West Side House LTC Facility

In the surveyor’s words

From the most serious findings on record at West Side House LTC Facility, in the surveyor’s own words.

• Actual harm, isolatedF760Mar 24, 2021

  Based on record review and interview, the facility failed to ensure one resident (#33) was free of significant medication errors prescribed to help control aggressive behavior, in a total sample of 13 residents. Findings include: Resident #33 was admitted to the facility in November of 2020. Review of the Minimum Data Set Assessment, dated 11/16/20, indicated Resident #33 had cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 9 out of 15, had exhibited verbal behaviors 4 to 6 of the 7 previous days and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a consult from a Behavioral Health Group, dated 1/19/21, indicated the following: -Resident #33 continues to exhibit aggression. […]

• No harm, potential for more than minimal, widespreadF812Dec 30, 2024

  Based on observation, and interview, the facility failed to follow professional standards of practice for food safety in the main kitchen to prevent the potential spread of foodborne illnesses to residents who are at high risk. Specifically, the facility failed to ensure food temperatures were taken and documented prior to meal service in the facility's main kitchen to ensure the food temperatures were within acceptable parameters for food safety. Findings include: Review of the facility policy titled Food Temperature Testing, dated July 2013, indicated the following: -Temperature of food items in the steam table are to be taken at the beginning of service and at the end of service using the following method: a. Sanitize thermometers by cleaning with alcohol wipes. b. […]

• No harm, potential for more than minimal, widespreadF812Sep 7, 2023

  Based on observations, interviews and policy review, the facility failed to maintain professional standards for safe and sanitary food storage in the main kitchen and in two out of two kitchenettes. Findings include: Review of the facility policy titled Food Rotation Policy, dated 3/2023, indicated the following: -Label and date food items on food delivery day. Review of the 2022 United States Food and Drug Administration Food Code indicated the following: >Food shall be protected from contamination by storing the food: -In a clean, dry location. -Where it is not exposed to splash, dust, or other contamination. -At least 15 centimeters (six inches) above the floor. […]

• No harm, potential for more than minimal, widespreadF727Feb 2, 2022

  Based on observation, record review and interview, the facility failed to: (1.) ensure the services of a registered nurse (RN) were used for at least 8 consecutive hours a day, 7 days a week and (2.) ensure a Director of Nurses (DON) was employed on a full time basis. Findings include: 1. The facility failed to ensure the services of an RN were used for at least 8 consecutive hours a day, 7 days a week. Review of the last two weeks of January 2022 nursing schedules indicated no RN was scheduled on 1/16/22, 1/18/22, 1/25/22, 1/29/22, and 1/30/22. During an interview on 2/02/22 at 9:56 A.M., Administrator #1 said he did not have evidence that a RN worked on 1/16/22, 1/18/22, 1/29/22, and 1/30/22, as required. He said he still needed to check on the other dates in question. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2022

  Based on observation, interview, and policy review the facility failed: (1.) to store food in accordance with professional standards for food service safety, and (2.) to monitor temperatures in the kitchen refrigerators and freezers and the nourishment kitchen refrigerator. Findings include: Review of the facility's policy for Food Rotation, dated ,d+[DATE], indicated the following: Purpose: To ensure food is stored and rotated properly. Procedure: -Food should be stored at proper temperature. -Maintain temperature log for refrigerator and freezer -Identify the expiration date on the food -Inspect dates and labels on food weekly 1. The facility failed to ensure that staff stored food in accordance with professional standards for food service and safety. […]