West River Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF690Aug 19, 2024

  Based on interview and record review, the facility failed to ensure services were provided to a resident with an indwelling urinary catheter to prevent the development of infection for 1 of 1 resident reviewed for a catheter-associated urinary tract infection (CAUTI). (Resident 32) This deficient practice resulted in Resident 32 developing a CAUTI with septic shock and pneumonia. Resident 32 required artificial ventilation and treatment at a hospital-based intensive care unit. (Resident 32) Finding includes: On 8/13/24 at 11:20 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease, obstructive uropathy, dementia. […]

• Actual harm, isolatedF689May 9, 2024

  Based on observation, interview, and record review, the facility failed to ensure effective supervision was provided to a cognitively impaired, dependent resident to prevent falls and failed to ensure the bed was in low position with a fall mat in accordance with the plan of care to prevent injury for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident B experiencing an unwitnessed fall from the bed, landing on the floor, and sustaining a left clavicle fracture. (Resident B) Finding includes: On 5/8/24 at 8:41 a.m., Resident B was observed sitting in a wheelchair in his room. On 5/8/24 at 9:39 a.m., Resident B's clinical record was reviewed. […]

• Actual harm, isolatedF689May 27, 2021

  Based on observation, record review, and interview, the facility failed to adequately supervise and implement effective interventions for 1 of 3 residents who were fall risks. Resident C acquired a fractured fibula related to a fall, after having had multiple falls with interventions that were not effective with his cognitive status, and increased confusion and impulsivity. ( Resident C) Finding includes: During the initial tour on 5/26/21 at 8:30 a.m., Resident C was observed in his room lying in bed. The MDS Coordinator indicated Resident C had a recent fall that had resulted in a fracture. On 5/27/21 at 12:24 p.m., Resident C was observed in dining room for lunch, conversing with other residents. […]

• No harm, potential for more than minimal, patternF677Aug 19, 2024

  Based on interview, record review, and observation, the facility failed to ensure residents dependent on staff for ADL (activities of daily living) were bathed for 4 of 4 residents reviewed for ADL care. (Resident 11, Resident 32, Resident 148, Resident 6) Findings include: 1. During an interview on 8/12/24 at 11:01 A.M., Resident 32's family indicated Resident 32 was not receiving showers as often as he should be. On 8/13/24 at 11:20 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. […]

• No harm, potential for more than minimal, patternF812Aug 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen and 1 of 1 observations of unit refrigerators. Food was not labeled, floors were soiled, and equipment was soiled. (Kitchen, Certified Locked Dementia Unit) Findings include: On 8/12/24 at 6:58 A.M., the following was observed in the kitchen: 1. walk in cooler - 2 bags of lunch meat, one open to air, no labels. 2. walk in freezer - clear bag of cookies no label, container of individually sealed frozen pork chops, no label. 3. […]