Westview of Derby Rehabilitation & Health Care Cen

In the surveyor’s words

From the most serious findings on record at Westview of Derby Rehabilitation & Health Care Cen, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 16, 2024

  The facility reported a census of 65 with three of residents selected for reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired R1, identified at risk for elopement. On 05/07/24 at 09:40 AM a CNA M let R1 out the front doors of the building. CNA M thought R1 had an appointment and was leaving to get on the facility transport vehicle. When R1 went out the doors his WanderGuard caused an alarm to activate, and CNA M did not check which resident caused the alarm. The facility did not know R1 was not in the building until almost 15 minutes later when a staff member driving by the facility saw the resident outside, unsupervised, and notified the facility. […]

• Immediate jeopardy, isolatedF689Jan 10, 2024

  The facility reported a census of 64 residents with three residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R)1, with a known history of elopement, from leaving the facility unsupervised and without staff knowledge on 12/31/23 at approximately 06:30 AM. The facility staff did not know R1 was not in the facility until the oncoming nurse, Licensed Nurse (LN) D, asked a Certified Nurse Aide (CNA) G to locate R1. The facility staff could not locate R1 on 12/31/23 at 06:30 AM and LN D started the elopement process. At 07:30 AM, CNA G found R1 outside, at the back of the facility, at the bottom of the concrete stairs. […]

• Immediate jeopardy, isolatedF689Sep 26, 2023

  The facility reported a census of 57 residents with three sampled for elopement. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe and secure environment for cognitively impaired Resident (R)1. On [DATE] at approximately 07:05 AM, Licensed Nurse (LN) I walked in the front doors of the facility to report for her shift while R1 walked out of the front doors. LN I assumed R1 was a visitor or employee. The facility staff did not realize R1 was missing until 07:45 AM (40 minutes later), at which time the facility staff began searching for R1. Around 10:00 AM the family notified the facility R1 was found deceased by the train tracks at approximately 08:30 AM, after being struck by a train. […]

• Immediate jeopardy, isolatedF689Jan 11, 2023

  The facility reported a census of 55 residents with 11 selected for review including three reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to ensure a safe environment for cognitively impaired and independently mobile Resident (R)2, who was identified as at risk of elopement, had a history of elopement, and the facility discontinued her elopement risk interventions. On 09/23/22, R2 exited the facility without staff awareness or supervision and crossed a heavily traveled four lane street. […]

• Actual harm, isolatedF689Jan 8, 2025

  The facility reported a census of 43 residents with three residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure one resident remained free of accident hazards related to mechanical lift transfers when Resident (R) 1 obtained an injury on 11/15/24 at approximately 07:00 PM when an unknown staff member failed to safely operate the mechanical lift and transferred the resident without another staff member present. This deficient practice resulted in a fracture (broken bone) of R1's left patella (kneecap). […]