Westbrook Acres

Inspectors wroteBased on clinical and hospital record review, observation, resident and staff interviews, and facility policy review, the facility failed to ensure a safe transfer and ambulation with the use of a gait belt as determined necessary by the care plan during Resident #1's staff-assisted transfer and ambulation on 3/13/26 for one of three residents reviewed for falls (Resident #1). Resident #1 fell to the floor, sustained a hip fracture with 7 out of 10 pain level, and required hospitalization with surgical repair. The facility reported a census of 44 residents.

Inspectors wroteBased on staff interview, clinical record review and facility policy review, the facility failed to obtain consent to administer psychotropic medications taken by 1 of 5 residents reviewed for unnecessary medications (Resident #9). The facility reported a census of 40 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility policy review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days unless the prescribing practitioner documented a rationale to extend medication for 1 of 5 residents reviewed for unnecessary medications (Resident #34). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to complete a comprehensive assessment and evaluation of a resident for readmission to the facility after hospitalization for 1 of 3 residents reviewed for discharge (Resident #48). The facility reported a census of 40 residents.

Inspectors wroteBased on time card review, schedule review, and staff interview, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. The facility reported a census of 44 residents.

Inspectors wroteBased on review of the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024 - September 30, 2024, facility staffing reports, and staff interviews the facility failed to submit accurate staffing reports for the PBJ Staffing Data Report. The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview the facility failed to follow the Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule for pneumococcal vaccination for 1 of 5 residents sampled (Resident #31).

Inspectors wroteBased on document review, policy review, and staff interview, the facility failed to utilize a grievance form to address missing resident items for 1 of 2 residents sampled (Resident #40). The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to inform the Long-Term Care (LTC) Ombudsman office of a resident hospitalized for 2 of 2 residents reviewed (Resident #4 and Resident #46). The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User's Manual, Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Vaccination Schedule, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of 1 of 5 residents reviewed for pneumococcal immunizations (Resident #31). The facility identified a census of 44 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow a physician's order for 1 of 1 residents reviewed with a tube feeding (Resident #39). Resident #39 was ordered to have water every 2 hours through her PEG (percutaneous endoscopic gastrostomy) tube (a flexible feeding tube inserted through the abdominal wall and into the stomach for nutritional support). This resident received the water every hour. The facility reported a census of 51 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage daily (in a 24 hour period). The facility reported a census of 51 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the bed hold policy for 1 of 2 residents reviewed (Resident #39). On 12/8/23 Resident #39 was sent to the hospital for seizures. A bed hold policy was not discussed/given to Resident #39's representative. The facility reported a census of 51 Residents.

Inspectors wroteBased on observation, record review, resident and staff interviews, and facility policy review, the facility failed to implement safety measures and interventions to protect residents on the Chronic Confusion and Dementing Illness (CCDI) Unit from resident to resident physical abuse from Resident #3, for 2 of 19 residents reviewed (Residents #2 and #7) that resided on the CCDI unit. Resident #3 had a history of physical violence directed at staff and resident's that included: On 7/8/23 alleged to have hit Resident #3 in the chest that caused an 8 X 10 centimeter (cm) purple bruise. On 7/10/23 Resident #3 was sent to the local emergency room (ER) for behavioral health placement before return to the facility. Resident #3 was described by facility on transfer documents as angry, agitated, with a history of physical aggression to residents and staff, raises fists to everyone. [...]

Inspectors wroteBased on clinical record review, observation, staff interviews, Pharmacist interview, facility investigation review, and facility policy review, the facility failed to ensure 1 of 3 resident's reviewed (resident #1) remained free from misappropriation of Tramadol, a narcotic pain medication. The facility reported a census of 51 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #1 dated 4/12/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition and identified diagnosis which included Non-Hodgkin's Lymphoma. The pain assessment interview identified no pain or hurting at any time in the last 5 days. A Physician's Telephone Order Audit, dated 3/14/23, documented Tramadol 50 milligrams (mg) with directions to give 1 by mouth every 6 hours as needed for pain. [...]