Inspection Reports for
Wellbrooke of Westfield

Complaint IN00458674 was investigated and found to have no deficiencies related to the allegations. The unauthorized photo incident involved a terminated employee sending a nude photo of Resident B and a photo including Resident C to another staff member. The facility corrected the issue by 5/8/25 with staff education and policy enforcement.

No deficiencies related to the complaint allegations were cited; however, unrelated deficiencies were found involving unauthorized photos taken by staff of residents, violating privacy rights. The deficient practice was corrected prior to the survey.

The complaint involved a terminated employee sending unauthorized photos of residents to a current staff member. The photos included a nude resident and another resident's face. The facility policy prohibits staff from taking photos without authorization. The deficient practice was corrected by staff reeducation and audits.

The facility failed to ensure staff did not take and share unauthorized photos of residents, specifically for 2 of 3 residents reviewed. The deficient practice was corrected prior to the survey by staff education and implementation of a systemic plan.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE).

The facility failed to accurately complete pre-admission screening and resident review (PASARR) for some residents, did not document care plan meetings for several residents, failed to ensure oxygen therapy was administered per physician orders, had medication labeling and narcotic count log deficiencies, and did not properly document meal intakes for a resident.

Complaint IN00455772 was investigated and no deficiencies related to the allegations were cited.

The facility was found to have multiple deficiencies including inaccurate PASARR documentation for residents, insufficient documentation of behavior care plans and care plan meetings, failure to ensure oxygen therapy was administered per physician orders, incomplete medication labeling and narcotic count logs, and incomplete documentation of meal intakes. No deficiencies were cited related to the complaint investigation.

The facility was found not in compliance with emergency preparedness requirements, including failure to conduct required 36-month continuous emergency generator testing, failure to maintain fire alarm system emergency control functions and testing, deficiencies in life safety code related to egress door locking, hazardous area enclosures, sprinkler system maintenance, portable fire extinguisher installation, and boiler inspection certificates.

Complaint IN00428770 and IN00428393 were investigated with no deficiencies related to the allegations cited.

No deficiencies were cited related to the complaints investigated. Several deficiencies were cited including issues with Medicaid/Medicare coverage notices, transfer/discharge notifications, quality of care including medication administration and bowel monitoring, respiratory care, nurse staffing posting, unnecessary drug use, psychotropic medication monitoring, staff licensing, infection control, and medication storage.

The facility was found deficient in multiple areas including failure to properly document and inform residents about Medicare non-coverage notices, failure to notify the Ombudsman of resident hospitalizations, medication administration errors, inadequate monitoring of bowel movements, improper oxygen administration, failure to post daily nurse staffing, failure to obtain required lab tests for antibiotics, incorrect psychotropic medication monitoring, employment of a nurse without a valid state license, and improper infection control practices during medication handling and linen transport.

The complaint investigation found the facility did not obtain the required vancomycin trough lab for Resident I as ordered. The Assistant Director of Nurse Services and Clinical Support Nurse confirmed the lab was either not drawn correctly or lost, and the facility failed to follow its own policies regarding lab test ordering and antibiotic stewardship.

The facility failed to ensure that a vancomycin trough lab was obtained as ordered prior to administering the antibiotic for one of two residents reviewed. Interviews and record reviews confirmed the lab was not drawn or results were not available, indicating a lapse in following physician orders and facility policies.

The investigation involved four complaints (IN00419511, IN00414987, IN00402052, IN00401982). No deficiencies related to the allegations were cited for any of these complaints. The investigation revealed unrelated deficiencies involving medication misappropriation by a Registered Nurse (RN 2) who was terminated for gross misconduct.

No deficiencies related to the allegations of the complaints were cited. However, unrelated deficiencies were cited involving misappropriation of medications by a Registered Nurse who removed discontinued medications without consent and ordered medications without authorization for 5 residents. The deficient practice was corrected prior to the survey.

The complaint involved misappropriation of medications by a Registered Nurse (RN 2) who ordered and removed medications without authorization and gave them to a former employee. The medications were antibiotics and antifungals, some discontinued and some unauthorized. RN 2 was terminated for gross misconduct. The facility conducted audits and educated staff following the incident.

The facility failed to protect residents from misappropriation of medications by a Registered Nurse who removed discontinued and unauthorized medications from the facility. The facility also failed to maintain records of disposition/return of unused medications and ensure medications were authorized by licensed providers. The deficient practices were corrected prior to the survey.

The facility was found in compliance with Emergency Preparedness and Life Safety Code requirements overall, but a deficiency was cited for failure to properly secure and segregate five oxygen cylinders in the oxygen storage and transfilling room, which could affect residents, staff, and visitors.

The investigation was complaint-driven, addressing multiple allegations including medication self-administration without assessment, physical abuse and intimidation, failure to report abuse timely, failure to provide bed hold policy notification, inadequate incontinence care, failure to respond to change of condition, pressure ulcer care deficiencies, mobility assistance issues, respiratory care and equipment storage problems, pain management documentation failures, incomplete bed rail assessments, food safety violations, improper mask use, and unsanitary environment and equipment.

The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, failure to prevent and report abuse allegations timely, failure to provide bed hold policy notifications, failure to provide timely incontinence care, failure to respond appropriately to change of condition, inadequate pressure ulcer care, insufficient assistance with mobility, improper respiratory care and equipment storage, inadequate pain assessment documentation, incomplete bed rail assessments, unsafe food handling and storage practices, improper mask use by staff, and unsanitary resident care equipment and linens.

Complaint IN00394060 was substantiated. Federal/State deficiencies related to the allegations are cited at F677.

The facility was found to have multiple deficiencies including failure to assess residents for self-administration of medications, failure to prevent abuse and neglect, failure to provide bed hold policy notices, failure to provide timely incontinence care, failure to provide quality care for residents with change of condition, pressure ulcers, mobility assistance, respiratory care, pain management, bed rail assessments, medication storage, food safety, insulin storage, infection control, and COVID-19 vaccination compliance.