Westview of Derby Rehabilitation & Health Care Cen

Inspectors wroteThe facility reported a census of 62 residents; the sample included six residents reviewed for bowel movements and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R)1 for lack of bowel movements.

Inspectors wroteThe facility reported a census of 62 residents; the sample included six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to implement an intervention to prevent further falls after a fall with serious injury for Resident (R) 1.

Inspectors wroteThe facility identified a census of 69 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested and recorded the dish machine temperatures. This deficient practice placed residents at risk for contamination and food-borne illness.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 69 residents residing in the facility. Findings Included: - On 03/03/25 Administrative Nurse D provided a Facility Assessment updated 08/12/24. A review of the assessment revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. [...]

Inspectors wroteThe facility had a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 38's protected health information (PHI) private on a medication cart parked in the main dining room. This deficient practice placed R38 at risk for impaired privacy.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, with eight residents reviewed for activities of daily living (ADL) for dependent residents. Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was provided for Resident (R) 11, R34, R14, and R15 who were dependent on staff assistance with ADLs. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide resident directed, interactive activities based on resident preferences for the residents on the weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for December 2024, January 2025, and February 2025 was completed. The calendars revealed the residents were provided church related services via television or internet on Sundays. The calendar revealed movies were played for the residents at 02:30 PM and the evening news at 06:00 PM on Sundays. The calendars lacked engaging staff-led activities for Sundays. [...]

Inspectors wroteThe facility had a census of 69 residents. The sample included 18 residents, with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure areas containing hazardous materials out of reach of seven cognitively impaired /independently mobile residents in the secured unit. The facility further failed to implement interventions related to Resident (R)28's falls. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - The facility identified that Residents (R) 5, R16, R22, R30, R42, R53, and R60 were cognitively impaired and independently mobile within the facility. On 03/03/25 at 07:03 AM, a walkthrough of the facility was completed. Upon inspection of the facility's supplemental oxygen storage room revealed the entry door was unlocked. [...]

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, with one medication room and three medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This placed the residents at risk for misappropriation and/or diversion of controlled substances.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for Resident (R) 60's as needed antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality). The facility also failed to ensure the CP identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for R4. The facility also failed to ensure the physician reviewed and addressed the CP's recommendations for reeducation of R14's analgesics (pain relief) dosage. [...]

Inspectors wrote- The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R57's admission Minimum Data Set (MDS) dated 12/19/24 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS noted he required substantial to maximal assistance with transfers, toileting, bed mobility, bathing, and personal hygiene. The MDS noted he took anxiolytic medication. [...]

Inspectors wroteThe facility identified a census of 69 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to store oxygen saturation equipment and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) tubing in a sanitary manner and further failed to ensure the required personal protective equipment (PPE) was worn while doing tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) care. This deficient practice placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24's call light was within her reach and further failed to provide foot pedals for R25 while pushing her in the hall. This deficient practice left R24 vulnerable to unmet care needs due to the inability to call for staff assistance and placed R25 at an increased risk for preventable falls and injuries. Findings Included: [...]

Inspectors wroteThe facility reported a census of 69 residents. The sample included 18 residents, with one reviewed for personal funds. Based on record review, interviews, and observations, the facility failed to prevent unnecessary charges to Resident (R) 218 bank account resulting in multiple charges to his bank account. This deficient practice placed R218 at risk for misappropriation of funds. Findings Included: - The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Chronic obstructive pulmonary disorder (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), senile degeneration of the brain, and dementia (a progressive mental disorder characterized by failing memory and confusion). R218's EMR indicated he was admitted to the facility on [DATE]. [...]

Inspectors wroteThe facility identified a census of 69 with 18 residents included in the sample. The facility identified 12 residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 63. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24's heels were offloading, heel protectors were applied to both heels and further failed to monitor R24's low air loss mattress. This placed R24 at increased risk for developing pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently monitor and document Resident (R) 54's dialysis (a procedure where impurities or wastes were removed from the blood), shunt for bruit (blowing or swishing sound heard when blood flows through a shunt), thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt), and dressing. This deficient practice placed R54 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, with seven reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure R4's Diclofenac (topical medicated ointment used to treat pain) medication had a dosage administration amount. This deficient practice placed both residents at risk for unnecessary medications and potential side effects. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, aphasia (difficulty speaking), chronic kidney disease, and heart failure. [...]

Inspectors wroteThe facility identified a census of 69 residents. The sample included 18 residents, three medication carts, and one medication room. Based on observation, record review, and interviews, the facility failed to properly label medication in one of the three medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

Inspectors wroteThe facility reported a census of 43 residents with three residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure one resident remained free of accident hazards related to mechanical lift transfers when Resident (R) 1 obtained an injury on 11/15/24 at approximately 07:00 PM when an unknown staff member failed to safely operate the mechanical lift and transferred the resident without another staff member present. This deficient practice resulted in a fracture (broken bone) of R1's left patella (kneecap).

Inspectors wroteThe facility reported a census of 65 with three of residents selected for reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired R1, identified at risk for elopement. On 05/07/24 at 09:40 AM a CNA M let R1 out the front doors of the building. CNA M thought R1 had an appointment and was leaving to get on the facility transport vehicle. When R1 went out the doors his WanderGuard caused an alarm to activate, and CNA M did not check which resident caused the alarm. The facility did not know R1 was not in the building until almost 15 minutes later when a staff member driving by the facility saw the resident outside, unsupervised, and notified the facility. [...]

Inspectors wroteThe facility reported a census of 70 residents with three selected for review for bathing services. Based on observation, record review, and interview, the facility failed to provide adequate bathing services for the three residents reviewed, Resident (R)1, R2, and R3.

Inspectors wroteThe facility reported a census of 60 residents which included two residents sampled for allegations of abuse. Based on interview and record review, the facility failed to suspend alleged perpetrator in response to an allegation of abuse, neglect, exploitation, or mistreatment, to prevent further potential abuse for the residents of the facility on one of four halls (400 hall) of the facility while an investigation of abuse was in progress related to Resident (R)1.

Inspectors wroteThe facility reported a census of 64 residents with three residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R)1, with a known history of elopement, from leaving the facility unsupervised and without staff knowledge on 12/31/23 at approximately 06:30 AM. The facility staff did not know R1 was not in the facility until the oncoming nurse, Licensed Nurse (LN) D, asked a Certified Nurse Aide (CNA) G to locate R1. The facility staff could not locate R1 on 12/31/23 at 06:30 AM and LN D started the elopement process. At 07:30 AM, CNA G found R1 outside, at the back of the facility, at the bottom of the concrete stairs. [...]

Inspectors wroteThe facility reported a census of 57 residents with three sampled for elopement. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe and secure environment for cognitively impaired Resident (R)1. On [DATE] at approximately 07:05 AM, Licensed Nurse (LN) I walked in the front doors of the facility to report for her shift while R1 walked out of the front doors. LN I assumed R1 was a visitor or employee. The facility staff did not realize R1 was missing until 07:45 AM (40 minutes later), at which time the facility staff began searching for R1. Around 10:00 AM the family notified the facility R1 was found deceased by the train tracks at approximately 08:30 AM, after being struck by a train. [...]

Inspectors wroteThe facility reported a census of 56 residents. The facility had one main kitchen. The kitchen served food to one main dining area. Based on observation, interview, and record review, the facility failed to properly store food in the main kitchen refrigerators due to foods left uncovered, boxes placed directly on the floor in the kitchen area, and staff failed to discard expired foods in accordance with professional standards for food service safety, to prevent food borne illness to the residents.

Inspectors wroteThe facility reported a census of 56 residents. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for the residents and staff related to items/areas in the facility laundry.

Inspectors wroteThe facility reported a census of 56 residents. Based on interview and record review, the facility failed to develop, implement and permanently maintain an in-service training program for nurses aides that is appropriate and effective as to ensure the continuing competence of nurse aides with no less than 12 hours per year. Five of five nurse aides also lacked dementia management training, resident abuse prevention training

Inspectors wroteThe facility reported a census of 56 residents with 14 residents included in the sample. Based on interview and record review, the facility failed to provide a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfers to the hospital. This included Resident (R) 14, R 13, R 47, R 164.

Inspectors wroteThe facility reported a census of 56 residents with 14 sampled which included two residents reviewed for choices. Based on observation, interview, and record review, the facility failed to provide choices for Resident (R)39 related to her preferences for waking up in the morning.

Inspectors wroteThe facility reported a census of 56 residents with 14 sampled that included three for hospitalization. Based on observation, record review, and interview the facility failed to notify/ send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman of the reason for the transfers for Resident (R) 13, R14, and R47's required hospitalizations. - Review of R13's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Furthermore, the resident discharged to the hospital again on 04/30/23 and returned to the facility on [DATE]. Review of R13's Medical Record lacked evidence of a written notification of the facility-initiated hospitalizations transfer/discharges to the Office of the State Long-Term Care Ombudsman. [...]

Inspectors wroteThe facility reported a census of 56 residents, with 14 sampled including two residents sampled for Preadmission Screening and Resident Review (PASARR). Based on interview and record review the facility failed to coordinate an assessment with the PASARR program for a level II screening as recommended for Resident (R) 22. Findings Included: - The Electronic Health Record (EHR) for R22 revealed the following diagnoses included anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and schizoaffective disorder (mental health disorder characterized by a combination of symptoms of schizophrenia). The 11/13/19 Preadmission Screening and Resident Review (PASARR) Determination Letter indicated a need for further evaluation and would be referred for a Level II screening. The 05/09/23 Care Plan lacked documentation of PASARR Level II requirements. [...]

Inspectors wroteThe facility reported a census of 56 residents, with 14 residents sampled for review. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 13 and R15 which included oxygen use and care.

Inspectors wroteThe facility reported a census of 56 residents with 14 residents sampled which included two residents reviewed for nutrition. Based on observation, interview, and record review the facility failed to accurately obtain weight and verify weights as needed to monitor and address Resident (R)23's nutritional status/weight loss.

Inspectors wroteThe facility reported a census 56 residents with 14 residents sampled which included one resident reviewed for dialysis (a process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 55, who required dialysis, receive services, consistent with professional standards of practice, to monitor for the effectiveness and adverse reactions related to dialysis.

Inspectors wroteThe facility reported a census of 56 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to Resident (R) 26's urinary catheter, and R13 and R15, related to nubulizer storage.

Inspectors wroteThe facility reported a census of 56 residents with 14 residents sampled which included five residents selected for review of influenza, pneumococcal, and COVID vaccines. Based on interview and record review, the facility failed to ensure the resident/resident representative received information/education regarding the benefits, risks, or medical contraindications of influenza, pneumococcal, and/or COVID vaccines for Resident (R)39.

Inspectors wroteThe facility census totaled 42 residents. Based on interview and record review, the facility failed to ensure a qualified Dietician or Certified Dietary Manager (CDM) worked in the facility to carry out the functions of food and nutritional services for the 42 residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed ensure the safe and sanitary meal preparation, service, and storage when kitchen staff failed to adequately monitor the daily temperatures of the refrigerators and freezers, failed to monitor the chemical sanitization of the low temperature dishwasher each shift, and failed to test the sanitizing solution used to clean surfaces in the kitchen and dining room. These failures had the ability to affect all residents served meals from the kitchen.

Inspectors wroteThe facility census totaled 42 residents. Based on interview and record review, the facility failed to ensure five Certified Nurse Aide (CNA) staff reviewed, completed 12 hours of required in-service training annually.

Inspectors wroteThe facility census totaled 42 residents. Based on interview and record review, the facility failed to ensure all facility staff were trained on dementia care and social media annually.

Inspectors wroteThe facility census totaled 42 residents (R) with 12 included in the sample and two residents reviewed for transfers out of the facility. Based on observation, interview, and record review the facility failed to ensure staff completed notifications to the ombudsman for R38s transfer to the hospital and R45's discharge to another long-term care (LTC) facility.

Inspectors wroteThe facility census totaled 42 residents (R) with 12 residents in the sample and one resident reviewed for hospitalization. Based on observation, interview, and record review the facility failed to notify R38's representative in writing and complete the bed hold for the resident's facility initiated hospitalization transfer.

Inspectors wroteThe facility census totaled 42 residents with 12 residents (R) in the sample. Based on observation, interview, and record review the facility failed to ensure the accuracy of the completed Minimum Data Set (MDS) regarding falls experienced by R9, which were not noted on the MDS.

Inspectors wroteThe facility census totaled 42 residents with 12 residents (R) in the sample. Based on observation, interview, and record review the facility failed to ensure the resident's comprehensive Care Plans reflected the needs of the residents to ensure person-centered care. R10's comprehensive care plan lacked information regarding hospice care, R36's comprehensive care plan lacked information/interventions regarding dialysis (a procedure where impurities or wastes were removed from the blood) services received, and R9's comprehensive care plan lacked revisions related to fall interventions.

Inspectors wroteThe facility reported a census of 42 residents, with 12 sampled, including one for discharge to the community. Based on interview and record review the facility failed to complete a discharge summary to include the recapitulation of Resident (R) 45's stay in the discharge summary.

Inspectors wroteThe facility census totaled 42 residents with 12 residents (R) in the sample and one sampled for hospice care. Based on observation, interview, and record review the facility failed to ensure hospice care/services were documented and communicated to staff for the continuity of care regarding R10.

Inspectors wroteThe facility reported a census of 42 residents, with 12 sampled and three reviewed for falls. Based on observation, interview, and record review the facility failed to adequately complete fall investigations, to include identifying causal factors related to falls and implement interventions to prevent further falls for Resident (R) 4, R9, and R26.

Inspectors wroteThe facility census totaled 42 residents (R) with 12 residents in the sample, and one resident sampled for dialysis services. Based on observation, interview, and record review the facility failed to complete pre-dialysis weights and vital signs, assess the dialysis access site, record resident fluid intake, and obtain physician ordered labs for R36.

Inspectors wroteThe facility census totaled 42 residents with 12 residents (R) in the sample and five sampled for medication regimen reviews. Based on interview, observation, and record review the facility failed to maintain documentation of the consultant pharmacist's identified recommendations and failed to act upon recommendations for multiple months for R10, R26, and R31.

Inspectors wroteThe facility reported a census of 42 residents, with 12 sampled and five reviewed for unnecessary medications. Based on interviews and record review, the facility failed to follow the physicians' orders regarding R31's diabetes when staff did not document and notify the provider of blood glucose (BG, blood sugar) values outside the designated parameter. The facility further failed to ensure blood pressure parameters for R26 and R31.

Inspectors wroteThe facility census totaled 42 residents with 12 residents (R) in the sample and five sampled for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure an appropriate diagnosis for R10s antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications.

Inspectors wroteThe facility reported a census of 42 residents with three residents requiring a pureed diet. Based on observation, interview, and record review the facility failed to ensure the staff prepared foods by methods which conserve nutritive value, flavor, and appearance. Observation of kitchen staff not following a recipe for the preparation of the pureed lunch menu, resulted in unappetizing and runny food, with a change in nutritive value when staff substituted milk in place of other thinning ingredients as listed in the recipe (such as broth and/or butter), and failed to follow the recipe measurements and staff was eyeballing measurements of ingredients used in the purees, meant to thin or thicken the puree, and failed to serve all items on the menu in puree form or offer substitutes for items she did not puree.