Westside Retirement Village

Inspectors wroteBased on observation, and interview, the facility failed to ensure proper food storage when opened meat was found stored among lettuce, expired and improperly wrapped unidentified foods were stored in the walk-in refrigerator, and opened boxes of foods were found under a prep table; and the facility failed to maintain clean and sanitary conditions in the kitchen, dish room, and walk-in refrigerator for 2 of 2 food storage and food preparation observations. These deficient practices had the potential to affect 88 of 88 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be informed of and choose her treatment when the facility transferred a resident to a psychiatric facility against her will for 1 of 3 residents reviewed for abuse and neglect (Resident C).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for 1 of 3 residents reviewed for abuse and neglect (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff reported an allegation of resident-to-resident verbal abuse for 1 of 3 residents reviewed for abuse and neglect. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to document, report, or conduct a thorough investigation of an allegation of resident-to-resident verbal abuse for 1 of 3 residents reviewed for abuse and neglect. (Resident C)

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff responsible for food service and kitchen sanitation demonstrated competency in monitoring food service equipment and maintaining required temperature documentation for safe food preparation and storage. This deficient practice had the potential to affect 86 of 86 residents served from the kitchen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure general cleanliness, proper sanitation and infection control practices during food preparation and dishwashing activities. This deficient practice had the potential to affect 86 of 86 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents and/or their family members were treated with respect and dignity by the Social Services Director (SSD) and the Kitchen Manager who spoke to and interacted with residents in a dismissive, argumentative, and disrespectful manner for 5 of 5 residents who participated in a resident council meeting (Residents 35, 43, 57, 75 and 85) and 1 of 2 randomly observed resident/staff interactions (Resident 12).

Inspectors wroteBased on record review and interview, the facility failed to ensure discharge communication and documentation was completed for 4 of 5 residents reviewed for transfers and discharges (Residents 9, 87, 89, and 84).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was provided with adaptive equipment related to a visual impairment for 1 of 28 residents reviewed for accommodation of needs (Resident 15).

Inspectors wroteBased on interview and record review, the facility failed to ensure behavior monitoring and documentation in the medical record to support rationales for denying gradual dose reductions (GDR) for antipsychotic and antidepressant medications for 2 of 5 residents reviewed for unnecessary medications (Resident 81 and 2).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 of 19 residents' MDS assessments reviewed (Residents 15, 12, and 3).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) level one was completed after a new major mental illness diagnoses was added to the diagnoses lists for 2 of 2 residents reviewed for PASRR compliance (Resident 81 and 2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided to residents who required assistance to maintain their personal hygiene for 2 of 28 residents reviewed for ADLs (Residents 6 and 15).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a functional resident call system for 1 of 1 resident reviewed for call light concerns (Resident 7).

Inspectors wroteBased on interview and record review, the facility failed to complete a physician's order by documenting fluid intakes for a resident on restricted fluid intake for 1 of 4 residents reviewed for quality of care. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a resident's call light in reach and to apply ordered oxygen for 1 of 4 residents reviewed for neglect. (Resident D)

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, orderly shower room for resident use on 1 of 3 shower rooms observed for cleanliness. (100 hall)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperature and palatability of food served for 5 of 6 residents reviewed for food temperature (Residents C, D, E, F, and M). This had the potential to affect 89 of 89 residents who received food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, and sanitary environment on 1 of 2 units (100) observed for cleanliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or document showers for 1 of 3 residents reviewed for bathing preferences (Resident D).

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances were followed up, an investigation completed, and grievances resolved for 3 of 3 residents reviewed for grievances (Residents B, C, and M), and 3 of 3 months reviewed for Resident Council (March, April, and May 2025).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who wanted to register to vote were registered and the residents who were registered to vote were able to vote for 5 of 5 residents who wanted to vote in the 2024 Presidential Election (Residents B, C, D, E, and F).

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure a timely and appropriate response to grievances related to answering call lights in a timely manner. This deficient practice had the potential to affect 11 of 11 residents who spoke on behalf of the facility during a resident council meeting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment was maintained in the main dining room of the memory care unit when remnants of feces were not cleaned up after a resident's incontinent episode, which had the potential to effect 22 of 22 residents who resided on the memory care unit , and the facility failed to ensure the floors for 2 of 22 residents' rooms (Residents 193 and 6) were free from large areas of staining due to resident incontinent episodes.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident H) who had a history of falls received interventions to prevent a fall in which he sustained a nasal fracture for 1 of 8 residents reviewed for accidents. B. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when a resident, (Resident 193) who had exhibited behaviors of intrusive wandering, continued to intrusively wander into other residents' rooms and upset them for 1 of 8 residents reviewed for accidents. C. Based on observation, interview, and record review, the facility failed to ensure the Elopement binder was up to date that included four current residents (Residents 193, 89, 74 and 73) who were at risk for elopement for 4 of 8 residents reviewed for accidents. D. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide hand hygiene between residents and wear gloves when administering an ear drop to a resident (Resident 19) for 1 of 1 Qualified Medication Aide (QMA 21) observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity when a Certified Nurse Aide (CNA) spoke harshly to a resident and the resident's room had pictures with insturctions hanging in public view (Resident 1) and when a resident (Resident 40) was not assisted to the restroom in a timely manner by two staff members who were available for 2 of 2 residents reviewed for dignity.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had advanced directives or code statuses for 3 of 4 reviewed for advanced directives (Residents 250, 45, and B) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for 2 of 18 residents reviewed for MDS (Residents 193 and 81).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that accurate information was submitted on a Pre-admission Screen and Record Review (PASRR) Level I for 1 of 6 residents reviewed for PASRR, (Resident 68), and the facility failed to complete a new level I for a resident who admitted to the facility on a 30 day exclusion for pre-admission screening and resident review (PASARR) for 1 of 2 residents reviewed for PASARR (Resident 90).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were reviewed and revised as needed with resident's updated interventions for 1 of 18 residents reviewed for care plan revisions, (Resident 14).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's activities of daily living were completed for 1 of 8 residents reviewed for completed ADLs (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a gastrointestional tube had appropriate services and documentation for medications and nutrition for 1 of 1 residents reviewed for gastrointestinal tube (G-tube) (Resident 295).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen (O2) levels were set correctly for 2 of 2 residents using nasal cannulas (NC) (Resident Z and B), and the facility failed to ensure humidifier bottles for oxygen administration were changed at 7 day interval, and a bipap mask and tubing were protected from contamination for 1 of 2 residents reviewed for contamination of bipap masks and tubing when not in use (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to obtain a blood pressure as indicated in an order prior to administration of a blood pressure medication for 1 of 4 residents reviewed (Resident 250).

Inspectors wroteBased on observation and interview, the facility failed to remove expired drugs from the population for 2 of 2 medication rooms observed (medication rooms [ROOM NUMBERS]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's wheelchair (WC) (Resident 14) was maintained in a safe operating condition with a broken brake and brake handle and a resident's WC's left arm did not slide inappropriately forward and back (Resident 1) for 2 of 16 wheelchair reviewed for proper working order

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate supervision, monitoring, and interventions were implemented for a resident who had a diagnosis of dementia (chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life) and a history of aggressive behaviors for 1 of 6 residents reviewed for dementia (Resident BB), resulting in verbal and physical threats, and resident to resident altercations against his dementia diagnosed peers (Residents CC, F, DD, EE, and U).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled, stored, and destroyed properly for 4 of 5 medication carts utilized for medication storage on the 100 and 300 hallways.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided showers per the resident's choice for 1 of 3 residents reviewed for activities of daily living and showers (Resident (B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed when providing catheter care to 1 of 2 residents reviewed for catheter care (Resident D).

Inspectors wroteBased on interview and record review, the facility failed to address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions for the Resident Council meetings and the facility's grievance log for 4 of 4 residents reviewed for grievances (Residents E, K, Q, and R).

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise care plans for 2 of 6 residents reviewed for care plan revision (Residents GG and H).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure effective wound management for a resident admitted with an open area on the coccyx that worsened resulting in a stage 3 pressure ulcer (full thickness tissue loss - subcutaneous fat may be visible, and slough may be present) to the coccyx for 1 of 3 residents reviewed for pressure ulcers (Resident H).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely meal service, failed to maintain food temperatures before serving meals to residents, and failed to provide appealing meals per resident preference and repeated complaints. This deficient practice had the potential to effect 102 of 102 residents who were served from the kitchen.

Inspectors wroteA. Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a general state of cleanliness, failed to ensure proper label/dating of foods, failed to remove expired items from rotation, failed to ensure hair restraints were in use during food preparation and failed to cover foods during meal preparation to prevent the potential for contamination. This deficient practice had the potential to effect 102 of 102 residents who were served from the kitchen. B. Based on observations and interviews, the facility failed to ensure staff utilized hand hygiene during meal service for 2 of 2 dining observations observed in Memory Care (Residents G, MM, NN, U, and P)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was maintained in good and working condition to prevent the potential for accidents. This deficient practice had the potential to effect 102 of 102 residents who were served from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident Council Grievances were followed up on and failed to ensure effective resolutions were achieved for 12 of 102 residents who attended a resident council meeting (Residents D, E, F, AA, BB, CC, DD, EE, FF, GG, HH and JJ).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Memory Care (MC) resident rooms and bathrooms were kept clean, toilets were safe to use without risk of falling, and failed to ensure all walls were intact for 18 of 24 MC resident rooms (Resident B, G, H, J, K, L, M, N, O, P, Q, R, S, T, U, V, and W). Based on observation, interview, the facility failed to keep the 100 Hall shower area warm enough for residents to use and the 300 Hall shower area was in disrepair, cluttered, and dirty for 2 of 3 hallway showers observed (Residents D, E, F, AA, CC, DD, EE, FF, GG, HH, and JJ).

Inspectors wroteBased on record review and interview, the facility failed to code the Minimum Data Set (MDS) with accurate information pertaining to PASRR (Pre-admission Screening and Resident Review) (an assessment for screening for possible serious mental illness or intellectual disabilities) (Resident 2, E, 38, 21, EE and FF) and failed to accurately code a resident (Resident O) for a hospital discharge for 7 of 7 residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to care plan advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for 13 of 15 residents reviewed for care plans (Resident B, 83, L, Z, 38, 18, 43, P, 4, 87, 48, 256 and 74), end of life care/hospice services for 1 of 15 residents reviewed for care plans (Resident 13), and failed to address a resident's care plan for unnecessary medications for Resident P for 15 of 15 residents reviewed for comprehensive care planning.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide range of motion to maintain a resident's range of motion for 3 of 4 residents reviewed (Resident 18, 73 and FF).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet the needs and wants of the residents and failed to ensure call lights were answered in a timely manner for 6 of 6 days of observation and for 14 of 14 residents interviewed (Residents OO, PP, Z, AA, DD, D, E, BB, CC, EE, FF, GG, HH, and JJ).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective supervision and monitoring of residents with dementia (Residents 4 and 52) for 2 of 3 residents who were reviewed for Dementia care and services, and the facility failed to prevent intrusive wandering into peers' rooms by a resident with dementia for 1 of 3 residents who were reviewed for Dementia care and services (Resident 52).

Inspectors wroteBased on observation and record review, the facility failed to date eye drops and insulin pens and failed to remove expired eye drops from the medication carts for 2 of 3 medication carts observed (Resident 11 and 22).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure glucometers (machines to take blood sugars) were cleaned between residents and in a manner to ensure the machines were disinfected for 4 of 5 observations of Accuchecks (Residents 62, 67, 80, and 94).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the opportunity to received influenza, pneumonia, and COVID-19 vaccinations for 5 of 5 residents reviewed for vaccinations (Resident Q, W, M, R, and N).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with dignity for 4 of 5 residents reviewed for dignity (Residents 79, MM, 83, and R).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a resident shower twice a week for 1 of 1 resident reviewed for showers (Resident Y).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's wound treatment was done as ordered and expired solution was not used on the resident's wound for 1 of 4 wounds reviewed (Resident Q).

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to provide services to intervene and promote skin integrity for 1 of 3 residents reviewed for pressure ulcers (Resident 18).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, (Resident 4) received sufficient monitoring and interventions to prevent falls, failed to ensure a resident (Resident 256) was free from the potential for accidents related to his specialized diet orders, failed to ensure a resident (Resident 78) was free from the potential for accidents related to her fall interventions, and failed to prevent the potential for accidents for a Memory Care resident (Resident 86) who was found to have medication in her room for 4 of 4 residents reviewed for accidents.

Inspectors wroteBased on interview and observation, the facility failed to ensure a resident's indwelling catheter bag and tubing did not contact the floor and failed to ensure residents were free from constipation for 2 of 5 residents reviewed for bowel and bladder (Resident Y and 18).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident's did not have significant weight loss and interventions were implemented to prevent further weight loss for 2 of 4 resident's reviewed for weight loss (Resident 34 and 53).

Inspectors wroteBased on observation, interview, and record review, the facility failed to date a peripherally inserted central catheter (PICC) dressing and failed to date intravenous (IV) tubing for 1 of 1 resident reviewed for IVs (Resident 18).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 4) was treated for pain after a fall from which he sustained several rib fractures and the facility failed to ensure a resident (Resident P) was given effective interventions for pain after a fall from which she sustained a fractured wrist for 2 of 3 residents reviewed for pain.

Inspectors wroteBased on record review and interview, the facility failed to ensure blood glucose monitoring was obtained for a resident with diabetes mellitus with insulin to manage (Resident FF), failed to ensure a resident's medications had an appropriate diagnoses for use and an indication for medication use (Resident X), and failed to provide documentation pharmacy review of medications (Resident 4) for 3 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide diets and fluids according to residents' orders for 2 of 2 residents reviewed for diet orders (Residents 40 and 91).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for abuse was free from abuse which resulted in actual harm as Resident B was seen crying out and verbally indicated she was afraid when she was roughly put into bed, scolded, and threatened by nursing staff members. Using the reasonable person concept, the staff abuse was likely to have caused chronic and recurrent fear and anxiety for the resident (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse for 1 of 3 residents reviewed for abuse (Resident B).

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise and follow care plans for 1 of 2 residents reviewed for care planning (Resident F).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for accidents when the secured memory care doors were not adequately monitored during a malfunction which unlocked the secured door, and a resident was able to exit two separate doors and was later found walking in the parking lot for 1 of 3 residents reviewed for elopement (Resident D).

Inspectors wroteBased on observation and interviews the facility failed to ensure a resident had their call light within reach for 1 of 1 resident reviewed (Resident F).