Western Hills Healthcare Residence

In the surveyor’s words

From the most serious findings on record at Western Hills Healthcare Residence, in the surveyor’s own words.

• Immediate jeopardy, patternF580Mar 25, 2024

  48883 Based on observation, interview, and record review, the facility failed to have a system in place to monitor that nursing staff were notifying the physician for 4 of 6 residents (Resident #3, Resident #11, Resident #31, Resident #38) when insulin was held and resident blood glucoses over 250 for 2 of 6 (Resident #38, Resident #31) residents reviewed for diabetic care. 1. The facility failed to notify the physician when Resident #3's Insulin Glargine and Insulin Lispro were held without a physician order 13 times during a 3-month review (January 2024, February 2024, March 2024). 2. The facility failed to notify the physician when Resident #11's Insulin Glargine and Novolin R Solution was held without a physician order 4 times during a 1-month review (March 2024). 3. […]

• Immediate jeopardy, patternF726Mar 25, 2024

  44728 Based on interview and record review, the facility failed to provide residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for Diabetic care. 1. The facility failed to ensure RN C notified the physician that Resident #38's blood glucose was over 250, 5 times during a 3-month review period. 2. The facility failed to ensure RN C administered Resident #3's Insulin Glargine 3 times during a 3-month review period and Resident #38's Insulin Glargine 2 times during a 3-month review period, per physician order. 3. […]

• Immediate jeopardy, patternF760Mar 25, 2024

  48883 Based on observation, interview, and record reviews, the facility failed to remain free of significant medication errors for 4 of 6 (Resident #3, Resident #11, Resident # 31, Resident #38) residents reviewed for medication administration. 1. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 6 times during a 3-month review period (January 2024, February 2024, March 2024) and Resident #38's Insulin Glargine 1 times during a 3-month review period (January 2024, February 2024, March 2024)., per physician order. 2. The facility failed to ensure RN C administered Resident #3's Insulin Lispro 7 times during a 3-month review period (January 2024, February 2024, March 2024). 3. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2025

  Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 05/12/2025 between 10:45AM and 11:30 AM of the kitchen revealed: Dry Storage: 1. Cheerios type cereal out of the original container not labeled with a use by date. 2. Raisin bran type cereal out of the original container not labeled with a use by date. 3. [NAME] crispy type cereal out of the original container not labeled with a use by date. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2024

  Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly. The facility failed to ensure that food items were disposed of properly. The facility failed to ensure the freezer was free from loose food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 03/18/2024 between at 10:15 AM too 10:45 AM of the kitchen revealed: Refrigerator 1. 2 gallon jugs of sweet tea without an open or use by date 2. […]