What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DAYVILLE, CT, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTVIEW HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Health Inspection: Westview Health Care Center

FF0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise

Review of the feeding helpless patient policy dated 1/9/20 directed, in part, assist the resident to a comfortable position and put on bib or napkin.

Encourage residents to assist as much as able.

Feed residents slowly with a fork or spoon, filled only half full.

Never rush the residents through meals.

Review of Formal Dining Room and Recreation Room policy directed, in part, to provide a dining experience in the formal dining room or recreation room that maintains and/or enhances each resident's dignity and ability to maximize their dining experience.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0641

Ensure each resident receives an accurate assessment.

screen submitted to Physical Therapy, skin integrity dietary screen submitted to the Dietician, Braden

daily living. LPN #4 identified that she did not complete wound measurements but indicated that

Although requested, a policy for RN assessment was not provided.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0644

Coordinate assessments with the pre-admission screening and resident review program; and referring

not have a contracted behavioral health service for medication management or therapeutic counseling

services staff and the APRN become involved with behavioral health management depending on the

mental health services as indicated.

The Medical Director was aware of SW #1's credentials (BSW, BA) and indicated the social worker was qualified to make decisions for day-to-day care.

The Medical Director identified he considers himself the psychiatric practitioner for the facility based on his geriatrician certification and that he manages medications and orders monitoring for staff to follow through on.

The Medical Director identified he does not provide ongoing therapeutic counseling services.

Interview on 1/30/25 at 12:43 PM with the Lead Level II Assessor for Specialized services for the State of Connecticut (Assessor) identified that if facility staff provided behavioral health services to residents, the facility staff should have some type of behavioral health education to enable assisting residents with certain behavioral health issues.

She indicated that some of the medications and counseling can be managed by primary care or facility staff, but specified that counseling services that are recommended, should be performed by someone with a Masters level of education or higher.

The Assessor identifed supportive counseling can be managed by facility staff for reassurance, redirection, or issues that arise day to day with mood and behavior but if a resident had a change in symptoms, hallucinations, paranoia, or any increase in symptoms, a new level II should be completed by re-evaluation of the resident.

The state requirements for preadmission and resident review page 55 identified that for residents exhibiting active, or specialized treatment needs, the state authority was determined to be responsible for providing that treatment.

Routine and ongoing rehabilitative treatment needs were determined to be the responsibility of facility staff following the identification of those service needs through PASSR.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared,

Review of the clinical record failed to identify a provider order for monitoring, a frequency or duration for monitoring, specification for monitoring or documentation of monitoring to be performed. yh Review of Resident #87's clinical record on 1/27/25 at 2:10 PM identified Resident #87 had not been seen by a provider since his/her expressions of SI on 1/20/25.

Review of the clinical record failed to identify revisions to the RCP to include further interventions related to the documented expressions of SI.

Facility policy titled, Resident Care plan updates, identified that the resident care coordinator or designee will review the 24 hour written reports of each wing daily as well as interview nurses for any changes that would result in alterations on the care plan.

The care plan will be adjusted if applicable within a reasonable length of time.

Therapy programs are updated on the care plan as submitted to the resident care coordinator.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Review of the clinical record failed to identify a repeat Braden Risk Assessment Scale after the development of a new pressure injury 11/21/24.

Review of the clinical record failed to identify updated interventions in the RCP to reflect the development of a new pressure injury and applicable treatment interventions and failed to identify preventative interventions for prevention of additional wounds.

Review of the Physicians orders failed to identify new preventative interventions Interview with RN #1 (MDS coordinator) on 1/29/25 at 10:32 AM identified that was she was not aware of Resident #16 ' s new wound until sometime in mid-January of 2025. RN #1 identified that she discovered the new wound while reviewing Resident #16 ' s clinical record and identified a nurses note from 1/1/25 that identified slough in the wound. RN #1 identified she staged the wound as a stage III pressure injury based on wound documentation on 1/1/25 and indicated the wound progressed to a stage IV based on documentation provided by MD #3 on 1/27/25. RN #1 identified that no Pressure Ulcer Packet was completed on 11/21/24 when the wound was initially discovered or on 1/1/25 when the wound worsened, therefore, a new Braden Risk Assessment Scale was not performed and appropriate interventions were not triggered.

The facility policy titled, Pressure Ulcers, identified that if a patient is identified at risk for the development of pressure ulcers or is noted to have a pressure area, the pressure ulcer packet is to be completed and nursing interventions for treatment and prevention based on Braden Risk Assessment score are implemented.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0692

Provide enough food/fluids to maintain a resident's health.

Resident #31's CHF diagnosis.

weighed upon admission and subsequently consistent with physician orders.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0726

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a

anniversary.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0741

Ensure that the facility has sufficient staff members who possess the competencies and skills to

perofrming risk assessments.

APRN #1 and MD #1 both cleared Resident #87 of SI and rendered him/her safe in the facility.

The facility policy titled, Suicide, Early Warnings, did not include a protocol for SI but only included definitions/examples of SI.

Although requested, the facility did not provide a policy related to behavioral health assessments for residents with suicidal ideations.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0742

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental

such as 1:1 monitoring or transfer to the ER. MD #1 then stated He/she should have been a 1:1 if

corded call bell should have been apparent .Re-interview and review of the secure text message

Resident #87's SI statements through secure text message once and confirmed that in that 1 message, he was made aware of 3 expressions of SI and responded with a secure text message directing staff to monitor Resident #87. MD #1 indicated that Resident #87 is demented and indicated he does not think Resident #87 would have acted on the statements. MD #1 further identified that the facility Social Worker should have followed up with Resident #87 after the expressions of SI were made. MD #1 identified that he inquired about Resident #87's status via secure text message on 1/21/25 and received a response from RN #6 indicating Resident #87 was back to baseline. MD #1 identified that he did not evaluate Resident #87 and could not identify if another facility provider had evaluated Resident #87 since the expressions of SI made on 1/20/25.Interview with NA #7 on 1/29/25 at 11:45 AM identified that Resident #87 requested her to give him/her a rope to hang him/herself, 3 times, while she was in the bathroom with him/her. NA #7 identified that she stayed with Resident #87 in the bathroom until he/she was finished, provided personal care and assisted him/her back to the wheelchair. NA #7 identified she then wheeled Resident #87 to the nurse's station within view of the charge nurse and then reported the expressions of SI to RN #6 because she believed there was a safety issue. NA #7 identified that she left Resident #87 with RN #6 and continued her assignment.The facility policy titled, Suicide, Early Warnings, did not include a protocol for SI but only included definitions/examples of SI.Interview with the Administrator on 1/27/25 at 6:45 PM identified the current facility policy for SI was insufficient, had been in place for decades, and required revisions.The facility developed a removal plan on 1/27/25 which was approved by the SA and included: SI policy was revised and updated to include a protocol for SI, Resident #87 was evaluated for suicidality by both APRN #1 and MD #2 and deemed safe in the facility.

Facility staff were educated on the new SI policy related to care of residents with SI and residents in the facility identified to have moderate-severe depression were screened for SI.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0745

Provide medically-related social services to help each resident achieve the highest possible quality of

Review of the nursing 24-hour report logs dated 1/19/25 through 1/25/25 failed to identify documentation of Resident #87's expressions of SI on 1/20/25.

Review of Resident #87's clinical record on 1/27/25 at 2:10 PM identified Resident #87 had not been seen by a provider since his/her expressions of SI on 1/20/25.

Interview with MD #1 on 1/27/25 at 4:30 PM identified that the facility Social Worker should have followed up with Resident #87 after the expressions of SI were made.

The facility policy titled, Suicide, Early Warnings, did not include a protocol for SI.

Although requested, a policy related to medically related social services, social services assessments or social services visits was not provided.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and

days.

Nursing will be responsible for dating all perishable food/beverages as they are opened so that

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0838

Conduct and document a facility-wide assessment to determine what resources are necessary to care

Review of staff education documents identified that for 2024 69 staff members failed to complete communication-related education, 61 staff members failed to complete resident rights education, 61 staff members failed to complete abuse education, 61 staff members failed to complete QAPI education, 61 staff members failed to complete infection control education, 61 staff members failed to complete compliance and ethics education, 58 active NA ' s failed to complete competencies, 33 active NA ' s failed to complete all or most of their 12 hour education, 49 active NA ' s failed to complete any (0%) of their assigned 2024 education via Healthcare Academy (the primary source of education material), and 58 active NA ' s failed to complete competency training.

The Administrator failed to complete any of the mandatory facility in servicing for 2024 and does not have an account in the Healthcare Academy for online for coursework.

Cross reference F-F550, F-F644, F-F657, F-F726, F-F741, F-F742, F-F745, F-F840, F-F940, F-F941, F-F942, F-F943, F-F944, F-F945, F-F946, F-F947, F-F949

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0840

Employ or obtain outside professional resources to provide services in the nursing home when the

Review of the Annual Facility assessment dated [DATE] - September 30, 2024, completed on 10/10/2024 identified services and care offered based on Resident's needs included mental health and behavior services.

Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identification and implementation of interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, 1:1 visit with social services designee for the purpose of allowing verbalization of feelings and issues surrounding SNF placement, and coping with grief and loss.

Additionally, Facility Resources needed to provide competent support and care for the resident population every day and during emergencies identified Behavioral and Mental Health Providers including Psychologist (Contract).

Interview with Advanced Practice Registered Nurse (APRN) #1 on 1/25/25 at 11:20 AM identified there had not been contracted behavioral health services since 2020. APRN #1 indicated the Medical Director, who is a Geriatrician, and herself (APRN #1) managed the psychotropic medications, gradual dose reductions (GDR's) and Abnormal Involuntary Movement Screening (AIMS), but do not offer psychotherapy. APRN #1 further identified the Social Worker would determine the need for an outside referral for psychotherapy or services that were not available in the facility and the Social Worker would make the referral. APRN #1 indicated the need for a referral to behavioral health services was communicated through a communication book that the Social Worker checked daily and/or a census report document that is used for communication to each department. APRN #1 identified a new contract for behavioral health services would begin on 2/1/25.

Interview on 1/29/25 at 11:28 AM with the Medical Director identified he was aware the facility did not have a contracted behavioral health service for medication management or therapeutic counseling services.

The Medical Director indicated he was a fellowship board certified geriatrician which qualified him to manage mental health medications.

The Medical Director identified that social services staff and the APRN become involved with behavioral health management depending on the acuity.

The Medical Director identified that SW #1 was responsible for making referrals to outpatient mental health services as indicated.

The Medical Director was aware of SW #1's credentials (BSW, BA) and indicated the social worker was qualified to make decisions for day-to-day care.

The Medical Director identified he considers himself the psychiatric practitioner for the facility based on his geriatrician certification and that he manages medications and orders monitoring for staff to follow through on.

The Medical Director identified he does not provide ongoing therapeutic counseling services.

Cross reference F 644, F 741, F 742, F 838

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0841

Designate a physician to serve as medical director responsible for implementation of resident care

The facility failed to utilize resources effectively to attain/maintain the resident's well-being.

Cross reference F-F644, F-F657, F-F741, F-F742, F-F745, F-F835, F-F838, F-F840, F-F949

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0880

Provide and implement an infection prevention and control program.

Observation on 2/3/25 at 11 AM of signage outside of Resident #87 ' s room identified 3 separate signs: Contact Precautions sign directing: hand hygiene, dedicated patient equipment, gloves, and a gown; Droplet Precautions sign directing: hand hygiene, eye protection, procedure mask, dedicated patient equipment, gloves, and a gown; Airborne Respirator Precautions sign directing: hand hygiene, dedicated patient equipment, CAPR/PAPR or fitted N95 mask, keep door closed, and notify maintenance to add a fan to room.

Interview with the IP on 2/3/25 at 12:49 PM identified that all 3 precautions signs are posted outside of resident rooms with potential or confirmed cases of Covid-19 because staff need to utilize a portion of each precaution to achieve Transmission Based Precautions for COVID-19 infections.

The IP indicated that Airborne Respirator Precautions are modified as the facility is not equipped to provide rooms with negative pressure (ventilation requiring 6 air exchanges per hour and an exhaust directed outside through a HEPA filter).

The IP indicated that having 3 different precautions signs with different instructions may be confusing to staff and visitors.

The IP indicated facility staff were educated on the signage.

Review of the Transmission Based Precautions education form identified no staff signatures to indicate which staff members, if any, were educated.

Review of Transmission Based Precautions Policy dated (updated 8/2022) directed, in part, there are 3 categories of Transmission Based Precautions: Contact Precautions, Droplet Precautions and Airborne precautions.

Transmission Based Precautions are used when the route of transmission is not completely interrupted using standard precautions alone.

For some diseases that have multiple routes of transmission, more than 1 Transmission Based Precautions category may be used.

When either singly or in combination, they are always used in addition to Standard Precautions. If a communicable disease or infection is suspected or confirmed in a resident, the resident shall be placed on the appropriate Transmission-Based Precaution immediately.

The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: Appendix A will be used when determined appropriate transmission- based precautions.

CDC guidelines identified Respiratory Infections Cough/fever/pulmonary infiltrate in any lung location in an HIV-infected patient or a patient at high risk for HIV infection, M. tuberculosis, Respiratory viruses, S. pneumoniae, S. aureus (MSSA or MRSA) use Airborne Precautions plus Contact Precautions, use eye/face protection if aerosol-generating procedure performed or contact with respiratory secretions anticipated. If tuberculosis is unlikely and there are no AIIRs and/or respirators available, use Droplet Precautions instead of Airborne Precautions.

Respiratory Infections Cough/fever/pulmonary infiltrate in any lung location in a patient with a history of recent travel (10-21 days) to countries with active outbreaks of SARS, avian influenza, M. tuberculosis, severe acute respiratory syndrome virus (SARS- CoV), avian influenza use Airborne plus Contact Precautions plus eye protection. If SARS and tuberculosis are unlikely, use Droplet Precautions instead of Airborne Precautions.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0940

Develop, implement, and/or maintain an effective training program for all new and existing staff

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education, RN #4's monthly schedule of course assignments for facility staff by department, and nursing department orientation packets failed to identify education related to cultural competence, intellectual disability, person centered care, care planning, interdisciplinary collaboration, quality of life and care.

Review of the Annual Facility assessment dated [DATE] through 9/30/2024 identified in addressing training/competencies the facility initiated Task Forces in 2024 for the following areas: Dietary Task Force, Support Services Task Force, Rehabilitation Task Force, and Nursing Task Force.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education, RN #4's monthly schedule of course assignments for facility staff by department, read and sign education for 2024, and Staff Education Report for Year-to-Date 2024 by RN #4 failed to identify education related to Task Forces initiated in 2024 for training and competencies and failed to identify education related to QAPI initiatives and performance improvement projects related to mobility assessment program, feeding assistant program and increase of the vaccination rate in employees.

Review of the Staff Development Corporate Compliance policy identified annual mandatory in-services each staff member was responsible for completing by the end of the month that their annual evaluation was due and an individual training record for each staff member was to be maintained by the Director of Staff Development.

The Policy does not include department specific education topic requirements based on the resident needs identified within the facility assessment.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0941

Develop, implement, and/or maintain an effective training program that includes effective

Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 73 out of 227 (32.1%) facility staff members did not complete communication training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 32 out of 75 (42.6%) Nurse Aides did not complete communication training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 15 out of 44 (34%) Licensed Nurses did not complete communication training in 2024.

Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked completion of courses monthly. RN #4 identified after checking course completion, she notified department heads of staff members within their department with incomplete courses.

Interview with Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notified her of nursing staff with outstanding Healthcare Academy courses.

The DNS indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses.

For those staff members who had not completed any (0%) of their assigned courses, the DNS stated We are working on that.

The DNS further identified she did not oversee RN #4 who was the Director of the Education Services department and that RN #4 worked autonomously.

Review of the facility Organizational Chart identfied RN #4 reported directly to the Administrator.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 64 out of 227 (28.1%) facility staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the communication training course.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 53 out of 119 nursing staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the communication training course.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual mandatory in-services, to include effective communication, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0942

Ensure that staff members are educated on resident rights and facility responsibilities to properly

Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 44 out of 227 (19.3%) facility staff members did not complete resident rights training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 28 out of 75 (37.3%) Nurse Aides did not complete resident rights training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 9 out of 44 (20.4%) Licensed Nurses did not complete resident rights training in 2024.

Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked completion of courses monthly. RN #4 identified after checking course completion, she notified department heads of staff members within their department with incomplete courses.

Interview with the Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notified her of nursing staff with outstanding Healthcare Academy courses.

The DNS indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses.

For those staff members who had not completed any (0%) of their assigned courses, the DNS stated We are working on that.

The DNS further identified she did not oversee RN #4 who was the Director of the Education Services department and that RN #4 worked autonomously.

Review of the facility Organizational Chart identfied RN #4 reported directly to the Administrator.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 64 out of 227 (28.1%) facility staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the resident rights training course.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 53 out of 119 (44.5%) nursing staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the resident rights training course.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual mandatory in-services, to include resident rights, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0943

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to

education course completions identified 53 out of 119 (44.5%) nursing staff members completed less

mandatory in-services, to include abuse prevention and reporting and dementia strategies, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0944

Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance

Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 60 out of 227 (26.4%) facility staff members did not complete QAPI training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 33 out of 75 (44%) Nurse Aides did not complete QAPI training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 13 out of 44 (29.5%) Licensed Nurses did not complete QAPI training in 2024.

Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked completion of courses monthly. RN #4 identified after checking course completion, she notified department heads of staff members within their department with incomplete courses.

Interview with the Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notified her of nursing staff with outstanding Healthcare Academy courses.

The DNS indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses.

For those staff members who had not completed any (0%) of their assigned courses, the DNS stated We are working on that.

The DNS further identified she did not oversee RN #4 who was the Director of the Education Services department and that RN #4 worked autonomously.

Review of the facility Organizational Chart identfied RN #4 reported directly to the Administrator.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 64 out of 227 (28.1%) facility staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the QAPI training course.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 53 out of 119 (44.5%) nursing staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the QAPI training course.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual mandatory in-services, to include QAPI training, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0945

Include as part of its infection prevention and control program, mandatory training that includes

and control training, BBP training, PPE training, and enhanced barrier precautions training courses.

mandatory in-services, to include infection prevention and control, tuberculosis, COVID-19, bloodborne pathogens, personal protective equipment, transmission based precautions, and enhanced barrier precautions, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0946

Provide training in compliance and ethics.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 29 out of 75 (38.6%) Nurse Aides did not complete corporate compliance and ethics training in 2024.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 10 out of 44 (22.7%) Licensed Nurses did not complete corporate compliance and ethics training in 2024.

Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked completion of courses monthly. RN #4 identified after checking course completion, she notified department heads of staff members within their department with incomplete courses.

Interview with Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notified her of nursing staff with outstanding Healthcare Academy courses.

The DNS indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses.

For those staff members who had not completed any (0%) of their assigned courses, the DNS stated We are working on that.

The DNS further identified she did not oversee RN #4 who was the Director of the Education Services department and that RN #4 worked autonomously.

Review of the facility Organizational Chart identfied RN #4 reported directly to the Administrator.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 64 out of 227 (28.1%) facility staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the corporate compliance and ethics training course.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 53 out of 119 (44.5%)nursing staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the corporate compliance and ethics training course.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual mandatory in-services, to include corporate compliance and ethics training, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0947

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in

Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 37 out of 75 (49.3%) nurse aides did not complete at least 12 hours of education in 2024.

Facility handwritten read and sign inservices for 2023 and 2024 were additionally reviewed, and with the addition of read and sign inservices, 12 hours of education was not met.

Interview with RN #4 on 2/3/2025 at 11:33 AM identified that she was responsible for assigning education courses to all staff in Healthcare Academy, that she monitored their completion monthly, and notified facility department heads of any staff within their department who did not complete their courses. RN #4 indicated that she notified the DNS of nursing staff who had not completed their courses.

Interview with the Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notified her of nursing staff with outstanding Healthcare Academy courses.

The DNS indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses.

For those staff members who had not completed any (0%) of their assigned courses, the DNS stated We are working on that.

The DNS further identified she did not oversee RN #4 who was the Director of the Education Services department and that RN #4 worked autonomously.

Review of the Staff Development Corporate Compliance Policy identified records of educational training were to be maintained in the Staff Development Room, an individual training record for each employee would be maintained, and NA's are required by state regulations to obtain at least 12 hours of continuing education each year and the 12 hours must be completed prior to their respective anniversary.

075078 02/03/2025

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF0949

Provide behavior health training consistent with the requirements and as determined by a facility

Review of the facility Organizational Chart identfied RN #4 reported directly to the Administrator.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 64 out of 227 (28.1%) facility staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the behavioral health-TIC training and dementia management training courses.

Review failed to identify facility staff education for 2024 related to psychosis (hallucinations/delusions), impaired cognition, depression, bipolar disorder, schizophrenia, and anxiety, as determined by the facility assessment.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 53 out of 119 (44.5%)nursing staff members completed less than 75% of their assigned mandatory annual courses for 2024 which included the behavioral health-TIC training and dementia management training courses.

Review failed to identify facility staff education for 2024 related to psychosis (hallucinations/delusions), impaired cognition, depression, bipolar disorder, schizophrenia, and anxiety, as determined by the facility assessment.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual mandatory in-services, to include behavioral health training, that each staff member was responsible for completing, by the end of the month prior to their annual evaluation.

The policy identified that an individual training record for each staff member was to be maintained by the Director of Staff Development.

FF947

Minimal harm or Few Based on review of the Facility Assessment the facility failed to update the facility assessment after the affected

Review of the Annual Facility assessment dated [DATE] through September 30, 2024, completed on 10/10/2024 (annual update due 10/1/2025) identified services and care offered based on Resident's needs included mental health and behavior services.

Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identification and implementation of interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, 1:1 visit with social services designee for the purpose of allowing verbalization of feelings and issues surrounding SNF placement, and coping with grief and loss.

Additionally, Facility Resources needed to provide competent support and care for the resident population every day and during emergencies identified Behavioral and Mental Health Providers including Psychologist (Contract).

Interview with Advanced Practice Registered Nurse (APRN) #1 on 1/25/25 at 11:20 AM identified there had not been contracted behavioral health services since 2020. APRN #1 indicated the Medical Director, who is a Geriatrician, and herself (APRN #1) managed the psychotropic medications, gradual dose reductions (GDR's) and Abnormal Involuntary Movement Screening (AIMS), but do not offer psychotherapy. APRN #1 further identified the Social Worker would determine the need for an outside referral for psychotherapy or services that were not available in the facility and the Social Worker would make the referral. APRN #1 indicated the need for a referral to behavioral health services was communicated through a communication book that the Social Worker checked daily and/or a census report document that is used for communication to each department. APRN #1 identified a new contract for behavioral health services would begin on 2/1/25.

Interview on 1/29/25 at 11:28 AM with the Medical Director identified he was aware the facility did not have a contracted behavioral health service for medication management or therapeutic counseling services.

The Medical Director indicated he was a fell owship board certified geriatrician which qualified him to manage mental health medications.

The Medical Director identified that social services staff and the APRN become involved with behavioral health management depending on the acuity.

The Medical Director identified that SW #1 was responsible for making referrals to outpatient mental health services as indicated.

The Medical Director was aware of SW #1's credentials (BSW, BA) and indicated the social worker was qualified to make decisions for day-to-day care.

The Medical Director identified he considers himself the psychiatric practitioner for the facility based on his geriatrician certification and that he manages medications and orders monitoring for staff to follow through on.

The Medical Director identified he does not provide ongoing therapeutic counseling services.

075078

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 075078 B.

Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

FF949

Minimal harm or Few Based on observations, review of the clinical record, facility documentation, facility policy and interviews for affected

Review of the Transmission Based Precautions education form identified no staff signatures to indicate which staff members, if any, were educated.

Review of Transmission Based Precautions Policy dated (updated 8/2022) directed, in part, there are 3 categories of Transmission Based Precautions: Contact Precautions, Droplet Precautions and Airborne precautions.

Transmission Based Precautions are used when the route of transmission is not completely interrupted using standard precautions alone.

For some diseases that have multiple routes of transmission, more than 1 Transmission Based Precautions category may be used.

When either singly or in combination, they are always used in addition to Standard Precautions. If a communicable disease or infection is suspected or confirmed in a resident, the resident shall be placed on the appropriate Transmission-Based Precaution immediately.

The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: Appendix A will be used when determined appropriate transmission- based precautions.

CDC guidelines identified Respiratory Infections Cough/fever/pulmonary infiltrate in any lung location in an HIV-infected patient or a patient at high risk for HIV infection, M. tuberculosis, Respiratory viruses, S. pneumoniae, S. aureus (MSSA or MRSA) use Airborne Precautions plus Contact Precautions, use eye/face protection if aerosol-generating procedure performed or contact with respiratory secretions anticipated. If tuberculosis is unlikely and there are no AIIRs and/or respirators available, use Droplet Precautions instead of Airborne Precautions.

075078

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 075078 B.

Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westview Health Care Center 150 Ware Rd Dayville, CT 06241

Westview Health Care Center

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