Western Hills Health Care Center

In the surveyor’s words

From the most serious findings on record at Western Hills Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 19, 2026

  Based on record review and interviews, the facility failed to ensure one (#2) of three residents at risk for elopement out of three sample residents received adequate supervision and was kept free from elopement.Resident #2 was admitted on [DATE] with diagnoses of unspecified dementia, abnormalities of gait and mobility, history of falling and depression. On 7/3/26 the nurse noticed Resident #2 was not in the dining room for dinner. His room and the facility's lobby were checked because that was where the resident usually sat. Resident #2 could not be located. The facility was notified by the police department that Resident #2 was in the hospital following a fall outside with a head injury. […]

• No harm, potential for more than minimal, widespreadF908May 14, 2026

  Based on observations and interviews, the facility failed to ensure that essential food service equipment was maintained in a safe and functional condition in the main kitchen.Specifically, the facility failed to repair a broken, nonfunctional heated plate dispenser in the main kitchen.Findings include:I. ObservationDuring a continuous observation on 5/13/26, beginning at approximately 11:45 a.m. and ending at the kitchen's heated plate dispenser/lowerator was observed to be completely disconnected from electrical power, with its power cord left unplugged and coiled on the floor beside the unit.The staff were placing the plates on top of the broken dispenser without electrical power. The internal heating elements were inactive and the unit was cold to the touch. […]

• No harm, potential for more than minimal, widespreadF677Jul 13, 2021

  Based on observations, record review and interviews, the facility failed to ensure eight (#13, #74, #68, #9, #65, #70, #29 and #27) of eight dependent residents reviewed for assistance with activities with daily living (ADLs) out of 40 sample residents received appropriate treatment and service to maintain personal hygiene. Specifically, the facility failed to ensure dependent Residents #13, #74, #68, #9, #65, #70, #29 and #27 received regular bathing in accordance with their plan of care. The failure to ensure bathing was provided in accordance with plans of care for dependent residents affected all eight sample residents and was recognized to affect all other residents who were dependent on staff for bathing. […]

• No harm, potential for more than minimal, widespreadF725Jul 13, 2021

  Based on observation, interviews and record review, the facility failed to provide sufficient nursing staff to ensure residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically,that facility failed to consistently provide adequate nursing staff to ensure that residents received regular and routine showers and/or baths and assistance with activities of daily living. Cross-reference the following citations: F676 and F677: the facility failed activities of daily living to residents that impacted residents facility-wide. The facility failed to provide resident bathing according to their preference to residents who required supervision to be fully dependent on staff to meet their bathing needs. […]

• No harm, potential for more than minimal, widespreadF867Jul 13, 2021

  Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify a QAPI plan, which was in place, to address residents not receiving showers in accordance with their plan of care, was unsuccessful and put new interventions into place to successfully address the concern. Cross reference F676: the facility failed to ensure showers were provided to residents in accordance with their plan of care. […]