Western State Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 20Number of residents cited: 2The facility failed to provide a dignified existence for two residents by not ensuring lap covering for two residents, R35 and R18. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for two (2) of twenty (20) sampled residents (Resident 18 and 35). The findings include: Review of facility policy dated October 2000, item 21 titled Dignity revealed, the facility must promote care for residents in a manner that maintains or enhances each individual's dignity and respects his or her dignity.A review of MDS information revealed R35 was admitted on [DATE] with a diagnosis of unspecified symptoms and signs involving cognitive functions and awareness and does not have a BIMS…

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, interview, and review of facility policy, the facility failed to follow standard precautions to be followed to prevent the spread of infection. Appropriate infection prevention and control practices were not implemented during medication administration. Hand hygiene was not performed while administering medications to one of two residents, Resident (R) 28. The findings include:Review of facility policy, titled Psychobiological/Pharmacological Interventions Medication Administration and Documentation, revised January 2023, revealed all medication will be prepared and administered as per manufacturer's specifications and accepted professional standards.Review of facility policy, titled Infection Prevention and Control, revised October 2022, revealed Western State Nursing Facility will maintain an Infection Prevention and Control Program intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference…

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 Number of residents sampled: 20Number of residents cited: 1The facility failed to ensure that one resident could access the call light R46. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair, or other sleeping accommodations for one (1) of twenty (20) sampled residents (R46). The findings include: Review of MDS information on 12/08/2025 revealed that R46 was admitted on [DATE] and had a BIMS of 99 with a diagnosis of schizophrenia and is not interviewable. Review of functional abilities (GG0130A1) shows partial to moderate help needed for using eating utensils. Review of care plan dated 10/20/2025, an intervention for high risk of fall was to ensure the call light is within reach. An observation made on 12/08/2025 at 2:00 PM revealed that Resident 46 was sitting in a Broda chair 2 feet from her bed with a call light wedged behind the recliner at the foot of her bed. An observation…

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, interview, record review, and facility policy, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the Medical Director or his/her representative. The facility failed to ensure or encourage real-time alternative methods of participation, such as videoconferencing and teleconference calls to include the Medical Director or his/her representative. The findings include: Review of the facility's policy titled, Quality Assessment and Assurance Committee, dated 10/2022, revealed the facility would maintain a QAA committee consisting of a minimum of the Administrator or representative, Director of Nursing (DON) or representative, Physician, Infection Preventionist or representative, and three facility staff. Further review revealed the QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance Performance Improvement (QAPI) program. During an interview with the Administrator, on 08/08/2024 at 4:30 PM, she stated the Director of Nursing (DON), Assistant Director…

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 observation, interview, review of the facility's policy and resident's medical record, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident #22 (R22)). Staff failed to perform hand hygiene when indicated; contaminated residents' clothing and bed linens; and, failed to prevent the contamination of clean dressings. The findings include: Review of the facility's policy titled, Infection Control Practices in Maintaining Sanitary Environment in the Prevention of Development and Spread of Contagious Viruses and Pathogens, dated 12/2006 and revised 03/2019 revealed the facility will maintain infection control practices that promote a sanitary environment to prevent the development and spread of contagious viruses and pathogens. Review of the facility's policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 revised 08/2022…

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, interview, and review of the facility policy, it was determined the facility failed to distribute and serve food in accordance with professional standards for food service safety related to staff not washing hands or changing gloves after leaving the meal tray prep area and prior to returning to area. Review of the Census and Condition, dated 11/19/19, revealed eighty-three (83) of ninety-three (93) residents received their meals from the kitchen. The findings include: Review of the facility's policy titled, Handwashing, last reviewed 10/2018, revealed routine hand washing should be completed after situations during which microbial contamination of hands is likely to occur and after touching inanimate sources that are likely to be contaminated with virulent or epidemiological important microorganisms of special clinical or epidemiological significance; for example: multiple drug resistant bacteria. Observation on 11/19/19 at 11:30 AM, revealed the dietary cook left the tray line three (3) times, once she touched a tray cart, the second time she touched the…

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, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents' right to privacy was honored (Resident #93). Staff were observed to walk by Resident #93's room while he/she was up in his/her wheelchair, in his/her doorway, with his/her gown pulled up exposing his/her incontinent brief; however, the staff failed to assist Resident #93 in covering him/herself up to ensure the resident's privacy per facility policy. The findings include: Review of the facility policy, Resident Rights, last revised March 2017, revealed the facility will protect and promote the rights of each resident. Resident rights will be recognized and honored to insure a dignified existence and self-determination. The policy further revealed the facility must promote care for residents in a manner that maintains and enhances each individuals dignity and respects his/her individuality. Record review revealed the facility admitted Resident #93 on 10/15/08, with diagnoses which included Schizophrenia 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.

Based on interview, record review and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for two (2) of twenty-two (22) sampled residents (Residents #80 and #88 ) Record review for Residents #80 and #88, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident transfers. The finding include: Review of the facility policy titled, Placement, Discharge, Planning, and Transfers, last reviewed July 2016, revealed while on leave/bed hold, the facility will notify the resident and/or representative of the transfer or discharge and the reasons for the move. 1. Record review revealed the facility admitted Resident #80 on 08/15/13, with diagnoses which included Seizure Disorder and Psychotic Disorder. Review of a Nurses Note dated 09/10/19, revealed Resident #80 was sent to the emergency room (ER) for evaluation 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.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with wounds in the selected sample of twenty-two (22) residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan (Resident #41). Licensed staff failed to provide wound care in accordance with professional standards of practice for Resident #41. The findings include: Review of the facility policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 and reviewed June 2017 revealed, The facility will ensure that optimal skin care is provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and the National Pressure Ulcer Advisory Panel. Any resident identified with an actual skin care problem or identified as a high risk for pressure injury or skin injury with have an individualized plan of care developed and initiated per the licensed nurse to address specific goals 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.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with pressure ulcers in the selected sample of twenty-two (22) residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Licensed staff failed to provide pressure ulcer care for Resident #30 according to professional standards of practice which resulted in the Nurse contaminating the wound with feces. The findings include: Review of the facility policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 and reviewed June 2017 revealed, The facility will ensure that optimal skin care is provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and the National Pressure Ulcer Advisory Panel. Any resident identified with an actual skin care problem or identified as a high risk for pressure injury or skin injury with have an individualized plan of care developed…

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, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents received the appropriate care and services to prevent urinary tract infections to the extent possible (Resident #30) related to poor hand hygiene during indwelling catheter care. The findings include: Review of the facility policy Care of the Indwelling Catheter to Prevent Infections dated March 2001 and revised April 2017 revealed the facility will closely monitor all residents with long term indwelling catheter placement for signs and symptoms of infection and urosepsis. A resident will not be catheterized unless their clinical coneition demonstrates that the catheterization is necessary. Residents with an indwelling catheter will receive perineal and catheter care every shift and following every bowel movement. Catheter care includes cleaning at least the first four inches of the catheter closest to the insertion site plus the perineal area with soap and water. The tubing will be assessed after care to ensure it…

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, interview, and facility policy review, it was determined the facility failed to ensure to help prevent the development and transmission of communicable diseases and infections for two (2) of twenty-two (22) sampled residents (Residents #30, and #89). In addition, the facility failed to ensure linens were transported so as to prevent the spread of infection. Observation revealed staff failed to perform handwashing to prevent infections during pressure ulcer care and catheter care for Resident #30 and catheter care and gastrostomy care for Resident #89. In addition, observation revealed staff carried a resident's clothing protector under his arm prior to placing it around a residents neck during meal service. The findings include: Review of the facility policy titled, Handwashing, last revised October 2018 revealed, handwashing is considered the single most important procedure for preventing infection or the spread of infection. Indications: when you arrive at work, before and after touching wounds, after situations during which microbial contamination of hands…

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.