Quality Life Services - Westmont

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 26 residents reviewed (Residents 14, 24, 32). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415A was to be coded if the resident received an antipsychotic medication during the seven-day assessment period, and Section N0451K was to be coded if the resident received an anticonvulsant medication during the seven-day assessment period. Physician's orders for Resident 14, dated January 16, 2021, included an order for the resident to receive 100 milligrams (mg) of gabapentin (anticonvulsant 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.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for one of 26 residents reviewed (Resident 6) who was on Enhanced Barrier Precautions (EBP) for having a surgically implanted drain. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 5, 2025, revealed that the resident was cognitively intact and dependent on staff for daily care tasks. Physician's orders for Resident 6, dated May 16, 2024, included an order that the resident may not be showered due to his surgically implanted percutaneous drain (gallbladder drain). Physician's order, dated June 12, 2024, included an order for the staff to flush the gallbladder drain vigorously daily. Observations of Resident 6 on February 18, 2024, at 10:08 a.m. revealed that the resident had a sign on his door indicating that he was on EBP and had personal protective equipment…

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's weight as recommended by the dietician for one of 23 residents reviewed (Resident 14). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding weights, dated April 8, 2024, revealed that if a weight is obtained and a five-pound weight loss or gain has occurred for individuals weighing greater than 100 pounds or a three-pound weight loss or gain occurred for individuals weighing less than 100 pounds, then a re-weight should be obtained within 24 hours of the first obtained weight. Staff were to ensure the individual was weighed on the same scale as previously used, and when the re-weight was obtained the weight should be documented in the medical record, stating that it was a re-weight and the previous weight should be struck out. All residents with a significant weight change would be assessed and referred to the dietitian for assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated…

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 26 residents reviewed (Resident 33). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated December 23, 2024, revealed that the resident was understood, could understand others, and had a diagnosis of anxiety. A care plan for the resident, dated October 14, 2024, revealed that the resident uses anti-anxiety medications related to an anxiety disorder, and staff was to administer the anti-anxiety medications to the resident as ordered by the physician. Physician's orders for Resident 33, dated December 20, 2024, included an order for the resident to receive a one milligram (mg) tablet of Clonazepam (a narcotic medication used to prevent and treat anxiety disorders) every eight hours as needed. Resident 33's controlled drug logs for January and February…

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 26 residents reviewed (Resident 33). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated December 23, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included anxiety. A care plan for the resident, dated October 14, 2024, revealed that the resident uses anti-anxiety medications related to an anxiety disorder, and staff was to administer the anti-anxiety medications to the resident as ordered by the physician and that staff should attempt non-pharmacological interventions (e.g., massage, music, quiet time, reading, watching TV, etc.) before the resident is offered the as needed psychotropic medication (medications that affect the mind and behavior). Physician's orders for 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.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 26 residents reviewed (Residents 1, 4, 12). Findings include: The facility's policy regarding care plan development and revision, dated October 12, 2023, indicated that resident care plans are reviewed and updated at least quarterly and as a resident's condition changes (such as when medications are added or discontinued, resident returns from the hospital, and with changes in mood, behaviors or care needs). A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included heart failure, high blood pressure, and dementia. A care plan for Resident 1, dated March 22, 2023, revealed that the resident had oxygen related…

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 26 residents reviewed (Resident 1, 4, 12). Findings include: The facility's policy regarding physician's orders, dated October 12, 2023, revealed that physician's orders were to be followed in accordance with good nursing principles and practice and were to be transcribed and carried out by the persons legally authorized to do so. A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included heart failure, high blood pressure, and dementia. Physician's orders for Resident 1, dated May 9, 2023, included an order for the resident to receive 60 milligrams (mg) of isosorbide mononitrate (a medication for high blood pressure) one time a day and to hold…

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 26 residents reviewed (Residents 1, 30, 31). Findings include: The facility's policy regarding medication administration, dated October 12, 2023, indicated that medications administered will be documented on the Medication Administration Record (MAR). For as needed medications, the nurse will document initials and time of administration on the MAR. A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnosis that included heart failure, high blood pressure, and dementia. Physician's orders for Resident 1, dated December 28, 2023, included an order for the resident to receive 50 milligrams of Tramadol (a controlled medication used to…

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 review of the clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a clean and homelike environment related to the cleanliness of wheelchairs for one of 26 residents reviewed (Resident 18). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated February 14, 2024, indicated that the resident was moderately cognitively impaired, required assistance from staff for his daily care needs, had impairment on one side of the upper and lower extremities, and used a wheelchair. Observations on April 1, 2024, at 3:32 p.m. and April 3, 2024, at 11:05 a.m. revealed that Resident 18's wheelchair had a dried, brown/tan, removable substance on the metal bars of the chair. Interview with Nurse Aides 1 and 2 on April 3, 2024, at 11:07 a.m. confirmed that the chair had a dried, brown/tan, removable substance on the wheelchair that needed cleaned. Housekeeping and nursing staff were responsible for cleaning wheelchairs as needed 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 review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for one of four employees reviewed (Licensed Practical Nurse 3). Findings include: The facility's abuse policy, dated October 12, 2023, indicated that the facility developed and implemented personnel and other policies to ensure that all staff are qualified and meet all regulatory standards for hire. The facility's screening procedures included conducting reference checks of previous and present employers, criminal background checks on potential employees as well as contracted personnel, verification of nursing licenses with the State Board of Nursing, and verification of nurse aide standing with the state Nurse Aide Registry. The personnel file for Licensed Practical Nurse 3 revealed that she was hired on January 4, 2024, and as of April 2, 2024, (four months after hire) a professional licensure verification with the Pennsylvania State Board of Nursing had…

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 facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop individualized care plans that included resident-centered interventions for two of 26 residents reviewed (Residents 23, 30). Findings include: The facility's policy regarding care plan development, dated October 12, 2023, indicated that an individualized, interdisciplinary care plan is initiated within 24 hours of admission based on available resident-specific information related to resident assessments, interviews, previous medical records, identified goals, and physician's orders. The care plan is formally reviewed and completed within 21 days after admission. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated March 6, 2024, revealed that the resident was cognitively intact, required assistance from staff for his daily care needs, and was frequently incontinent of bowel and bladder. Interview with Resident 23's wife (the resident's representative) on April 2,…

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 review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of 26 residents reviewed (Resident 12) who was at risk for falls. Findings include: The facility's policy regarding managing falls and fall risks, dated December 21, 2022, indicated that in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). A care plan for Resident 12, dated January 15, 2024, revealed that the resident had 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 facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a physician's order was obtained to provide oxygen therapy for two of 26 residents reviewed (Residents 12, 30). Findings include: The facility's policy for oxygen administration, dated October 12, 2023, revealed that oxygen therapy via nasal cannula will be administered as ordered by a physician and will include correct flow rate, concentration, mode of delivery, and frequency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). A review of physician's orders for Resident 12 revealed that there was no order for the resident to receive oxygen therapy. A care plan for Resident 12, dated June…

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 review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 26 residents reviewed (Resident 12). Findings include: The facility's policy regarding physician's orders, dated October 12, 2023, revealed that physician's orders are to be followed in accordance with good nursing principles and practice and are to be transcribed and carried out by the persons legally authorized to do so. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included diabetes mellitus. Physician's orders for Resident 12, dated May 1, 2023, included an order for the resident to receive 5 units of insulin Novolog (used to lower blood sugar levels) before meals and to hold if Accucheck is 150 milligram/deciliter (mg/dL) or less.…

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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to discard two expired multi-dose insulin vials in one of one medication carts reviewed (B Hall), and failed to securely store medication in one of one medication carts reviewed (B Hall). Findings include: The facility's policy regarding administering medications, dated [DATE], indicated that during medication administration the medication cart will be locked if it is not clearly within view. No medications will be left unattended on top of the medication cart. Observations of a medication pass on [DATE], at 8:52 a.m. revealed that Licensed Practical Nurse 5 left a card of Januvia (a medication used to help lower blood sugar) 25 milligrams (mg) tablets on top of the medication cart unsupervised while she entered a resident's room to administer medication. Interview with Licensed Practical Nurse 5 at that time confirmed that she should not have left the medication on top of the cart…

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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by not discarding an opened, expired food item. Findings include: The facility's policy regarding food storage, dated October 12, 2023, revealed that all staff must provide the date a food or beverage item is opened with a date marked to indicate the date by which the food item should be consumed or discarded. Foods with a manufacturer use-by date must be used or discarded by the stamped date. Observations in the small kitchen refrigerator on April 1, 2024, at 8:43 a.m. revealed an opened container of Miracle Whip salad dressing with a resident's name on it and an opened date of September 2023. No use-by date was indicated on the jar and the container had a stamped expiration date of January 2024. Interview with the Dietary Manager, at the time of observation, confirmed that the opened container of Miracle Whip salad dressing was expired and should have been discarded…

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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the surveys ending May 18, 2023; August 21, 2023; and October 12, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 3, 2024, identified repeated deficiencies related to comprehensive care plans, care plan timing and revision, quality of care, safe environment/supervision, respiratory care, pharmacy services, labeling and storage of drugs/biologicals, and food…

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident's representative was notified of changes in condition and new physician's orders for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding communication of health status/notification of family, dated October 12, 2023, indicated that the facility was to notify the resident and/or the resident's family/responsible party of any changes in resident's condition, including new physician orders or changes in current orders. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 9, 2023, indicated that the resident was cognitively intact, required assistance from staff with daily care tasks, had an indwelling urinary catheter (a flexible tube inserted into the bladder through the urethra or suprapubically to allow for urine drainage), and had diagnoses that included acute cystitis (infection…

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 review of policies, clinical records, and investigative reports, as well as staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out neglect and/or abuse for one of three residents reviewed (Resident 2). Findings include: The facility's policy for protection from abuse, neglect or exploitation, dated March 2, 2023, indicated that all reports of injuries of unknown source will be investigated. All investigations will be conducted thoroughly and will attempt to gather as much factual information as possible. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated September 7, 2023, revealed that he was alert and able to make his needs known; required extensive assistance of one for hygiene, eating, and bed mobility; used oxygen; and had a tracheostomy (a tube that is placed into a surgical opening made in the neck and into the trachea to breathe through). The plan of care for Resident 2, dated May 3, 2023, indicated that he agreed on a method…

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of three residents reviewed (Resident 2). Findings include: The facility's policy for care plan and interdisciplinary care conferences, dated March 2, 2023, indicated that an individualized care plan is a working tool and that it was to be reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated September 7, 2023, revealed that he was alert, able to make his needs known; required extensive assistance of one for hygiene, eating, and bed mobility; used oxygen; and had a tracheostomy (a tube that is surgically placed in the neck and into the trachea that the resident breathes through). The resident's plan of care, dated May 11, 2023, indicated that staff were to monitor him for any risk…

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified about a significant change in condition for one of three residents reviewed (Resident 2), resulting in a delay in treatment. Findings include: The facility's policy regarding physician notification, dated March 2, 2023, revealed that upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician as indicated. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and are needs) for Resident 2, dated July 20, 2023, indicated that the resident was cognitively impaired, had behaviors, required extensive assistance with daily care needs, including transfers and ambulation (walking), had a history of falls, and had diagnoses that included dementia. A nursing note, dated July 26, 2023, at 8:58 p.m. revealed that Resident 2…

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.