Westchester Gardens Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Westchester Gardens Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF842Jun 5, 2025

  Based on interview and record review, the facility failed to maintain an accurate medical record for medication and transmission-based precautions for one resident (#451) of 36 sampled residents on five of five days reviewed involving five nurses on three different shifts. Findings included: Review of Resident #451's medical record revealed Resident #451 was admitted to the facility on [DATE] for short-term rehabilitation. On 5/29/25 the resident was placed on empiric contact transmission-based precautions for a rash identified on the resident's skin. […]

• No harm, potential for more than minimal, patternF880Jun 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during meal service in four halls (200, 300, 400 and 500 hall of six halls observed, and for nine residents (#3, #60, #452, #448, #96, #76, #1, #58 and #43) of 36 residents sampled. 2) The facility failed to implement their infection prevention and control plan by failing to provide evidence of process surveillance of staff practices directly related to resident care. 3) The facility failed to properly use enhanced barrier precautions (EBP) for one resident (#19) of two residents observed for EBP with indwelling medical devices. […]

• No harm, potential for more than minimal, patternF761Jun 25, 2021

  Based on observations, interviews, and record review the facility failed to appropriately secure medications in four medication carts (100,200,400 and 500 Halls) of five medication carts sampled. Findings included: On 6/24/2021 at 02:51 p.m., an observation was conducted of the Medication Cart located on 100 Hall, which included in the sixth draw from the top of the medication cart, loose tablets. Staff A, Registered Nurse (RN) confirmed the presence of the one (1) white tablet, two (2) one- half (1/2) pieces of a white tablet and one quarter (1/4) of a white tablet observed to be in the third draw from the top of the medication cart. On 6/24/2021 at 3:03 p.m., an observation of medication cart located on the 400 Hall included four (4) loose tablets. […]

• No harm, potential for more than minimal, isolatedF684Dec 3, 2025

  Based on interviews and record reviews, the facility failed to implement the ordered interventions to alleviate pressure to the heels for one resident (#1) out of three reviewed for following wound care provider orders.Findings included: Review of admission Record showed Resident #1 was admitted to the facility on [DATE], with diagnoses to include left hip fracture, emphysema, respiratory failure, dementia and moderate protein calorie malnutrition. Review of Resident #1's Wound and Healing progress notes, dated 9/24/2025, showed wound orders for wound #2 on the left heel and wound #3 right heel to off load wound, and float heels in bed. […]

• No harm, potential for more than minimal, isolatedF550Jun 5, 2025

  Based on observations, interviews, and record review, the facility failed to ensure residents received a dignified dining experience in two halls (200 and 300) of six halls toured and for three residents (#1, #58 and #43) of 36 residents sampled. Findings included: 1. An observation was conducted on 06/02/25 at 12:26 p.m. of Resident #1 in her room during her lunch meal. The resident was receiving meal assistance from Staff R, Clinical Student. Staff R was observed standing over the resident. An observation was conducted on 06/02/25 at 12:16 p.m. of Resident #58 in her room during her lunch meal, being assisted by Staff V, Clinical Student. […]