Western Hills Health Care Center

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/08/2024 and 04/14/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/01/2024 and 04/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is one story, Type V(111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1963 and is license for 140 beds. This re-certification survey conducted on March 20, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenanc.. STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. Testing of the emergency power systems.1) At the time of the survey no records were available to verify testing and recording of batteryconductance testing in connection with the emergency power supply system (Emergency Generator) monthly.2) During document review, the testing documents did not indicate the amperage or voltage out.. STANDARD is not met as evidenced by: It was determined through observation during the survey that the facility failed to provide curtains that comply with NFPA 701 in all areas, as required by the Life Safety Code. This deficiency has the potential to affect all building occupants, including all staff, visitors, and residents. The facility was unable to provide documentation at the time of the survey to reflect that undocumented curtains throughout resident' s rooms met the requirements of NFPA 701. Curtains The Life Safety Code Section 21.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 .. STANDARD is not met as evidenced by: Based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals annually for not less than 1 ½ hours.7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered e.. STANDARD not met: Based on observation and staff interview during the tour of the facility, it was determined the facility failed to maintain the Heating, Ventilating, and Air-Conditioning Systems in accordance with Section 9.2, 19.5.2.1.9.2, NFPA 90A and 19.5.2.2. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. Sheet metal screws utilized to connect the pipe joints on the exhaust vents on both Type 2 clothes dryers in the laundry. NFPA 54, Section 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system.The dryer vent deficiencies were discussed wit..

A recertification survey with complaint #CO34773 and #CO34991 was completed on 2/21/24 to 2/27/24. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 2/21/24 to 2/27/24. No deficiencies were cited. Based on interviews and observations, the facility failed to ensure residents the right to retain and use personal possessions that promote a homelike environment and support each resident in maintaining their independence for four (#4, #234, #65 and #22) of five residents reviewed for a homelike environment out of 38 sample residents.Specifically, the facility failed to ensure Resident #4, Resident #234, Resident #65 and Resident #22 were a.. Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater.Specifically, the facility medication administration observation error rate was 7.14% or two errors out of 28 opportunities.Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607, retrieved on 2/28/24, "Take.. Based on observations, record review and interviews, the facility failed to ensure one (#41) of two residents with limited mobility reviewed for range of motion (ROM) out of 38 sample residents received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.Specifically, the facility failed to order physical therapy or occupational therapy to ensure Resident #41 did not have a potential decline in ac.. Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for two out of three units.Specifically, the facility failed to:-Ensure disinfectant dwell times were followed by the housekeeping staff when cleaning resident' s rooms; and,-Ensure staff performed hand hygiene .. Based on record review and interviews, the facility failed to report an allegation violation of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#41) of two residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an allegation of verbal abuse of Resident #41 by a staff member to the facility administrator, local law enforcement or the State Agency. Findings inclu.. Based on record review and interviews, the facility failed to thoroughly investigate an allegation of physical abuse involving two (#41 and #21) of two residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to:-Investigate allegations of physical and/or emotional abuse reported by Resident #41 to a provider; and,-Conduct an investigation of a bump and bruising (injuries of unknown origin) to Resident #21. Cross-refer.. Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#140) of one resident out of 38 sample residents.Specifically, the facility failed to:-Ensure clinical signs and symptoms of an infection were identified for Resident #140 prior to administering antibiotics; and,-Ensure a urinalysis with a culture (laboratory test..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/01/2024 and 01/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.