Western Hills Retirement Village

Inspectors wroteBased on interview and record review, the facility failed to provide wound care as ordered. This affected one resident (#10) out of three residents reviewed for wounds. The facility census was 100. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses include lymphedema, cerebral infarction, hemiplegia, type II diabetes, mild protein-calorie malnutrition, cellulitis, and heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the medical record for Resident #10 revealed wound care orders as follows:Bilateral dorsal feet, cleanse with normal saline (NS), pat dry, apply xeroform and follow by kerlix every day shift for arterial ulcers dated 06/03/26. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure vents in the kitchen were maintained in a clean and sanitary manner. This had the potential to affect all 100 residents in the facility. The facility census was 100.

Inspectors wroteBased on record review, interview, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report an allegation of abuse to the state agency. This affected one resident (#29) out of one resident reviewed for abuse. The facility census was 100.

Inspectors wroteBased on record review, interview, review of Self-Reported Incidents, and policy review, the facility failed to timely investigate an allegation of abuse. This affected one resident (#29) out of one resident reviewed for abuse. The facility census was 100.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure care plans reflected the resident's current status. This affected one resident (#91) of five residents reviewed for care planning. The facility census was 100.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure fall interventions were in place at the time of a fall. This affected one (Resident #98) of four residents reviewed for falls. The facility census was 100.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure antipsychotic medications were used only when necessary and appropriate. This affected three residents (#22, #29 and #75) of five residents reviewed for unnecessary medications. The facility census was 100.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate related to a change in condition. This affected one resident (#26) out of 20 residents reviewed for resident records. The facility census was 100.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Foley catheter bags were managed in a manner to prevent the potential spread of infection. This affected one resident (#32) of two residents reviewed for Foley catheters. The facility census was 100.

Inspectors wroteBased on medical record review, staff interviews, observations, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to ensure staff followed hand hygiene procedures when providing incontinent care. This affected one (#24) resident of three residents reviewed for incontinent care. The facility census was 106.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure expired control solution for blood glucose monitors and an expired insulin pen was properly removed from the medication carts. This had the potential to affect five (#17, #24, #43, #74 and #93) residents who utilized glucose monitors and one (#89) of three resident's observed to utilize insulin pens. The facility census was 91.

Inspectors wroteBased on record review, observation, resident and staff interview, the facility failed to provide activities of daily living (ADL) assistance to dependent residents. This affected one (#9) of 24 facility-identified residents dependent on staff with bathing. The census was 91.

Inspectors wroteBased on record review, observation and resident and staff interview the facility failed to ensure residents wore braces as ordered by the physician to treat limited range of motion. This affected one (#24) of two facility-identified residents with orders for braces to the lower extremities. The census was 91.

Inspectors wroteBased on record review, staff interview, review of facility incident investigation, and review of facility policy, the facility failed to ensure staff followed appropriate transfer recommendations per the resident's plan of care to prevent falls and/or accidents. This affected one (#348) of nine residents reviewed for accidents. The census was 91.

Inspectors wroteBased on record review, observation, staff and resident interview, review of manufacturer recommendations and review of facility policy, the facility failed to label resident oxygen tubing and with the date it was initiated. The facility also failed to ensure staff did not use expired distilled water in resident's mechanical ventilation device. This affected one (#9) of nine facility-identified residents receiving respiratory treatments. The census was 91.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pharmacist's Medication Regimen Review (MRR) recommendations were reviewed and addressed by the attending physician. This affected one (#63) of five residents reviewed for unnecessary medications. The census was 91.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs related to duplicate drug therapy. This affected one (#12) of six residents reviewed for unnecessary Drugs. The facility census was 91.

Inspectors wroteBased on medical record review, staff interview, review of online medication resource Medscape, and review of the facility policy, the facility failed to ensure a resident was free from unnecessary psychoactive medications regarding the use of an antipsychotic medications without an adequate indication for use. This affected one (#63) of 18 residents with orders for antipsychotic medications. The census was 91.

Inspectors wroteBased on medical record review, observations, staff interviews, review of the facility policy, and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when entering resident rooms who were in Coronavirus Disease 2019 (COVID-19) quarantine to potentially prevent the spread of COVID-19. This affected one (#398) out of 91 residents observed for infection control. The facility census was 91.