Westwood Vlge Nrsg and Rhb Ctr

Inspectors wroteBased on interview and record review, the facility failed to provide an accurate quarterly statements to the residents who have Individual Resident Fund accounts for four (R1, R2, R3 and R6) of six residents (R1-R6) reviewed for resident funds and has the potential to affect all 111 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in the sample of five.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from verbal abuse for two (R1 and R2) out of four residents reviewed for resident-to-resident abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the air temperature in the facility resident rooms was 71 to 81 degrees Fahrenheit (F) for 23 residents (R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24 and R25) reviewed for inadequate cooling.

Inspectors wroteBased upon interview and record review the facility failed follow policy procedures, failed to document an incident report, and failed to implement the abuse prevention program for one of four residents (R1) reviewed for abuse.

Inspectors wroteBased upon record review and interview the facility failed to follow the abuse prevention program and failed to report allegation verbal abuse and misappropriation of funds to the state surveying agency within regulatory requirements one of four residents (R1) reviewed for abuse.

Inspectors wroteBased upon interview and record review the facility failed to follow the abuse prevention program and failed to conduct thorough investigations for one of four residents (R1) reviewed for abuse.

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures and failed to ensure that two of three residents (R1, R3) reviewed for medication administration remained free from significant medication errors.

Inspectors wroteBased on observations, interviews and record reviews, facility failed to follow their policy to ensure foods were labeled and dated in the dry food storage. This failure has the ability to affect all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, facility failed to administer medications timely and failed to follow the facility's medication administration policy for 7 residents (R13, R48, R62, R64, R71, R90, R98) out of 7 residents reviewed for medication administration in a sample of 21 residents. Findings Include: On 12/09/2024 at 10:11AM V5 (Licensed Practical Nurse/LPN) was observed during medication administration. V5 had 7 residents (R13, R48, R62, R64, R71, R90, R98) that did not receive their scheduled 9:00AM medications. V5 stated, On a regular day, when I work a shift, I am usually done passing medications to all by residents by 10:15 AM. I try my best to finish my morning medication administration on time, but I work with many different residents who ask for things in a specific way. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to assess for self-administration of albuterol medication. This failure effected 2 residents (R58 and R79) out of 4 residents with chronic obstructive pulmonary disease (COPD) reviewed for self-administering medications in a total sample of 21 residents. Finding Include: 1.) R58's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: chronic obstructive pulmonary disease, muscle wasting and atrophy, not elsewhere classified, multiple sites, emphysema, unspecified, hypertensive heart disease without heart failure, cerebral infarction, unspecified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light was within reach of one resident (R32) reviewed for the call light system.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store insulin medications and gastrostomy tube (g-tube) feeding extension tubing supplies. This failure impacted 2 residents (R14 and R53) who had expired insulin inside the medication cart during inspection. This failure also resulted in expired gastrostomy tube feeding extension tubing supplies being found in the medication storage room. Finding Include: On 12/09/24, at 12:49 PM, the 1st floor Medication Cart # 3 was inspected with V20 (Licensed Practical Nurse/LPN). R14's Novolog FlexPen U-100 Insulin (insulin aspart u-100) was found in drawer, marked with the open date of 07/24/2024, and marked with the expiration date of 08/21/2024. Surveyor found 3 10mL (milliliter) syringes marked with the expiration date of 09/30/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a reusable blood pressure cuff device was properly cleaned and disinfected in between resident use for 3 residents (R17, R22, R62) out of 8 residents reviewed for infection control and prevention in a total sample of 21. Finding Include: 1.) R17's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: primary generalized (osteo)arthritis, schizoaffective disorder, unspecified, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Care plan (dated 02/07/2024) requires a therapeutic diet related to type 2 diabetes mellitus and hypertension. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a resident's plan of care interventions for fall prevention and failed to provide the resident with a working call light for a resident high risk for falls in one (R1) of three residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the spread of foodborne illnesses by improperly thawing meat and not securing bulk item scoops. This failure has the potential to affect all residents receiving oral nutrition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff logged off the computer clinical record system prior to leaving the medication cart and failed to ensure empty medication dispensing cards which contained resident's health information were not left unattended. These failures affected 2 (R63 and R70) residents reviewed for confidentiality of records and has the potential to affect all the residents on Side 2 of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed nursing personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect three residents on side two medication cart who were prescribed controlled substances and eight residents on side one medication cart who are prescribed controlled substances.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two medication carts out of the three medication carts reviewed were free of loose tablets. This deficient practice has the potential to affect 27 residents who receive medications from side two medication cart and 22 residents who receive medications from side one medication cart.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the container of the multi blood glucose test strips were labeled with the open date. This failure has the potential to affect 15 residents who receive blood glucose monitoring.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly disinfect shared equipment used on three residents (R62, R83, and R98) and failed to safely handle a needle for one resident (R50). These failures affected four (R50, R62, R83, and R98) residents in the sample of 55 residents in preventing the spread of microorganisms when reviewed for infection control.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a call light device was within a dependent resident's reach to call for staff assistance which affected one resident (R52) in the total sample of 55 residents when reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Practitioner Order for Life-Sustaining Treatment (POLST) form was completed properly which affected one resident (R79) in the total sample of 55 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have a home like environment. This failure affected 2 residents (R75 and R86), reviewed for resident's rights to have a comfortable home like environment, in a total sample of 55 residents. Findings Include: On 1/28/24 at 10:30am, R86 pointed at the window next to (R86's) bed which had towels secured to the bottom of the window with clear tape and stated that (R86) had to do that about a week ago because the wind blows through the closed window. R86 stated that the wind coming through the closed window even moves the blinds. R86 stated (R86) reported it to the nurses a few times and all the nurses did was turn up the heat. R86 stated, The wind coming through gives me a chill. I am going to get pneumonia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who depends on staff assistance for ADL (Activities of Daily Living) care and grooming receive nail care. This affects 1 resident (R80) reviewed for accommodation of needs in the total sample of 55 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an adaptive device (splint/palm grip) was in place for a contracted hand which affected one resident (R57) in the total sample of 55 residents when reviewed for limited mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen tubing and humidifier bottle was changed weekly and labeled with the date for two residents (R19 and R72). These failures have the potential to affect 2 residents (R19, R72) out a total of 12 residents who receive oxygen therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were four medication errors out of 28 medication opportunities, resulting in a 14.29% medication error rate and affected three residents (R50, R62 and R102) observed for medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to secure the lid on the outside garbage dumpster to prevent pest and rodents from entering into the facility. This failure has the potential to affect all the residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident was treated with dignity and respect for 1(R8) of 3 (R1, R2, R8) residents in a sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to handle, store and transport linens in a manner to prevent the spread of infections. This failure has the potential to affect all 104 residents in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to safely store medication, failed to ensure that medication cart was locked, failed to label medication with expiration date as required for the following residents: R20, R36, R41, R49 and R74. This failure has the potential to affect all residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the outside dumpster was not overflowing with trash and failed to ensure the dumpster lid is closed to maintain a sanitary environment. This failure has the potential to affect all 86 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was within reach for one resident (R52) out of a sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (R62) was free from mental abuse. This failure affected one resident (R62) in the total sample of 48 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (R2) was safe from falls. This failure affected one resident that is classified as a moderate to high fall risk. Findings Include: R52's diagnosis includes but not limited to Bipolar Disorder, Dementia with Behavioral Disturbances, Parkinson's Disease, Hypertension, and Cardiomegaly. R52 has a Brief Interview Score of 14 that suggests cognitively intact. On 3/27/2023 at 10:41am surveyor observed R52's bed in a high position and there were no CNAs (Certified Nurse Assistants) in the room. R52 stated that she does not like the bed this high. On 3/27/2023 at 10:43am V27 (CNA) said, When I am going to change someone it is, I was getting ready to change R52. [...]

Inspectors wroteR34's diagnosis includes Schizophrenia, Dependence on Renal Dialysis, and End Stage Renal Disease. Brief Interview of Mental Status score is 14 that suggests cognitively intact. On 3/27/2023 at 10:52am the surveyor observed R34's oxygen tubing on the floor under the bed not labeled. On 3/27/2023 at 10:57am V26 stated it (nasal cannula) was just in her nose but is now under the bed. On 3/28/2023 at 10:59am V7 (Licensed Practical Nurse) stated that the tubing is changed weekly and yes, it should be labeled with the date. V7 stated that the nasal canula should be on the resident and not on the floor. On 3/29/2023 at 2:14pm V3 (DON) stated that date should be included on the tubing when the oxygen tubing is changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that controlled substances were counted and accounted for per shift and failed to ensure that staff document the administration of a controlled substance at the time of administration for R339.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 5 medication errors out of 31 medication opportunities, resulting in a 16.13% medication error rate. Two residents (R29 and R81) were affected out of three residents (R29, R70, and R81) reviewed for medication administration in the total sample of 48 residents.