Focused Care at Westwood

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #1) residents reviewed for respiratory care.-The facility failed to ensure Resident #1 had an order for oxygen before administering oxygen at 3.5 L via nasal cannula from 05/12/26 through 06/16/26. This failure could have placed residents at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #67 and Resident #3) reviewed for comprehensive care plans. 1. The facility failed to provide Resident #67 with a comprehensive person-centered care plan to address colostomy. 2. The facility failed to address Resident #3's digoxin and insulin on his care plan. This failure could place residents at risk of not having personalized plans developed to address their specific care needs.

Inspectors wroteNumber of residents sampled: Number of residents cited: The facility failed to ensure physician orders were obtained and care plans were updated to reflect the use of bed rails for 5 of 5 residents reviewed with bed rails. This failure had the potential to result in the inappropriate use of bed rails and increased risk of entrapment, injury, and decline in resident well-being. This failure could place residents at risk for entrapment, injury, restricted movement, and the use of unnecessary physical restraints.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 1 medication storage rooms, 1 of 8 (100 Hall Nurse Cart) medication carts, and 1 of 1 (Resident #77) residents, reviewed for pharmacy services.-The facility failed to ensure Resident #77's expired Furosemide 20mg was not stored with current medications on the 100 Hall Nurse Cart.-The facility failed to ensure 9 expired wound cultures were not stored with current medications and cultures in the medication storage room. These failures could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 1 (Resident #65) residents reviewed for tube feeding. -The facility failed to ensure Resident #65's G-tube was in the correct place before he was administered medications on 5/20/26. This failure could place residents at risk for the medications going into the abdominal cavity, pain, infection, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #41) sampled for parenteral fluids.-The facility failed to ensure Resident #41's PICC line was clean before an IV line was attached to it on 5/20/26.-The facility failed to ensure Resident #41 received all of his ordered antibiotic on 5/20/26. These failures could place residents at risk for infection and risk for not receiving the full therapeutic benefits of the antibiotic.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6%, based on 2 errors out of 33 opportunities, which involved 1 of 7 residents (Resident #65) and 1 of 4 staff (LVN O) observed during medication administration reviewed for medication errors.-The facility failed to administer Resident #65 the correct medication (Calcium 600mg) and instead gave Calcium with Vitamin D 600mcg/10mcg, on 5/20/26.-The facility failed to administer Resident #65 their Insulin Glargine on 5/20/26. These failures could place residents at risk of not receiving the therapeutic effects of their prescribed medications and possible adverse reactions.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 7 (Resident #65) residents reviewed for pharmacy services.-The facility failed to administer Resident #65's ordered Insulin Glargine on 5/20/26. This failure could place residents at risk of not receiving the therapeutic benefits of their medication and possible hyperglycemia (high blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. The facility failed to ensure Resident #1's supra pubic Foley catheter was placed below the bladder during wound care by LVN A and CNA A.These failures could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions while performing pressure ulcer treatment on 11/5/25. These failures could place residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure staff did not store their personal items on the left second shelf of the walk-in cooler, including:. 1. Jumex mango energy drink can. 2. Red bull watermelon drink can 3. Coffee mate coconut liquid crème 32fl oz 4. A black and white with yellow brown flower lunch bag with 2 bottles of water, and one of the bottled water was open. The facility failed to ensure staff did not store three gray crates on the floor by Dishwasher A. These failures could place residents at risk for cross contamination and air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 refrigerator reviewed for food safety. The refrigerator located on the 400 hall contained undated and unlabeled perishable food items. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #49) reviewed for care plans. The facility failed to ensure Resident #49's Dementia and Hypertension diagnoses and medications were addressed in her comprehensive care plan. This failure could place residents at risk of not receiving appropriate care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to prevent pressure ulcers for one (Resident #49) of eight residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #49 was repositioned every two hours as indicated in Resident #49's physician orders on 3/11/2025 at 1:24 p.m. and 3/12/2025 at 11:49 a.m. 2. The facility failed to ensure Resident #49 was repositioned every frequently and as necessary as indicated in Resident #49's care plan. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #45) reviewed for incontinent care. The facility failed to ensure CNA O did not place the foley catheter bag on Resident #45's bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure based on a resident's comprehensive assessment, a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 3 (Residents # 32, #37 and #49) of 4 residents reviewed for g-tube medication administration . RN A failed to ensure Resident #32's GT (g-tube, a surgically placed device including a tube that leads from the outside of the body to the stomach to provide nutrition or medication) medications and water were administered by gravity, not by pushing the water via Resident #32's g-tube. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices goals and preferences for 1 of 3 (Resident #49) residents reviewed for pain management. -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors for for 1 of 3 (Resident #49) residents reviewed for pharmacy services. The facility failed to ensure Resident #49 was free of significant medication errors when Resident #49 was reviewed for pain management in that: -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including hand hygiene procedures to be followed by staff involved in direct resident contact for 1 (Resident #49) of 6 residents reviewed for infection control. -The facility failed to ensure CNA H utilized proper handwashing, infection control procedures , and completely cleaned Resident #49 when she did not open Resident #49's labia to clean or clean her buttocks and CNA H did not sanitize her hands between changing gloves during indwelling foley and incontinent care. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1of 6 residents (Resident #1) reviewed for cleanliness and sanitization. - The facility failed to ensure Resident #1 had a clean drinking cup. The noncompliance was identified as past noncompliance (PNC) and began on 02/20/2024 and ended on 02/20/2024. The facility corrected the noncompliance before the investigation began. These deficient practices could place residents at risk of living in an unsafe, unclean, and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible, and each resident receives adequate supervision to prevent accidents for 5 (Resident #2, #3, #4, #5, #6) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure that the facility's main door alarmed notifying staff when residents with wander guard's exited (Resident #2). -The facility failed to ensure the facility's main entrance wander guard alarmed when residents with wander guard's exited (Resident's #2, #3, #4,#5 and #6). This failure could place residents at risk of injury from accident and hazards. The noncompliance was identified as past noncompliance (PNC) and began on 08/02/2024 and ended on 08/03/2024. The facility corrected the noncompliance before the investigation began.

Inspectors wroteBased on interviews and record reviews a facility must coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes, Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 5 of 5 (Resident #1, #2, #3, #4, #5.) resident with PASRR recommendations in that: Resident #1 NFSS for therapy services was not submitted timely. Resident #2 NFSS for therapy services was not submitted timely. Resident #3 NFSS for therapy services was not submitted timely. Resident #4 NFSS for therapy services was not submitted timely. Resident #5 NFSS for therapy services was not submitted timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 12 residents (Resident #49) reviewed range of motion. -The facility failed to ensure Resident #49, with contractures to both hands, was wearing a hand splint device on both hands as care planned and ordered by the physician. - This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life.

Inspectors wroteBased on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that The facility failed to prevent the following. 1. A Plastic Container of Shredded Cheese dated 1/15/24. 2. A Plastic Container of Mozzarella Cheese dated 1/02/24. 3. A Plastic Container of Chili dated 1/02/24. The scoop was left in the flour bin in the storeroom. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 01/23/24 at 8:30 AM revealed that leftover foods were not discarded prior to the use by date. Observation of the facility's food storeroom on 01/23/24 at 8:40 AM revealed that a scoop was left in the flour bin. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 Residents (Resident #78) reviewed for administration. -The facility failed to completely and accurately document Resident #78's use of splint/braces on his care plan; These failures could place residents at risk of having incomplete and inaccurate records.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services in that -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.