Western Slope Health Center

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to one of four sampled residents (Resident 1) when appropriate monitoring, care planning, and Resident 1's representative notification were not implemented following the removal of a chronic indwelling catheter (a flexible tube placed in the bladder to continuously drain urine) and by failing to document post voiding residual (a monitoring process to check if the bladder is emptying after indwelling catheter is removed). These failures resulted in inappropriate urinary catheter management and led to Resident 1 requiring an emergency room visit for the replacement for urinary catheter only hours after being discharged from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately assess, identify, monitor, and provide appropriate skin care and treatment for one of four sampled residents (Resident 1) when staff failed to recognize and address an ulcerated skin lesion on Resident 1's left wrist in a timely manner. This failure resulted that the wound became infested with multiple maggots and placed Resident 1 at risk for infection and worsening skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. There were food debris on shelves with clean and ready-to-use sheet pans,2. A container in the clean and ready-to-use storage area was stacked wet,3. Two small cups of yogurt were stored in the refrigerator uncovered and,4. The microwave for residents' food was not clean. These failures had potential to cause food-borne illnesses in a highly susceptible population of 91 out of 91 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure nonpharmacological interventions were implemented for two residents (Resident 3 and Resident 4) of 24 sampled residents, when target behavior and side effect monitoring were not performed for Resident 3's and Resident 4's psychotropic medications. These failures had the potential to result in unnecessary medication for Residents 3 and 4 and an increased risk and exposure to side effects associated with psychotropic medications such as sedation, memory loss, falls, abnormal involuntary movements, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective documentation of controlled medications (those with high potential for abuse or addiction), when:Random controlled medication audits for two out of four residents (Resident 5, and Resident 19) were not reconciled. The medications were documented in the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; and,Resident 12's controlled medication was observed as given but was not reconciled in CDR at the time of medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when:Resident 58's nebulizer mask (neb mask-a face mask that fits over the nose and mouth to deliver medication into the lungs) and CPAP mask (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) and Resident 64's nebulizer mask were not stored in antimicrobial bag and Resident 64's oxygen tubing was on the floor. Meal trays, with uncovered salad, were transported to residents' rooms. Resident 12's foley catheter (a device that drains urine from the bladder) drainage bag was touching the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary assistance with nail care and hand hygiene for one out of 24 sampled residents (Resident 11). This failure to maintain clean and trimmed fingernails may increase the risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was free from significant medication error when Resident 1 did not receive prescribed antiarrhythmic medication (treat and prevent irregular heartbeats) in accordance with the physician's order. This failure had the potential to result in Resident 1 to have experienced irregular heartbeats and other unnecessary side effects which could have negatively affected Resident 1's health. Resident 1 was admitted to the facility in January 2025 with multiple diagnoses which included paroxysmal atrial fibrillation (fast, irregular heartbeat that comes and goes) and unspecified atrial flutter (abnormal heart rhythm that's too fast). A review of Minimum Data Set (MDS, an assessment tool), dated 1/29/25, indicated Resident 1 had intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store foods according to professional practice standards for a census of 90 residents when: 1. Potentially Hazardous Food (PHF) such as unpasteurized eggs, cheese, half and half, turkey, and ham was left unattended on the floor and shelving outside of the kitchen refrigerator for longer than two hours; 2. Expired banana pudding was found in the kitchen refrigerator available for use; and, 3. Twelve individual containers of salad dressing were stored unlabeled and undated in the kitchen refrigerator available for use. These failures had the potential to cause a widespread foodborne illness among residents from consumption of contaminated, spoiled or unlabeled foods.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for two of 23 sampled residents (Resident 94 and Resident 6) when: 1. Anti-anxiety medication was given without first offering nonpharmacological interventions for Resident 94, and 2. Bladder scan was not completed for Resident 6. These failures placed Resident 94 at risk for unnecessary medication and increased the risk for Resident 6 for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened medications were dated and properly stored for two residents (Resident 31 and Resident 16) for a census of 90. This failure had the potential for residents to receive medications with unsafe or reduced potency from improper storage for Resident 16 or being used past their expiration date for Resident 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection prevention guidelines for a census of 90 residents when: 1. Personal wash basins were unlabeled, and 2. Male urinals were inconsistently labeled. These failures had the increased potential to place the residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimal staffing reqirements were met when: 1. A minimum of 3.5 direct care services hours per day (DHPPD - a tool to assess the value nursing staff provides to patient safety and care quality) were not met for three out of 23 days audited; and, 2. A minimum of 2.4 Certified Nursing Assistant (CNA) DHPPD for 21 out of 23 days audited were not met. These failures had the potential to prevent residents from receiving necessary care and maintaining the highest practicable physical, mental, and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for a census of 92 when the garbage dumpster was found with garbage bags rising out of the top with the lid not properly closed. This failure had the potential to attract pests to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for a census of 92 when flies were observed in hallways and in Resident 1's room. This failure had the potential to spread infections and diseases among the residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulations, to be the DM to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the full time Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (Cross Reference F803), and safe food handling and sanitation (Cross Reference F812), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day-to-day food service operation for the skilled nursing facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. Food items with missing or incorrect labeling and dating were found in dry storage and walk-in refrigerator; 2. Food items with opened packages were found not covered properly to prevent cross contamination in dry storage and walk-in refrigerator; 3. Ice machine was not clean; 4. Thawing meats found in the walk-in refrigerator were not dated to show when they were to be used or discarded; 5. A box of supplement shakes (nutrition drinks provide additional nutrients and are perishable) were not dated to show when they were to be used or discarded in the walk-in refrigerator; 6. Four individual ice cream cups were found in the reach-in refrigerator and were soft to touch; 7. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one out of four garbage disposal bins, located outside by the kitchen, was overflowing with bags of trash and was not securely closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, handling, and labeling of respiratory care equipment consistent with the facility's policy and procedures (P&P) for three out of 19 sampled residents when: 1. Resident 294's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was left wrapped around Resident 294's bed rail while not being used and was not labeled with the date it was first used; 2. Resident 47's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was left on top of the nebulizer machine after use and was not labeled with the date it was initially used; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the opening of an Emergency kit ([E-Kit], a limited supply of medications in the facility to use during an emergency or after-hours) for a census of 83 residents. This failure had the potential to delay the replacement of the E-Kit and contribute to decreased availability of medications in an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility had a 6.25% error rate when two medication errors out of 32 opportunities were observed during a medication pass for two of seven residents (Resident 50 and Resident 46). This failure resulted in medications not given in accordance with the prescriber's orders, which resulted in residents not receiving the intended therapeutic effect of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: 1. One Dietary Aide (DA 1) was unable to demonstrate and verbalize the process of manual dishwashing by using a three-compartment sink (cross refer to F812, number 8), and 2. One [NAME] (Cook 1) was: a. unable to verbalize the proper cool down procedure for the cooked meats (cross refer to F812, number 9), and b. unable to follow a recipe or menu when preparing food for the lunch meal on 11/14/23 (cross refer to F803, number 5). These failures had the potential to place 81 out of 83 highly susceptible residents who received food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for a therapeutic diet during the lunch meals on 11/14/23 when: 1. 10 residents (Resident 2, 8, 20, 33, 35, 36, 43, 56, 59, and 295) who were on diets without fortification (addition to meats or vegetables to increase calories and/or protein) received fortified (butter) carrots; 2. 10 residents (Resident 7, 10, 18, 35, 43, 45, 56, 57, 63, and 80) who were with diets such as Heart Healthy/Cardiac (diet for people to manage heart disease) and (2-2.5 g (gram) Na (sodium=salt), and Low fat/low cholesterol (diet for people to control fat and cholesterol intake from food) received tartar sauce instead of a lemon wedge; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 83 residents when: 1. A facility staff entered a room requiring use of an N95 mask (a type of mask that filters up to 95% of particles in the air), face shield, gown, and gloves wearing only a surgical mask (a type of mask that protects the mouth and nose from splashes, sprays, and large droplets that may include microorganisms) and gloves; 2. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not cleaned and sanitized after use for resident care and before storage; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident's right to privacy and confidentiality of personal and medical records for two residents out of a census of 83 residents when computer screens showed a resident's photo and confidential personal and medical information were left unsecured. These failures had the potential to result in unauthorized access of residents' personal and medical information.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 19 sampled residents (Resident 73, Resident 60, and Resident 15), when: 1. No care plan was developed or implemented for Resident 73's peripherally inserted central catheter (PICC) line (a tube inserted into a vein in the arm to access large veins near the heart for medications, liquid nutrition, and drawing blood); 2. No care plan was developed or implemented for Resident 60's renal dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to); and 3. No smoking care plan was developed for Resident 15. These failures had the potential to result in residents not attaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain an acceptable parameter of nutritional status when one out of 19 sampled residents (Resident 90) lost 11.1% of his body weight over an 18-day period. This failure placed Resident 90 at risk for potential muscle loss, increasing his susceptibility to infection and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services to one out of 19 sampled residents (Resident 23) when Resident 23 did not have any evaluation of dental needs. This failure had the potential to result in the facility to not be aware of Resident 23's dental needs and Resident 23 not provided with appropriate and adequate dental/oral care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate assistive drinking equipment to one out of 19 sampled residents (Resident 23) when Resident 23 was not provided a specialized drinking cup during the 11/14/23 breakfast meal. This failure had the potential to result in Resident 23 not being able to safely drink and potential for hydration problems.

Inspectors wroteBased on interview, record review and policy and procedure review, the facility failed to ensure one of three sampled residents (Resident 1) was free of accident hazards when Resident 1, who had an order to not be fed any food or water by mouth (NPO), was given a meal tray. This failure resulted in Resident 1 to choke evidenced by coughing, labored breathing, and low oxygen levels. He was subsequently transferred to the hospital and passed away.