Wentworth Rehab & HCC

In the surveyor’s words

From the most serious findings on record at Wentworth Rehab & HCC, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 5, 2025

  Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that fall risk assessments are accurate, failed to develop and/or implement preventive interventions, and failed to provide supervision to two of three residents (R2, R5) reviewed for falls. These failures resulted in the following: R5 sustained (12/31/24) fall resulting in intracranial hemorrhage and traumatic head injury requiring 4 staples. R1 sustained (1/10/25) fall resulting in left eyebrow laceration requiring 6 sutures. Findings include: R5 was admitted (11/25/24) with diagnoses which include Alzheimer's disease, glaucoma, (1/8/25) traumatic subarachnoid hemorrhage and fall, subsequent encounter. […]

• Actual harm, isolatedF692Nov 8, 2024

  Based on observation, interview, and record review, the facility failed to a.) implement/revise the care plan interventions addressing the resident's required nutritional support for one (R4) resident b.) the facility's intermittent failure to provide required assistance/monitoring with eating resulted in poor intake for one (R4) resident out of three residents reviewed, in a total sample of three residents. This failure resulted in R4's significant, not severe, unplanned weight loss. […]

• Actual harm, isolatedF689May 31, 2024

  Based on observations, interviews, and records review, the facility failed to ensure a safe environment that is free from accidents and hazards for one (R85) of 5 residents reviewed in a sample of 35. This failure resulted in R85 falling and sustaining a fracture of the 2nd left finger. Findings include: R85's current face sheet documents R85 is a [AGE] year-old individual with medical conditions that include but not limited to: End stage renal disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, displaced fracture of shaft of second metacarpal bone, left hand, subsequent encounter for fracture with routine healing, history of falling, type 2 diabetes mellitus without complications. […]

• Actual harm, isolatedF689May 23, 2024

  Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement appropriate fall prevention interventions, and/or failed to provide supervision for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1 sustaining a fall that resulted in laceration and sutures to R1's left eyebrow. Findings include: On 5/21/24 at 1:32pm, surveyor inquired about resident fall prevention interventions (post fall). V10 (Restorative Nurse) stated We want to put in an intervention based off of what we observed to prevent this from happening again or prevent injury. The intervention is in the care plan, we update the care plan. […]

• Actual harm, isolatedF600Mar 22, 2024

  Based on interviews and records review the facility failed to ensure two (R5, R10) of three residents were free from abuse. This failure resulted in R5 being hit on the face and R10 being bitten on the arm by R6. Findings include: R6 is a [AGE] year-old resident. R6's diagnoses include but are not limited to schizoaffective disorder, bipolar type, bipolar disorder, moderate intellectual disabilities, generalized anxiety disorder, schizophrenia, altered mental status. According to R6's care plan, R6 has impaired cognitive functioning related to R6's diagnoses of schizophrenia, unspecified and altered mental status, unspecified and moderate intellectual disabilities. R6 has difficulties managing anger/frustration related to diagnoses of schizophrenia and bipolar disorder. […]