Westhampton Care Center

Based on observation, record review and interviews during the recertification survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not ensure that food was stored and/or served in accordance with professional standards for food safety. This was identified during the Kitchen task observation on 6/6/2025. Specifically, there was no system in place to monitor the temperatures of cold food items. The finding is: A facility policy and procedure titled Food Temperature (effective 1/2024), documented How to Keep Cold Food Cold: cold holding equipment (i.e. refrigerator, serving station, salad bar, deli bar) must keep food temperature at 40 degrees Fahrenheit or lower; check product temperature often, as directed. The facility policy contained a Hot Food Temperature Chart that did not include a space to record cold temperatures for food items other than milk. The chart documented All items must be held at 40 degrees or lower/141 degrees or higher. During an interview on 6/6/2025 at 11:44 AM, [NAME] #1 stated they take the food temperature when they set the items on the…

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, record review, and interviews during the Recertification Survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not ensure that a comprehensive patient-centered care plan was implemented to include measurable objectives and timeframes to meet a resident's medical and nursing needs. This was identified for one (Resident #143) of one resident reviewed for the environment (Call Bell). Specifically, Resident #143 was admitted with diagnoses that included Legal Blindness and Glaucoma and there was no documented evidence that a care plan was developed to address the resident's visual impairment. The finding is: The facility's Comprehensive Care Plan Policy revised on 11/2019 documented a Comprehensive Care Plan for resident's needs shall be developed within 14 days of admission. The Comprehensive Care Plan meeting (with the inclusion, by invitation, of the resident and /or family) will be conducted within 21 days from admission. Within 14 days of the resident's admission, a…

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 interviews during the Recertification Survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not ensure that all biologicals were stored in locked compartments in accordance with accepted professional principles. This was identified for one (Resident #12) of one resident reviewed for Dental Services. Specifically, on multiple occasions, Resident #12 was observed with Flonase (Fluticasone) (nasal spray with steroids) 50 micrograms Nasal Spray at their bedside and there was no staff in the vicinity on both occasions. The Flonase order was discontinued by the resident's Physician on 12/9/2024. Resident #12 did not have a physician's order and was not assessed to self-administer their medication. The finding is: The facility's Self-Administration of Medication Policy and Procedure revised in 9/2020 documented that upon determining the resident's desire and ability to self-medicate an order from the attending should be obtained. This order must be specific…

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 interviews during the Recertification Survey initiated on 6/3/2025 and completed on 6/10/2025, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #88) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #88 had a physician's order for Contact Precautions due to Methicillin Resistant Staphylococcus Aureus (antibiotic-resistant bacteria) and Osteomyelitis (bone infection) to the right great toe. During the initial tour on 6/3/2025, the Contact Precautions signage was not posted in a conspicuous location outside the resident's room. A visitor was observed in the resident's room without the use of Personal Protective Equipment and was coming in contact with the resident's bed. The finding is: The facility policy and procedure titled Transmission-Based Isolation, dated October 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 observations, record review, and interviews conducted during the Recertification survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure that each resident was cared for in a manner that maintained or enhanced his or her dignity. This was identified for one (Resident #12) of one resident reviewed for Dignity. Specifically, Licensed Practical Nurse (LPN) # 2 was observed responding to Resident # 12's call bell in an undignified manner. The finding is: The facility's policy titled Resident Rights dated September 2019 documented the resident has the right to be treated with respect and dignity. Resident # 12 has diagnoses that include Morbid (severe) Obesity, Generalized Chronic Pain Syndrome, and Osteoarthritis of both knees. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. The resident had no verbal or physical behavior problems…

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, record review, and interviews, conducted during the Recertification survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure that it promoted and facilitated resident self-determination through support of resident choice. This was identified for one (Resident #12) of one resident reviewed for Choices. Specifically, Resident #12 was observed complaining of pain in their legs to Licensed Practical Nurse # 2 and requested that their heel booties be removed. Licensed Practical Nurse #2 denied the resident's request and walked out of the resident's room without providing an explanation or exploring alternate interventions. Resident #12 was upset and appeared in pain as evidenced by squinting their eyes and pursing their lips. In lieu of Resident #12's response, the surveyor requested Registered Nurse #4 to intervene, who then assessed the resident and removed the resident's heel booties. The finding is: The facility's policy titled Resident Rights dated September 2019…

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 interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00319951) initiated on 1/03/2024 and completed on 1/11/2024, the facility did not ensure that the resident or designated representative was notified when the need to discontinue a treatment was identified. This was identified for one (Resident #149) of one resident reviewed for Notification of Change. Specifically, Resident #149 had a physician's order to administer Heparin (blood thinner medication) 5000 units every 12 hours and Aspirin (blood thinner) 81 milligrams one time daily. The vendor pharmacy identified a drug to drug interaction and a medical alert was generated in the Electronic Medical Record. The Heparin 5000 unit was discontinued as per the resident's physician's orders. There was no documented evidence that the resident or the resident's representatives were notified of the change in the resident's medication regimen. The finding is: The facility's Policy and Procedure titled,…

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, record review, and interviews during the Recertification Survey initiated on 1/03/2024 and completed on 1/11/2024, the facility did not implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #81) of one resident reviewed for Dementia Care. Specifically, Resident #81 with a diagnosis of Diabetes Mellitus, had a Physician's order to monitor blood sugar via finger sticks every morning and to notify a Physician of blood sugar results of less than 60 milligrams per deciliter (mg/dL) or greater than 350 milligrams per deciliter (mg/dL) . There was no documented evidence that Resident #81's finger sticks were performed from 12/15/2023 through 1/08/2024 to obtain the blood sugar levels as per the physician's orders. The finding is: The facility's policy titled, Diabetic Finger Stick Parameters Policy last reviewed in July 2019, documented that…

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 interviews during a Recertification survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice in accordance with the resident's plan of care. This was identified for one (Resident #136) of one resident reviewed for Intravenous (IV) access. Specifically, Resident #136 had a Peripherally Inserted Central Catheter (PICC) line. The physician's orders included measuring the Peripherally Inserted Central Catheter length and the resident's arm circumference weekly and changing the injection cap of the Peripherally Inserted Central Catheter line access weekly. There was no documented evidence that the physician orders were followed for three of four weeks on the December 2023 Treatment Administration Record. The finding is: The policy and procedure for the Peripherally Inserted Central Catheter line dated July 2019 documented procedures and assessments to include -…

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, record review and interviews conducted during a Recertification Survey initiated on 1/3/2024 and completed on 1/11/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 1/3/2024. Specifically, the reach-in refrigerator was observed with multiple trays of assorted desserts and nourishments that included three trays of vanilla pudding, one tray of applesauce, two trays of crushed pineapple, one tray of strawberry applesauce, and one tray of butterscotch pudding. The items on the trays were not labeled and dated. The finding is: Facility's policy titled Dating Food last reviewed on 1/5/2023 documented that all refrigerator items will be placed in the refrigerator with labels that identify the items and are dated. All prepared foods will be identified as to the date of preparation. Facility policy titled Food Storage last reviewed on 1/5/2023 documented that all containers of food will be stored…

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 observation, record review, and interviews during the Recertification Survey completed on 1/18/2022 the facility failed to ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases including COVID-19 infection was implemented on 2 of 5 nursing units. Specifically, 1) during the medication pass observation on Unit 2 on 1/11/2022, the Licensed Practical Nurse (LPN) #1 did not wear appropriate personal protective equipment (PPE) when providing medications and checking blood sugar for Resident #26 who was on contact and droplet precautions; in addition, LPN#1 did not wear gloves while administering insulin; 2) on Unit 2 two certified nursing assistants (CNA #1 and #2) did not wear appropriate PPE when adjusting Resident #68 in bed, who was on contact and droplet precautions; 3) on Unit 4, a family member of Resident #55, who was on contact and droplet precautions, was observed exiting the resident's room and walking down the hallway wearing a…

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 interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00277754) completed on 1/18/2022 the facility did not ensure that each resident's representative was immediately informed when there was a need to alter treatment significantly. This was identified for one (Resident #314) of one resident reviewed for choices. Specifically, Resident #314's family member was not informed when the facility staff initiated a gradual dose reduction of the antipsychotic medication, Seroquel, on 5/5/2021. The finding is: The facility Family Notification policy dated 7/2019 documented that the facility must immediately notify the resident's interested family member when there is a need to alter treatment significantly. Resident #314 was admitted on [DATE] with the diagnoses of Non-Alzheimer's Dementia, Major Depressive Disorder with Psychotic Features, and Functional Quadriplegia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #314 had a Brief…

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 staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00276066) completed on 1/18/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health (NYSDOH) for one (Resident #364) of four residents reviewed for Accidents. Specifically, Resident #364 was care planned for two-person assistance for bathing. however, the resident was showered only by one Certified Nursing Assistant (CNA) and was not properly secured with a safety belt while sitting on the shower chair. Subsequently, Resident #364 fell to the floor and sustained a head injury resulting in a Subdural Hematoma. The facility did not report the incident to the NYSDOH. The finding is: The facility's policy titled Abuse Mistreatment and Neglect dated July 2019 documented the term neglect shall mean failure to provide timely, consistent, safe, adequate, and appropriate services,…

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 interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY00277754) completed on 1/18/2022 the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice for one (Resident #314) of one Resident reviewed for choices. Specifically, Resident #314 had a history of receiving Seroquel (an antipsychotic medication) 25 milligrams (mg) per day in the community. Resident #314 was hospitalized after a fall at home and was discharged to the facility with recommendation to receive Seroquel 37.5 mg total daily. The facility Physician prescribed Seroquel 12.5 mg daily without obtaining Resident #314's history for Seroquel usage and did not obtain a psychiatry consult until 20 days after the gradual dose reduction when the resident started to exhibit behavioral changes. The finding is: The facility's Gradual Dose Reduction and Psychoactive Medication policy dated 7/2019 documented all residents on psychoactive…

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.