Westview Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jun 1, 2023

  Based on observation, interview, and record review, the facility failed to ensure four residents (Residents #1, #2, #8, and #9) were free from verbal and mental abuse. The Director of Nurses (DON) yelled at Resident #9 and pursued the resident into his/her bathroom. The resident was upset and crying and made threats to harm himself/herself as a result of the DON's actions towards him/her. The DON continued to provide care to one resident, Resident #2, who was visibly upset and did not want the DON to provide his/her care. The DON continued to provide care for the resident despite the resident's response and refusal. The resident reported the DON was verbally abusive to him/her during care. This upset the resident who then made comments of self-harm. […]

• Immediate jeopardy, patternF610Jun 1, 2023

  Based on observation, interview, and record review, the facility failed follow their policies and procedures to report to the administrator and to conduct an investigation of staff to resident abuse for two residents (Residents #2 and #9) and implement interventions to protect residents from abuse at the facility. On 5/3/23, Resident #9 reported to staff the Director of Nursing (DON) yelled and screamed at him/her. On 5/4/23, Resident #2 reported the DON yelled at him/her. Staff did not report the allegations of abuse to the administrator, and the DON continued to work on 5/3/23 and 5/4/23. The facility census was 56. The administrator was notified of the Immediate Jeopardy (IJ) on 5/25/23 at 12:55 P.M. which began on 5/3/23. […]

• Immediate jeopardy, isolatedF684Jan 17, 2023

  Based on interview and record review, the facility failed to follow hospital discharge orders for two residents (Resident #1 and Resident #2) in a review of 19 residents. Resident #1 was admitted to the hospital on 12/29/22 with lithium (medication used for a mood stabilizer) toxicity which required hemodialysis (a treatment to filter wastes and water from your blood) to correct and high potassium levels and was discharged back to the facility with orders to discontinue lithium, haloperidol (used to treat certain mental/mood disorders such as schizophrenia, schizoaffective disorders), benztropine (used to treat tremors) and clonazepam (used for the acute management of panic disorders and seizure disorders). […]

• Immediate jeopardy, isolatedF600Nov 2, 2022

  Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from sexual abuse by another resident (Resident #2). Resident #2 had a history of sexually inappropriate behavior, and was off the secured, locked unit, unsupervised. Resident #2 walked into the dining room where Resident #1 was seated and exposed his/her genitalia to Resident #1. Resident #2 then touched Resident #1's leg and genital area over the top of his/her clothing. Resident #2 then asked to touch Resident #1's breasts. Resident #1 said he/she had a history of sexual abuse as a child and cried for days following the event. A sample of seven residents was selected for review. The facility census was 51. […]

• Immediate jeopardy, isolatedF760Oct 4, 2022

  Based on interview and record review, the facility failed to ensure one resident (Resident #2), was free from a significant medication error. The resident had an order, dated 9/6/22, for Invega Sustenna (antipsychotic) 234 milligrams (mg)/ 1.5 milliliters (ml), injected intramuscularly (IM) every 28 days. Staff administered the injection to the resident on day shift on 9/6/22. Staff administered the injection a second time to the resident on night shift on 9/6/22 and a third time on day shift on 9/7/22. Staff identified the error on 9/8/22. The resident developed low blood pressure on 9/9/22 and was sent to the emergency room for evaluation and treatment where he/she was diagnosed with a drug overdose of Invega. A sample of 12 residents was selected for review. […]