Western Hills Health Care Center

Inspectors wroteBased on observations and interviews, the facility failed to ensure that essential food service equipment was maintained in a safe and functional condition in the main kitchen. Specifically, the facility failed to repair a broken, nonfunctional heated plate dispenser in the main kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNA) reviewed. Specifically, the facility did not complete a performance review for CNA #3, CNA #7, and CNA #8.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for two of three units. Specifically, the facility failed to:-Clean resident rooms in a hygienic manner;-Clean high touch areas; and, -Ensure dwell times were followed.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life to one (#90) out of three residents of 46 total sample residents. Specifically, the facility failed to ensure Resident #90 was provided with clean clothing.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for two (#44 and #66) of three residents reviewed for grievances out of 46 sample residents. Specifically, the facility failed to:-Effectively report, document, resolve, and follow-up on Resident #44's grievance regarding missing hearing aides and charger; and, -Effectively report, document, resolve and follow-up on Resident #66's grievances about two boxes of Christmas ornaments that went missing.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an allegation of misappropriation of residents property for two (#44 and #66) of two residents out of 46 sample residents. Specifically, the facility failed to investigate allegations of misappropriation of property for Resident #44 and Resident #66.

Inspectors wroteBased on observations, record review and interview, the facility failed to develop an acute/baseline care plan for one (#51) of two residents reviewed for care planning out of 46 sample residents. Specifically, the facility failed to include Resident #51's seatbelt use on the baseline care plan.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide ongoing programs to support choices of activities and engaging programming based on the comprehensive assessment and care plan, that were designed to meet the interests of and support the physical, mental, and psychosocial well-being of one (#89) of two residents reviewed for activities out of 46 sample residents. Specifically, the facility failed to offer and provide personalized, meaningful activity programs for Resident #89 as documented in her care plans.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#44) of two residents reviewed for hearing and vision problems out of 46 sample residents. Specifically, the facility failed to ensure Resident #44 was assisted with alternate devices while she waited for her missing hearing aids to be replaced.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#16 and #90) of three residents who required respiratory care received care consistent with professional standards of practice out of 46 total sample residents. Specifically, the facility failed to set the oxygen concentrator according to the physician's order.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for two out of three units. Specifically, the facility failed to: -Ensure disinfectant dwell times were followed by the housekeeping staff when cleaning resident's rooms; and, -Ensure staff performed hand hygiene appropriately when passing medications.

Inspectors wroteBased on record review and interviews, the facility failed to report an allegation violation of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#41) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an allegation of verbal abuse of Resident #41 by a staff member to the facility administrator, local law enforcement or the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an allegation of physical abuse involving two (#41 and #21) of two residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to: -Investigate allegations of physical and/or emotional abuse reported by Resident #41 to a provider; and, -Conduct an investigation of a bump and bruising (injuries of unknown origin) to Resident #21. Cross-reference F609 failure to report an allegation of abuse to the State Agency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the facility medication administration observation error rate was 7.14% or two errors out of 28 opportunities.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#140) of one resident out of 38 sample residents. Specifically, the facility failed to: -Ensure clinical signs and symptoms of an infection were identified for Resident #140 prior to administering antibiotics; and, -Ensure a urinalysis with a culture (laboratory test to identify bacteria) and sensitivity (a laboratory test used to determine what medication/antibiotic will work best to treat an infection) (C&S) were obtained, according to a physician's order, prior to administering antibiotics for Resident #140.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure oxygen was administered at the physician-ordered flow rate to prevent potential complications for 1 (Resident #80) of 3 sampled residents reviewed for oxygen therapy.