Western Hills Retirement Village

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Aug 20, 2026

  Based on observation, staff interview, and policy review, the facility failed to ensure food was procured, stored, and prepared in a sanitary condition. This had the potential to affect all of the residents residing in the facility. The facility census was 105 residents. Findings include:1. Observation on 08/17/26 at 9:18 A.M. of the walk-in refrigerator revealed it contained a box of diced cabbage with a delivery date of 07/24/26 and a best if used by date of 08/02/26 written on the box.Interview on 08/17/26 at 9:18 A.M. with Dietary Director (DD) #791 confirmed the box of cabbage was expired and should have been discarded. […]

• No harm, potential for more than minimal, widespreadF812Oct 24, 2024

  Based on observation and staff interview, the facility failed to ensure vents in the kitchen were maintained in a clean and sanitary manner. This had the potential to affect all 100 residents in the facility. The facility census was 100. Findings include: Observation on 10/21/24 at 8:55 A.M. revealed a duct in the center of the kitchen food preparation and service area with two vents on each side, fully coated in a dark gray and fuzzy substance. Interview at the same time with Dietary Director (DD) #65 verified the four vents were coated in a dark gray fuzzy substance. DD #65 stated the vents were cleaned monthly and needed to be cleaned again. Observation on 10/23/24 at 11:55 A.M. […]

• No harm, potential for more than minimal, widespreadF880Mar 9, 2021

  Based on observation, staff interview, review of list of residents positive for COVID-19 and review of Centers for Disease Control (CDC) guidelines, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to effectively prevent the potential spread of COVID-19. The facility had seven cases of COVID-19 within the last month. This had the potential to affect all 82 residents residing in the facility. Findings include: Observation on 03/02/21 at 5:56 P.M. revealed Nursing Assistant (NA) #315 entered Resident #73's room on the facility's 1-West wing. The door to Resident #73's room displayed a sign indicating contact and droplet precautions were to be followed, including the need to don a gown prior to entering the room. […]

• No harm, potential for more than minimal, patternF584Aug 20, 2026

  Based on observation and staff interview the facility failed to ensure that residents were served meals in a manner that created a home-like environment. This affected 18 of 18 residents observed during lunch in the second-floor dining area. The facility census was 105 residents.Findings include:Observation on 08/17/26 at 12:27 P.M. revealed lunch was served to all 18 residents in the dining area on the second floor on trays. During an interview on 08/17/26 at 1:07 P.M. Licensed Practical Nurse (LPN) #591 confirmed all 18 residents present in the second-floor dining area were served their lunch meal on trays. LPN #591 stated all meals served to residents in the second-floor dining area are served on trays.During an interview on 08/20/26 at 2:46 P.M. […]

• No harm, potential for more than minimal, patternF761Sep 23, 2021

  Based on observation, staff interview and policy review, the facility failed to ensure expired control solution for blood glucose monitors and an expired insulin pen was properly removed from the medication carts. This had the potential to affect five (#17, #24, #43, #74 and #93) residents who utilized glucose monitors and one (#89) of three resident's observed to utilize insulin pens. The facility census was 91. Findings included: 1. Observation on [DATE] at 4:01 P.M. of the medication cart on two-west revealed the blood glucose control monitor solution had expired. The high control solution had an expiration date of [DATE]. The low control solution had an expiration date of [DATE]. Interview on [DATE] at 4:08 P.M. […]