Westfield Rehabilitation and Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the MD when a stage three pressure ulcer was identified for 1 of 1 resident reviewed for pressure ulcer (Resident #71). Findings Included: Resident #71 was admitted to the facility on [DATE] for fracture of right femur with a plan for discharge home after rehabilitation. Resident #71 was discharged from the hospital after surgery to repair a right femur fracture. Review of the Wound Care Nurse's assessment on admission on [DATE] revealed she noted redness to sacral area. On 08/23/24 at 12:31 pm a telephone interview with Nurse #1 revealed on 08/13/24 she was called to the resident's room by the (Nurse Aide) NA providing care to Resident #71. She reported the sacral pressure ulcer appeared to have slough, she measured it and left a message for the Wound Care Nurse to further assess. Wound Care Nurse's note dated 08/14/24 revealed that a sacral pressure ulcer was noted by the 11:00 PM to 7:00 AM shift nurse. This…

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 review, observations, and staff and Medical Director (MD) interviews, the facility failed to do a weekly skin assessment which resulted in the delay of identification of a stage three pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #71). The findings included: Resident #71 was admitted to the facility on [DATE] for fracture of right femur with a plan for discharge home after rehabilitation. Resident #71 was discharged from the hospital after surgery to repair a right femur fracture. Review of the Wound Care Nurse's assessment on admission on [DATE] revealed she noted redness to sacral area. Further review of records revealed that on 08/02/24 a verbal order for zinc oxide external ointment 20% (topical), apply to sacrum topically two times a day was initiated and to do weekly skin checks. A care plan dated 08/05/24 revealed interventions of assistance with incontinence care and bed mobility to reduce the risk of pressure ulcer development. The admission Minimum Data Set…

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 review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Residents # 22, #4 & #1), accidents (Resident #4 & #26), diagnoses (Resident #4) and urinary status (Resident # 54) for 5 of 20 sampled residents whose MDS were reviewed. Findings included: 1 a. Resident # 4 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF). Resident #4 had a physician's order dated 12/14/22 for Bumetanide (a diuretic drug) 1 milligram (mg.) by mouth twice a day for CHF. Review of the January 2023 Medication Administration Records (MARs) revealed that Resident #4 had received Bumetanide from January 1 through January 31, 2023. The annual MDS assessment dated [DATE] did not indicate that Resident #4 had received a diuretic medication during the assessment period. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the physician's orders and the January 2023 MARs and…

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 review, observation, and interviews with the Physician, Wound Physician and staff, the facility failed to obtain an order for treatment to the left buttock pressure ulcer (Resident #4) and failed to ensure the alternating air mattress was functioning resulting in a deflated air mattress (Resident #29) for 2 of 3 sampled residents reviewed for pressure ulcers (Residents #4 & #29). Findings included: 1. Resident # 4 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus, thoracic, thoracolumbar, lumbosacral, and intervertebral disk disorder, stage 4 chronic kidney disease, and congestive heart failure (CHF). A review of Resident #4's weekly decubitus ulcer assessments dated 1/11/23 revealed that Resident #4 had a stage 3 pressure ulcer on the right buttock measuring 2.7 centimeter (cm) by (x) 2.6 cm x 0.1 cm. with 25 % slough (dead tissue). Resident #4 had a physician order dated 1/11/23 to clean the right buttock pressure ulcer with wound cleanser, pat dry,…

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, Nurse Practitioner, Medical Director and staff interviews, the facility failed to hold diabetic medications (Residents #18 and #42) and blood pressure medications (Residents #42 and #22) as ordered by the physician for 3 of 6 residents whose medications were reviewed. The findings included: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact. Review of Resident #18's February 2023 and March 2023 physician orders included an order for Levemir Solution (a diabetic medication) 100 unit per milliliter. Inject 5 units subcutaneously in the morning for diabetes. Please hold for blood sugar less than 120. The February 2023 and March 2023 Medication Administration Records (MARs) were reviewed and revealed Resident #18 had received Levemir, despite the blood sugar less than 120 on the following dates: - 2/7/23- blood sugar 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.

Based on record reviews, observations, Nurse Practitioner, Medical Director, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey on 7/1/21. This was for four deficiencies that were cited in the areas of Accuracy of Assessments, Activities of Daily Living Care Provided to Dependent Residents, Treatment/Services to Prevent/Heal Pressure Ulcers and Drug Regimen is Free From Unnecessary Drugs. The duplicate citations during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: These citations are cross referenced to: 1. F641- Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Residents # 22, #4 & #1), accidents (Resident #4 & #26), diagnoses (Resident #4) and urinary status (Resident # 54) for 5 of 20 sampled residents…

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 review and staff interview, the facility failed to refer a resident with newly evident diagnosis of mental illness for Preadmission Screening and Resident Review (PASARR) level II screen for 1 of 1 sampled resident reviewed for PASARR (Resident #7). Findings included: Resident # 7 was admitted to the facility on [DATE] with PASARR level I screen which indicated the screen did not go to level II. Resident #7 had no mental health related diagnosis noted on admission to the facility. The psychiatric note dated 3/8/21 indicated that Resident #7 had a diagnosis of major depressive disorder and was on Zoloft and Doxepin for depression and Remeron for appetite stimulant. The note indicated to discontinue Doxepin as part of gradual dose reduction (GDR). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #7 had a diagnosis of depression and had received an antidepressant medication during the assessment period. The psychiatric note dated 5/3/21 revealed that Resident #7…

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 review, observation and family and staff interviews, the facility failed to provide showers as scheduled for 1 of 5 sampled residents who needed extensive assistance or were dependent on the staff for activities of daily living (Resident #59). Findings included: Resident #59 was admitted to the facility on [DATE] with multiple diagnosis including hemiplegia/hemiparesis following cerebral infarction affecting the left dominant side and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #59 had moderate cognitive impairment and she needed extensive assistance with personal hygiene and bathing. The assessment further indicated that the resident had no behaviors including rejection of care. Resident #59's care plan that was reviewed on 1/29/23 revealed that she had an activity of daily living (ADL) self -care performance deficit related to hemiplegia/hemiparesis. The approaches included I required staff extensive assistance with grooming and personal…

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 review, observations and staff interviews, the facility failed to ensure oxygen therapy was provided as ordered by the physician for 1 of 4 sampled residents for respiratory care (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. She required extensive assistance with 2 people with bed mobility, dressing, and toilet use. She was coded as utilizing oxygen. Resident #33's care plan dated 05/11/22 revealed she required oxygen therapy due to congestive heart failure. The goal included she would have no signs or symptoms of poor oxygen absorptions through the review date. Interventions, in part, included oxygen settings are based on physician orders and observe for signs and symptoms of…

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 review, observation and resident and staff interview, the facility failed to have accurate and complete medical records in the areas of pressure ulcers (Resident #4), wound care (Resident #29) & splint application (Resident #1) for 3 of 20 sampled residents whose medical records were reviewed (Residents # 1, # 4 & #29). Findings included: 1. Resident # 4 was admitted to the facility on [DATE]. A review of the weekly decubitus ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) assessments was conducted. The assessment revealed that Resident #4 had developed a stage 3 pressure ulcer on the left buttock on 1/24/23. Review of the physician's orders from January 2023 through March 2023 revealed there was no treatment ordered for the stage 3 pressure ulcer on the left buttock. Review of the January through March 2023 Treatment Administration Records (TARs) revealed there was no evidence that treatment was provided to the left buttock pressure ulcer. On 3/7/23…

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.