Westlake Convalescent Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for one of four sampled resident (Resident 1) by failing to ensure Resident 1's curtain strings were untangled, and the ceiling did not have multiple brownish stains. This failure had the potential to negatively impact on Resident 1's quality of life, and possible risk of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that is free from accident hazards in preventing avoidable accidents to one of six sampled residents (Resident 1) when Resident 1 was left unattended while up in the Hoyer lift (a medical device designed to safely transfer patients with limited mobility between beds, chairs, wheelchairs and showers). This deficient practice had the potential to negatively impact on Resident 1's safety, placing Resident 1 for possible fall or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe environment by failing to maintain the:Toilet, counter top and sink in the all gender bathroom next to the nursing station in good working order, clean and sanitary, by not securing the toilet to prevent it from shifting during use, keeping the sink counter corners free from crumbling grout/caulk, as well as, the sink being free from black mold-like build up under the lip of the counter. Wall in room [ROOM NUMBER] from crumbling behind the baseboard and it falling free from the wall, prevent crumbling wall corners above the baseboards and corners, as well as, free from dust and grime build up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment by failing to secure the upper end of the stairway handrail (on the right side as you go up) to the wall. This deficient practice had the potential to affect staff and residents' safety while using the stairs. During a concurrent observation and interview on 4/10/26 at 11:51 am with the Maintenance Supervisor (MS) and Maintenance Assistant (MA), the handrail for the right hand side of the stairs from the parking lot to the first floor of the facility was observed with the top-end of the handrail loose from the wall, easily movable. The MS and MA both validated the handrail was loose, and the MS stated he just had to screw it in tighter to secure it, then the MA stated they may have to add a piece of wood to fix it but that it would get fixed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe resident smoking practices by failing to ensure one of one sampled resident (Resident 17) did not have a lighter in her possession. This deficient practice had the potential to cause injury to Resident 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 7/15/2025 by failing to ensure puree diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding.) received rice texture in form that meet their needs and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed rice was thick and stuck to the spoon and the roof of the mouth. This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. The temperature of the walk-in refrigerator was 45 degrees Fahrenheit, and the gasket (door seal) of the walk-in refrigerator glass display door was broken, not allowing for the glass door to close tight. The temperature of the milk located by the glass display door was 44 degrees Fahrenheit. 2. Dishwasher 1 (DW1) working in the dish machine area did not wash hands and/or replace gloves when removing the clean and sanitized dishes form the dish machine.3. The base of the Dietary tray card holders was rusted. (Card Holder with a round base which sets firmly on resident meal tray with a holder to grip the diet cards-diet cards have the resident name and the diet order with resident preferences and allergies written on them).4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of five trash bins in the dumpster area were maintained in a sanitary manner. One trash bins had the lid open and three trash bins were rusted, broken and had corrosion that resulted in holes exposing the content inside the trash bins. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) had a follow up on coordinating a Preadmission Screening and Resident Review Level II (PASRR II- this evaluation determines the individuals specific needs and whether specialized services are required, ensuring the least restrictive setting for their care). This failure had the potential for Resident 10 to have a lack of necessary mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to label the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing for two of two sampled residents (Resident 84 and Resident 24). This failure had the potential for Resident 84 and Resident 24 to be at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit, collection of supplies that you might need during a time of emergency) at bedside for one of seven sampled residents on dialysis (Resident 85). This failure had the potential for Resident 85 to receive delayed intervention in managing complications such as bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two errors out of 29 opportunities contributed to an overall error rate of 6.9 % affecting one of four residents observed for medication administration (Resident 31). The errors noted were as follows:1. Attempted administration of approximately 7.5 milliliters (mL) of vitamin C (a vitamin supplement) liquid, instead of 5mL as per physician's orders.2. Attempted administration of approximately 7.5mL of levetiracetam (a medication used to treat seizures) liquid, instead of 5mL as per physician's orders. The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 31 may have experienced medical complications that could result in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents observed for medication administration (Resident 31) was free of significant medication errors (an observed or identified incident in the preparation or administration of medications that causes the patient discomfort or jeopardizes their health or safety) when on 7/16/2025 Licensed Vocational Nurse 3 (LVN 3) was observed attempting to administer 7.5 milliliters (mL) of levetiracetam liquid (a medication used to treat seizures) instead of 5mL ordered by the physician. The deficient practice of failing to administer medications in accordance with the physician's orders increased the risk that Resident 31 may have experienced medical complications resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that alerts healthcare providers that the patient needs assistance) was within reach for one of one sampled resident (Resident 22). This deficient practice had the potential to result in delay in meeting Resident 22's need for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services for three of five sampled residents (Resident 20, 57, and 64) as evidenced by: -For Resident 20 the facility staff did not empty the indwelling catheter urinary collection bag (designed to collect urine drained from the bladder via a catheter) as ordered by the physician. -For Resident 57 the facility failed to maintain the resident's urinary catheter bag below the level of the bladder. -Fore Resident 64, there was no assessment for indwelling catheter removal. [...]

Inspectors wroteBased on observation and interview, the facility failed to store Tuberculin purified protein derivative (Tuberculin PPD- used in skin test to help diagnose tuberculosis [ infection caused by bacteria Mycobacterium tuberculosis]), according to manufacturer's recommendation. -Label Latanoprost (eye drops used to increase the outflow of fluid from the eye) with an open date. -Discard multi-dose of Clearlax (a medication used to treat occasional constipation) and Reguloid (a medication used to treat constipation) after 60 days of opening. This deficient practice had a potential for the residents to receive medications with improper efficacy due to improper storage condition of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch service when: -Fortified diets (diet enriched to increase caloric content) were not prepared and were not served to 10 residents who were on fortified diet. -Six residents on pureed diet (foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding) did not receive the pureed lettuce, tomato, and pickles with their meal per the menu. This deficient practice had the potential to result in meal dissatisfaction for residents on puree diet, decrease caloric intake and unintentional weight loss for residents who were on fortified diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices when: -Two previously cooked and frozen roast pork was thawing in the walk-in refrigerator with no pull out or thaw date. -One large turkey thawing in the walk-in refrigerator labeled with the wrong thaw date. -The walk-in freezer had ice buildup on the freezer ceiling, condenser, and pipes. Icicles hanging from the ceiling above food. There was a large deep pan in the freezer filled with solid ice and water leaking from above. These deficiencies had the potential to result in harmful bacteria growth, cross contamination (transfer of harmful bacteria form one place to another) and inappropriate storage of food and had the potential to affect 30 out 63 residents who eat food from facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within reach for one of five sampled residents (Resident 22). This deficient practice had the potential to result in the resident not being able to call nursing staff for assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a current copy of the resident's advance directive (AD, a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart for one of three sampled residents (Resident 40). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate communication needs for one of five sampled residents (Resident 59) by failing to keep a Korean communication board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) that help residents at bedside within the resident's reach. This deficient practice had the potential for Resident 59 to not be able to communicate their needs to the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care for one of three sampled residents (Resident 2), who was totally dependent upon staff for all activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet), was unable to breathe independently and was ventilator (a machine that helps one breathe) dependent. This deficient practice had the potential to place Resident 39 at risk for ventilator associated infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for two of five sampled residents (Residents 2 and 20). These deficient practices had the potential to place Residents 2 and 20 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change Resident 2's oxygen tubing every seven days per the residents care plan and physician order for one of three sampled residents (Resident 2). This deficient practice had the potential to cause complications associated with oxygen and mechanical ventilation therapy including infection or respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician completed in person visits in a timely manner for one of three sampled residents (Resident 3), by failing to: -Ensure the physician initial face-to-face visit was made by a physician within 30 days after Resident 3s admission. -Ensure Physician visits were alternated with a Nurse Practitioner visits (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) every 60 days after the first 90 days of Resident 3`s admission. These deficient practices had the potential to result in an undetected decline in medical, health, or psychosocial condition and can lead to a delay in necessary care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to enforce its own policy related to a safe, sanitary environment and infection control for two of five sampled residents (Resident 10 and 29) by failing to: -Ensure staff members perform hand hygiene between glove changes for Resident 29. -Ensure to label Resident 10's Intravenous catheter (a thin plastic tube inserted into a vein using a needle) and to lock the needleless system after completion of antibiotic infusion. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 10 and 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up on insurance authorization to have a modified barium swallow study (MBSS- an exam that looks at how you swallow different liquids and foods using real time x-ray called fluoroscopy) in a timely manner for one of three sampled residents (Resident 1). This deficient practice may have caused a delay in service subsequently causing Resident 1 to become angry and refuse meals.

Inspectors wroteBased on interview and record review, the facility failed to conduct a weekly skin evaluation and assessment follow up of the sacrococcyx and left lower leg pressure injury (bedsore, the breakdown of skin integrity due to pressure, occurs when a bony prominence is under persistent contact with an external surface) for one sampled resident (Resident 1). Resident 1 did not receive a weekly assessment follow up and debridement on 8/31/2023 to evaluate the pressure injuries. This deficient practice caused an increased risk in harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards for four of 28 sampled residents (Resident 32, 46, 108, and 56) by failing to: -Ensure the wheelchair brakes were locked while assisting Resident 46 with transfers from standing to sitting in the wheelchair. -Prevent Resident 32 from slipping out of the wheelchair while wearing ankle foot orthoses (AFO, brace applied to the leg to hold the foot and ankle in the correct position). -Remove an unsecured television from Resident 108's rolling bedside table. -Post appropriate signage outside Resident 56's doorway to indicate the presence of oxygen in accordance with the facility's policy. These deficient practices had the potential to result in injury to the residents and place the facility at risk for fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of six Restorative Nursing Aides (RNA, nursing aide program that helps residents to maintain their function and joint mobility) demonstrated competency for the provision of range of motion (ROM, full movement potential of a joint) exercises. One of six RNAs did not provide adequate passive range of motion (PROM, movement of a joint through the range of motion with no effort from resident) exercises to one of 16 sampled residents (Resident 42). This deficient practice had the potential for 47 residents with physician's orders for RNA services to receive ROM exercises to experience a decline in ROM, which increased the likelihood of developing contractures (chronic loss of joint motion associated with deformity and joint stiffness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food under sanitary conditions and maintain the kitchen in a sanitary manner as evidenced by: -Food products stored past labeled use by dates. -Unlabeled plastic bag with hot dogs in kitchen freezer. -Kitchen floor with dirty particles, dust, and white substance. These deficient practices caused an increased risk to cross-contaminate food with pathogens (germs) that could expose residents receiving food from the kitchen; and place them at risk for developing food borne illness (food poisoning) leading to symptoms including an upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which can lead to hospitalization and/or death.

Inspectors wroteBased on observation, interview and record review, the facility did not implement appropriate infection control practices to prevent the transmission of communicable diseases by failing to: a. Ensure staff had access to a handwashing station in Resident 58 room, who was currently under transmission-based precautions (the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission). b. Properly disinfect a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) and front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) between residents' use for Resident 53, 26, and 46. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident with dignity and respect by not sitting when assisting the resident with meal and eating at eye-level for one of 28 sampled residents (Resident 22). This deficient practice had the potential for Resident 22 to feel less respected as a person, which could negatively impact the resident's sense of dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents health information was protected by not posting a sign above each resident's bed disclosing medical information regarding their dialysis access for two of three sampled residents (Resident 18 and Resident 42). This deficient practice had the potential of exposing residents medical information to staff who were not providing care to these resident and to visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment with adequate lighting for two of 28 sampled residents (Resident 22 and 32). This deficient practice had the potential to place Resident 22 and 32 at risk for choking hazards while being assisted with meals and decreased the residents' alertness to adequately eat, which increases their potential for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 28 sampled residents (Resident 32) with care and services to maintain the ability to perform activities of daily living (ADLs, tasks related to personal care) by failing to: -dress Resident 32 in appropriate clothes and assist Resident 32 out-of-bed daily in accordance with the care plan and the facility's policy, and -provide Resident 32 with a Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) feeding program in accordance with the physician's order. These deficient practices had the potential for Resident 32 to experience a decline in overall function, endurance, strength, and mental health, which affects the resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to endure residents received treatment and care in accordance with professional standards for three of eight sampled residents (Residents 2, 11, and 58). The physician's orders were not followed these residents causing an increased risk in worsening pressure related skin injuries and the potential for increased harm and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 16 sampled residents (Resident 42) with: -appropriate passive range of motion exercises (PROM, movement of a joint through the range of motion with no effort from resident) and -equipment to prevent further range of motion (ROM, full movement potential of a joint) loss in the left leg. These deficient practices placed Resident 42 at increased risk for the development of contractures (chronic loss of joint motion associated with deformity and joint stiffness), which could lead to increased pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to: -Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements for one of three inspected medication carts (Sub-Acute Medication Cart 3) affecting Resident 57. -Remove expired insulin from one of three inspected medication carts (Sub-Acute Medication Cart 4) affecting Resident 18. These deficient practices increased the risk that Residents 18 and Resident 57 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide an appropriate meal for one of 28 sampled residents (Resident 32). Resident 32 consistently coughed during three meal observations which was not reported to nursing. This deficient practice placed Resident 32 at increased risk for aspiration.