Westover Retirement Community

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Oct 5, 2021

  Based on record review, observation, interview, policy review, review of online resources from Centers for Disease Control (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19, failed to ensure visitation was suspended when an employee tested positive for COVID-19, failed to ensure staff wore personal protective equipment (PPE) in the facility to prevent the potential spread of Coronavirus (COVID-19), and failed to ensure staff administered medications utilizing proper infection control practices to prevent the potential spread of infectious disease. This had the potential to affect all 40 residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF886Oct 5, 2021

  Based on record review, interview and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. […]

• No harm, potential for more than minimal, isolatedF641Nov 25, 2025

  Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This affected one resident (#43) of four resident assessments reviewed. The facility census was 51. Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no oral or dental issues. Observation on 11/19/25 at 1:58 P.M. […]

• No harm, potential for more than minimal, isolatedF684Nov 25, 2025

  Based on record review and staff interview, the facility failed to follow a physician order for referral services. This affected one Resident (#43) of four residents reviewed for physician orders for referral services. The facility census was 51. Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety.Review of the provider progress note dated 07/22/25 revealed Resident #43 was seen by Nurse Practitioner (NP) #105 and the resident was referred to neurology related to neuropathy. Review of the nurse's progress note dated 07/22/25 and timed 5:52 A.M. revealed a nurse's note stating Resident #43 was referred to neurology by NP #105 related to neuropathy. […]

• No harm, potential for more than minimal, isolatedF791Nov 25, 2025

  Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure timely dental services. This affected one resident (#43) of four residents reviewed. The facility census was 51.Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no issues with oral or dental status. Additional review of the medical record for Resident #43 revealed no documentation regarding a dental care plan or attempts to schedule a dental appointment. Observation on 11/19/25 at 1:58 P.M. […]