Every finding on record at Westview Care Center

Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED].#32). The facility reported a census of 47 residents. Findings include: 1. According to the Order Review Report dated 11/1/18 - 11/30/18 Resident #32 had [DIAGNOSES REDACTED]. The Physicians Order Review Report signed and dated by the ARNP (advanced registered nurse practitioner) on 11/20/18 instructed staff to administer [MEDICATION NAME] ER, extended release 24 hour, 25 milligrams. Give one tablet by mouth one time a day related to hypertension. Hold if pulse less than 60, or systolic blood pressure less than 110, with a start date of 3/15/18. The Order Review Report dated 1/1/19 - 1/31/19 signed by the resident's physician on 1/8/19 instructed staff to administer [MEDICATION NAME] ER, extended release 24 hour, 25 milligrams. Give one tablet by mouth one time a day related to hypertension. Hold if pulse less than 60, or systolic blood pressure less than 110, with a start date of 3/15/18. Review of the Medication Administration Record [REDACTED]. On 1/15/19 review of the MAR for 1/1/19-1/31/19 revealed the MAR failed to include the daily pulse and blood pressures from 1/1/19 through 1/15/19. The Plan Of Care with a Target date of 12/20/18 identified the following: Focus I have hypertension and [MEDICAL CONDITION] I receive medication for this daily. I had a halter monitor in place for two weeks following hospitalization . Goal I will not require an increase in my hypertension medication. I will not be hospitalized for [REDACTED]. Interventions a. Monitor me for side effects of my hypertension medication such as: slow heart rate, low B/P, dizziness or SOB. Update my provider with side effects as needed. b. My blood pressure and pulse are monitored daily prior to giving my hypertension medication. My hypertension medication is to be held if my pulse is below 60 or if my systolic B/P is below 110. c. Update my provider with any complaints of chest pain, lethargy, lightheadedness/dizziness or any abnormal B/P or pulse. During an interview on 1/15/19 at 1:20 PM the Director Of Nursing confirmed that the clinical record and the MAR failed to include the daily pulse and blood pressure and that the nurses are expected to follow the physicians orders as written. A Physician Communication Sheet dated 1/15/19 documented resident on current order for [MEDICATION NAME]-order currently reads to hold if systolic blood pressure was less than 110 or pulse less than 60. There was an order 3/30/18 to change to facility protocol for blood pressure and pulses. This was discontinued off of the [MEDICATION NAME] order. Currently we are only checking blood pressure weekly and pulse monthly and as needed. What would you prefer to be done-daily or weekly. Doctor responded- I would recommend daily pulse check with beta blocker. Hold if pulse less than 60 and fax me if held. Blood pressure may continue as per facility policy as blood pressure was topic of previous fax- blood pressure weekly is fine, signed and dated 1/15/19.

Based on clinical record review, observation, resident and staff interview the facility failed to ensure 1 of 11 residents reviewed (Resident #6) received services to accommodate the resident's needs and preferences. (Residents #6). The facility reported a census of 46 residents. Findings included: 1. The Minimum Data Set (MDS) with an assessment reference dated 8/16/17, documented Resident #6 with [DIAGNOSES REDACTED]. The MDS documented the resident with no cognitive impairments and and able to make independent decision making abilities. The MDS documented the resident required limited assistance with all aspect of activities of daily living, and continent of bowel and bladder. The resident's care plan with a target dated 10/24/17, stated I am occasionally incontinent of my bladder and continent of my bowels. I am able to alert staff to my toileting needs. Staff will offer/encourage me to utilize the bathroom upon rising, before and/or after meals and at bed. I am need one staff to assist me with transferring in and out of the bathroom and with adjusting my clothing. During an interview on 10/2/17 at 3:15 p.m., Resident #6 stated, on Saturday September 30, 2017, she sat in the day room after lunch with her husband for over 2 hours waiting for staff to take her to the bathroom with no call light device within her reach. She stated that she faced the south wall while in the chair watching television and could see the clock (to the right of the television) and keep track of the time. She stated that after staff finally came she had soiled her brief and was embarrassed. She stated she apologized to the staff for the accident that they would have to help clean up. Observation on 10/3/17 at 7:10 a.m., revealed Resident #6 sitting in an armed chair in the day room with no call device within her reach. On 10/3/17 at 8:30 a.m., observation revealed Resident #6 sitting in the middle of three armed chairs in the day room without a call light within reach. Resident #6 asked Staff A, certified nurse aide (CNA) to take her back to her room., Staff A, replied that they needed to remove residents from the dining room and then they would come back and get her. On 10/3/17 at 8:50, observation revealed Resident #6 asked another staff member to take her to her room and the staff member stated they would be back in a few minutes. Continued observation on 10/3/17 at 9:30 a.m., revealed Resident #6 remained seated in the armed chair in the day room with no call light device within her reach. On 10/3/17 at 10:00 a.m., observation revealed the facility Director Of Nursing stopped by the resident due to the resident holding her hand in the air to get staff attention and assistance to her room. During interview on 10/4/17 at 2:30 p.m., the corporate consultant stated that the facility needed to give Resident #6 a call light pendent when in the day room, so she can alert staff when she needs to leave.

Based on observation and staff interviews the facility failed ensure refrigerator items were covered, dated and labeled. The facility reported a census of 51 residents. Findings include: During initial kitchen tour on 8/1/16 at 9:15 a.m. observation revealed the following: a. 6 glasses of thicken liquid and an open container of butter on the shelf in a refrigerator. The glasses lacked a cover, date or label, the open butter container lacked the date when opened. The Dietary Manager removed the items, covered the drinks and dated the butter. During an interview on 8/1/16 at 9:15 a.m. the Dietary Manager stated the glasses were Residents therapeutic drinks to be served later. The Dietary Manager confirmed the items in the fridge needed to be covered and dated. Policy Review: Dietary Policy and Procedure Refrigerated Food Storage dated 4/15/05 directed: Refrigerated foods received, stored, prepared and served, will be properly labeled, dated and used or discarded according to the regulatory requirements and maintenance of food quality. Procedure: 4. All foods not stored in their original container will be labeled and dated. 13. Other prepared and opened foods/beverages (thickened liquids and supplements will be labeled when opened and used according to the manufactures' guidelines for storage.

Based on observation, record review, and staff interview the facility failed to provide privacy during personal cares for 1 of 6 residents observed (Resident #6). The facility reported a census of 51 residents. Findings include: 1. A Minimum Data Set (MDS) assessment tool dated 5/20/16, documented Resident #6 unable to speak, rarely/never made self understood, the staff unable to assess Resident #6's memory status, the resident had severely impaired cognition skills, had total staff dependence for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing, and always incontinent of bladder and bowel. The MDS revealed the resident had bilateral upper and lower body range of motion impairment. The MDS documented Resident #6 had [DIAGNOSES REDACTED]. The resident's care plan identified a Focus area for bowel and bladder incontinence, start date 10/29/13, and interventions directed 2 staff required to check and change the resident with a.m. and p.m. cares and before and after meals. During an observation 8/2/16 at 8:38 a.m., Staff A and Staff B, Certified Nursing Assistants, checked and changed Resident #6. The staff immediately removed the resident's hospital type night gown and pulled the sheet down to provide perineal care and exposed the resident's upper body. The staff removed the resident's heel boots. Staff B pulled the sheet up the resident's right side and across the upper body leaving the resident's perineal area, covered with a brief, exposed for Staff A to provide cares. Staff A provided anterior perineal care, the resident turned to the right side (resident's brief dry), and Staff A washed the resident's left buttock. At 8:45 a.m., the staff turned the resident to the left side for Staff B to wash the resident's left buttock, the sheet fell off, and exposed the resident's upper body. The staff turned the resident to the left side again, Staff A washed the resident's left buttock again, and placed a new brief. The Staff turned the resident to the left side again to pull the brief to the resident's right side and the resident's upper body remained exposed until the resident's shirt put on at 8:52 a.m. The staff stated the resident received incontinent cares at 6:00 a.m. when they came on duty. During a meeting with facility staff on 8/3/16 at 3:00 p.m., the ADON (Assistant Director of Nursing) denied the need for staff to complete perineal care in a different manner on 8/2/16. The ADON had no comment when questioned the need for staff to immediately remove the resident's night gown, exposing the resident's upper body, to provide perineal care. On 8/4/16 at 9:20 a.m., the ADON and Corporate Nurse Consultant brought hand written statements from Staff A and Staff B. The staff wrote the resident and staff had attempted to cover self during cares. Observation revealed Staff B attempted to cover the resident 1 time at the beginning of cares and the resident had not attempted to cover self. The facility undated Incontinent Care Audit directed staff to provide privacy.

Based on observation, record review and staff interview the facility failed to assure care plan interventions followed for 1 of 11 active residents reviewed (Resident #1). The facility reported a census of 48 residents. Findings included: 1. The Minimum Data Set ((MDS) dated [DATE] documented Resident #1 with [DIAGNOSES REDACTED]. The MDS documented the resident with long and short term memory problems and moderately impaired decision making abilities, needs limited assistance with transfers and ambulation, and the resident had a fall since the prior assessment with no injury. The Fall Risk assessment dated [DATE], documented a Score of 23, for which indicated the resident at high risk for falls. A Progress Note dated 3/1/15 at 7:55 p.m., documented resident laying on floor in their bathroom, feet were in the bathroom facing south and their head was outside of the bathroom facing north. Interventions in place at the time of the incident: visual monitor on working, call light in place, resident was in their room that is closer to the nurses station. Hand bell was sitting within reach to ring and notify staff of needing assistance. Preliminary Recommendations, for consideration as further preventative measures: A bell was tied to the walker with a string and will ring when resident is up on their own to notify staff of self transfers. The careplan with a target dated 12/3/15, had a focus area of I have [MEDICATION NAME] kyphosis. I have a stooped or bent forward posture. I do have poor balance at times, I am at risk for falling. Interventions addressed on the care plan included, I have a bell tied to my walker to notify staff when I am up on my own. Observation on 10/6/15 at 6:50 a.m., revealed no bell hanging on resident walker. Observation on 10/6/15 at 8:55 a.m., revealed staff assisting resident for morning cares. Staff assisted the resident to stand and ambulate to the sink to brush their teeth and the bell failed to ring. The bell noted to be on the bed side night stand. Observation on 10/7/15 at 8:25 a.m., revealed no bell on the resident walker and the bell on the bed side night stand. During interview on 10/7/15 at 8:30 a.m., the facility Director Of Nursing (DON) confirmed and verified the bell needed to be on the resident's walker at all times due to the resident with history of falls, and also agreed that the bell failed to ring when staff proceeded to do morning cares on the resident and assisted the resident to ambulate to the sink to brush their teeth on 10/6/15. During interview on 10/7/15 at 3:30 p.m., the facility DON confirmed and verified the bell needed to be attached tighter to the walker with the pull tie and assured the bell will not come off due to the pull tie being tighter.

Based on clinical record review, staff, physician and family interview, the facility failed to complete ongoing resident assessment when one of four residents reviewed had a condition change that warranted the assessments (Resident #1). The facility census was 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 of 15, indicating moderately impaired cognition. The MDS identified the resident's admitted as 11/28/14 and the resident had [DIAGNOSES REDACTED]., aftercare of a healing traumatic [MEDICAL CONDITION], difficulty walking and anxiety. The MDS assessment documented the resident required extensive assistance for bed mobility, transfer, ambulation and toileting. A test for balance during transitions and walking identified the resident as not steady, but able to stabilize without staff assistance for surface to surface transfers, when moving on and off the toilet, during walking, and when moving from seated to standing position. The assessment identified the resident could not steady his/her balance without staff assistance when turning around to face the opposite direction while walking. A hospital discharge summary dated 11/26/14 documented the suffered a fall on 11/23/14 while living at the assisted living. The resident had uncontrollable pain and difficulty ambulating as result of a left [MEDICAL CONDITION]. Skilled nursing notes dated 11/29/14, for the evening shift documented the resident required limited staff assistance for transfer and ambulated with a steady gait. Progress Notes titled Incident Report dated 12/1/14 at 5:50 p.m. documented the resident requested to use the restroom at 5:45 p.m. and one staff assisted the resident with a 4 wheel walker to the restroom. The staff then assisted the resident to the recliner chair. Five (5) minutes later the CNA (certified nurse aide) heard a noise coming from his/her room and discovered the resident on his/her left side with his/her legs curled under his/her and resting on his/her left elbow. The resident said they didn ' t know what happened. An assessment completed on 12/1/14 documented vital signs were completed and the resident had been assessed with [REDACTED]. The progress note identified the resident complained of back pain on 12/4/14 at 3:30 and at 9 p.m., and the record indicated staff completed an assessment including vitals to rule out physical reason for pain. The resident had been treated with pain medication which relieved the pain. The progress note dated 12/4/14 at 9:14 p.m. documented the resident had left hip pain when ambulating. Skilled nursing notes dated 12/5/14, for the evening shift documented the resident required extensive staff assistance for transfer and mobility and had an unsteady gait. The evening shift nurse noted the resident rested for long periods of time, which per the resident's family member was "normal" after he/she received pain medication. The progress notes dated 12/6/14 at 8:34 a.m. revealed Resident #1 had been unable to ambulate this am (morning) and had been walking one foot over the other and crossing his/her feet one over the other and stated, he/she could not walk. The resident picked up his/her feet up off the floor and held the front wheeled walker. Two staff lifted him/her with a chair lift and gait belt. The progress notes dated 12/6/14 at 11:30 a.m. documented the resident ' s family member called for a status update today. The nurse reported to the family member the resident had increased tremors and an inability to ambulate. The family member stated they are trying to have Resident #1 off of the [MEDICATION NAME] so that the neurologist can see the difference in his/her abilities to ambulate and the improvement in mental status. The family reported the resident had an appointment on Monday and will evaluate then. The family member asked about the resident's pain and staff mentioned he/she had complained of left hip pain when staff assist him/her. The progress notes dated 12/6/14 at 2:30 p.m., documented the resident's family here at this time. The family member asked the nurse if she knew what the issue was with the resident's decline with cognition and ambulation. The nurse responded she was unsure if it was related to injury or related to discontinuation of medication ([MEDICATION NAME]) (both happening at the same time). The nurse reported the only way to know is to send the resident to the ER (emergency room ) and have her evaluated. The family member stated she did not want to do send the resident to the ER but to try restarting the [MEDICATION NAME] medication and go from there in the next couple days; then if the resident didn't show improvement have him/her evaluated by the neurologist who wanted to see the resident with a "clear mind. " Skilled nursing notes dated 12/6/14, for the day shift documented the resident required extensive assistance of 2 staff for transfer and mobility was totally dependent for toileting and was unable to ambulate. The nurse noted this was a notable change in activities of daily living (ADL) and noted the resident crossed his/her feet when staff stood/transferred him/her. The resident complained of left hip pain which was relieved with pain medication. Nurse notes dated 12/6/14 at 2:49 p.m., revealed the nurse notified the physician on call that the resident's family member requested [MEDICATION NAME] resume and the nurse reported on the resident ' s condition. A physician ' s telephone order dated 12/6/14 reflected the physician ordered the [MEDICATION NAME] per family request. Skilled nursing notes dated 12/6/14, for the evening shift documented the resident required extensive assistance of 2 staff for transfer and eating, totally dependent upon staff for toileting and had an unsteady gait and a flat affect. The resident complained of pain all over. The resident's family member was present for the evening shift. The progress note dated 12/7/14 at 6:00 a.m. documented the resident slept until 4:30 a.m., then had been yelling out, " help me, over and over. The resident received the assistance of two to bedside commode. Skilled nursing notes dated 12/7/14, for the day shift documented the resident as totally dependent upon staff for bed mobility and transfer, limited staff assistance with eating, and complained of low back pain relieved with pain medication. The nurse noted the resident required 1:1 and requested a car to take him/her to an appointment. The resident did not ambulate. Skilled nursing notes dated 12/7/14, for the evening shift documented the resident required extensive assistance of 2 staff for transfer, toileting, eating, had a poor appetite and complained of pain all over. The nurse assessed no decreased movement of his/her lower extremities. Skilled nursing notes dated 12/8/14, for the day shift documented the resident required extensive assistance of 2 staff for bed mobility, transfer and toileting, limited assistance with eating, poor appetite and tired. At 6:45 a.m., the resident was tearful, with rigid legs and rubbed his/her legs in pain. The resident was unable to ambulate and had decreased movement of the right and left lower extremities. [MEDICATION NAME], a pain medication, was administered at 6:45 a.m. and Tylenol at 8:30 a.m. for complaints of pain. Nurse notes indicated the resident's family member arrived at 9:30 a.m. and took the resident out of the facility for a physician appointment. The clinical record lacked evidence to indicate the physician was notified of the change in status noted by staff on 12/7/14 and 12/8/14. The progress note dated 12/8/14 documented the ER doctor called and reported the resident had an examination which revealed a right [MEDICAL CONDITION] the resident would be transferred to another hospital. An emergency room progress note dated 12/8/14 at 7:43 p.m., revealed the resident arrived at the emergency department with his/her family member. An X-Ray revealed the resident sustained [REDACTED]. A physician note dated 12/8/14, noted the appointment occurred at 3:05 p.m. The physician did not assess the resident's gait as he/she presented in a wheelchair but noted overall cranial nerves appeared to be "pretty intact." The physician recommended the resident seek further evaluation to include an X-Ray due to a bruise on the right ribs. According to a hospital report dated 12/8/15, the resident's family reported a week ago the resident was walking and the nursing home reported he/she had a fall on 12/1/14. According to the family, the resident after the fall on 12/1/14, the resident really did not walk again. Today the resident had a follow up appointment with neurology and they felt he/she was dehydrated and so they recommended that the resident come to the ER. The X-ray of the pelvis reveals a right intertrochanteric [MEDICAL CONDITION]ly obtained from the fall on 12/1/14. The resident had a recent left greater trochanteric fracture. On 1/20/15 at 10:37 a.m., the orthopedic surgeon stated the resident had a displaced [MEDICAL CONDITION] hip that required surgical repair. In their professional opinion when the resident had exhibited symptoms of a [MEDICAL CONDITION] such as increased pain and the foot turned inward they had a [MEDICAL CONDITION]. The surgeon added the fracture could have become displaced during transfer/transport while out of the facility. On 12/26/14 at 9:55 a.m., Staff A, Licensed Practical Nurse, (LPN) confirmed she provided nursing care to the resident on 12/6/14 (Saturday) and 12/7/14 (Sunday). Staff A indicated she was very concerned with the resident's status change on Sunday, 12/7/14 and felt badly for the resident who seemed so uncomfortable. Staff A stated she did not notify the physician because the resident had an appointment on Monday 12/8/14. Staff A stated she knew the resident was in pain from the facial grimacing, restlessness and wanted staff with him/her. On 12/30/14 at 10:31 a.m. Staff H, Registered Nurse, RN confirmed she provided nursing care on Sunday evening and informed at report the resident did not have a good morning. Staff H stated she noted increased confusion, the resident was non-ambulatory and did not want to stand. Staff H stated when staff attempted to stand the resident, the resident grimaced and complained of back pain. Staff used a wheelchair for transport. Staff H stated she requested additional assistance from the main floor staff to get the resident. Staff H stated she did not report the resident's change in condition to the physician because the resident had a physician's appointment on Monday, 12/8/14. On 12/26/14 at 11:55 a.m., Staff F, LPN confirmed she provided nursing care to the resident on Monday, 12/8/14. Staff F stated when she arrived on 12/8/14 the night nurse reported the resident had a restless night and anti-anxiety medication was ineffective but did not report pain. The resident was tearful and cried, "help me, help me, help me." The resident displayed 5/5 facial (expression) and was in agony. Staff F administered [MEDICATION NAME], and 2 hours later Tylenol for pain. Staff F stated the resident could not walk, required a wheelchair for transfer and noted the resident's right lower extremity turned inward. The resident was unable to uncross his/her feet, very shaky and stiff a "huge difference." Staff F confirmed she did not notify the physician of the "huge change" because the resident had a neurology appointment that afternoon.

Based on record review, observation, and staff interview, the facility failed to ensure one of nine residents reviewed received adequate supervision and assistive devices to prevent accidents (Resident #5). The facility reported a census of 54 residents. Findings included: The Minimum Data Set with assessment reference date of 3/11/11 noted Resident #5 had a BIMS score of 7, indicating severely impaired cognitive status. The resident required extensive assist with walking in his/her room and limited assist with toilet use. Resident #5's balance for moving on and off the toilet coded as not steady, only able to stabilize with human assistance. The Review of Indicators of Cognitive Loss/Dementia for Resident #5 noted the resident was impulsive and attempted to get up without staff assist, but was usually easily redirected. The care area assessment (CAA) review report dated 3/11/11 noted Resident #5 was admitted to the CCDI for closer supervision from another facility. The resident's gait was slow and unsteady but able to be stabilized by staff. The report indicated the resident had a history of [REDACTED]. Resident #5 had a [DIAGNOSES REDACTED]. The Urinary Incontinence and Indwelling Catheter CAA Review Report dated 3/11/11 noted Resident #5 required an assist of one with ambulation to and from the bathroom with a front wheeled walker or when transferring from the wheelchair to toilet and back. The Interdisciplinary Progress Notes for Resident #5 dated 5/9/11 at 1:25 p.m. noted the resident had been taken to the toilet by staff, the resident attempted to self transfer and slid to the floor on to his/her right knee and sat on floor. The note indicated the resident had sustained no injury to the right knee, and that one staff would assist the resident with toileting and would remain with the resident and that grip strips had been placed on the floor by his/her toilet. During an interview on 6/22/11 at 4:00 p.m., Staff A stated the nurse that had taken Resident #5 to the toilet on 5/9/11 had left the resident alone on the toilet when he/she heard another resident's alarm sound. During an observation on 6/22/11 at 8:55 a.m., Staff C went to Resident #5's room when he/she heard the resident's motion sensor sound. The resident had gotten self up from bed and was ambulating into the bathroom. Staff C assisted the resident the rest of the way into the bathroom. Once the resident sat on the toilet, Staff C left the bathroom and went and shut the room door, then walked to the sink and washed and dried her hands before going back into the bathroom. Resident #5 did his/her own peri care, stood up with minimal assist, and pulled up his/her own underwear and pajama pants. Staff C helped the resident grab hold of the walker, provided stand by assist out of the bathroom, and directed the resident to the sink to wash his/her hands. Resident #5 had not been visible to anyone in the room or hallway while sitting on the toilet as the bathroom is at the far end of the room and back around the bathroom door. The sink was located in the resident's room on the same wall as the bathroom door, not within sight of the toilet. During an interview on 6/22/11 at 2:00 p.m., Staff B stated she would expect staff to maintain visual contact with Resident #5 when the resident was on the toilet. The resident's Interdisciplinary Progress Notes (IDP Notes) dated 6/7/11 at 6:30 p.m noted Resident #5 had attempted to self transfer without assist. A staff member saw the resident positioned half-way up from the recliner located in the dayroom, and before the staff member could get to the resident to assist, the resident fell and landed on his/her right side. The resident sustained [REDACTED]. The resident stated the area was tender to the touch. The resident had a motion sensor in place and a hi/low bed (in the bedroom). The IDP Notes stated the resident would continue to have a motion sensor and would give the resident activities to do while sitting in the day room. During an interview on 6/22/11 at 8:55 a.m., Staff C stated Resident #5 only used the motion sensor in his/her bedroom. Resident #5's Care Plan, with a run date of 3/24/11, directed staff to ambulate and transfer the reisdent with an assist of one with front wheeled walker, gait belt, and wheelchair to follow. An intervention had been added to the care plan on 3/25/11, after the resident had a fall in the dayroom, to increase activities when in the dayroom, such as folding towels, washcloths, crafts, etc.