Westover Hills Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Westover Hills Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care, in that: The facility failed to coordinate care with hospice and implement interventions to address Resident #1's mental health needs. Resident #1 was readmitted to the facility with the diagnosis of depression, hospice had communicated to the facility staff that was overheard by ADON C, that the resident had tried to harm himself when he was at home. On 11/01/2024, Resident #1 hung himself with a gait belt attached to the bar in the closet that resulted in his death. An IJ was identified on 11/04/2024. […]

• Actual harm, isolatedF689Nov 10, 2023

  Based on interview and record review, the facility failed to ensure residents received adequate supervision with the use of a mechanical lift to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #2). The facility failed to ensure adequate supervision while utilizing the mechanical lift to move Resident #2 in the shower room, resulting in Resident #2 having a fractured nose and a laceration to the hand. The failure contributed to Resident #2's fractured nose and laceration of the hand. This failure could place residents who required the use of a mechanical lift for accidents. […]

• No harm, potential for more than minimal, patternF761Jun 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 2 of 11 Residents (Resident #118 and Resident #162) and 1 of 5 medication carts (100 Hall Medication Aide Cart) reviewed for medication storage:1. The facility failed to ensure Resident #162 did not have a prescription medication of Mupirocin Ointment 2% at the bedside.2. The facility failed to ensure the 100 Hall Medication Aide Cart was not unlocked and unattended. 3. […]

• No harm, potential for more than minimal, patternF812Jun 12, 2026

  Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for service safety for 1 of 1 kitchen. The facility stored one food item without the manufacturer's use-by date and one food item beyond the manufacturer's use-by date. 2. The facility failed to ensure pureed bread and baked beans were maintained at the required holding temperature of 135 degrees on the steam table. These deficient practices had the potential to place residents at risk for consuming unsafe food and developing foodborne illness.Findings included: 1.Observation on 06/09/2026 at 9:15 a.m. […]

• No harm, potential for more than minimal, patternF759Mar 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate below 5 percent (%) or greater. The facility had a medication error rate of 16.12% based on 5 out of 31 opportunities which involved 1 of 5 residents (Resident #1) and 1 of 1 staff (LPN B) observed for medication administration errors. LPN B administered Docusate Sodium (a stool softener used to relieve constipation), Fluoxetine HCl (a drug used to treat depression), Meloxicam (an analgesic, a drug used to reduce pain and swelling), Methenamine Hippurate (a drug used to prevent recurrent urinary tract infections), and Polyethylene Glycol (a drug used as a laxative to relieve constipation) to Resident #1 at 12:12 p.m., one (1) hour and twelve (12) minutes after the… […]