West Ridge Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Sep 21, 2022

  Based on record review, staff interview, and facility policy review the facility failed to assess, document, notify the provider and family and provide ongoing assessment of a reported wound for one of three residents reviewed (Resident #2). On [DATE] Therapy reported a wound on Resident #2's left elbow to a nurse. The nurse dressed the wound, but failed to assess and document, failed to notify the provider and family, and failed to communicate to the Wound Nurse for ongoing assessment and treatment. On [DATE] the family alerted staff that drainage was leaking out of the dressing that was dated as applied on [DATE]. […]

• No harm, potential for more than minimal, patternF812Jul 29, 2021

  Based on observation, record review and staff interview, the facility failed to date opened items when placed in the refrigerator and failed to properly label and store dried food items opened. The facility reported a census of 43 residents. Findings Include: During the initial tour of the kitchen on 7/26/21 which began at 9:55 AM with the Administrator revealed: A review of the Maximum refrigerator revealed the following items that had not been dated when opened a. A 2 quart bottle of Ruby [NAME] of grape juice. b. A ½ gallon bottle of Musselmann apple juice which had been approximately ¼ full. c. Two 64 ounce bottles of Ruby [NAME] white cranberry juice 64 oz bottles x 2 opened. d. A 64 ounce bottle of Thickit thickened water. e. […]

• No harm, potential for more than minimal, isolatedF657Nov 16, 2023

  Based on clinical record review, observations, resident, resident family members and staff interviews, and facility policy review, the facility failed to ensure Care Plans were comprehensively reviewed and revised for 1 of 1 residents reviewed for hearing (Resident #19), for 1 of 1 residents reviewed for hypnotic (sleeping pill) medications (Resident #24), and for 1 of 4 residents reviewed for pain (Resident #39). The facility reported a census of 50 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed diagnoses of vascular dementia, anxiety disorder, and other speech/language deficits following cerebrovascular disease. […]

• No harm, potential for more than minimal, isolatedF641Nov 17, 2022

  Based on clinical record review, Resident Assessment Instrument (RAI) Manual review and staff interview, the facility failed to accurately code the use of as needed pain medication on the Minimum Data Set (MDS) Assessment for 1 of 2 residents (Resident #25) sampled for pain. The Facility identified a census of 45 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 showed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive loss. The Resident required extensive assistance with bed mobility, transfer, ambulation in the room, dressing and toileting. The MDS listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF657Nov 17, 2022

  Based on observation, clinical record review, policy review, and staff interview the facility failed to follow the Care Plan as written for 2 of 12 residents (Residents #9 and #45) reviewed. The facility failed to follow Enhanced Barrier Precautions for Resident #45 and failed to measure gastric residual volume prior to a tube feeding for Resident #9. The facility reported a census of 45 residents. Findings Include: 1. Resident #9's Minimum Data Set (MDS) dated [DATE] documented the resident as receiving 51% or more of her total calories and 501 milliliters (ml) or more of fluid daily through her gastric tube. The MDS diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. […]