Westover Retirement Community

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This affected one resident (#43) of four resident assessments reviewed. The facility census was 51. Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no oral or dental issues. Observation on 11/19/25 at 1:58 P.M. of Resident #43 revealed the resident to be without natural upper teeth.Interview with Resident #43 at the time of the observation revealed the resident had lost several teeth since her admission to the facility. Resident #43 verbalized wishes to see a dentist however she has not been offered assistance in obtaining a dental appointment since her admission. Interview on 11/20/25 at 10:38 A.M. with Minimum Data Set Registered Nurse (MDS RN) #70 revealed she was not…

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 review and staff interview, the facility failed to follow a physician order for referral services. This affected one Resident (#43) of four residents reviewed for physician orders for referral services. The facility census was 51. Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety.Review of the provider progress note dated 07/22/25 revealed Resident #43 was seen by Nurse Practitioner (NP) #105 and the resident was referred to neurology related to neuropathy. Review of the nurse's progress note dated 07/22/25 and timed 5:52 A.M. revealed a nurse's note stating Resident #43 was referred to neurology by NP #105 related to neuropathy. Resident with left foot and leg heaviness, numbness and having a hard time lifting leg and foot. Resident made aware of the referral. Review of a provider's progress note dated 07/28/25 and signed at 2:58 P.M. by NP #105 revealed Resident #43 had previously been referred to neurology for left leg and foot…

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, medical record review, staff interview, and resident interview, the facility failed to ensure timely dental services. This affected one resident (#43) of four residents reviewed. The facility census was 51.Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no issues with oral or dental status. Additional review of the medical record for Resident #43 revealed no documentation regarding a dental care plan or attempts to schedule a dental appointment. Observation on 11/19/25 at 1:58 P.M. of Resident #43 revealed the resident to be without natural upper teeth. Interview with Resident #43 at the time of the observation revealed the resident had lost several teeth since her admission to the facility. Resident #43 verbalized wishes to see a dentist however she has not been offered assistance in obtaining a dental appointment…

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, resident and staff interviews and policy review, the facility failed to provide activities for a resident in isolation. This affected one (#22) out of one residents reviewed for activities. The facility census was 50. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/26/24. Diagnoses include chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident with moderate cognitive impairment. Resident required set-up assistance with eating, partial assistance for oral hygiene and bathing, substantial assistance with dressing, personal hygiene, bed mobility, and transfers, and was dependent on staff assistance with toileting hygiene. Review of Resident #22's care plan, dated 05/09/24…

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, staff, pharmacy staff and Nurse Practitioner (NP) interviews and review of medication information from Medscape, the facility failed to ensure a resident received a cardiac medication as as ordered resulting in significant medication errors. This affected one (#207) out of one residents reviewed for medication errors. The facility census was 50. Findings include: Review of the medical record for Resident #207 revealed an admission date of 10/04/24. Diagnoses include intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain, chronic respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) revealed no information was available due to Resident #207 being a new admission. Review of Resident #207's physician orders revealed an order dated 10/04/24 for Entresto Oral Tablet 24-26 milligrams (mg) (Sacubitril-Valsartan), give one (1) tablet by mouth two times a day related to…

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, interview, policy review, review of online resources from Centers for Disease Control (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19, failed to ensure visitation was suspended when an employee tested positive for COVID-19, failed to ensure staff wore personal protective equipment (PPE) in the facility to prevent the potential spread of Coronavirus (COVID-19), and failed to ensure staff administered medications utilizing proper infection control practices to prevent the potential spread of infectious disease. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed…

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, interview and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. During interview on 09/28/21 at 10:51 A.M., the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift…

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, interview and policy review, the facility failed to ensure the physician was notified of abnormal blood glucose and blood pressure levels. This affected one (Resident #08) of one resident reviewed for notification. The facility census was 40. Findings include: Review of the medical record of Resident #08 revealed the resident admitted to the facility on [DATE] with diagnoses including anemia, anxiety disorder, peripheral vascular disease, major depressive disorder, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, hyperlipidemia, gastro-esophageal reflux disease, chronic atrial fibrillation, and pulmonary hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] the resident had intact cognition. Review of the physician's orders revealed orders dated 04/06/21 to check blood glucose before meals and at bedtime and call the attending practitioner and follow the Abnormal Glucose Policy if glucose is over 350 mg/dL (milligrams per…

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, interview, and policy review, the facility failed to ensure there was ongoing communication, coordination and collaboration between the facility and the dialysis center. This affected one (Resident #35) of one resident who received dialysis in the facility. The census was 40. Findings include: Review of medical record for Resident #35 revealed an original admission date of 07/14/21. Additional admissions /discharges included resident was discharged with a return not anticipated on 07/21/21 and readmitted on [DATE]. Diagnosis included hypertensive emergency, hypertension, diabetes mellitus, chronic kidney disease with end stage renal disease with dependence on renal dialysis and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 08/20/21, revealed Resident #35 was cognitively intact, had no behaviors, did not reject care, was a one-person physical assist, required limited assistance and/or supervision for activities of daily living and received dialysis.…

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.