Westbrook Acres

In the surveyor’s words

From the most serious findings on record at Westbrook Acres, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 3, 2026

  Based 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. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam. […]

• Actual harm, isolatedF600Sep 28, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Mar 6, 2025

  Based 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. Finding include: Review of all Nursing Schedules from 7/1/2024 thru 9/30/2024 and Time Card Punches from 7/1/2024 thru 8/18/2024 revealed the facility failed to staff an RN for 8 consecutive hours on the following dates: 7/6/24, 7/7/24, 8/4/24, 8/17/24, and 8/18/24. During an interview on 3/5/25 at 2:47 PM, the Administrator revealed the facility uses an accounting company to submit all Payroll Based Journal staffing data. The accounting company emailed the Administrator a report reflecting the staffing data submitted. […]

• No harm, potential for more than minimal, patternF638Feb 16, 2023

  Based on clinical record review and staff interviews, the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner using the Resident Assessment Instrument (RAI) as directed by Centers for Medicaid and Medicare Services (CMS) for 11 of 20 residents reviewed (Resident #5 #7 #17 #25 #29 #33 #34 #35 #40 #41 and #148). The facility reported a census of 47 residents. Findings Include: Review of a facility created document during the days the Survey conducted of 2/13/23 to 2/16/23 and signed by the Administrator and the Assistant Director of Nursing (ADON)/MDS Coordinator listed 11 residents with overdue MDS assessments. The document included the following dates the MDS Assessments due: a. Resident #5 Quarterly Assessment due 12/28/22 b. […]

• No harm, potential for more than minimal, patternF550Sep 1, 2021

  Based on observation, staff interview, and record review the facility failed to ensure a dignified dining experience in the dining room off the unit during the lunch meal on 8/29/21. The facility reported a census of 48 residents. Findings include: Observation on 8/29/21 at 12:22 PM, revealed four residents seated at a table in the dining room. Staff E, Certified Nursing Assistant (CNA), assisted the four residents standing at times while meal assistance provided, and moved around the table and switched between the four residents present while she assisted them. Additional observations on 8/29/21 at 12:29 PM, 12:37 PM, 12:42 PM, 12:43PM, 12:54 PM, and 1:01 PM revealed Staff E stood while she provided assistance with dining. […]