Western State Nursing Facility

In the surveyor’s words

From the most serious findings on record at Western State Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF550Dec 10, 2025

  Number of residents sampled: 20Number of residents cited: 2The facility failed to provide a dignified existence for two residents by not ensuring lap covering for two residents, R35 and R18. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for two (2) of twenty (20) sampled residents (Resident 18 and 35). […]

• No harm, potential for more than minimal, isolatedF880Dec 10, 2025

  Based on observation, interview, and review of facility policy, the facility failed to follow standard precautions to be followed to prevent the spread of infection. Appropriate infection prevention and control practices were not implemented during medication administration. Hand hygiene was not performed while administering medications to one of two residents, Resident (R) 28. The findings include:Review of facility policy, titled Psychobiological/Pharmacological Interventions Medication Administration and Documentation, revised January 2023, revealed all medication will be prepared and administered as per manufacturer's specifications and accepted professional standards.Review of facility policy, titled Infection Prevention and Control, revised October 2022, revealed Western State… […]

• No harm, potential for more than minimal, isolatedF919Dec 10, 2025

  Number of residents sampled: 20Number of residents cited: 1The facility failed to ensure that one resident could access the call light R46. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair, or other sleeping accommodations for one (1) of twenty (20) sampled residents (R46). The findings include: Review of MDS information on 12/08/2025 revealed that R46 was admitted on [DATE] and had a BIMS of 99 with a diagnosis of schizophrenia and is not interviewable. Review of functional abilities (GG0130A1) shows partial to moderate help needed for using eating utensils. […]

• No harm, potential for more than minimal, isolatedF868Aug 8, 2024

  Based on observation, interview, record review, and facility policy, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the Medical Director or his/her representative. The facility failed to ensure or encourage real-time alternative methods of participation, such as videoconferencing and teleconference calls to include the Medical Director or his/her representative. The findings include: Review of the facility's policy titled, Quality Assessment and Assurance Committee, dated 10/2022, revealed the facility would maintain a QAA committee consisting of a minimum of the Administrator or representative, Director of Nursing (DON) or representative, Physician, Infection Preventionist or representative, and three facility staff. […]

• No harm, potential for more than minimal, isolatedF880Aug 8, 2024

  Based on observation, interview, review of the facility's policy and resident's medical record, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident #22 (R22)). Staff failed to perform hand hygiene when indicated; contaminated residents' clothing and bed linens; and, failed to prevent the contamination of clean dressings. […]