Westhaven Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Mar 30, 2023

  Based on interviews, review of record and facility policy, the facility failed to re-evaluate and update one resident's (Resident (R)1) out of two sampled residents for advance directives, code status wishes. The facility's deficient practice increased R1's risk of inconsistent (wishes/desires) code status treatment. On [DATE] at 5:06 PM, the Administrator and the Director of Nursing (DON) were notified of immediate jeopardy (IJ) at F578- Advance Directives. The Immediate Jeopardy began on [DATE] when the team identified the facility failed to re-evaluate one resident's (R1) wishes for her code status. The facility provided an acceptable removal plan for the Immediate Jeopardy at F578 on [DATE] at 7:36 PM. […]

• No harm, potential for more than minimal, patternF812Apr 30, 2026

  Based on observations, staff interviews, and policy review, the facility failed to properly wear and change out gloves during meal services for 2 of 2 dining rooms observed. The facility reported a census of 59. Findings include:During a continuous observation on 4/30/26 at 12:15 PM, Staff I, Culinary Assistant, wore a glove on one hand (right) while preparing resident lunch plates in the Westown independent resident dining room. They touched the refrigerator door, cabinet door, counter top, and scoop handles with the gloved hand. The same glove was also worn as Staff I prepped and placed buns on resident plates. During a continuous observation on 4/20/26 at 12:00 PM, Staff H, Culinary Assistant, prepared resident lunch plates in the Bistro resident assist dining room. […]

• No harm, potential for more than minimal, patternF880Apr 3, 2025

  Based on clinical record review, observations, staff interviews, and policy review, the facility failed to disinfect equipment after resident use and failed to ensure staff changed gloves and sanitized hands in accordance with proper infection control techniques when contaminated to protect against cross contamination and potential infection for 4 of 8 residents observed during medication administration and for 2 of 3 residents observed for cares. The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnosis of chronic obstructive pulmonary disease (COPD) and heart failure. The Care Plan initiated 1/16/25 revealed the resident had lung cancer. […]

• No harm, potential for more than minimal, isolatedF602Jul 8, 2026

  Based on clinical record review, police record review, resident interview, staff interview and policy review, the facility failed to protect the resident's right to be free from abuse in the manner of misappropriation of resident property/financial exploitation by a staff member for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 55 residents. Findings include;The Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had diagnoses to include heart failure and diabetes mellitus. […]

• No harm, potential for more than minimal, isolatedF554Apr 30, 2026

  Based on observations, staff and resident interviews, resident health record review, and policy review the facility failed to obtain an order for self administration of medication and allowed resident to consume her medications without observation for 1 of 5 residents reviewed. The facility reported a census of 59 residents. Findings include:The Minimum Data Set (MDS) for Resident #57, dated 1/6/26, included diagnoses of stroke, diabetes, and depression. A Brief Interview for Mental Status (BIMS) score of 12 indicated mild cognitive impairment. On 4/30/26 at 8:18 AM, observed Resident #57 sitting at the dining room (DR) table with several pills in a cup sitting on the table in front of her. […]