Western Convalescent Hospital

In the surveyor’s words

From the most serious findings on record at Western Convalescent Hospital, in the surveyor’s own words.

• Immediate jeopardy, patternF880Apr 28, 2023

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program for scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) for eight of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 7, Resident 8, Resident 19, Resident 21 and Resident 26) afterfacility was informed Resident 1 (who was transferred from the facility to a general acute care hospital [GACH] on 3/25/2023 with rashes) was diagnosed and treated for scabies on 3/26/2023 and returned to the facility on [DATE]. The facility failed to: 1. […]

• Immediate jeopardy, patternF580Jan 28, 2021

  Based on interview, and record review, the facility failed to implement interventions to prevent the decline of residents who were confirmed with COVID-19 (a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) in accordance with the facility's policies and procedures (P/P) and mitigation plan ((MP) a plan to prevent loss of life by failing to ensure the following: 1. Resident 1 had a change in condition (COC) of a decrease in oxygen (O2) saturations (amount of oxygen in the blood) and notify the family about the change in condition in a language that they understood to confirm their wishes for end of life. The facility did not honored Resident 1's Physician order [REDACTED]. […]

• Actual harm, isolatedF689Apr 7, 2023

  Based on interview, and record review, the facility failed to prevent one of three sampled residents (Resident 1), who was at risk for falls and had a history of involuntary movements from falling off the bed to the floor by failing to: 1. Ensure a Certified Nursing Assistant (CNA) 1, used a two-person assist while providing care to Resident 1 on 3/5/2023. 2. Follow Resident 1's care plan titled At risk for falling from Low Air Loss Mattress ([LAL], a mattress designed to prevent and treat pressure wounds) which indicated Resident 1 required a two-person assist with transfers, repositioning, and daily care. […]

• No harm, potential for more than minimal, widespreadF880Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to implement its infection control program by failing to: 1. Ensure the Laundry Aide (LA) performed hand hygiene, changed gown and gloves after sorting dirty linen and prior to handling clean linen. This deficient practice put all the residents at risk for cross contamination (movement of bacteria from one place to another) and infection. 2. Refrigerate opened food item, as indicated in the bottle container, for one of three sampled residents (Resident 93). This deficient practice had the potential for Resident 93 to experience foodborne illnesses (food poisoning). Findings: 1. During a concurrent observation and interview on 3/19/2025 at 11:54 a.m. […]

• No harm, potential for more than minimal, widespreadF803Aug 17, 2021

  Based on observation, interview, and record review, the facility failed to use the correct scoop size for ground meat, regular starch, puree potatoes and mechanical soft meat during lunch service for 41 of 41 residents who were ordered regular, mechanical soft, chopped and pureed diet. These deficient practice had the potential to result in inadequate calories and protein to residents who did not receive the correct amount of food. Findings: During an observation on 8/10/21 at 11:45 a.m. in the kitchen during serving of the lunch trays (trayline), the cook (Cook 1) was observed using the following: 1. Scoop size number 16 [equal to one fourth (1/4) cup or 2 ounces] for regular ground meat 2. […]