Westhaven Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF661Aug 28, 2024

  Based on record review and interview, the facility failed to complete a discharge summary of the residents' stay for three (#60, 67, and #69) of three sampled residents reviewed for discharge. The DON reported 66 residents resided in the facility. Findings: 1. Res #60 was discharged from the facility on 08/22/24. A review of the resident's record did not contain a discharge summary. 2. Res #67 was discharged from the facility on 05/29/24. A review of the resident's record did not contain a discharge summary. 3. Res #69 was discharged from the facility on 05/31/24. A review of the resident's record did not contain a discharge summary. On 08/28/24 at 10:56 a.m., the DON reported the discharge summary's were not completed.

• No harm, potential for more than minimal, patternF756Aug 28, 2024

  Based on record review and interview, the facility failed to ensure a MRR pharmacy request to physician had been sent to the physician to be acted upon for one (#6) of five sampled residents reviewed for unnecessary medications. The DON identified 55 residents received psychotropic medications. Findings: A Drug Regimen Review policy, dated 2024, read in part, .The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the .Director of Nursing .the Primary Physician .physician provides a written response of the report to the facility within one month after the report is sent . Res #6 had diagnoses which included diabetic neuropathy. […]

• No harm, potential for more than minimal, patternF758Aug 28, 2024

  Based on record review and interview, the facility failed to ensure: a. an as needed psychotropic medication had a 14 day stop date for one (#14), and, b. a MRR psychotropic reduction request was acted upon for one (#37) of five sampled residents reviewed for unnecessary medications. The DON identified 66 residents resided in the facility and 55 residents received psychotropic medications. Findings: 1. Res #14 had diagnoses which included anxiety. A physician order, dated 03/25/24, documented to administer lorazepam 1mg/1ml topically every four hours as needed. The order documented the physician was to re-evaluate on 04/08/24. The order was discontinued on 05/21/24. A physician order, dated 07/15/24, documented to administer lorazepam 1mg/1ml topically every four hours as needed. […]

• No harm, potential for more than minimal, patternF761Aug 28, 2024

  Based on observation, record review, and interview, the facility failed to ensure the removal of expired medications and supplies were removed from the medication storage room. The DON reported 66 residents resided in the facility. Findings: On 08/28/24 at 9:20 a.m., a tour of the medication room was completed with the DON. The following medications and supplies were observed to be expired or passed the use by date. 2- boxes of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 04/10/24, 1- box of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 07/19/24, 2- boxes of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of 11/23/24, 1- box of Ipratropium Bromide 0.5mg and Albuterol Sulfate 3mg with a use by date of… […]

• No harm, potential for more than minimal, patternF695May 17, 2023

  Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed as ordered for one (#3) and failed to ensure an oxygen concentrator had a filter for one (#11) of three sampled residents who utilized oxygen. The DON identified 17 residents who utilized oxygen. Findings: The facility's undated Maintenance of O2 Equipment policy, read in parts, .Change cannula .every 2 weeks on night shift .Date cannula and connective tubing when changed .Clean concentrator filters .every 2 weeks on night shift . 1. […]