Westbury Center Of Jackson For Nursing And Healing

Based on observations, staff interviews, and the facility policy titled Infection Prevention and Control Program, the facility failed to maintain sanitary conditions to prevent the transmission of communicable diseases and infections. This deficient practice created a potential for infection and cross contamination for 53 sampled residents (R).Findings Include:Review of the Facility's Infection Prevention and Control Program Policy, implemented on 10/01/2022, showed that the Facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standard and guidelines. 11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all…

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, staff interviews, record reviews, and review of the facility's policy titled Quality of Life- Dignity, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one of 53 sampled residents (R) (R37). This failure had the potential to diminish R37's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Finding include: Review of the facility's policy titled Quality of Life Dignity, dated December 2022, revealed the Policy Statement was Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individually. The Policy Interpretation and Implementation section included, 1. Resident shall be treated with dignity and respect at all times. 10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the clinical record revealed R37's…

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, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure medications were not left at the bedside of two of 53 sampled residents (R) (R86 and R287) who were not assessed for medication self-administration. This deficient practice had the potential to place R86 and R287 at risk of serious health complications, including medication misuse or overdose, and compromise their safety and well-being. Findings Include: A review of the facility's policy titled Resident Self-Administration of Medication, revised on 3/2024, revealed the Policy section was It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The Policy Explanation and Compliance Guidelines section included . 7. Bedside 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 observations, staff interviews, record review, and review of the facility-provided document titled Logbook Documentation - Heating, Ventilation and Air Conditioning (HVAC)/ Packaged Terminal Air Conditioner (PTAC): Clean Air Filters, the facility failed to ensure that the PTAC filters were maintained in a clean condition for two of 120 resident rooms (rooms [ROOM NUMBERS] ). In addition, the facility failed to maintain a home-like environment in two of 120 resident rooms (rooms [ROOM NUMBERS]) observed with chipped paint and loose baseboards. These deficient practices had the potential to place the residents residing in the rooms at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings include: Review of the facility-provided document titled Logbook Documentation - HVAC (PTAC): Clean Air Filters revealed the Steps section included: 1. Remove or open access cover 2. Remove air filter and inspect for cleanliness. If filter is dirty either…

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.

Based on staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, the facility failed to submit an application for Level II PASARR for evaluation and determination of specialized services for three of four residents (R) (R32, R87, and R90) reviewed for PASARR. This failure had the potential to place R32, R87, and R90 at risk of not receiving services and/or care according to their needs. Findings include: Review of the facility policy titled Resident Assessment-Coordination with PASARR Program, date reviewed/revised December 2022, revealed the Policy stated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance Guidelines section included, 1. All applicants to this facility will 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 observations, resident and staff interviews, record review, and a review of the facility-provided binder titled Rehab: Patient Level of Assistance, the facility failed to ensure restorative nursing care was provided to one of two residents (R) (R99) sampled for range of motion (ROM) and mobility. This deficient practice had the potential to place R99 at risk of worsening contractures and a diminished quality of life. Findings include: Review of the facility-provided binder titled Rehab: Patient Level of Assistance, revealed instructions on the level of assistance required for each resident in the facility. The binder contained a Restorative Nursing Instruction Form, completed by Occupational Therapy (OT) and/or Physical Therapy (PT), which documented each resident's needs of ROM, ambulation, transfers, splinting/bracing, eating/swallowing, and other activity of daily living (ADL) needs. Review of R 99's admission Record revealed diagnoses including, but not limited to, contracture of muscle of left…

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.

Based on observations, staff interviews, record review, and review of the facility's policy titled Insulin Pen, the facility failed to ensure the medication error rate was less than five percent. There were two errors with 30 opportunities for two of four residents, R (R119 and R147), for a medication error rate of 6.67 percent. These failures had the potential to place R119 and R147 at risk of medical complications and decreased therapeutic effects of medications. Findings include: Review of the facility policy titled Insulin Pen, revised 8/2023, revealed the Policy section included . 17. Keep the pen straight and insert the needle into the skin. Using your thumb, press the injection button all the way down. When the number in the window returns to '0,' slowly count to 10 before removing the needle. 1. Review of R119's clinical record revealed diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease. Review of R119's Physician's Orders revealed an order dated 9/28/2024 for insulin glargine 100 units/milliliter (ml) solution (a…

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.

Based on staff interviews, record review, and a review of the facility policy titled Notification of Changes, the facility failed to notify the resident's representative of a change in the resident's condition for 1 of 3 sampled residents (R) (R5) reviewed for notification of change in condition. Findings included: A facility policy titled, Notification of Changes, revised date of 1/2024, revealed Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2023, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Review of the care plan for R5, initiated on 12/21/2023, revealed the resident was new to the facility. Interventions directed the staff to notify the resident's family of changes in the resident's condition. A…

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.

Based on observation, staff interviews, record review, and a review of the facility's policy titled, Insulin Pen, the facility failed to maintain professional nursing standards of quality, as evidenced by one Licensed Practical Nurse (LPN) administering insulin to one of 55 Residents (R) (#14) without priming pen prior to administration. Finding include: A review of the facility policy titled Insulin Pen, last reviewed/revised August 2023, revealed the Policy Explanation and Compliance Guidelines numbered: 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. 11. h. Prime the insulin pen: i. Dial two units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. A review of the manufacturer's instructions for Humalog Kwik Pen on page three and section titled Priming your Pen stated: If you do not prime before each injection, you may get too much or too little insulin.…

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, staff interviews, record reviews, and a review of the facility's policies titled Peripheral Intravenous Catheter Insertion, Maintenance, and Removal, Nebulizer Therapy, and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to maintain infection control standard precautions by not removing an intravenous (IV) access timely after discontinuation of the IV antibiotic for one Resident (R) (#8) of three with an IV site, not keeping nebulizer mask enclosed inside a bag when not in use for one of one Resident (R) (#39), and not cleaning or disinfecting equipment between residents who were COVID-19 positive for two residents (room [ROOM NUMBER] A/B) reviewed for Transmission Based Precautions (TBP). Findings Include: 1. Review the policy titled Nebulizer Therapy revised date March 2023 revealed Section Care of the Equipment line number seven states, Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Observation on 08/29/2023 10:20…

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.