Western Slope Health Center

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 18, 2023

  Based on interview, record review and policy and procedure review, the facility failed to ensure one of three sampled residents (Resident 1) was free of accident hazards when Resident 1, who had an order to not be fed any food or water by mouth (NPO), was given a meal tray. This failure resulted in Resident 1 to choke evidenced by coughing, labored breathing, and low oxygen levels. He was subsequently transferred to the hospital and passed away. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and had a Gastrotomy Tube (G-Tube, a tube inserted through the stomach that brings nutrition, hydration, and medications). Review of Resident 1's Order Summary Report, revealed an order dated [DATE] for NPO diet. […]

• Actual harm, isolatedF600Jun 10, 2021

  Based on interview and record review, the facility failed to ensure one resident (Resident 1) in a sample of three was free from physical abuse when a resident (Resident 2) with known aggressive behaviors walked over to Resident 1, grabbed for his arm and scratched him. This failure resulted in two skin tears on Resident 1's arm, which required treatment, and increased the risk of Resident 1 experiencing a decline in his emotional wellbeing. Findings: Review of an Admission Record indicated Resident 1 was admitted to the facility in December 2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's Admission Record indicated she was admitted to the facility in August 2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Apr 15, 2021

  Based on interview and record review, the facility failed to ensure one resident (Resident 1) in a sample of three was free from physical abuse when Resident 1's roommate (Resident 2) walked over to Resident 1's bed and hit him in the face. This failure resulted in physical injury to Resident 1 whereby he developed a red, swollen mark on his left cheek, and increased the risk of Resident 1 experiencing a decline in his emotional wellbeing. Findings: Review of the Admission Record indicated Resident 1 was admitted to the facility in the spring of 2019 with diagnoses, which included a stroke resulting in paralysis (inability to move) of his left arm and left leg. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. There were food debris on shelves with clean and ready-to-use sheet pans,2. A container in the clean and ready-to-use storage area was stacked wet,3. Two small cups of yogurt were stored in the refrigerator uncovered and,4. The microwave for residents' food was not clean.These failures had potential to cause food-borne illnesses in a highly susceptible population of 91 out of 91 residents who received food from the kitchen.Findings: 1. During a concurrent observation and interview on 3/3/26 at 8:11 a.m. […]

• No harm, potential for more than minimal, widespreadF801Nov 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulations, to be the DM to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the full time Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. […]