Westlake Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#4) of four residents were free from significant medication errors out of five sample residents. Specifically, the facility failed to ensure Resident #4 did not receive another resident's medications. Findings include: I. Professional reference According to Clinical Nursing Skills & Techniques by [NAME], [NAME] & [NAME], 8th Edition (2021), page 480-489, Safe medication administration: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: -The right medication; -The right dose; --The right patient; -The right route; -The right time; and, -The right documentation. Read the label on the medication container and compare it with the MAR (medication administration record) at least three times before removing the container from the supply drawer, when placing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure two ceiling swamp cooler vents, two shower rooms and eight mechanical rooms were thoroughly cleaned, free from debris and did not contain any black discoloration on any surfaces. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised September 2024, was provided by the assistant director of nursing (ADON) on 10/16/24 at 12:12 p.m. The policy revealed that in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This included ensuring that the resident could receive care/services safely and the physical layout of the facility maximized resident independence and did not pose a safety risk. The environment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of two units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure nebulizers (an apparatus that allows medications to be inhaled) were stored and cleaned according to professional standards of practice. Findings include: I. Housekeeping A. Professional reference The Centers for Disease Control (CDC) Environment Cleaning Procedures, (5/4/23), retrieved on 4/17/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118 included the following recommendations, documented in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure level II preadmission screening and resident review (PASRR) were completed for one (#33) of two residents out of 32 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional and psychosocial well-being. Specifically, the facility failed to follow PASRR level II recommendations for Resident #33. Findings include: I. Facility policy and procedure The PASRR completion policy, revised 2/23/24, was provided by the quality mentor (QM) on 4/11/24 at 11:40 p.m. It read in pertinent part, If the resident has a PASRR Level II, the community is responsible for ensuring that any recommendations from the PASRR Level II are implemented and care planned for the resident. II. Resident status Resident #33, age above 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included history of falling, weakness, generalized anxiety disorder, major depressive disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#31) of two residents out of 32 sample residents. Specifically, the facility failed to provide eating assistance for a resident who required supervision and cueing and who was at high risk for weight loss. Finding include: I. Facility policy and procedure The Weight Management policy and procedure, reviewed 2/29/24, was provided by the quality mentor (QM) on 4/11/24 at 11:39 a.m. It read in pertinent part, Residents are monitored for weight change on a regular basis. Results are reviewed and analyzed by the facility for interventions as appropriate. Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, registered dietician (RD) evaluation and assisted dining. II. Resident #31 A. Resident status Resident #31,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two (#35 and #51) out of two residents out of 32 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Follow hospital physician orders to remove Resident #35's cervical neck brace after six weeks; -Monitor the skin under Resident #35's cervical neck brace; -Ensure Resident #35 was transported to and attended her neuro-orthopedic doctor' s appointment; and, -Support and position Resident #51 in her wheelchair properly. Findings include: I. Professional reference The Hull University Hospital Guide to Wearing Your Cervical Hard Collar, dated 3/19/21, was retrieved from https://www.hey.nhs.uk/patient-leaflet/guide-wearing-cervical-hard-collar/ on 4/16/24. It read in pertinent part, A hard collar is a device designed to limit movement of your neck. It is most commonly used to manage spinal fractures. It is important the collar is removed daily to be able to wash,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#33 and #35) of two residents reviewed for accidents out of 32 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Complete a root cause analysis and implement person centered fall interventions for Resident #33 and Resident #35; and, -Ensure a registered nurse (RN) completed an assessment after Resident #33 sustained a fall. Findings include: I. Facility policy and procedure The Fall management policy and procedure, revised 2/29/24, was provided by the quality mentor (QM) on 4/11/24 at 11:39 a.m. it read in pertinent part, A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Please note interventions are to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#51 and #70) of five residents reviewed for significant medication errors out of 32 sample residents. Specifically, the facility failed to: -Ensure Resident #51 received the correct medications by ensuring the correct resident was identified before administering another resident's (Resident #20) medications; -Ensure Resident #51 had documentation, monitoring and follow up for possible adverse outcomes after receiving multiple wrong medications; and, -Ensure Resident #70 was given a scheduled opioid medication according to physician orders. Findings include: I. Professional reference [NAME], A., [NAME], L. M. (September 5, 2022). Nursing Right of Medication Administration. Stat Pearls. National Library of Medicine was retrieved on 4/16/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/. It read in pertinent part, Nurses have a unique role and responsibility in medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for three (#6, #62 and #17) of six residents reviewed for psychotropic medications out of 25 sample residents. Specifically, the facility failed to: -Obtain appropriate risk versus benefits statements for Resident #6; -Attempt gradual dose reductions (GDR) for psychotropic medications for Resident #6; -Track and monitor behaviors accurately to justify continuation of psychotropic medications for Resident #6; -Have the residents physician document the rationale for extending the use and indicate the duration of a PRN (as needed) psychotropic medications for Resident #62 and Resident #17; -Attempt non-pharmacological interventions prior to administering PRN antipsychotics for Resident #62 and Resident #17; -Develop a resident specific care plan for psychotropic medications to include non-pharmacological interventions for Resident #62; and, -Failed to document, implement and revise…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (#120) of six residents out of 25 sample residents. Specifically, the facility failed to ensure a licensed practical nurse (LPN) administered medications for Resident #120 without touching the medications with her bare hands. Findings include: I. Facility policy and procedure The Medication Administration policy, last revised on 11/1/22, was provided by the assistant director of nursing (ADON) on 12/14/22 at 11:41 a.m. It read in pertinent part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Wash hands prior to administering medication per facility protocol. Remove medication from source, taking care not to touch medication with bare hands. II.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure medication error rates were not 5% or greater. Out of 25 opportunities for medication errors, 10 errors were observed, resulting in an error rate of 40%. These errors affected one (#120) of six residents out of 25 sample residents. Specifically, the facility failed to ensure medications for Resident #120 were not administered late. Findings include: I. Professional reference According to [NAME], [NAME] and [NAME], (copyright 2017), Fundamentals of Nursing (ninth edition), page 614, Safe drug administration involves adherence to prescribed doses and dosage schedules. Follow the medication administration policies of your agency about the timing of medications to ensure that you administer medications at the right time. II. Facility policy and procedure The Medication Administration policy, last revised on 11/1/22, was provided by the assistant director of nursing (ADON) on 12/14/22 at 11:41 a.m. It read in pertinent part,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.