Health Inspection

Westview Health Care Center

Inspection Date: February 3, 2025

Total Violations 2

Facility ID 075078

Location DAYVILLE, CT

Inspection Findings

F-Tag F947

Harm Level: Minimal harm or

Residents Affected: Few Based on review of the Facility Assessment the facility failed to update the facility assessment after the

F-F947, F 949

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51183

Residents Affected - Few Based on review of the Facility Assessment the facility failed to update the facility assessment after the dissolution of the facility contracted behavioral health service in 2020 and failed to ensure compliance of required staff training and competencies. The findings include:

1. Review of the Annual Facility assessment dated [DATE REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 2. Review of the Annual Facility assessment dated [DATE REDACTED] through September 30, 2024, completed on 10/10/2024 (annual update due 10/1/2025) identified staff training/education and competencies are provided Level of Harm - Minimal harm or upon new hire orientation, annually, as well as adding new training as needed. This emphasis on education potential for actual harm maintains and ensures the staff competencies needed to care for the needs of the current and changing resident populations served. Such education is provided through mixed media forms which include online Residents Affected - Few coursework, written coursework, video education, off site seminars, webinars, on site live education sessions, individual and group in-service training as well as daily quick reminder memos, read and sign important blasts and team report huddles on each wing before each shift and as needed throughout. The following training/education/review of facility specific Policies and Procedures are required for all employees of the facility upon hire and annually: Resident Rights, Assault and Abuse prevention and Reporting, Confidentiality/HIPPA, Emergency Preparedness and Fire safety, Infection Prevention and Control, Tuberculosis, Covid-19, Exposure Control, Bloodborne Pathogens, Hazardous Chemicals, Personal Protective Equipment/Transmission Based Precautions/Enhanced Barrier Precautions, Corporate Compliance, Ethics, Quality Assurance and Performance Improvement, Effective Communication , including dementia- specific strategies and Trauma Informed 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-Tag F949

Harm Level: Minimal harm or

Residents Affected: Few Based on observations, review of the clinical record, facility documentation, facility policy and interviews for

F-F949

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50179 potential for actual harm Based on observations, review of the clinical record, facility documentation, facility policy and interviews for Residents Affected - Some one sampled resident observed with transmission based precaution signage (Resident #87), the facility failed to provide clear and accurate signage for transmission based precautions. The findings include:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 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, Level of Harm - Minimal harm or severe acute respiratory syndrome virus (SARS- CoV), avian influenza use Airborne plus Contact potential for actual harm Precautions plus eye protection. If SARS and tuberculosis are unlikely, use Droplet Precautions instead of Airborne Precautions. Residents Affected - Some 51183

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51183 potential for actual harm Based on facility documentation, facility policy and interviews the facility failed to maintain an effective Residents Affected - Few training program for all new and existing staff based on the facility assessment.

Review of the Annual Facility assessment dated [DATE REDACTED] through 9/30/2024 identified 19 areas of mandatory education for all staff upon hire and annually to include: resident rights, abuse prevention and reporting, confidentiality/Health Insurance Portability and Accountability Act (HIPAA), emergency preparedness, fire safety, infection prevention and control, tuberculosis, COVID-19, exposure control, bloodborne pathogens (BBP), hazardous chemicals, personal protective equipment (PPE), transmission based precautions (TBP), enhanced barrier precautions (EBP), corporate compliance/ethics, quality assurance and performance improvement (QAPI), effective communication, dementia-specific strategies (communication), and trauma informed care (TIC). The facility assessment failed to include annual mandatory education for workplace violence which is in the facility policy.

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 64 out of 227 (28.1%) facility staff members completed less than 75% of their assigned mandatory annual courses for 2024.

Review of the monthly schedule of course assignments for facility staff by department identified 19 courses assigned to all staff over 12 months. January-Communication Basics and Annual Federal Summary; February-Resident Rights and Workplace Violence; March-Infection Control for All Staff and Corporate Compliance; April-Abuse, Neglect and Exploitation and Trauma Informed Care; May-HIPAA; June-Fire Safety and Emergency Preparedness; July-Challenging Behaviors: Dementia; August-Bloodborne Pathogens and PPE; September-Hand Hygiene and Rules and Regulations of Nursing Homes; October-QAPI; November-Customer Service; and December-Sexual Harassment.

Review of RN #4's monthly schedule of course assignments for facility staff by department identified 7 additional courses assigned to licensed nurses. March-Antibiotic Stewardship; April-Intravenous (IV) Therapy and Central Venous Access Device (CVAD) Therapy; July-Nursing Documentation for Long Term Care; September-Advanced Pain Management for Long Term Care; October-Recognizing Change of Condition; and December-Medication Administration.

Review of the monthly schedule of course assignments for facility staff by department identified 7 additional courses assigned to nurse aides (NA). March-Skin Care Basics for nurse aides and Body Positioning Basics; April-Abuse Prevention in People with Dementia; May-NA Care of IV Patient; September-Pain Recognition for Non-nursing Staff; October-Recognizing and Reporting Change of Condition; and December-Death, Dying and Postmortem Care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Review of the Certified Nursing Assistant Orientation Packet identified new hire Nurse Aides (NA) were given

an 80 hour orientation training schedule to start with additional hours as needed, and all assigned inservice Level of Harm - Minimal harm or education in Healthcare Academy must be completed by the end of the orientation period. potential for actual harm

Review of Healthcare Academy reports dated 1/30/2025 for 2024 staff education course completions Residents Affected - Few identified 6 out of 21 actively employed NAs hired in 2024 lacked documentation of completed courses in Healthcare Academy for 2024.

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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 51183

Residents Affected - Few Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with communication training. The findings include:

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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 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 Level of Harm - Minimal harm or the end of the month prior to their annual evaluation. The policy identified that an individual training record for potential for actual harm each staff member was to be maintained by the Director of Staff Development.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Level of Harm - Minimal harm or potential for actual harm 51183

Residents Affected - Few Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with resident rights training.

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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 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 Level of Harm - Minimal harm or the month prior to their annual evaluation. The policy identified that an individual training record for each staff potential for actual harm member was to be maintained by the Director of Staff Development.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 51183

Residents Affected - Few Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with abuse, neglect, and exploitation training and the facility failed to ensure staff compliance with dementia management training.

1. 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 35 out of 227 (15.4%) facility staff members did not complete abuse, neglect, and exploitation 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 22 out of 75 (29.3%) Nurse Aides did not complete abuse, neglect, and exploitation 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 7 out of 44 (15.9%) Licensed Nurses did not complete abuse, neglect, and exploitation training in 2024.

2. 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 34 out of 227 (14.9%) facility staff members did not complete dementia management 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 23 out of 75 (30.6%) Nurse Aides did not complete dementia management 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 5 out of 44 (11.3%) Licensed Nurses did not complete dementia management training in 2024.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 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 Level of Harm - Minimal harm or 75% of their assigned mandatory annual courses for 2024 which included the abuse, neglect, and potential for actual harm exploitation training and dementia management training courses.

Residents Affected - Few 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 abuse, neglect, and exploitation training and dementia management training courses.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 51183

Residents Affected - Few Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with Quality Assurance and Performance Improvement (QAPI) (framework used to improve resident safety and the quality of their services) training.

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.

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

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 51183

Residents Affected - Few Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with their infection control program (infection prevention and control, tuberculosis, COVID-19, bloodborne pathogens, personal protective equipment, transmission based precautions, and enhanced barrier precautions) training.

A. 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 53 out of 227 (23.3%) facility staff members did not complete infection prevention and control 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 30 out of 75 (40%) Nurse Aides did not complete infection prevention and control 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 11 out of 44 (25.0%) Licensed Nurses did not complete infection prevention and control training in 2024.

B. Documentation of staff completion of tuberculosis education for 2024 was not provided.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions failed to identify education on tuberculosis was assigned to facility staff in 2023 or 2024.

C. Documentation of staff completion of COVID-19 education for 2024 was not provided.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions failed to identify education on COVID-19 was assigned to facility staff in 2023 or 2024.

D. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 51 out of 227 (22.4%) facility staff members did not complete bloodborne pathogens (BBP) 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 12 out of 44 (27.2%) Licensed Nurses did not complete BBP training

in 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 E. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 59 out of 227 (25.9%) facility staff members did not complete Level of Harm - Minimal harm or personal protective equipment (PPE) training in 2024. potential for actual harm

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff Residents Affected - Few education course completions identified 31 out of 75 (41.3%) Nurse Aides did not complete PPE training in 2024.

in 2024.

F. Documentation of staff completion of transmission-based precautions education for 2024 was not provided.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions failed to identify education on transmission-based precautions was assigned to facility staff in 2023 or 2024.

G. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 66 out of 227 (29.0%) facility staff members did not complete enhanced barrier precautions 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 35 out of 75 (46.6%) Nurse Aides did not complete enhanced barrier precautions 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 (34.0%) Licensed Nurses did not complete enhanced barrier precautions training in 2024.

Interview with the Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notifies 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 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 Level of Harm - Minimal harm or 75% of their assigned mandatory annual courses for 2024 which included the infection prevention and potential for actual harm control training, BBP training, PPE training, and enhanced barrier precautions training courses. Review failed to identify tuberculosis education, COVID-19 education, and transmission-based precautions education. Residents Affected - Few

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 infection prevention and control training, BBP training, PPE training, and enhanced barrier precautions training courses. Review failed to identify tuberculosis education, COVID-19 education, and transmission-based precautions education.

Review of the Staff Development Corporate Compliance policy identified, in part, a list of annual 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 51183 potential for actual harm Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance Residents Affected - Few with corporate compliance and ethics training.

Note: The nursing home is Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for disputing this citation. 2023 and 2024 staff education course completions identified 52 out of 227 (22.9%) facility staff members 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 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.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 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 Level of Harm - Minimal harm or completing, by the end of the month prior to their annual evaluation. The policy identified that an individual potential for actual harm training record for each staff member was to be maintained by the Director of Staff Development.

Residents Affected - Few

Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 51183

Residents Affected - Few Based on facility documentation, facility policy and interviews the facility failed to ensure Nurse Aides (NA) completed at least 12 hours of education for 2024.

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.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51183 potential for actual harm Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance Residents Affected - Few with behavioral health training.

A. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 96 out of 227 (42.2%) facility staff members did not complete behavioral health-trauma informed care (TIC) 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 47 out of 75 (62.6%) Nurse Aides did not complete behavioral health-TIC 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 20 out of 44 (45.4%) Licensed Nurses did not complete behavioral health-TIC training in 2024.

B. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 34 out of 227 (14.9%) facility staff members did not complete dementia management training in 2024.

C. Review of the Westview Health Care Center Annual Facility assessment dated [DATE REDACTED] identified the facility provides care for residents admitted with or who develop the following diagnoses: psychosis (hallucinations/delusions), impaired cognition, mental disorder, depression, bipolar disorder, schizophrenia, post-trumatic stress disorder, anxiety, and behaviors requiring interventions.

Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 68 075078 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Interview with Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notifies her of nursing staff with outstanding Healthcare Academy courses. The DNS indicated that the goal for annual Level of Harm - Minimal harm or education was for each staff member to complete 75% of their assigned courses. For those staff members potential for actual harm 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 Residents Affected - Few 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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 68 075078

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Westview Health Care Center

Inspection Findings

F-Tag F947

F-Tag F949

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