Western MD Hospital Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF695Jun 4, 2024

  Based on review of medical records and facility investigation documentation and interviews it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards. This was found to be evident for one (Resident #40) out of four residents reviewed for respiratory care. This failure resulted in a determination on 5/31/24 at 9:45 AM of an Immediate Jeopardy for Resident #40. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 5/24/24. […]

• Actual harm, isolatedF578Jun 4, 2024

  Based on medical record review and staff interview, it was determined the facility failed to 1.) to have a process in place to ensure that the resident's wishes for resuscitation were communicated to staff so that the staff would know immediately what action to take during an emergency. This resulted in harm to Resident #96, who had a do not resuscitate (DNR) order, receiving cardiopulmonary resuscitation (CPR). The resident was resuscitated, remained at the hospital for 8 days, and returned to the facility with a chest tube inserted in each lung; 2.) reveal evidence that the resident was informed of their right to formulate an advanced directives by failing to document discussions regarding advanced directives and the outcome of the discussion in the resident's medical record and failed… […]

• No harm, potential for more than minimal, widespreadF801Dec 2, 2025

  Based on interviews it was determined that the facility failed to employ a qualified food service director. This was found to be evident for the one food service director and has the potential to affect all residents. On 11/20/25 the Food Service Director (FSD #13) confirmed that he is not a Certified Dietary Manager (CDM). The FSD reported he has taken the class and is eligible to take the exam but was not yet scheduled for the test. On 11/21/25 at 12:51 PM the FSD reported the facility has a dietitian (#11) who they consult and contact for guidance. On 11/21/25 at 12:51 PM interview with the dietitian revealed she works at the facility 20 hours per week conducting primarily clinical work such as nutritional assessments. […]

• No harm, potential for more than minimal, widespreadF812Dec 2, 2025

  Based on observation and interview it was determined that the facility failed to ensure staff identified when the automatic dishwasher was in need of maintenance and repair, and failed to ensure containers used for food preparation and service were stored in a sanitary manner. This was found to be evident during 3 out of 3 observations made in the kitchen during the survey and has the potential to affect all residents.The findings include: 1.On 11/19/25 at 8:45 AM surveyor started the initial tour of the kitchen. Dietary Clerk (#14) informed the surveyor that the Food Service Director was not working today and indicated she would get a supervisor. […]

• No harm, potential for more than minimal, widespreadF657Jun 4, 2024

  Based on observation, medical record review and staff interview, it was determined the facility failed to review and revise resident care plans after each assessment. This was evident for 2 (Resident #13 and #6) of 24 residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. […]