Western State Nursing Facility

Inspectors wroteNumber of residents sampled: 20Number of residents cited: 2The facility failed to provide a dignified existence for two residents by not ensuring lap covering for two residents, R35 and R18. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for two (2) of twenty (20) sampled residents (Resident 18 and 35).

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to follow standard precautions to be followed to prevent the spread of infection. Appropriate infection prevention and control practices were not implemented during medication administration. Hand hygiene was not performed while administering medications to one of two residents, Resident (R) 28.

Inspectors wroteNumber of residents sampled: 20Number of residents cited: 1The facility failed to ensure that one resident could access the call light R46. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair, or other sleeping accommodations for one (1) of twenty (20) sampled residents (R46).

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the Medical Director or his/her representative. The facility failed to ensure or encourage real-time alternative methods of participation, such as videoconferencing and teleconference calls to include the Medical Director or his/her representative.

Inspectors wroteBased on observation, interview, review of the facility's policy and resident's medical record, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident #22 (R22)). Staff failed to perform hand hygiene when indicated; contaminated residents' clothing and bed linens; and, failed to prevent the contamination of clean dressings.

Inspectors wroteBased on observation, interview, and review of the facility policy, it was determined the facility failed to distribute and serve food in accordance with professional standards for food service safety related to staff not washing hands or changing gloves after leaving the meal tray prep area and prior to returning to area. Review of the Census and Condition, dated 11/19/19, revealed eighty-three (83) of ninety-three (93) residents received their meals from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents' right to privacy was honored (Resident #93). Staff were observed to walk by Resident #93's room while he/she was up in his/her wheelchair, in his/her doorway, with his/her gown pulled up exposing his/her incontinent brief; however, the staff failed to assist Resident #93 in covering him/herself up to ensure the resident's privacy per facility policy.

Inspectors wroteBased on interview, record review and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for two (2) of twenty-two (22) sampled residents (Residents #80 and #88 ) Record review for Residents #80 and #88, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident transfers.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with wounds in the selected sample of twenty-two (22) residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan (Resident #41). Licensed staff failed to provide wound care in accordance with professional standards of practice for Resident #41.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with pressure ulcers in the selected sample of twenty-two (22) residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Licensed staff failed to provide pressure ulcer care for Resident #30 according to professional standards of practice which resulted in the Nurse contaminating the wound with feces.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents received the appropriate care and services to prevent urinary tract infections to the extent possible (Resident #30) related to poor hand hygiene during indwelling catheter care.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure to help prevent the development and transmission of communicable diseases and infections for two (2) of twenty-two (22) sampled residents (Residents #30, and #89). In addition, the facility failed to ensure linens were transported so as to prevent the spread of infection. Observation revealed staff failed to perform handwashing to prevent infections during pressure ulcer care and catheter care for Resident #30 and catheter care and gastrostomy care for Resident #89. In addition, observation revealed staff carried a resident's clothing protector under his arm prior to placing it around a residents neck during meal service.