Western Hills Healthcare Residence

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment development and inform of staffing decisions, inform of specific staffing needs, and plan to maximize recruitment and retention of direct care staff for 1 of 1 facility to care for its residents.1. The facility failed to outline in their Facility Assessment the informed staffing decisions to ensure that there were enough staff with the appropriate competencies and skill sets. 2. The facility failed to outline in their Facility Assessment the specific staff needs for each resident unit in the facility, specific staffing needs for each shift and adjust as necessary.3. The facility failed to develop and maintain a plan to maximize recruitment and retention of direct care staff. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 4 (Resident #1, Resident #3, Resident #14, and Resident #28) of 15 residents reviewed for unnecessary medications. The facility failed to ensure Resident #1's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #3's PRN Lorazepam was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #14's PRN Diazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #1, Resident #3, and Resident #28) of 15 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included certificate of terminal illness to ensure that the needs of the resident are addressed and met 24 hours per day to ensure Resident #1, Resident #3, and Resident #28 received adequate end-of-life care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 15 residents (Resident #48) reviewed for antipsychotic medication consents. The facility failed to ensure Resident #48's HHSC Form 3713 for Risperdal (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability) was signed by Resident #48 or Resident #48's responsible party, prior to resident receiving the medication. This failure could affect residents who received antipsychotics by placing them at risk of not being informed of their treatment options , to make informed decisions regarding their care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of property and exploitation for 1 of 15 residents (Resident #6) reviewed for misappropriation and exploitation, in that: The facility failed to ensure that Resident #6 was not subject to financial misappropriation or exploitation from the BOM. The BOM accepted $3700 cash from Resident #6 on 11/18/2024 and failed to apply the money too Resident #6's account. The noncompliance was identified as Past Non-Compliance. The noncompliance began on 11/18/2024 and ended on 04/14/2025. The facility had corrected the non-compliance before the survey began. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 2 (Residents #10, and Resident #34) of 6 residents reviewed for smoking safety. The facility failed to ensure Resident #10's lighter and cigarettes were not stored on their person. The facility failed to ensure Resident #34's lighter and cigarettes were not stored on their person. These failures could affect residents who smoke by putting them at risk of serious bodily harm, physical impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to monitor that nursing staff were notifying the physician for 4 of 6 residents (Resident #3, Resident #11, Resident #31, Resident #38) when insulin was held and resident blood glucoses over 250 for 2 of 6 (Resident #38, Resident #31) residents reviewed for diabetic care. 1. The facility failed to notify the physician when Resident #3's Insulin Glargine and Insulin Lispro were held without a physician order 13 times during a 3-month review (January 2024, February 2024, March 2024). 2. The facility failed to notify the physician when Resident #11's Insulin Glargine and Novolin R Solution was held without a physician order 4 times during a 1-month review (March 2024). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for Diabetic care. 1. The facility failed to ensure RN C notified the physician that Resident #38's blood glucose was over 250, 5 times during a 3-month review period. 2. The facility failed to ensure RN C administered Resident #3's Insulin Glargine 3 times during a 3-month review period and Resident #38's Insulin Glargine 2 times during a 3-month review period, per physician order. 3. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to remain free of significant medication errors for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for medication administration. 1. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 6 times during a 3-month review period (January 2024, February 2024, March 2024) and Resident #38's Insulin Glargine 1 times during a 3-month review period (January 2024, February 2024, March 2024)., per physician order. 2. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 7 times during a 3-month review period (January 2024, February 2024, March 2024). 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly. The facility failed to ensure that food items were disposed of properly. The facility failed to ensure the freezer was free from loose food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 4 of 13 residents (Resident #6, #33, #54) reviewed for abuse. The facility failed to conduct a thorough investigation and report findings from their investigation of pharmaceutical services and misappropriation of property within 5 working days regarding Resident #6. The facility failed to conduct a thorough investigation and report findings from their investigation of abuse within 5 working days regarding Resident #33. The facility failed to conduct a thorough investigation and report findings from their investigation of neglect within 5 working days regarding Resident #54. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care for 2 (Resident #110 and Resident #258) of 6 residents reviewed for baseline care plans. The facility failed to complete Resident #110 and Resident #258's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #30, Resident #33, and Resident #38) of 6 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plan that included preventative pressure ulcer interventions for Resident #30. The facility failed to update care plan with current dental care needs for Resident # 33. The facility failed to develop care plan that included smoking care needs for Resident #38. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 3 of 3 residents (Residents #1, #2, and #6) reviewed for respiratory care. The facility failed to ensure that Residents #1, #2 and #6 oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen at risk of respiratory complications and/or possible respiratory infections.

Inspectors wroteBased on interviews and record reviews the facility failed the ensure physician visits were conducted once every 30 days for 2 of 24 residents (Resident #3, Resident #20) and every 60 days for 4 of 24 residents (Resident #31, Resident #33, Resident #38, Resident #45) who were review for physician visits. The facility failed to have Resident #3 seen by physician at least once every 30 days for the first 90 days after admission since 10/03/2023. The facility failed to have Resident #20 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. Resident #20 was last seen on 11/09/2023. The facility failed to have Resident #31 seen by physician at least every 60 days after the first 90 days for the past year from 02/2023. Resident #31 was last seen 04/16/2023. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 3 (Resident #24, Resident #41, and Resident #49) of 4 residents reviewed for (DRR) Drug Regimen Review. The facility failed to timely follow up on Resident #24, Resident #41 and Resident #49's medication regimen review which had pharmacy recommendations. The facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #24, Resident #41, and Resident #49) of 4 residents reviewed for unnecessary medications. The facility failed to ensure Resident #24's, Resident #41's and Resident #49's PRN Ativan/lorazepam (medicine used to treat the symptoms of anxiety) were discontinued after 14 days or a documented rational for the continued provision of the medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 9 of 9 (Residents #5, #12, #21, #19, #25, #30, #34, #15, #24) residents who received a pureed meal reviewed during the lunch meal. The facility failed to ensure residents receiving a pureed texture diet were provided the food according to the menu, including a garlic biscuit. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Resident #30) of 6 residents reviewed for medical records. The facility failed to ensure Resident #30 had accurate weekly skin assessments and accurate pressure ulcer assessments. These failures place residents at risk of health and safety due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (CNA I, LVN L and RN H) of 6 staff and 2 of 2 linen carts reviewed for infection control practices. The facility failed to ensure CNA I and RN H performed hand hygiene when changing gloves at the appropriate times while providing resident care. The facility failed to ensure LVN L sanitized the glucometer in between residents when obtaining blood sugars. The facility failed to ensure clean linens remained in clean and covered environment free from cross contamination from residents. These failures could affect the residents by placing them at risk for the spread of infection.

Inspectors wroteBased observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked when unattended by RN-H. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 1 resident (Resident #38) reviewed for labs. The facility failed to provide evidence they obtained routine labs for Resident #38's Hcb HGB A1C levels (common blood test to show average blood sugar over past two to three months) as ordered by the physician. This failure could place resident at risk of a delay in receiving the necessary interventions to treat their medical condition(s).

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 3 of 5 (Resident #10, Resident #103, Resident #203) residents reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan to address Resident #10's supra pubic catheter (a catheter placed directly in the urinary bladder through an ostomy, or hole, in the lower abdomen) identified in the comprehensive assessment. The facility failed to develop a comprehensive person-centered care plan to meet goals and address Resident #103's active diagnoses and care areas identified on Resident #103's MDS. [...]

Inspectors wroteBased on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 4 (DS C, DS E, DS F and DM) of 9 dietary staff reviewed for Food Handler's certificates. The facility failed to ensure that dietary staff DS C, DS E, DS F and DM serving in the kitchen were working with a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses due to lack of dietary staff training.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents in 1 of 2 medication rooms in that: The facility failed to ensure that all medications were properly stored on Hall 200 storeroom medications were not past their expiration dates. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents of 2 of 3 medication carts reviewed for storage in that: The facility failed to ensure that all medications were properly stored in Hall 200 medication cart. The facility failed to ensure that all medications and supplies stored on Hall 100 cart were properly stored. This failure could result in a drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents to obtain or provide dental service for 1 of 1 resident (Resident #36) reviewed for dental service in that: The facility failed to arrange transportation for Resident #36 to her dental appointment. This failure could cause resident to have dental problems, which could cause pain, complications, and a poor quality of life.