Westside Care Center

Inspectors wroteBased on observations, review of facility policy and staff interview, the facility failed to ensure that a section of the kitchen undergoing construction was appropriately sealed off from food preparation and storage areas to prevent the spread of infection.

Inspectors wroteBased on resident interview, observations, review of facility documentation and staff interviews for (9 of 13) air conditioners on all units sampled, the facility failed to ensure the hallway and dining room air conditioners were maintained in a clean and sanitary manner. The facility also failed to ensure the laundry area was clean and dust free.

Inspectors wroteBased on clinical record review, review of facility documents, review of policy and staff interviews for 1of 3 residents (Resident # 117) reviewed for Abuse, the facility failed to ensure Resident # 59 was free from abuse.

Inspectors wroteBased on clinical record review, review of facility documentation, review of policy and staff interviews, the facility failed to conduct a thorough Resident-to-Resident abuse investigation when Resident # 59 told RN # 5 she/he hit Resident # 117 when Resident # 117 attempted to strike at her/him with a cane.

Inspectors wroteBased on review of the clinical record, facility policy and staff interviews for 1 of 2 residents (Resident #96) reviewed for pressure ulcers, the facility failed to develop a timely comprehensive, preventative care plan for a resident at risk for skin breakdown to prevent skin impairment on the heels that resulted in a pressure ulcer development. The findings Include: Resident #96's diagnosis included displaced fracture of the right femur (hip fracture), end stage renal disease, diabetes mellitus, and congestive heart failure. [...]

Inspectors wroteBased on clinical record reviews, review of facility policy and staff interviews for 1 resident (Resident # 5) reviewed for Continuous Positive Airway Pressure (CPAP) a non-invasive machine that uses air pressure to keep the airways open to treat periods of non-breathing during sleep with machine, the facility failed to revise the resident care plan to address the utilization of the CPAP.

Inspectors wroteBased on clinical record review, observation and staff interviews for 1 sampled resident (Resident # 11) reviewed for Hospice Care, the facility failed to ensure continuation and implementation of hospice directed medication as directed by the physican orders for comfort care.

Inspectors wroteBased on review of the clinical record, facility policy review and interview for 1 of 2 residents for (Resident #96) reviewed for pressure ulcer, the facility failed to complete weekly skin checks, develop a preventative skin breakdown care plan for a resident at risk and when pressure ulcers were identified, physician's orders for treatment were delayed for 3 days.

Inspectors wroteBased on clinical record review, observations, facility documentation, review of policy and interviews for 1 of 2 residents ( Resident # 2), reviewed for dining observation, the facility failed to follow dietary guidelines and restrict the use of Styrofoam products during dining to prevent a potential accident.

Inspectors wroteBased on observations, review of facility documentation facility policy and staff interviews for 1 of 5 residents (Resident # 5) reviewed for Infection control, the facility failed to ensure staff served food items on a resident table where no urinary items were stored, the facility failed to ensure CPAP machine, bedside table were not kept clean and mask stored in a clean bag. The facility also failed to ensure staff handled resident food appropriately when peeling a hard-boiled egg while preparing a resident breakfast tray to serve.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for ADL care, the facility failed to ensure a resident was treated with respect and dignity when they failed to ensure privacy was maintained when providing personal care to a resident.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to notify responsible party timely of a change in condition.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for accidents, the facility failed to ensure adequate supervision for a resident while at an outpatient dental appointment.

Inspectors wroteBased on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure that the physician was notified when the resident's prescribed pain medication was unavailable and an alternate pain medication that was administered was ineffective. Resident #3 had diagnoses of acute osteomyelitis of the left ankle and foot. Review of Resident #3's Care Plan dated 11/1/24 identified the resident was on pain medication therapy with interventions directed to administer analgesic medications as ordered by the physician, and to monitor and document the side effects and effectiveness. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severe cognitive impairment. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #1) who were reviewed for an allegation of resident to resident abuse, the facility failed to ensure Resident #1 was free from physical abuse.

Inspectors wroteBased on review of clinical records, interviews, and review of facility policy and documentation for two (2) of three (3) residents (Resident #4, and #5) reviewed for medication administration, the facility failed to administer resident's medications in accordance with facility policy.

Inspectors wroteBased on review of clinical records, interviews, and facility documentation for one (1) of three (3) residents (Resident #3) reviewed for pain management, the facility failed to ensure medications were available to and treat a resident's unrelieved pain.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (2) of two (2) residents (Resident #1 and #2) reviewed for resident-to-resident abuse, the facility failed to ensure residents were free from physical and verbal abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for resident-to-resident abuse, the facility failed to complete and document 1:1 and every fifteen minute (Q 15) checks subsequent to a resident-to-resident abuse event per facility policy.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, job descriptions, and interviews, for 2 of 4 units, the facility failed to ensure the environment was maintained in good repair and in a homelike manner and for 1 resident, (Resident #95) the facility failed to ensure a homelike environment.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #97 and 59) reviewed for resident to resident altercations, for Resident #97, the facility failed to protect Resident #97 from physical abuse by Resident #217 and 71 who had a history of resident to resident altercations, and for Resident #59 the facility failed to protect Resident #59 from physical abuse by Resident #73.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interview for 4 of 4 residents (Resident #43, 84, 89, and 111) who reside on a locked dementia unit, the facility failed to provide the method of opening doors independently to the residents who voluntarily reside on the unit and do not meet the criteria for the unit, failed to educate the social worker on required assessments according to the Greater Hartford Memory Care Center Program guidelines, failed to complete initial and ongoing assessments of the residents according to the Greater Hartford Memory Care Center Program guidelines, and failed to ensure the clinical record included documentation according to 483.12(a)(1) to ensure the residents were free from involuntary seclusion.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interview the facility failed to ensure the nourishment refrigerator was clean and sanitary, and food items were labeled and dated, and discarded timely, and failed to ensure food transport carts were clean and sanitary prior to placing meals on carts.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interview for 3 residents (Resident #64, 79, and 368) reviewed for transmission based precautions (TBP), the facility failed to ensure that facility staff implemented infection control measures for 2 residents (Resident #64 and 79) who required transmission-based precautions due to active respiratory infections, and for 1 resident (Resident #368), the facility failed to ensure that transmission based precautions were implemented for a resident with an active infection related to a multi drug resistant organism (MDRO).

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #317) reviewed for ADL's the facility failed to feed the resident in a dignified manner and according to facility policy.

Inspectors wroteBased on review of the clinical record, facility policies, and interviews for 1 of 2 residents (Resident #103) reviewed for advance directives, the facility failed to accurately document the resident's life support choices.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #76) reviewed for unnecessary medications, the facility failed to notify the physician or APRN of a change in condition and for 1 resident (Resident #111) reviewed for accidents, the facility failed to ensure that the resident representative was notified when the resident was found smoking in his/her room and was found with smoking materials in his/her room, and for 1 of 3 residents, (Resident #4) reviewed for ADL's, the facility failed to ensure the physician and resident representative were made aware when the resident continued to refuse showers.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #102, 76) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the residents were provided a weekly shower on scheduled shower days.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Residents #76, 81, 116, 63, 103, 7 and 59) the facility failed to provide care in accordance with professional standards of practice, and physician's orders. For 1 of 5 residents (Resident #76) reviewed for unnecessary medications, the facility failed to document an RN assessment when the resident exhibited a change in condition and failed to obtain weights according to facility policy and physician order. For (Resident #81) reviewed for nutrition, the facility failed to monitor the resident's fluid intake and output and weights per the physician's orders. [...]

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interview for 3 of 7 residents (Residents #20, 13 and 111) reviewed for accidents, the facility failed to implement interventions and/or assistive devices to ensure the residents safety and a safe environment. For 1 of 2 residents (Resident #20) the facility failed to ensure the resident consistently utilized the smoking apron while smoking, for 1 resident (Resident #13) the facility failed to ensure a fan being used in the resident room had its cover in place, and for 1 of 7 residents (Resident #111) the facility failed to ensure the resident was reassessed and interventions implemented after multiple smoking policy violations to ensure the safety of the residents in the facility.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interview for the 1 resident (Resident #7) reviewed for falls, the facility failed to ensure the resident's medication orders were correctly transcribed and administered resulting in a significant medication error.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #49, 78, and 94) the facility failed to ensure that the resident or resident representative were provided education on the benefits and potential side effects of the influenza vaccine before receiving the vaccine.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for two of six sampled residents (Residents #1 and #2) who were reviewed for an allegation of resident-to-resident physical abuse, Resident #2 had the right to be free from physical abuse by Resident #1.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for four (4) of nine (9) residents, (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights, the facility failed to allow residents to exercise their rights for room searches, food preferences, and leave of absences.

Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for abuse, the facility failed to ensure that the resident was free from verbal abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident #10), reviewed for abuse, the facility failed to follow the plan of care for one to one supervised smoking, leading to a resident-to-resident incident of verbal abuse.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #76) reviewed for injury of unknown origin, the facility failed to submit the outcome of an investigation in a timely manner.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #90) reviewed for smoking, the facility failed to ensure the care plan was revised to include individualized interventions and measures to restore smoking privileges following a safety violation according to policy.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 8 residents (Resident #52) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to accurately code the MDS.