West Side House LTC Facility

Based on observation, and interview, the facility failed to follow professional standards of practice for food safety in the main kitchen to prevent the potential spread of foodborne illnesses to residents who are at high risk. Specifically, the facility failed to ensure food temperatures were taken and documented prior to meal service in the facility's main kitchen to ensure the food temperatures were within acceptable parameters for food safety. Findings include: Review of the facility policy titled Food Temperature Testing, dated July 2013, indicated the following: -Temperature of food items in the steam table are to be taken at the beginning of service and at the end of service using the following method: a. Sanitize thermometers by cleaning with alcohol wipes. b. Insert the thermometer into food items in steam table. Take reading and document on Daily Temperature Checklist for Meal Service form after temperature plateaus. -Temperatures are to be taken from the steam table for all three meals on a daily basis. During a kitchen observation on 12/27/24, the surveyor observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the right of residents to be free from physical restraints for one Resident (#2) out of a total sample of 14 residents. Specifically, for Resident #2, the facility failed to: -appropriately assess and re-assess the use and the need for a wheelchair seat belt used as a restraint when the Resident was seated in the wheelchair. -obtain informed consent and review the risk/benefits with the Resident's Representative for the use of the wheelchair seat belt, which was used to prevent Resident #2 from sliding off the wheelchair, increasing the potential risk of accidental falls and injury. Findings include: Review of the facility policy titled Device/Restraints Policy and Procedure, revised April 2017, indicated it was the policy of the facility to ensure each resident attains/maintains the highest practicable well-being in an environment that improves functional status and ability. The policy also included the following: -every resident…

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, and record review, the facility failed to adhere to infection control standards of practice during a bolus feeding (a method of tube feeding administering a dose of the formula through a feeding tube using a catheter syringe [syringe without a needle]) procedure for one Resident (#51) out of a total sample of 14 residents. Specifically, for Resident #51, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other residents within the facility. -perform hand hygiene procedure as required between glove changes while providing care. -open/pierce a Jevity (therapeutic nutrition) container foil in a sanitary manner. Findings include:…

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 interviews and records reviewed, for two of three sampled residents (Residents #1 and #2), who were severely cognitively impaired and had court ordered legal guardianships in place, the Facility failed to ensure that staff implemented and followed the Facility Abuse Prohibition Policy when, on 10/17/24, although Nurse #1 and Nurse #2 were made aware of an allegation of abuse, that Resident #1 was at Resident #2's bedside engaged in a sexual act, neither of them reported the allegation to the Director of Nursing or Administrator, and as a result, they were not made aware until more than 12 hours later, when Nurse #3 became aware and reported the allegation. Findings include: Review of the Facility Policy titled Abuse Prevention Policies and Procedures, revised 4/2017, indicated that all staff members are responsible for reporting incidents that may constitute or lead to any form of resident abuse, neglect, mistreatment, exploitation or misappropriation. The Policy indicated that upon observation of…

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, interviews and policy review, the facility failed to maintain professional standards for safe and sanitary food storage in the main kitchen and in two out of two kitchenettes. Findings include: Review of the facility policy titled Food Rotation Policy, dated 3/2023, indicated the following: -Label and date food items on food delivery day. Review of the 2022 United States Food and Drug Administration Food Code indicated the following: >Food shall be protected from contamination by storing the food: -In a clean, dry location. -Where it is not exposed to splash, dust, or other contamination. -At least 15 centimeters (six inches) above the floor. >Time/Temperature control for safety, cold holding: -Except during preparation, cooking, or cooling, or when time is used as the public health control, food shall be maintained at 5 degrees Celsius (41 degrees Fahrenheit) or less. On 9/5/23 from 7:55 A.M. to 8:15 A.M., the surveyor conducted an initial tour of the kitchen with [NAME] #1 and observed the following: -In the dry storage area, three bags of open pasta were…

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, interviews and records reviewed, the facility failed to maintain a medication pass error rate of less than five percent (%). Specifically, the medication error rate was observed to be 31.03%, for two Residents (#34 and #18), out of three applicable residents, out of 29 opportunities. 1. For Resident #34, medication errors occurred relative to the administration of medications not given within the required timeframe. 2. For Resident #18, medication errors occurred relative to the administration of medications not given within the required timeframe and omitting a prescribed medication. Findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration dated 1/1/22, indicated, but was not limited to the following: -Verify each medication administered: >is the correct medication >at the correct dose >at the correct route >at the correct rate >at the correct time >for the correct resident, as set forth in the facilities medication administration schedule. 1. Resident #34 was admitted to the facility in June 2020 with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed for three Residents (#30, #17, and #4) out of five sampled residents for immunizations, the facility failed to offer or provide Pneumococcal Vaccinations as required. Specifically, the facility staff failed to: 1. Provide a Pneumococcal Vaccination for one Resident (#30) after the Resident's Representative requested the vaccination. 2. Provide education, assess for eligibility, and offer Pneumococcal Vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations to two Residents (#17 and #4) and/or their Representatives. Findings include: Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to [AGE] years of age (cdc.gov) dated 3/15/23, indicated the following: For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23), and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine…

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 interview and records reviewed for one Resident (#7) out of a total sample of 13 residents, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment within the required 14 days. Findings include: Review of the Centers for Medicare and Medicaid (CMS), Resident Assessment Instrument Manual (RAI-dictions used to code an MDS) dated [DATE], indicated the following: -The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice elections (which can be the same or later than the date of the hospice election statement, but not earlier than.). -The MDS completion date .must be no later than 14 days from the ARD .and no later than 14 days after the determination that the criteria for a Significant Change in Status Assessment (SCSA) were met. Resident #7 was admitted to the facility in May 2022. Review of the Resident's medical record indicated the Resident elected Hospice services on 9/6/22. Review of the SCSA MDS…

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, and records reviewed, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#23) out of a total sample of 13 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #23. Findings include: Resident #23 was admitted to the facility in October 2016 with diagnoses including Unspecified Dementia and Major Depressive Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely cognitively impaired and needed assistance with activities of daily living (ADLs- include bathing, showering, dressing, getting in and out of bed or a chair, walking, toileting and eating). Review of the most recent Activity Assessment, dated 1/9/23, indicated the Resident's current preferences for hobbies/interests included: -exercise/sports -watching TV -ball toss groups. Further review of the Activity…

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, interviews and records reviewed for two residents (Residents #26 and #30) out of a total sample of 13 residents, the facility failed to ensure recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed timely and implemented as required. Specifically, 1. For Resident #26, the facility staff failed to implement recommendations for medication dosage adjustment and obtain lab work to monitor lipid levels and liver function timely. 2. For Resident #30, the facility staff failed to obtain lab work to monitor lipid levels timely. Findings include: Review of the facility's policy titled Medication Regimen Review, revised 8/17/23, indicated, but was not limited to: -The attending Physician should address the Consultant Pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. 1. Resident #26 was admitted to the facility in October 2018 with the following diagnoses: Dementia and status post Cerebral Vascular Accident…

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, interviews and policy review, the facility failed to ensure that medications were stored in a safe and secure manner and medication storage rooms were maintained in a sanitary manner. Specifically, facility staff: -stored Heparin flushes in an unlocked drawer of a resident's nightstand with availability to any resident having access to the room. - were using and storing personal food containers in the medication storage room, with risk of spilled contents and contamination. Findings include: Review of the facility's policy titled Storage of Medications, revised April 2007, indicated, but was not limited to: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments containing drugs and biologicals shall be locked when not in use shall not be left unattended if open or otherwise potentially available to others. -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. On 9/6/23 at 2:50 P.M., the surveyor and Nurse #3…

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 and records reviewed for one Resident (#23) out of a total sample of 13 residents, the facility failed to ensure an accurate medical record was maintained relative to Physician's orders for the care and services of a Foley urinary catheter (tubing inserted into the bladder to that allows urine to drain outside the body). Findings include: Review of the facility policy titled Foley Catheter Insertion ., revised October 2010, indicated the following: -Verify there is a Physician's order in place for catheter insertion (procedure) -Document the size of the Foley catheter inserted . Resident #23 was admitted to the facility in October 2016 with a diagnosis of urinary retention (inability for the bladder to fully empty). Review of the September 2023 Physician's orders indicated the following orders: -Change Foley catheter monthly 16 French (Fr-the size of the catheter tube) 10 milliliter (ml) balloon (a device that is inflated in the urinary bladder to hold the catheter in place) with a start date of 10/18/22. Further review of the September 2023 Physician's orders…

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.