 200 new employees since the last survey. The census was 63. Review of the facility's Protection of Residents: Reducing the Threat of Abuse and Neglect Policy, revised on 8/10/21, showed the following: -Introduction: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse; -Policy: It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the practice of self-administration of medication was clinically appropriate for 1 (Resident #166) of 1 resident reviewed for self-administration of medication. The census was 58.

Inspectors wroteBased on interviews, record review, facility document review, and a review of the facility's policy, the facility failed to protect a resident (Resident #1) from physical abuse by another resident (Resident #13). This affected 1 (Resident #1) of 3 residents reviewed for abuse. The facility census was 58.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to address the presence and care of a port-a-cath (an implanted device that allows easy access to a patient's veins) and the use of intravenous antibiotics on the baseline care plan for 1 (Resident #216) of 3 residents reviewed for intravenous access. The facility census was 58.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to develop and/or implement a comprehensive resident-centered care plan for 2 (Resident #165 and Resident #13) of 38 sampled residents. Specifically, the facility failed to develop a care plan for the care and treatment of a peripherally inserted central catheter (PICC) line (a type of intravenous (IV) access) and the use of IV antibiotics for Resident #165. In addition, the facility failed to implement Resident #13's care plan intervention to supervise the resident to prevent physical aggression. The facility census was 58.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised when the resident sustained a fall during the quarterly review period for 1 (Resident #61) of 3 residents reviewed for falls. The facility census was 58.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to collaborate with the hospice provider to coordinate a plan of care for 1 (Resident #365) of 1 resident reviewed who was receiving hospice care and failed to provide care in accordance with physician's orders/facility procedures for 1 (Resident #216) of 2 residents who had vascular access devices (a tube placed in a large vein to allow for repeated and long-term access to the bloodstream for medication administration). The facility census was 58.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure accident hazards were identified through investigation of falls for 1 (Resident #61) of 3 residents reviewed for falls. Resident #61 sustained a fall from their wheelchair on 04/28/2023 and the facility failed to conduct an investigation to determine the root cause of the fall and ensure accident hazards were identified for the resident. The facility census was 58.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to have ongoing communication and collaboration with the dialysis center for 1 (Resident #56) of 2 residents reviewed for dialysis services. The facility census was 58.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to accurately assess residents for risk of entrapment from bed rails and attempt alternatives prior to use for 1 (Resident #40) of 1 resident reviewed for bed rails. The facility census was 58.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure there were no significant medication errors for 1 (Resident #56) of 7 residents reviewed for medication administration. Specifically, the facility failed to ensure Resident #56, a dialysis resident, received their medications with meals as ordered by the physician to lower their high phosphorus levels. The facility census was 58.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure privacy curtains provided full visual privacy for residents who resided in 3 (rooms [ROOM NUMBER]) of 22 rooms.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a functioning call light was provided for 1 (Resident #44) of 24 residents observed. The facility census was 58.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed physician's orders expectations regarding elevated blood sugars. The facility identified 13 residents that received routine blood sugar checks (accu-checks). Of those 13, three had elevated blood sugars that exceeded the physician's parameters, and problems were found with all three. (Residents #4, #20 and #44). In addition, the facility failed to ensure physician approved pharmacist recommendations were added to a resident's orders, compression stockings were applied as ordered and proper hygiene and grooming was provided. (Residents #24, #6 and #15). The census was 92. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/5/19, showed: -Limited assistance of one person required for bed mobility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly assess residents for the use of bed/side rails, obtain physician's orders for the use of bed rails, attempt to use alternative measures prior to installing a bed/side rail and to update resident care plans regarding the use of bed/side rails for seven of 24 residents sampled. (Resident #83, #91, #54, #79, #32, #24 and #15). The census was 92. 1. Review of Resident #83's admission record, showed: -admitted on [DATE]; -Diagnoses included central cord syndrome of cervical spinal cord (the most common form of cervicl spinal cord injury, characterized by loss of motion and sensation in arms and hands), diabetes, muscle weakness, fractures and quadriplegia (paralysis that results in the total or partial loss of use of all four limbs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rates of less than 5 %. Out of 26 opportunities observed, there were two errors resulting in a 7.69% medication error rate. (Residents #71 and #8). The census was 92. 1. Review of Resident #71's physician's order sheet (POS), dated 10/1/19 through 10/31/19, showed an order for gabapentin (medication used to treat seizures and pain) 300 milligram (mg) by mouth twice a day at 8:00 A.M. and 8:00 P.M. Observation on 10/7/19 at 9:45 A.M., showed Nurse E administered the resident's morning medication which included gabapentin 300 mg. During an interview on 10/7/19 at 10:30 A.M., Nurse E said he/she should have administered the medication as ordered. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor and appearance by failing to follow three out of three recipes for four residents on a pureed diet. The census was 92. 1. Review of the pureed food guidelines for one serving of sausage, showed: -Two sausage patties; -Broth; -Begin with 1/2 cup (c) liquid; puree, then continue to alternate adding liquid and pureeing until product is correct consistency; -Consistency of pureed food should not be thinner than pudding or thicker than mashed potatoes. Observation and interview on 10/9/19 at 6:45 A.M., showed [NAME] L had the pureed food guidelines above the food prep counter. He/she said he/she was making seven servings of pureed sausage. [NAME] L used tongs to place seven sausage patties into the blender. He/she added approximately one cup of hot water. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and prepared in accordance with professional standards for food safety by exhibiting poor hand hygiene and using contaminated equipment during meal preparation, leaving trashcans uncovered while not in use and leaving scoops inside a dry bulk storage container. The census was 92. 1. Observation on 10/9/19 at 5:55 A.M., showed [NAME] L began breakfast meal preparation. He/she put on a pair of clean gloves and removed biscuits from the oven. A biscuit fell on the floor and [NAME] L picked it up with his/her right hand and threw it in the trashcan. He/she touched several pans when placing them in the warming server. With the same pair of gloves on, [NAME] L picked two dishwasher crates off the floor and moved them to a different area. He/she removed hanging pots and placed them on the gas range. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment, consistent with professional standards of practice, to pressure ulcers acquired by two residents. The facility identified two residents with pressure ulcers and problems were found with one (Resident #91), as well as another resident with a new pressure ulcer identified by hospice (Resident #32). The census was 92. 1. Review of the facility's Weekly Pressure Ulcer Tracking Report, dated 8/24/19, showed, for Resident #91: -A Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured blister) to the coccyx (tailbone), measuring 2 centimeters (cm) in length, 1 cm in width and 0 cm in depth (2.0 x 1.0 x 0); -Description: Pink; -Drainage: Small bloody; -Pain: No; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed their policy for infection control during two of three observations of residents receiving incontinence care. (Residents #86 and #71). The census was 92. 1. Review of Resident #86's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/30/19, showed: -Understood/understands; -Short/long term memory problem; -Extensive assistance of two (+) persons required for bed mobility, transfers, dressing and toilet use; -Limited assistance of one person required for personal hygiene and bathing; -Diagnoses of heart failure, stroke and dementia. Observation on 10/9/19 at 7:12 A.M., showed the resident lay in bed. Certified Nurse Aides (CNAs) B and C donned gloves and prepared to clean and dress the resident. [...]