Westlake Health and Rehabilitation Center

A complaint survey, prompted by #CO39594 and Incident #39723 was completed on 4/2/25 to 4/7/25. One deficiency was cited. Based on observation, record review and interviews, the facility failed to ensure one (#12) out of four sample residents were free from significant medication errors.Resident #12, who was admitted to the facility on 4/27/23, had a mechanical heart valve and was at a high risk for deep vein thrombosis (DVT). The resident had a physician' s order to receive warfarin (a bloodthinning medication) to assist with preventing blood clots. Additionally, the resident had a physician' s order to periodically monitor the resident' s PT/INR (prothrombin time test/international normalized ratio - a blood test that measures how long it takes the blood to clot). The resident' s physician adjusted the resident' s warfarin dose based upon the results of the PT/INR blood test. According to the pharmacist (PHA), Resident #12' s therapeutic level of warfarin (PT/INR goal range) was 2.5 seconds to 3.5 seconds (see PHA interview below). On 2/17/25 a physician' s order was obtained to hold Resident #12' s warfarin medication on 2/18/25 and 2/19/25 due to a PT/INR level of 4.84 seconds, which meant the resident' s blood clotting time was too high. The facility was to recheck the PT/INR and give a one-time dose of warfarin 4 milligrams (mg) on 2/20/25. The resident' s PT/INR was rechecked on 2/20/25 and was 3.12 seconds. The facility' s nurse received a verbal physician' s order to restart Resident #12' s warfarin at 3.5 mg and recheck the PT/INR the following Wednesday (2/26/25). However, the facility failed to ensure the 2/21/25 physician' s order for warfarin was transcribed into the electronic medication record (EMR) and onto Resident #12' s February 2025 medication administration record (MAR), which resulted in a failure to provide anticoagulant medication for seven days and led to a significant reduction in Resident #12' s PT/INR level to 0.97 seconds (indicating the resident' s blood clotting time was too low, potentially increasing the risk for the resident to develop blood clots).The facility' s failure to administer Resident #12' s anticoagulant therapy for seven days led to a n..

A complaint survey, prompted by #CO37641 and #CO37684 was conducted on 10/16/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.Specifically, the facility failed to ensure two ceiling swamp cooler vents, two shower rooms and eight mechanical rooms were thoroughly cleaned, free from debris and did not contain any black discoloration on any surfaces.Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy, revised September 2024, was provided by the assistant director of nursing (ADON) on 10/16/24 at 12:12 p.m. The policy revealed that in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This included ensuring that the resident could receive care/services safely and the physical layout of the facility maximized resident independence and did not pose a safety risk. The environment referred to any environment in the facility that was frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. The term orderly was defined as an uncluttered physical environment that was neat and well kept. The term sanitary included, but was not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment included but was not limited to, equipment used in the completion of the activities of daily living. Housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly and comfortable environment.II. Observations An environmental tour of the facility was conducted on 10/16/24 at 10:00 a.m. The following observations were made:The hallway ceiling air vent (Swamp Cooler) by resident room #305 had two missing vent louvers. There was dark debris on the vent louvers and on the ceiling surrounding the vent.The ..