WESTFIELD SENIOR LIVING

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

Postural Supports. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above by not obtaining a full bedrail doctor's order for R1 who was not currently on hospice care, which posed a potential health and safety risk to residents in care.

Official plan of correction

The Licensee/Administrator has conducted training on Postural Supports-Bed rails, and provided training materials to LPA on the day of the visit.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in 1 out of 1 aerosols, scissors, and lighter were accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee needs to ensure any hazardous items should be lock and inaccessible to residents.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(a)(7)(E)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration. Based on observation, the licensee did not comply with the section cited above in 1 out of 1 over the counter medication, PRN and staff medication was kept unlock in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee needs to ensure PRN and/or OTC medications shoule be stored in a lockbox in the refrigerator.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was observed were LPAs saw R4 bedroom has other individuals belongings in their bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee needs to ensure that R4 bedroom is free of other individuals belongings, only R4 can have their belongings inside.

Deadline recorded: Dec 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on the LPAs observations and interviews the licensee/administrator did not ensure one out of four files to be available for licensing to review which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

Administrator/Licensee shall do R4 complete files via email to LPA by: POC 12.2.2024.

Deadline recorded: Dec 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1 cleaning supplies, aerosols, scissors, lighter, and razors were accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2024 Plan of Correction Licensee needs to ensure any hazardous items should be lock and inaccessible to residents.

Official classification

Type A

Official code

1569.695(a)(7)(E)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: (a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1 over the counter medication, PRN and staff medication was kept unlock in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2024 Plan of Correction Licensee needs to purchase a lockbox for the refrigerator.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: This requirement is not met as evidenced by: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1 residents medications, suppliments and over the counter medications were not locked and was accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2024 Plan of Correction Administrator needs to lock all rx, PRN, and supplements.

Official classification

Type B

Official code

874659(c)(3)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 count out of 1 PRN medications were not documents in CSMDR which poses/posed a potential health, safet

Official plan of correction

POC Due Date: 11/06/2024 Plan of Correction All supplements and PRN medications needs to be documented in CSMDR.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: During the physical plant inspection, the the hot water taken at the bathroom sink was measured at 135 degrees. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of two bathrooms where the hot water temperature was taken, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2022 Plan of Correction Prior to the end of the visit, staff adjusted the hot water to insure it measures between 105-120 degrees. No further correction needed at this time.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: During the physical plant inspection, LPA observed air freshener in both bathrooms that are used by the residents. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in two out of two bathrooms that were inspected by the LPA, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2022 Plan of Correction During the inspection, staff removed the air fresheners from both bathrooms and stored them in a locked cabinet underneath the kitchen sink.