Wellbrooke of Westfield

In the surveyor’s words

From the most serious findings on record at Wellbrooke of Westfield, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 30, 2023

  Based on observation, interview and record review, the facility failed to ensure masks were worn correctly in the kitchen, failed to keep boxes off the floor of the freezer, failed to ensure foods were kept closed in the freezer and failed to ensure foods which had been opened were labeled with open dates. This deficient practice had the potential to affect 51 of 51 residents receiving food from the kitchen. Findings include: 1. a. During an observation of the kitchen with the Dietary Manager, on 01/23/22 beginning at 9:30 a.m., Cook 24 was observed working over a bowel of potatoes, which was prepared for all residents, with his face mask below his nose and chin. At that time, the Dietary Manager indicated the mask was to be worn over the nose and mouth. b. […]

• No harm, potential for more than minimal, patternF602Nov 9, 2023

  Based on interview and record review, the facility failed to protect residents from misappropriation of property, specifically medications, when a Registered Nurse removed discontinued medications from the facility without consent and ordered medications without the authorization of a licensed medical provider and then removed them from the facility for 5 of 5 residents reviewed for misappropriation of property. (Resident 2, 3, 4, 5, and 6) The deficient practice was corrected on 11/02/23, prior to the start of the survey and was therefore past noncompliance. Findings include: During an interview, on 11/06/23 at 10:10 a.m., the Executive Director indicated RN 2 was an employee with the facility. […]

• No harm, potential for more than minimal, patternF755Nov 9, 2023

  Based on interview and record review, the facility failed to maintain a record of disposition/return of unused and discontinued medications to the pharmacy and failed to ensure a licensed physician or nurse practitioner authorized or prescribed medications for 5 of 5 residents reviewed for pharmacy services. (Resident 2, 3, 4, 5, and 6) The deficient practice was corrected on 11/02/23, prior to the start of the survey and was therefore past noncompliance. Findings include: During an interview, on 11/06/23 at 10:10 a.m., the Executive Director indicated RN 2 was an employee with the facility. She had worked with another nurse who was terminated prior. RN 2 and the former employee were working together. RN 2 would take the medications out of the facility and give them to the former employee. […]

• No harm, potential for more than minimal, patternF625Jan 30, 2023

  Based on interview and record review, the facility failed to ensure the bed hold policy was provided to residents who transferred to the hospital or within 24 hours of the transfer to the hospital for 4 of 4 residents reviewed for notice of bed hold policy. (Residents 8, 15, 19 and 47) Findings include: 1. The record for Resident 8 was reviewed on 01/23/23 at 10:10 a.m. Diagnoses included, but were not limited to, Parkinson's disease, dementia, and muscle weakness. A nursing note, dated 10/11/22 at 11:18 a.m., indicated Resident 8 was sent to the hospital for right sided weakness. There was no scanned or written documentation in the record to show the bed hold policy was provided to the resident or responsible party. 2. The record for Resident 15 was reviewed on 01/23/23 at 10:04 a.m. […]

• No harm, potential for more than minimal, isolatedF645Mar 17, 2026

  Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for 1 of 4 residents reviewed for PASARR. (Resident 13)Findings include:The clinical record for Resident 13 was reviewed on 3/12/26 at 11:25 a.m. The diagnoses included, but were not limited to, Parkinsonism, major depressive disorder, and dementia.A physician's order, dated 10/3/25, indicated to administer escitalopram (an antidepressant medication) 5 milligrams (mg) for depression.A physician's order, dated 10/3/25, indicated to administer quetiapine (an antipsychotic medication) 50 mg for depression.There was no PASARR screening located in Resident 13's clinical record.During an interview, on 3/12/26 at 10:35 a.m., Clinical Support Nurse 1 indicated the… […]