Westgate Nursing & Rehabilitation Community

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to securely store medications in two of two medication carts reviewed for medication storage. (All times are recorded in Eastern Standard Time unless otherwise indicated.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for two Residents (#26 & #51) of eight residents reviewed for nutritional concerns. This deficient practice resulted in the potential for unmet nutritional needs and associated health complications.

Inspectors wroteBased on interview and record review, the facility failed to monitor and record the amount of tube feeding administered to one Resident (#45) of one resident reviewed for tube feeding management. (All times are recorded in Eastern Standard Time unless otherwise indicated.)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure implementation of enhanced barrier precautions (EBP) during high contact care activities was performed per standards of practice for one Resident (#6) of one resident reviewed for EBP.

Inspectors wroteThis deficiency pertains to Intake MI00152867. Based on interview, and record review, the facility failed to ensure licensed nursing staff maintained complete and accurate progress notes based on acceptable standards of practice for 1 Resident (R1) of 4 residents reviewed for complete medical records. This deficient practice resulted in lack of documentation in the medical record of the provision of wound care without a physician order, timely wound identification and documentation, and failure to provide notification and documentation of such to the physician and responsible party upon initial discovery of the R1's pressure injury wound. All times noted are Eastern Daylight Savings Time (ESDT) unless otherwise noted.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement measures to prevent additional pressure wound and/or prevent the development and worsening of pressure injuries for two Residents (R108 & R7) of five reviewed, resulting in harm for R108 with the development of a stage III pressure wound which worsened, required hospitalization, antibiotics, and wound debridement. Findings Include: (All times are recorded in Eastern Daylight Time.) This citation is related to intake #MI00145848. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two of four residents reviewed for Beneficiary Notice, resulting in resident and/or a resident representative not being informed of the right to appeal and the potential for undue emotional and financial hardships:

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure weights were monitored and nutrition interventions implemented for one Resident #41 (R41) of four residents reviewed for weight loss. This deficient resulted in a significant weight loss for R41.

Inspectors wroteThis deficiency pertains to Complaint Intake #MI00138936 & #MI00137644. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing and prevent the development of pressure ulcers for four Residents (R1, R6, R30 and R51) of four residents reviewed for pressure ulcer care, out of a total sample of 15 residents. This deficient practice resulted in harm with the development of a facility acquired stage 3 pressure ulcer, the potential for delayed wound healing, infection, and deterioration of condition.

Inspectors wroteThis citation pertains to intake MI00139217. All observations and interviews are recorded in Eastern Standard Time (EST). Based on observation, interview and record review, the facility failed to safely transfer one Resident (R56) of three residents reviewed for accidents. This deficient practice resulted in actual harm when R56 fell to the floor and sustained a right hip fracture with subsequent hospitalization, and surgical intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure potentially hazardous foods (milk) were stored at proper temperature while waiting to be served. 2. Failing to demonstrate the proper cooling of potentially hazardous foods which were destined to be served at a later date. 3. Failing to properly wash and clean melons prior to slicing through the rind and cutting into sections. These deficient practices have the potential to result in food borne illness among any and all 57 residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide dementia-specific care training for employees before assigning them to work independently with residents. This deficient practice resulted in the potential for inappropriate staff-to-resident interactions and unmet resident care needs, potentially effecting facility residents with dementia.

Inspectors wroteBased on interview and record review, the facility failed to ensure pre-employment screening that included fingerprinting was conducted for two staff members. This deficient practice resulted in the potential for the facility to employ staff who have a past history of abuse and could have subjected the entire facility population to various types of abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse to the State Agency within the required time frame for one Resident (R30) of 15 sample residents reviewed for abuse. This deficient practice resulted in the potential for undetected and/or continuation of abuse for R30. All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one Resident (R30) of 15 sample residents reviewed for abuse. This deficient practice resulted in the potential for undetected and continued abuse within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that weights were obtained and monitored timely and accurately for one Resident (R17) of four residents reviewed for nutrition and hydration. This deficient practice resulted in an undetermined baseline weight, significant weight loss and compromised health conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pain medication as ordered for one Resident (R212) of two residents reviewed for pain. This deficient practice resulted in unrelieved pain for R212 and the potential for other residents to experience unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days and/or rationale was documented in the resident's medical record to indicate the rationale for an extended duration for PRN psychotropic medication orders for one Resident (R30) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for continued use of medications unnecessary to treat R30 and the potential for undesirable side effects associated with prolonged use of psychotropic medications. All times are Eastern Daylight Savings Time (EDST) unless otherwise noted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of ongoing collaboration and communication between the facility and hospice providers for two Residents (R51 and R54) of two residents reviewed for hospice services. This deficient practice resulted in the potential for gaps in coordination of care, and the potential for unmet needs during the dying process.

Inspectors wroteBased on interview and record review, the facility failed to develop a policy and implement a procedure for the laundry department, to ensure proper disinfection was occurring when transmission based precaution (TBP) sourced laundry was present in the facility. This failure has the potential to result in the transmission of pathogens to all 57 residents through the laundry process if proper disinfection parameters are not met.