Westy Community Care Home

In the surveyor’s words

From the most serious findings on record at Westy Community Care Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 31, 2024

  The facility identified a census of 33. The sample included three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and supervision). Based on observation, record review, and interviews, the facility failed to ensure interventions used to prevent elopement (window alarms) were functional and tamper-resistant. The facility further failed to accurately assess and identify Resident (R)1's elopement risk. R1 was cognitively impaired, lived on a secured memory unit, and had a history of wandering; though, the latest elopement assessment performed on 01/08/24 indicated the resident had no wandering and was at low risk for elopement. […]

• Actual harm, isolatedF686Feb 26, 2024

  The facility identified a census of 34 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, observation, and interview, the facility failed to implement interventions to prevent a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer to Resident (R) 1's left buttock and then failed to provide routine treatment and nutritional interventions to promote healing of R1's pressure ulcer. […]

• Actual harm, isolatedF689Mar 28, 2023

  The facility had a census of 30 residents. The sample included 13 residents, with four reviewed for falls. Based on observation, record review, and interview, the facility failed to implement the care planned interventions for Resident (R) 3, who had multiple falls related to inappropriate footwear, with one fall resulting in rib fractures (broken bones). The facility further failed to identify and implement interventions to prevent falls for R5, who had multiple falls. This placed the resident at risk for further falls and avoidable injury. […]

• No harm, potential for more than minimal, widespreadF801Jul 28, 2026

  Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 31 residents who resided in the facility and received their meals from the kitchen. Findings included:- On 07/26/2026 at 08:35 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 07/27/2026 at 09:30 AM, Dietary Staff BB verified she was the certified dietary manager and had been in the position for one month. Dietary Staff BB stated the facility had six residents with a pureed diet. […]

• No harm, potential for more than minimal, widespreadF801Sep 18, 2024

  The facility had a census of 31 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for the 31 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - On 09/16/24 at 08:10 AM, observation revealed the kitchen staff finishing the morning meal and preparing the midday meal. Dietary Staff CC stated the Dietary Manager had the day off and planned on returning within the survey period. On 09/18/24 at 08:30 AM, Dietary Staff BB reported he is in the process of obtaining a certified dietary manager course. […]