Inspection Reports for James L. West Center for Dementia Care

The complaint investigation was triggered by an incident of resident-to-resident abuse involving Residents #30 and #79, where Resident #30 physically assaulted Resident #79 after being startled by the roommate. The investigation also included review of catheter care and medication administration practices for other residents.

The facility failed to protect residents from abuse in a roommate altercation between Residents #30 and #79, failed to ensure proper catheter orders and care for Residents #47 and #73, and failed to administer and reorder prescribed glaucoma medication for Residents #21 and #38. Additionally, the facility did not include indications for use in medication orders for Residents #22 and #54.

Complaint investigation of abuse allegations involving CNA B physically and verbally abusing Resident #1 on 08/06/24, including restraint and rough handling despite resident refusal. Immediate Jeopardy was identified on 09/25/24 and 10/11/24. The facility failed to timely report, investigate, and prevent further abuse. The agency CNA was removed and staff were retrained.

The facility failed to ensure Resident #1 was free from abuse when CNA B pinned the resident's hands and arms to the bed, used his body weight to force care, and verbally abused the resident. The facility also failed to train agency staff on proper care and abuse prevention, and did not properly investigate or report the abuse allegations in a timely manner. Immediate Jeopardy was identified and removed after the facility implemented a plan of removal including staff training and removal of the agency CNA.

The complaint was substantiated based on a video showing CNA B slapping Resident #1 and verbally abusing her. CNA B admitted to striking Resident #1 and was arrested. The facility took immediate corrective actions including removal of CNA B, police involvement, and staff in-service on abuse and neglect.

The facility failed to ensure Resident #1 was free from abuse by CNA B, who was recorded verbally and physically abusing Resident #1. The abuse included slapping Resident #1 and verbal aggression. The facility removed CNA B immediately, notified authorities, and initiated staff in-service on abuse and neglect. Resident #1 showed no visible injuries and had no recollection of the incident.

Immediate Jeopardy was identified on 2024-04-25 due to failure to properly assess Resident #1 after an unwitnessed fall with head injury before moving him. The Immediate Jeopardy was removed on 2024-04-26 at 3:30 PM, but the facility remained out of compliance at a lower severity level due to the need to evaluate corrective systems.

The facility failed to ensure that Resident #1 received treatment and care according to professional standards after an unwitnessed fall with head injury. The resident was moved by staff without a full assessment, resulting in a displaced hip fracture requiring surgery. Immediate Jeopardy was identified but later removed after corrective actions were implemented.

The facility failed to ensure physician orders for immediate care, including hospice and catheter care, were entered at admission for Resident #74. The Minimum Data Set (MDS) and care plans did not accurately reflect hospice status or catheter use timely. Additionally, the facility failed to revise and review care plans for Residents #2 and #74 to address call light use, hospice care, and catheter use, potentially risking resident care quality.

The complaint investigation found that Resident #1, who required a two-person mechanical lift transfer, was transferred by one CNA alone. The CNA admitted to moving the resident alone to test the lift, despite training requiring two staff. The Director of Nursing confirmed the violation and planned corrective actions including suspension and retraining.

The facility failed to ensure Resident #1 was transferred using a two-person mechanical Hoyer lift as required, placing the resident at risk of falls or injuries. Interviews and video evidence confirmed that a CNA attempted a one-person transfer, contrary to training and facility policy. The Director of Nursing confirmed staff training requirements and planned suspension and retraining of the involved CNA.

The complaint investigation found that the facility did not notify Resident #1, the resident representative, or the Ombudsman in writing about the transfer/discharge to a behavioral hospital, the reasons for the move, or the right to appeal. The Ombudsman had only been included in email chains after the discharge and had not received a formal discharge notice. The facility's policy did not address transfer notice requirements.

The facility failed to notify Resident #1, the resident representative, and the Ombudsman in writing of the transfer/discharge to a behavioral hospital, the reason for the transfer, and the right to appeal. Interviews and record reviews confirmed the lack of formal discharge notice and inadequate policy addressing transfer notifications.