Westchester Gardens Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement the ordered interventions to alleviate pressure to the heels for one resident (#1) out of three reviewed for following wound care provider orders.Findings included: Review of admission Record showed Resident #1 was admitted to the facility on [DATE], with diagnoses to include left hip fracture, emphysema, respiratory failure, dementia and moderate protein calorie malnutrition. Review of Resident #1's Wound and Healing progress notes, dated 9/24/2025, showed wound orders for wound #2 on the left heel and wound #3 right heel to off load wound, and float heels in bed. Resident #1's plan of care was discussed with nursing.A review of Resident #1's order summary report, as of 9/29/2025, revealed that the orders to off-load the wound and float heels in bed, as directed by the wound care provider, were not entered.Review of Resident #1's care plans showed focus areas for alteration in skin integrity and potential for alteration in skin integrity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate medical record for medication and transmission-based precautions for one resident (#451) of 36 sampled residents on five of five days reviewed involving five nurses on three different shifts. Findings included: Review of Resident #451's medical record revealed Resident #451 was admitted to the facility on [DATE] for short-term rehabilitation. On 5/29/25 the resident was placed on empiric contact transmission-based precautions for a rash identified on the resident's skin. The resident received treatment on 5/31/25 for Ivermectin three milligrams, give three tablets by mouth one time only for one day. Review of the progress note documentation for 06/02/25 at 3:29 PM indicated the contact precautions were removed after the nurse practitioner examined the resident and treated her for folliculitis and ordered doxycycline antibiotic for seven days. Documentation by nurses for the ALERT antibiotic/infection note revealed the following: On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during meal service in four halls (200, 300, 400 and 500 hall of six halls observed, and for nine residents (#3, #60, #452, #448, #96, #76, #1, #58 and #43) of 36 residents sampled. 2) The facility failed to implement their infection prevention and control plan by failing to provide evidence of process surveillance of staff practices directly related to resident care. 3) The facility failed to properly use enhanced barrier precautions (EBP) for one resident (#19) of two residents observed for EBP with indwelling medical devices. 4) The facility failed to properly disinfect a multi-use blood glucometer for two staff members observed during medication administration (Staff members O, Licensed Practical Nurse (LPN) and P, Registered Nurse (RN)) of five staff observed. The current census was 113 residents. Findings included: 1. During a dining observation on the 500 wing on 6/02/25 at 11:32 AM, two staff members…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents received a dignified dining experience in two halls (200 and 300) of six halls toured and for three residents (#1, #58 and #43) of 36 residents sampled. Findings included: 1. An observation was conducted on 06/02/25 at 12:26 p.m. of Resident #1 in her room during her lunch meal. The resident was receiving meal assistance from Staff R, Clinical Student. Staff R was observed standing over the resident. An observation was conducted on 06/02/25 at 12:16 p.m. of Resident #58 in her room during her lunch meal, being assisted by Staff V, Clinical Student. Staff V was observed standing over the resident. A dining observation of Hall 200 was conducted on 06/02/25 at 12:04 p.m., observations were made of staff delivering trays to residents in their rooms. The staff members did not knock or announce themselves prior to entering the resident's rooms as follows: Staff T, Certified Nursing Assistant (CNA) and Staff W, CNA, were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility policy review, it was determined that the facility failed to ensure five resident room bathrooms out of ten resident room bathrooms toured on the 400 hallway of the facility's Queen's Way resident unit were maintained in a clean, homelike environment. (Photographic evidence obtained.) The findings include: On 06/02/25 at 10:38 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:11am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:15 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:18 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:30 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust. On 06/03/25 at 9:32 am, the bathroom vent above the toilet in room [ROOM NUMBER] was observed covered in dust.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide necessary services to maintain grooming and personal hygiene for one resident (#49) out of four residents sampled for grooming and personal hygiene services. The findings include: On 06/02/25 at 11:16 a.m., Resident #49 was observed in a wheelchair in the 400 hallway. His right-hand fingernails were observed elongated with brown debris under each nail. His left-hand fingernails were observed elongated. On 06/02/25 at 11:39 a.m., Resident #49 was observed in his room. His right-hand fingernails were observed elongated with brown debris under each nail. His left-hand fingernails were observed elongated. Resident #49 was interviewed at the time of the observation, and he said he likes his nails short, and he doesn't think staff clean and trim his fingernails. Photographs of Resident #49's fingernails were obtained with his verbal permission. On 06/03/25 at 9:35 a.m., Resident #49 was observed lying in bed, awake and dressed for the day. His right-hand fingernails were observed elongated with brown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations interview and record review, the facility failed to ensure continuous oxygen therapy was provided per physician orders, and failed to ensure respiratory equipment was stored appropriately for one resident (#76) of one resident sampled. Findings included: During facility tours conducted on 06/02/25 at 09:43 a.m. and 06/03/25 at 09:24 a.m. Resident #76 was observed in her room lying on her bed. The resident was observed with continuous oxygen (O2) on. The oxygen concentrator revealed her oxygen was set at 3.2 liters. During these observations, Resident #76's nebulizer mask was observed on her bedside table uncovered. (Photographic Evidence Obtained). Review of Resident #76's admission record revealed an admission date of 08/23/24 with diagnoses to include respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of physician orders for Resident #76 revealed the following: O2 at 2L/min (liters per minute) via N/C (nasal cannula) PRN (as needed) for O2 sats (saturation) lesser than 92% DX (diagnosis): Hypoxia - Start date 08/23/2024.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one resident (#59) of three sampled residents who require wound care were provided with pain management services and staff accurately assessed for the presence of pain. Findings included: On 6/2/25 at approximately 10:48 AM, Resident #59 was observed in his room and Staff I, Licensed Practical Nurse (LPN) was observed to be preparing supplies for wound care treatments. Staff I, LPN requested a Certified Nursing Assistant (CNA) to assist her with turning the resident onto his right side. The CNA held the resident on his right side and Staff I, LPN proceeded to remove a sacral dressing and a dressing to the left ischial (buttock) area. Resident #59 was observed to attempt and reach back behind him with his left hand toward the CNA and the CNA was observed to hold the resident's hand down. Staff I, LPN proceeded to use a gauze pad soaked with normal saline to clean the resident's wounds. Resident #59 began to make noises indicating he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for three residents (#37 #86, and #76) of 36 sampled residents. Findings included: 1. During a facility tour on 06/02/25 at 10:01 a.m. an observation was made of Resident #37 sitting in her wheelchair with her bedside table positioned in front of her. An observation was made of a white capsule medication on the bedside table. Another observation was made of an unidentified white powder in a medication measuring cup placed on top of the resident's dresser next to four bottles of a beverage. The resident could not answer questions related to the capsule medication or the unidentified powder. On 06/03/25 at 09:25 a.m. an observation was made of an unknown white powder in a plastic medicine cup on Resident #37's dresser next to bottles of beverages, similar to what as previously observed. Review of Resident #37's admission Record revealed Resident #37 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow care plan interventions related to fall mat placement for two of four observations made during a four-day survey, for one (Resident #12) of three residents reviewed for falls. Findings included: Review of Resident #12's admission record revealed the resident was admitted to the facility on [DATE], with medical diagnoses that included but were not limited to multiple sclerosis, repeated Falls, muscle weakness, abnormalities of gait and mobility, cognitive communication disorder, insomnia, and overactive bladder. During an observation on 04/03/23 at 09:16 p.m., Resident #12 was observed in his bed with one fall mat to the right side of his bed, in-between his bed and the wall. The resident was interviewed at this time, and he stated, They just left the mat there, they said I fell out of bed, but I got out of bed. It didn't turn out too good. I didn't use the call light. I didn't have injuries, just my pride was damaged because I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to appropriately secure medications in four medication carts (100,200,400 and 500 Halls) of five medication carts sampled. Findings included: On 6/24/2021 at 02:51 p.m., an observation was conducted of the Medication Cart located on 100 Hall, which included in the sixth draw from the top of the medication cart, loose tablets. Staff A, Registered Nurse (RN) confirmed the presence of the one (1) white tablet, two (2) one- half (1/2) pieces of a white tablet and one quarter (1/4) of a white tablet observed to be in the third draw from the top of the medication cart. On 6/24/2021 at 3:03 p.m., an observation of medication cart located on the 400 Hall included four (4) loose tablets. Staff B, Licensed Practical Nurse (LPN), confirmed the presence of unsecured medications of one (1) white round tablet and one yellow tablet seen in the 4th draw from the top of the medication cart. Staff B (LPN) also confirmed the presence of a white tablet located in the fifth draw and a pink unsecured tablet in the 6th draw. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to provide the Office of the State Long-Term Care Ombudsman with a written notice of the hospital transfers for two (#63 and #105) out of two residents reviewed for hospitalizations. Findings included: 1. Review of the Electronic Medical Record (EMR) census revealed Resident #63 was admitted on [DATE]. Further review of the EMR indicated that an unplanned transfer occurred for the resident to an acute care facility on 4/29/21 and was returned to this facility on 5/3/21. An additional review of the EMR did not include information that the Ombudsman was notified of Resident #63's transfer that occurred on 4/29/21. 2. Review of the Electronic Medical Record (EMR) census and the physical hard copy of the clinical record for Resident #105 that indicated the resident was admitted on [DATE]. Further review of the EMR and the hard copies indicated that the resident had an unplanned transfer on 4/28/21. An additional review of the EMR and hard copy of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview the facility failed to ensure care plan interventions were properly implemented for two (#65 and #305) of six residents sampled for care planning Findings included: 1. A review of the facility's fall log revealed that Resident #65 had documented falls on 6/7/21, 6/10/21, and 6/15/21. A review of Resident #65's clinical progress notes for the identified events on the facility's fall log revealed: -6/8/21 at 12:35 AM: Patient found on floor in kneeling position at bedside. Patient alert and confused. Unable to answer questions appropriately. Limited [Range of Motion (ROM)] to lower extremities. Patient PERRLA [pupils equal and reactive to light], strong hand grasps bilaterally, no complaints of H/A [headache], nausea or vomiting. Skin intact with slight redness to bilateral knees. Family and [Primary Care Physician (PCP)] notified by supervisor. Assisted patient back into bed via hoyer lift with assist of 2. Will monitor for any changes. Post fall evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed administered and two errors were identified for one (1) (Resident #103) of three (3) residents observed. These errors constituted a medication error rate of 7.41 percent. Findings included: An observation of 500 Hall medication administration on 06/24/2021 at 11 a.m., resulted in Staff E, Licensed Practical Nurse (LPN), giving Resident #103 two (2) medications for Hypertension (HTN) of Losartan Potassium 100mg (milligrams)and Metoprolol Tartrate 25 mg. Observation of the medication on the Electronic Medical Record (EMAR) computer screen that Staff E, (LPN) was looking at was noted to contain parameters for both medications read Hold if SBP [systolic blood pressure] is less than 110 or HR (pulse) less than 60. An immediate interview was conducted at 11:11 a.m. with Staff E, (LPN) related to administration of the two Blood Pressure (BP)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.