Bria of Westmont

Inspectors wroteBased on observations and interviews, the facility failed to maintain a sanitary environment in its outside dumpster area. This applies to all 184 residents (R1-R184) currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and comfortable environment by allowing food and trash debris to remain on floors and tables and permitted hallways throughout the facility to become cluttered with equipment and supplies. This failure applies to 2 of 6 residents (R1 and R4) reviewed for physical environment in the sample of 6.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the food preferences and individualized food choices of Indian residents were met, resulting in decreased nutritional intake and unplanned weight loss. This applies to 2 of 5 (R2 and R3) residents reviewed for food preferences in a sample of 5.1. R2's medical record showed that R2 was a [AGE] year-old with diagnoses including diabetes mellitus type 2, long-term use of insulin, heart disease, hemolytic anemia, and thrombocytopenia (Low platelet counts). The Minimum Data Set (MDS) quarterly assessment dated [DATE] showed R2's cognition was moderately intact and required supervision for touch-assisted activities of daily living. A review of the physician's order dated 04/10/2026 showed that R2 has a regular diet with a regular texture and consistency, prefers Indian food, and takes Glucerna twice daily. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that significant medications were administered to residents as indicated by physician orders. This applies to 7 of 7 residents (R8, R9, R10, R11, R12, R13, and R14) who were reviewed for medication administration in a sample of 14. On 02/17/2026 at 3:20 PM, after R8, R9, and R13 complained about receiving their morning medication in the afternoon, this writer asked V18 (Licensed Practical Nurse)-what time she administered medication to residents. V18 said that she was late in administering medications since she came to the facility after 10:00 AM due to some scheduling confusion, and she did not give the scheduled medications until after 11:00 AM and completed around 2:45 PM. V18 said the medications should be given as ordered, within a one-hour window before and after the ordered time.1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a physician was notified with Xray results for a resident with a confirmed fracture and failed to ensure prompt emergency care was provided for a resident with a confirmed fracture. This applies to 1 of 3 residents (R3) reviewed for change of condition in the sample of 13. This failure resulted in R3 experiencing a delay in emergency and surgical care after sustaining an acute comminuted and displaced distal femur fracture with large lipohemarthrosis (collection of fat and blood) and a subacute fracture of the proximal fibular diaphysis.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of a resident during a shower for 1 of 3 residents (R3) reviewed for accidents in the sample of 13. This failure resulted in R3 experiencing a fall from the shower chair and sustaining an acute comminuted and displaced distal femur fracture with large lipohemarthrosis (collection of fat and blood) and a subacute fracture proximal fibular diaphysis. R3 was admitted to the acute care hospital on [DATE] for surgical intervention and remained hospitalized until 12/4/25.

Inspectors wroteBased on observations, interview, and record review the facility failed to maintain an effective pest control program to support a sanitary environment and to enhance each residents' quality of life due to the continued presence of pests throughout the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent resident's bed was functioning to meet his needs for 1 of 13 residents (R7) reviewed for equipment in the sample of 13.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident who was dependent on staff for incontinence care received the necessary assistance in a timely manner. This failure affected two (R1, R2) of four residents reviewed for activities of daily living (ADLs) in the sample of 13.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide assistance to dependent residents with ADL (activities of daily living) activities. This applies to 4 of 4 (R1, R2, R3, R4) residents reviewed for ADLs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide transfer, toileting and dressing assistance to residents who were dependent on staff for ADLs (Activities of Daily Living). This applies to 7 of 7 residents (R5, R6, R10, R11, R12, R18 and R29) reviewed for assistance with ADLs in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve coffee per the facility planned/approved menu. This applies to 5 of 9 residents (R6, R10, R14, R16, R17) reviewed or coffee in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve palatable coffee during meals. This applies to 9 of 9 residents (R2, R4, R6, R10, R13, and R28) reviewed for coffee in a sample of 29.

Inspectors wroteBased on interview and record review the facility failed to provide certification for the acting Dietary Manager. This applies to all 177 residents receiving dietary services.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents food borne illness. This applies to all 177 residents receiving dietary services.

Inspectors wroteBased on observation, interview and record review, the facility failed to have interventions in place to prevent a resident from falling from bed. The facility also failed to store all smoking materials and failed to provide supervision to monitor residents for safe smoking. This affects 5 of 5 (R4, R53, R66, R106, R163) residents reviewed for falls and smoking in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to contain and secure resident medications. This applies to 4 of 4 residents (R1, R65, R84, R183) reviewed for medications in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place call lights within reach. This applies to 1 of 1 resident (R31) reviewed for call lights in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who were dependent on staff for care. This applies to 2 of 2 residents (R31, R11) reviewed for ADLs in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide splints as ordered. This applies to 2 of 5 residents (R31, R180) reviewed for splints in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the physician-ordered amount of tube feeding to prevent weight loss, and failed to ensure a resident's weight loss was identified in a timely manner. This applies to 2 of 2 residents (R19, R31) reviewed for nutrition in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to verify gastrostomy tube (G-tube) placement before administering medications and to date/label open gastrostomy tube feedings. This applies to 3 of 3 residents (R148, R180, and R196) reviewed for tube feeding management in the sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to coordinate outpatient appointment scheduling and transportation arrangements for resident. This applies to 1 resident (R45) reviewed for social services in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications for newly admitted residents were available for timely administration. This applies to 1 of 3 residents (R1) reviewed for pharmacy services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide ADL (Activities of Daily Living) care to meet the needs of the residents. This applies to 3 of 3 residents (R1 - R3) reviewed for ADLs care in a sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention interventions for a high-fall risk resident. This applies to 1 out of 3 (R1) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they employeed a qualified social worker on a full time basis. This has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely and thorough incontinence care was provided to 1 of 3 residents (R3) reviewed for incontinence care in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to coordinate with an outside agency in a timely manner to complete guardianship paperwork for a resident with severe mental illness for 3 of 3 residents (R1) reviewed for medically related social services in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 2 of 5 residents (R2 and R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R2 is 69-years-old with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R2 is substantial/maximal assistance on toileting hygiene. On 1/15/24 at 9:30 AM, R2 stated, Last Saturday on 1/11/25, I was sitting on my urine and feces for hours since 8:15 AM. Nobody didn't answer my call light or changed me for hours until 10:45 AM. I have my phone to note the time. R2 continued, Last night, I wasn't changed until 4: 00 AM. I put the call light at 10:30 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to administer diabetic, antihypertensive and heart medications to a resident (R16) with diagnoses of type 2 diabetes mellitus, CAD (coronary artery disease) and hypertension. This applies to 1 of 4 residents (R16) reviewed for significant medications in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to obtain vital signs as ordered by a physician for 1 of 3 residents (R3) reviewed for quality of care in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement transmission-based precautions for a resident (R2) who was COVID-19 positive. This applies to 1 of 3 residents reviewed for COVID-19 in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to administer wound care treatments as ordered by the physician. This applies to 2 of 3 residents (R1, R4) reviewed for improper nursing care in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to administer pressure ulcer treatments as ordered by the physician. This applies to 1 of 3 residents (R2) reviewed for improper nursing care in the sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 5 of 7 residents (R27, R39, R109, R115, and R453) reviewed for ADL (activities of daily living) in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide mechanical soft and pureed cubed beef steak portions as shown on menu spreadsheet for the lunch meal. This applies to 7 of 7 residents (R1, R24, R27, R36, R50, R81, R88) observed for dining in the sample of 33. On September 23, 2024 at 9:43 AM, V7 (Cook) stated that the meal prepared for the lunch meal that day was cubed steak (Salisbury steak), carrots and mashed potatoes. V7 stated that this meal was supposed to be served on Saturday but got switched as the residents chose to have the meal of the month on Saturday instead. Diet order spreadsheet for the above meal showed to serve #6 scoop of ground cubed steak with onion and gravy for mechanical soft diet and #6 scoop of the pureed steak with broth for the pureed diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve pureed consistency vegetables to the residents on pureed diets. This applies to 8 of 8 residents (R2, R27, R33, R37, R50, R57, R81, R88) reviewed for pureed diets in the sample of 33. Facility Week at a Glance Menu for September 24, 2024 showed Capri Mix Vegetables as the vegetable option for the lunch meal. On September 24, 2024 at 10:31 AM, the pureed meal prep by V10 (Assistant Food Service Manager) was observed in the facility kitchen. V10 stated that he is making about 12 servings as some of the residents on pureed diets have orders for double portions. V10 measured out twelve 4 oz (ounce) scoops of cooked zucchini into a [NAME] and processed the same. V10 continued to blend the mixture for several minutes, stopping in between to open the lid and stir the product with a spatula. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to offer the pneumococcal vaccine. This applies to 5 of 5 residents (R56, R71, R7, R34, and R68) in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders for life sustaining treatment reflected the resident's POLST (Physician Ordered Life Sustaining Treatment) form. This applies to 2 of 2 residents (R8 and R95) reviewed for advanced directives in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with a new diagnosis of a mental disorder to the appropriate state-designated authority for level II PASARR (Preadmission Screening and Resident Review). This applies to 1 of 8 residents (R95) reviewed for PASARR in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to document and hold interdisciplinary care plan conferences, at required intervals, in accordance with facility policy. This applies to 3 of 6 residents (R52, R87, and R116) reviewed for care plan conferences in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the treatment recommendations for a resident who was assessed to require the use of a hand splint to prevent further decrease of ROM (Range of Motion) and contractures in that extremity. This applies to 1 of 1 residents (R74) reviewed for splints in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and administer pain medication to the residents as ordered by the physician, to manage pain. This applies to 2 of 5 residents (R20 and R82) reviewed for pain management in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to document any information pertaining to a resident's death, in the medical record, in accordance with facility policy. This applies to 1 of 33 residents (R150) reviewed for documentation in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were trained on how to care for a resident with a LVAD (Left-Ventricular Assist Device) prior to admission, failed to obtain orders upon admission for a resident's LVAD, and failed to implement the LVAD orders once they were received for 1 of 1 resident (R4) reviewed for quality of care in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a sink was secured safely to the wall for 1 of 3 residents (R2) reviewed for furnishings in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to maintain a universal updated list of residents identified as high risk for elopement and failed to train its staff on its elopement policy. The facility also failed to update resident elopement care plans based on their elopement assessments. This applies to 20 out of 21 residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) reviewed for safety and supervision.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had a physician's order for suctioning, was assessed prior to and after suctioning, and was suctioned in a manner that maintained the comfort of the resident for one of three residents (R1) reviewed for hospice services in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to use a two person assist to safely turn a resident requiring a two a person assist during cares. This applies to one (R2) of three residents reviewed for safety/supervision in the sample of seven. This failure resulted in R2 [NAME] off the bed and sustainting a laceration to the forehead requiring sutures.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was sent to dialysis on time. This applies to one (R1) of three residents reviewed for dialysis in the sample of seven.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in the resident's condition in a timely manner. This failure resulted in a delay in treatment for R1, who experienced a decrease in activities of daily living and increased pain after sustaining a right hip fracture following a fall 4 days earlier. This applies to one of three residents (R1) reviewed for accidents in a sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to file a grievance and follow up on the grievance for a resident who notified staff of a concern. This applies to one of three residents (R3) reviewed for improper nursing care in a sample of eight.

Inspectors wroteBased on interview and record review the facility failed to correctly transcribe and reconcile a resident's hospital discharge medication orders upon readmission to the facility for one resident (R1) of three residents reviewed for medications orders received upon admission/readmission to the facility in a sample of three. This failure resulted in R1 being prescribed and administered the wrong medication regimen, including an opioid, antibiotic and anticoagulant medications resulting in R1 having a change in condition that required transfer to the local hospital emergency room with subsequent hospital admission.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from physical abuse. This applies to 4 of 4 residents (R3, R4, R14 and R15) reviewed for abuse in the sample of 17. This failure resulted in R3 being hospitalized with multiple facial fractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safety interventions were in place for a resident with a history of seizures for 1of 3 residents (R5) reviewed for safety in the sample of 17. This failure resulted in R5 having seizure like activity and falling from his wheelchair sustaining frontal skull fractures and a laceration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's bedding was clean for 2 of 17 residents (R1, R7) reviewed for clean comfortable and homelike environment in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve residents breakfast at their preferred time. This applies to 6 of 7 residents (R1, R2, R5, R6, R7, R8) reviewed for late meal service in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly respond to residents' call lights when residents require assistance. This applies to 2 of 3 residents (R3, R4) reviewed for timely call light response in the sample of 9.

Inspectors wroteBased on observation, interview and record review the facility failed to promptly address and provide treatment for a pressure wound that re-opened. This applies to 1 of 3 (R2) residents reviewed for pressure wounds from a total sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene to dependent residents in a timely manner. This applies to 2 of the 3 residents (R10, R11) reviewed for personal care from the total sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with sacral pressure injury was kept clean and dry of urine to promote wound healing. This applies to 1 of 3 residents (R10) reviewed for pressure ulcer in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care with two people assist during incontinent care and bed mobility. This failure resulted in R1 falling from the bed and sustaining a laceration on the top left part of her head requiring a staple and left femoral neck fracture. This applies to 1 of 9 residents (R1) reviewed for falls and accidents.

Inspectors wroteBased on interview and record review the facility failed to administer a resident's medications as ordered by the physician. This applies to 1 of 3 (R2) residents reviewed for medications in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care. This applies to 1 of 3 (R2) residents reviewed for incontinence care in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to store food items and maintain the kitchen in a manner that prevents food borne illness. This applies to 171 residents that are served food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have call light accessible to dependent residents, failed to provide means that allows residents to turn overhead bed light on and off independently, and failed to provide easy accessibility to the bathroom for a wheelchair bound resident. This applies to 4 of 4 residents (R78, R109, R124 and R131) reviewed for accommodation of needs in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to shave, provide nail care, and assist with dressing. This applies to 4 of 36 residents (R11, R12, R59, R66) reviewed for ADL's (Activities of Daily Living) in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store an oxygen cylinder and secure resident's smoking materials. This applies to 7 of 7 residents reviewed for safety (R11, R13, R37, R44, R83, R91 and R106) in a sample size of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove over the counter medication from resident's rooms, properly secure resident's medication and failed to obtain order for residents that have medication stored in resident's room. This applies to 7 out of 7 residents (R46, R64, R66, R82, R126, R127 and R479) reviewed for medication in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current standards of Infection Control during incontinence care and pressure wound dressing change. This applies to 5 of 5 residents (R35, R63, R108, R143, R480) reviewed for incontinence care and pressure wound dressing change in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility to properly position indwelling catheter bag and follow current standards of infection control. This applies to 2 of 2 residents (R109 and R480) reviewed for indwelling catheter in a sample of 36.

Inspectors wroteBased on observation, interview and record, the facility to verify gastrostomy tube (G-tube) placement prior to administering medications through the G-tube. This applies to 1 of 1 resident (R148) reviewed for medication administration via G-tube in the sample of 36.

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe and comfortable water temperature with the resident bathroom sinks. This applies to all 24 residents on the first floor C-wing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food to residents at a palatable temperature. This has the potential to affect all 173 residents consuming Food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal care to residents requiring assistance with ADL (Activities of Daily Living) needs. This applies to 3 of 5 residents (R9, R10, and R11) reviewed for activities of daily living (ADL) from a sample of 12.