Westchester House, The

In the surveyor’s words

From the most serious findings on record at Westchester House, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 7, 2022

  Based on interview and record review, the facility failed to promptly follow physician's orders by not immediately calling 911 when a resident had a change in condition (Resident #1) as evidenced by staff observing him/her to be slouched over in a chair, drooling with vomit and blood on the floor. Instead, staff called a non-urgent medical transportation service which took over two hours to arrive to transport the resident to the hospital. Staff failed to continually monitor and assess the resident's condition. The resident was placed in the intensive care unit (ICU) and placed on a ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently). […]

• Actual harm, isolatedF692Aug 28, 2024

  Based on observation, interview and record review, the facility failed to ensure a resident with a significant weight loss was provided appropriate mealtime assistance resulting in a 9.43% weight loss within a 30 day time frame (Resident #36). In addition, the facility failed to notify the physician and Registered Dietician (RD) when a resident experienced a weight loss for one resident (Resident #31) and failed to ensure nutritional supplements and double portions were provided for one resident at risk for weight loss (Residents #22). The sample size was 18. […]

• Actual harm, isolatedF684Aug 3, 2023

  Based on interview and record review, the facility failed to ensure a resident who admitted to the facility with a left ankle surgical wound on 6/26/23 received wound care orders timely. The facility obtained orders on 6/28/23 and failed to ensure dressing changes occurred after orders were received (Resident #1). The sample was 3. The census was 60. The administrator was notified on 8/3/23, of the past non-compliance. The facility has changed their admission order process to include if a resident is admitted with a wound that wound care orders will be verified. […]

• Actual harm, isolatedF600Mar 8, 2023

  See Event ID UBXX12 Based on interview and record review, the facility failed to protect Resident #20's right to be free from abuse when Certified Nursing Assistant (CNA) Y grabbed the resident by the wrists, forcing the resident to get out of bed against his/her wishes, resulting in skin tears to both wrists. Additionally, the facility failed to protect Resident #35 from abuse when he/she was left overnight in the same room with Resident #36 who yelled at, repeatedly hit him/her, and tried to force Resident #35 from their shared room. […]

• Actual harm, isolatedF692Mar 8, 2023

  36151 See Event ID UBXX12 Based on observation, interview and record review, the facility failed to follow their policies by failing to follow physician's orders, and/or Registered Dietician's (RD's) recommendations. The facility failed to make and provide any fortified foods (foods with additional calories/protein), provide double portions to residents with orders for double portions, provide accurate servings sizes per the recipe, and failed to consistently provide house shakes (nutritional drinks). The facility failed to ensure staff followed resident menu slips (used by dietary staff that shows each residents current diet orders/preferences) and/or failed to ensure menu slips, physician orders and care plans reflected residents' current diet order/preferences. […]