Westhills Village Health Care Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure that the current advance directives (a document that expresses a person's health care wishes if they become unable to speak for themselves) for five of five sampled residents (7, 13, 26, 27, and 60) were in the residents' medical records according to the provider's policy.Findings include: 1. Review of resident 7's medical record revealed she admitted to the facility on [DATE]. There was no documentation indicating that any advance directive paperwork, which expressed her wishes regarding her code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop), was completed upon admission. 2. Review of resident 13's medical record revealed she admitted to the facility on [DATE]. There was no advance directive or document that indicated her wishes regarding her code status in her medical record. 3. Review of resident 26's medical record revealed she admitted to the facility on…

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, record review, and policy review, the provider failed to ensure quality of care for one of one samples resident (27) with hemiplegia (one-sided paralysis) who was not provided a pillow under her arm for support as indicated in her care plan by one of one certified nursing assistant (I).Observation and interview on 3/10/26 at 1:08 p.m. in resident 27's room revealed she was seated in her wheelchair watching television. Her call light was lying on the bed to her left and her left hand was resting in her lap. A sign on the wall behind the resident read, Place a pillow under my left arm when I am up in the wheelchair Due to my Stroke. No pillow was positioned under resident 27's left arm. Resident 27 stated she was unsure when the staff had last placed a pillow under her left arm when she was seated in her wheelchair. 2. Observation on 3/11/26 at 1:30 p.m. revealed resident 27 was sitting in her wheelchair the commons area of the facility. Her left arm was positioned down between her…

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, record review, and policy review, the provider failed to ensure the staff followed standard infection prevention practices regarding urinary catheter (flexible tubing placed in the bladder to drain urine) care according to the provider's policy for one of one sampled resident (56) with her catheter supplies stores in a container on a shared bathroom floor, and lack of hand hygiene by two of two certified nursing assistants (D and F) observed assisting two of two sampled residents (15 and 19) with eating. Findings include:1. Observation on 3/10/26 at 10:05 a.m. in resident 56's room revealed resident 56 was asleep in her bed and shared a bathroom with her roommate. The bathroom door was open and there was an unlabeled pink plastic container on the floor under the sink. That container held a bottle of liquid with the label distilled vinegar, an empty 60cc (cubic centimeter) syringe, and an unlabeled urinary catheter (flexible tubing placed in the bladder to drain urine) urine…

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 South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review the provider failed to report to the SD DOH within the required time frame, for one of one sampled resident (1) who was sent to the emergency department, and hospitalized for observation and treatment after being administered the incorrect insulin by licensed practical nurse (LPN) D.Findings include: 1. Review of the provider's 5/4/25 SD DOH FRI regarding resident 1 revealed:*On 5/4/25 at 7:00 a.m. resident 1 was administered by injection 40 units of lispro (a fast-acting insulin) instead of the physician's ordered 40 units of glargine (a long-acting insulin) by LPN D.*At 7:04 a.m. physician G was notified of the medication error.-Resident 1 to receive an injection of glucagon (a medication used to increase the blood sugar in the body).-To continue encouraging resident 1 to eat and drink carbohydrates in an attempt to prevent resident 1's blood sugar from becoming too low.-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure: *Proper glove use by one of one cook (Q) during two of two observed meal services. *Proper temperature probe cleaning by one of one cook (Q) during one of one observed meal service. Findings include: 1. Observation on 11/19/24 at 11:06 a.m. of cook Q preparing for the noon-time meal service revealed: *He put on clean gloves, removed waffles from a plastic bag then placed them in a toaster. *Wearing the same gloves he: -Organized serving plates, paper products, and utensils for the meal. -Retrieved hot dog buns and hot dogs from two separate plastic bags. -Began cutting one of the hot dogs then turned his attention to the waffles that had popped up from inside of the toaster. --Touched the waffles then lowered them back inside of the toaster for additional toasting time. -Resumed cutting the hot dog. 2. Observation on 11/19/24 at 4:15 p.m. of cook Q temping food for the evening meal service and interview with food services manager…

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 record review, the provider failed to ensure communication and resident care were provided in a dignified manner for five of five sampled residents (19, 24, 31, 33, and 35) by one of one certified nursing assistant (CNA) N. Findings included: 1. Observation and interview on 11/19/24 at 9:30 a.m. in resident 33's room revealed: *She sat in her chair with a bedside table beside her. *She had a wheelchair and a hemi-walker (specialty walker to aid soneone with limitation on one side of their body) in her room. *She said an assistant told her she had not been walking enough. -She had a stroke that affected her left side and walked with a hemi-walker. *In the mornings when she would wake up, she would be unsteady and would not be ready to walk right away but CNA N would make her walk to the bathroom and the resident feared falling due to weakness on the left side of her body. *Resident 33 stated CNA N's tone had not been caring towards her. Review of resident 33's electronic medical record (EMR) revealed her 9/7/24 Brief Interview for Mental Status…

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.

3. Observation on 11/19/24 at 9:15 a.m. of certified nurse aide (CNA) M assisting resident 40 in her bathroom revealed: *The resident's nasal cannula was pulled out of her nose then dropped to the floor in front of the toilet when she transferred from her wheelchair onto the toilet seat. *After wiping the resident's peri-area with her gloved hands CNA M, without removing her unclean gloves, picked up the nasal cannula from off the floor and handed it to the resident to put back inside her nose. Continued observation and interview with CNA M after resident 40 exited her bathroom revealed: *The resident transferred from her wheelchair to a recliner in her room. She removed the nasal cannula connected to her portable oxygen and hung it over the back of her wheelchair. *CNA M retrieved a second nasal cannula and attached it to the resident's oxygen concentrator. -That cannula was laying underneath a reacher (adaptive grabbing device) and around a wheelchair footrest on the seat of a chair. *Without first cleaning that cannula CNA M handed it to the resident who placed it inside of her…

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 policy review, the provider failed to ensure in-room call lights were accessible for two of two sampled residents (12 and 33). Findings include: 1. Observation and interview on 11/19/24 at 9:30 a.m. in resident 33's room revealed: *She sat in her chair with a bedside table beside her. *There was a gray push call light placed on that bedside table that was to her right side. *She stated around three months ago she did not have her call light when she woke up in the morning, she had to holler to get the attention of a certified nursing assistant (CNA), the CNA came in and told her she had to stop hollering, she was upsetting the other residents. *On the morning of 11/19/24 she did not have her call light and she had to holler to get the attention of the morning CNA. *She stated at times the CNAs put the call light on her left side. -She had a stroke that affected her left side, and she could not use her left hand to push the button on the call light. *The call light that she…

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 policy review, the provider failed to ensure physician's orders were followed for: *Weight-bearing restrictions for one of one sampled resident (40). *A dressing change for one of one sampled resident (22). Findings include: 1. Observation and interview on 11/19/24 at 9:15 a.m. with certified nurse aide (CNA) M in resident 40's bathroom revealed: *The resident entered the bathroom in her wheelchair wearing a left leg immobilizer. *She twisted her upper extremity to the left and used both of her hands to reach towards the wall-mounted grab bar. She pulled herself up to stand holding those grab bars. -She then pivoted her body holding onto the grab bar and sat down on the toilet seat. *After using the toilet she used the same transferring method to return to her wheelchair. *The resident was pushed out of the bathroom in her wheelchair and positioned in front of her recliner. -She bent forward out of the wheelchair seat to grab the armrest of the recliner, pulled her body towards the chair, pivoted, then sat down in the recliner.…

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 record review, the provider failed to ensure two of two sampled residents (15 and 34) were screened for a history of trauma upon their admission to the facility. Findings include: 1. Observation and interview with resident 15 on 11/19/24 at 2:30 p.m. revealed: *She was in her recliner with her feet elevated. *When asked how she was doing she replied, How do you think I'm doing? -She indicated her right arm and shoulder, and her left leg weren't working. She had arthritis and used either a walker or a wheelchair for mobility. *She was living with her family before she came to the facility. She expected to remain there for long-term care. *She became teary-eyed talking about a flood in 1972 that damaged the family-owned business. In the 2000's, her home was destroyed by a wild fire. One of her sons was developmentally disabled. She voiced regret about having not been more active in things like the PTA (Parent-Teacher Association) when her children were school-aged. Review of resident 15's electronic medical record (EMR) revealed: *Her admission…

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.