Culver West Health Center

In the surveyor’s words

From the most serious findings on record at Culver West Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 15, 2023

  Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity for one of 10 sampled residents (Resident 1) by failing to: 1. Implement the Comprehensive Care Plan for diabetic ulcer (a slow-healing wound that commonly appears on the feet) interventions on monitoring Resident 1 ' s blood sugar to help with wound healing. 2. Ensure that a recommendation of a vascular consult (a doctor who specializes in the treatment of arteries and veins) by the Wound Care Specialist/Nurse Practitioner (WCS) was followed up with the physician to obtain an order after Resident 1 ' s left heel wound size changed from 8/8/2023 with a measurement of 4.2 centimeters (cm, unit of measurement) length by 4.7 cm width and… […]

• Actual harm, isolatedF689Jul 8, 2022

  Based on observation, interview and record review, the facility failed to ensure two of seven sampled residents (Residents 1 and 2), who were at risk of elopement (leaving the facility unsupervised, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decisions), had wandering behavior (occurs when a person roams around and becomes lost or confused about their location) and had high risk for falls, were provided a safe environment with supervision as indicated in the plan of care and the facility ' s policies. As a result: 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 19, 2024

  Based on observation, interview and record review, the facility failed to prepare and store food in safe and sanitary condition and/or manner to prevent growth of microorganisms when: 1. Hairnets were not worn in the kitchen according to the facility's policy and procedures. 2. Hand hygiene and apron change were not performed during dishwashing when transition from dirty dishes to clean dishes. 3. Drinks and other food items were left at bedside for Resident 33 without proper storage and/or refrigeration for over 14 hours. […]

• No harm, potential for more than minimal, widespreadF925Sep 15, 2023

  Based on observation, interview, and record review, the facility failed to maintain the facility pest free (free of cockroaches and flies), maintain the facility clean, prevent pest harborage areas, and maintain an effective pest control program. As a result of the noncompliance, Resident 1 was transferred to the general acute care hospital 1 (GACH 1) on 8/23/2023, and reported maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s left heel wound upon admission in the Emergency Department (ED). […]

• No harm, potential for more than minimal, widespreadF802Oct 28, 2021

  Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services as follows: 1. Cook 1 failed to describe how to properly calibrate (calibration is the process of configuring an instrument to provide a result for a sample within an acceptable range) thermometers; 2. Cook 1 failed to describe acceptable quaternary ammonium compound (a type of chemical that is used to kill bacteria, viruses, and mold) sanitizer range; 3. Trayline Staff 1 failed to describe how to properly sanitize when manually washing dishes; and 4. […]