Medilodge of Westwood

Inspectors wroteThis citation pertains to intake #3054443. Based on interview and record review, the facility failed to prevent significant medication errors in 1 of 1 resident (Resident #65) reviewed for medication errors, resulting in Resident #65 having an acute change of condition requiring hospitalization due to low blood sugar, decreased heart rate, low blood pressure, and admission to the ICU (intensive care unit).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and maintained under sanitary conditions, increasing the risk of foodborne illness to all residents that consume food from the kitchen. Findings Inlcude:On 7/14/26 at 9:28 AM, the three-compartment sink was observed with a sanitizer pre-dispense system with no test strips to ensure accuracy of the sanitizer. When asked if there were any test strips, [NAME] SS was unable to find them. On 7/14/26 at 9:35 AM, the cook line preparation table was observed with clean pots and pans stored on the underside. A review of the pans found two half pans and two quarter pans stacked and stored wet with moisture in-between. On 7/14/26 at 10:37 AM, the dish machine rinse gauge was observed cracked and loose on the dial allowing the needle to be open and exposed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and functional entry to the building, affecting all residents that utilize the exterior spaces. Findings Include: On 07/14/26 at 8:45 AM, numerous potholes were observed while entering the facility's parking lot through the north entrance. On 07/14/26 at 10:55 AM, Maintenance Director RR was interviewed and stated the parking lot has been an ongoing challenge for the facility. He reported a repair plan is in progress but could not provide a timeline for completion. In an observation on 7/16/26 at 10:05 am, a facility resident was noted sitting outside near the driveway to enter the parking lot smoking. The resident had to cross the parking lot from the front entrance, across the unrepaired driveway to get to the required smoking area. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice of Non-Coverage (ABN) for Medicare Part A services in 1 of 3 residents (Resident #33) reviewed for timely provision of notifications, resulting in the potential for the resident or resident representative to be unaware of changes regarding financial liability, frustration, and a delay in the ability to file an appeal.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean comfortable environment for 2 (Resident #8 and Resident #94) of 5 residents reviewed for environment resulting in unclean/unkempt resident rooms, resident frustration, and the potential for cross contamination and bacterial harborage.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and/or implement a comprehensive care plan for 3 residents (Resident #73, #3, & #65) of 18 residents reviewed for care plan development/implementation, resulting in the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary ADL (activities of daily living) care to 1 resident (Resident #16) of 5 residents reviewed for ADL's, resulting in the potential for feelings of embarrassment, humiliation, and diminished self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent a decrease in ROM (range of motion) for 2 residents (Resident #3 and #65) of 2 residents reviewed for range of motion, resulting in the potential for worsening of hand contractures (a permanent shortening of muscles, tendons, skin, or other soft tissues that restricts normal joint movement and can cause deformity).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weights and ensure nutritional preferences were met in 1 of 1 resident (R5) reviewed for nutrition, resulting in the potential for decreased nutritional status.

Inspectors wroteBased on interview, and record review, the facility failed to provide prompt dental services for 1 of 1 resident (Resident #73) reviewed for dental care, resulting in Resident #73 experiencing pain, difficulty eating and the potential for spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appetizing and palatable food at a palatable food temperature for 2 (Resident #8 and Resident 94) of 4 residents reviewed for food palatability and 4 of 4 residents from a confidential resident council meeting resulting in dissatisfaction with the food served and the potential for decreased intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for 3 residents (Resident #3, #65, and #46) of 18 residents reviewed for complete and accurate medical record documentation, resulting in incomplete and inaccurate documentation of treatments completed by the licensed nurse and tasks performed by the CNA's (Certified Nursing Assistant).

Inspectors wroteBased on interview and record review, the facility failed to explain terms of and ensure the validity of understanding/consent to enter into the agreement for an Alternate Dispute Resolution Agreement (ADR)- a legally binding contract that specifies the use of an ADR process - such as arbitration instead of going to court) for 2 (Resident # 32 and Resident #94) of 3 residents reviewed for arbitration agreements resulting in Resident #32 and Resident #94 signing ADR agreements when they did not wish to.

Inspectors wroteThis citation pertains to Intake # 2746228. Based on interview, and record review, the facility failed to ensure a safe/appropriate discharge in 1 of 3 residents (Resident #103) reviewed for discharge planning, resulting in an unsuccessful discharge to the community, resident distress, and rehospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan in 1 of 3 residents (Resident #105) reviewed for comprehensive care plans and accuracy of medical records, resulting in an inaccurate reflection of the resident's status and the potential for care and services to be provided that are inconsistent with the resident's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 2 of 7 residents (Resident #77, #75) reviewed for accidents and hazards, resulting in a fall with fracture for Resident #77 and the potential to negatively affect the residents' highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteIn a Confidential Group Meeting on 06/03/25 at 10:40 AM, 3 of 7 residents reported that their concerns and missing items were not being addressed and/or resolved. Resident #55 Review of an admission Record revealed Resident #55 was a male with pertinent diagnoses which included legal blindness, stroke, end stage renal disease, dialysis, and depression. Review of a current Care Plan for Resident #55, revised on 3/6/25, revealed the focus, .Resident has visual impairment related to legally blind . with the interventions .Announce yourself when entering the resident's room/space .Encourage resident to keep call bell, water pitcher, and personal belongings in the same place . In an interview on 06/02/25 at 10:55 AM, Resident #55 reported his debit care information was stolen. [...]

Inspectors wroteResident #33 During an observation of medication administration on 06/03/25 at 08:32 AM Registered Nurse (RN) EE prepared an insulin (used to manage blood sugar levels) injection (when a needle is used to administer medication) for Resident #33. The medication was labeled Lantus (a long acting insulin). Observed RN EE inject 10 units of the Lantus into Resident #33's right abdomen. RN EE did not use hand sanitizer prior to entering the room and did not wear gloves during the injection. In a subsequent interview on 6/3/25 at 8:35 AM, RN EE reported that she did not normally wear gloves with injections, nor did the person that trained her. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, affecting the following areas: Findings Include During a tour of the kitchen, at 8:48 AM on 6/3/25, observation of the dish machine area found worn and missing grout along portions of the back left floor juncture underneath the dish machine. Further review found multiple tiles pushed up from the floor underneath the garbage disposal allowing moisture to accumulate and create an environment conducing for the growth of insects and bacteria. Multiple gnats were found under the dish machine at this time. Mainly grouping around the unused floor drain and sections of the floor where grout is worn low, and water can accumulate and stagnate. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a dignified dining experience for 2 (Residents #590 and #50) of 4 residents reviewed for a dignified dining experience, resulting in the potential for feelings of frustration and loss of self-worth.

Inspectors wroteBased on interview and record review the facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) and Notice of Medicare Non-coverage (NOMNC) to 2 (Resident #642 and Resident #643) of 3 residents reviewed for proper notification related to Medicare A insurance Coverage, resulting in the potential for the loss of the right to appeal insurance benefit coverage.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper discharge notifications were completed in 2 residents (Resident #88 & #640) of 2 residents reviewed for discharge process, resulting in the State Long-Term Care (LTC) Ombudsman not receiving notification of resident's discharge to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 resident (Resident #4) of 18 residents received an accurate clinical assessment, reflective of the resident's status at the time of the assessment, resulting in inaccurate diagnosis of schizophrenia documented on MDS (Minimum Data Set) assessment.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice related to physician ordered medication and treatments for 2 residents (Resident #21 & #540) of 18 residents reviewed for the provision of nursing services, resulting in false documentation of medication and treatment administration, the lack of physician notification of missed medication, and and the potential for the worsening of medical conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living (ADLs) to a dependent resident, including shampooing of hair, for 1 (Resident #37) of 18 resident reviewed for activities of daily living, resulting in an unkempt appearance and the potential for feelings of diminished self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received care in accordance with professional standards in 2 residents (Resident #21 & #540) of 18 residents reviewed for quality of care, resulting in medication not being administered per physician order for the treatment of a mental disorder for Resident #21, wound care not provided per physician order for Resident #540, and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a positioning device was consistently applied for 1 (Resident #56) of 1 resident reviewed for positioning, resulting in the potential for decreased range of motion and related complications, skin breakdown, worsening of contracture (hardening of the muscles, tendons, and other tissues) and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1). Ensure that supplemental oxygen was continuously supplied at the rate ordered by the physician for 1 (Resident #37) and 2). Obtain physician orders for use of a continuous positive airway pressure (CPAP) machine and provide routine cleaning of CPAP mask for 1 (Resident #81) of 2 total residents reviewed for respiratory care resulting in the potential for excessive oxygen administration, improper use and/or inaccurate settings of an CPAP machine, and respiratory infection.

Inspectors wroteBased on interview and record review the facility failed ensure post dialysis assessment and monitoring was completed and documented for 1 (Resident #6) of 1 resident reviewed for dialysis care, resulting in the potential for the resident to not meet his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 2 (Resident #83, #63) of 18 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma.

Inspectors wroteBased on interview and record review the facility failed to provide specialized and individual mental health services for 1 (Resident #63) of 1 resident reviewed for mental health services resulting in psychological support service recommendations not being addressed, support services not being initiated when ordered by the physician, and the potential for a decline in psychological well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a medication error rate less than 5% in 2 residents (Resident #33 & #21) of 5 residents reviewed for medication administration, resulting in the potential for medication adverse effects and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs per manufacturer instructions and facility policy in 2 out of 6 medication carts, resulting in the potential for decreased efficacy of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to fully implement a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe storage and consumption. This deficient practice resulted in unknown discard dates and potentially hazardous foods being held passed their discard date, increasing the risk of contamination and food borne illness among residents who store personal food product in the facility.

Inspectors wroteThis citation pertains to Intakes: MI00147677 and MI00149818. Based on interview and record review, the facility failed to ensure the safety and 1.) fully implement a documented intervention of 1:1 supervision to prevent a fall for 1 (Resident #102) resident and 2.) ensure an enabler (grab) bar was securely engaged before moving a resident in bed for 1 (Resident #103) resident of 3 residents reviewed for accidents/hazards/falls, resulting in a preventable fall with a head injury for Resident #102 and a preventable fall with a skin tear for Resident #103.

Inspectors wroteThis citation pertains to intake: MI00147428. Based on interview and record review, the facility failed to take prompt action to resolve resident concerns of lengthy call light wait times in 3 (Resident #107, #106, and #101) of 3 residents reviewed for concern resolution, resulting in dissatisfaction with call light response and the potential for feelings of frustration as well as the potential for additional care concerns to go unaddressed.

Inspectors wroteThis citation pertains to intake MI00147428. Based on interview and record review, the facility failed to provide food products at a palatable temperature for 2 (Resident #106 and Resident #101) of 3 residents reviewed for food, resulting in dissatisfaction with meals and the potential for nutritional decline.

Inspectors wroteThis citation pertains to intake MI00147428. Based on interview and record review, the facility failed to ensure residents received requested food items for 2 (Resident #106 and Resident #101) of 3 residents reviewed for food, resulting in dissatisfaction with meals and the potential for nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen per physician order and professional standards of practice, and store oxygen tubing in a manner to prevent cross-contamination in 1 of 4 residents (Resident #104) reviewed for oxygen administration, resulting in the potential for respiratory distress, worsened respiratory status, and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness potentially affecting all 87 residents that reside in the facility. Findings Include: During an initial kitchen tour on 6/11/2024 at 8:33 AM, the following was observed in the reach in refrigerator: The outside temperature gauge temperature was at 53 degrees. The inside temperature gauge was at 46 degrees. On 6/11/2024 at 11:52 AM, it was observed the reach in refrigerator outside temperature gauge was 52 degrees and the inside temperature gauge was 45 degrees. The reach in refrigerator was still packed with food. [...]

Inspectors wroteBased on observation and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury among residents who reside in the B hall. Findings Include: During a tour of the B hall shower room, at 10:07 AM on 6/12/24, the hot water was checked with a rapid read digital thermometer and found to be 127F. When asked if hot water temperatures were taken today, Maintenance Director (MD) FF stated yes, Maintenance (M) O usually does it in the morning. Observation of the B hall soiled utility room sink, at 10:09 AM on 6/12/24, found the hot water to reach 128F. When asked if each hall has their own hot water system, MD FF stated yes. [...]

Inspectors wroteThis citation has two deficient practice statements. Deficient Practice Number 1. Based on observation, interview, and record review, the facility failed to ensure proper infection control protocols and practices in seven of 20 residents reviewed for infection control (Resident #46, Resident #57, Resident #48, Resident #49, Resident #65, Resident #15, Resident #83) including 1. Enhanced Barrier Precautions (EBP) per national standards of practice, 2. Routine cleaning and proper storage of continuous positive airway pressure (CPAP) machines and tubing 3. Proper use of PPE (Personal Protective Equipment) during catheter care and dressing changes, 4. Keeping an intravenous therapy (IV) pole clean, 5. Tube feeding practices and 6. [...]

Inspectors wroteThis citation pertains to intake #MI00144295 Based on observation and interview, the facility failed to maintain a clean homelike environment for 2 (Resident #33 and Resident #83) of 20 sampled residents resulting in an unclean room, unclean bathroom, and the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self -esteem.

Inspectors wroteThis citation pertains to intake #MI00145044. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse by a resident for 2 residents (Resident #15 & #40) of 4 residents, reviewed for abuse, resulting in the potential for physical harm, pain and mental anguish.

Inspectors wroteThis citation pertains to intake #MI00145044. Based on observation, interview, and record review, the facility failed to implement interventions to prevent further abuse during an ongoing investigation of abuse for 2 residents (Resident #15 & #40) of 4 residents, reviewed for abuse, resulting in the potential for physical harm, pain and mental anguish.

Inspectors wroteResident #30 (R30) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R30's original admission date was on 4/7/2023 with diagnoses of dysphagia (difficulty swallowing), anxiety, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R30 was cognitively intact (13-15 is cognitively intact). Resident was discharged to the hospital on 3/2/2024 due to congestion and shortness of breath and returned to the facility on 3/7/2024. During an interview on 6/11/2024 at 2:15 PM, R30 stated he had to go to the hospital several months ago due to pneumonia. R30 was unable to remember if he received a written transfer notice when he went to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident of the facility bed hold policy and provide a written copy upon hospital transfer for two residents (Resident #30, Resident #43) of four reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for one (Resident #141) of 20 residents reviewed for the provision of nursing services, resulting in IV (intravenous) medications being administered outside of the physician ordered parameters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a need for increased assistance with Activities of Daily Living (ADL) care and provide the necessary assistive devices, for one resident (Resident #67) of six reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance.

Inspectors wroteThis citation pertains to intake # MI00143208 Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to prevent the worsening of pressure ulcers in onr resident (Resident #15) of four residents reviewed for pressure ulcers, resulting in not receiving wound treatments per physician orders for pressure ulcers, and the potential for infection and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood for people whose kidneys cannot perform these functions) treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained in one (Resident #17) of one resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions and/or resident decline related to adverse reactions of dialysis treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent in 2 of 4 residents (Resident #7 & #340) reviewed for medication administration, resulting in a medication error rate of 16% (4 errors from a total of 25 opportunities for error).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate storage of medication and a self-administration of medications evaluation was conducted for two (R140 and R49) of two residents reviewed for self-administration of medications, including narcotics, resulting in the potential for adverse reactions and overdose.

Inspectors wroteThis citation pertains to intake #MI00143208. Based on observation, interview, and record review, the facility failed to ensure the accuracy of the documentation of pressure ulcer care and dressings changes for one (Resident #15) of four residents reviewed for pressure ulcers, resulting in the potential for inappropriate follow up care, lack of continued assessment, and worsening of the skin injury.

Inspectors wroteThis citation pertains to intakes: MI00136843, MI00137001 Based on observation, interview, and record review, the facility failed to maintain general cleanliness of the premises including floor care (Rooms 402, 306, 102, 203, 205), cleaning of high contact surfaces, and resident personal and shared equipment, resulting in the potential for the spread of infection.

Inspectors wroteThis citation pertains to intake #MI00140233. Based on interview, and record review, the facility failed to protect the residents right to be free from staff to resident verbal abuse in 1 of 4 residents (Resident #207) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to Intake # MI00141758. Based on interview, and record review, the facility failed to prevent the misappropriation of controlled resident medications in 2 of 5 residents (Resident #212 and #201) reviewed for misappropriation of property, resulting in loss of resident's pain medication, and the potential for uncontrolled pain and discomfort.

Inspectors wroteThis citation pertains to Intake # MI00141758. Based on interview and record review, the facility failed to implement policies and procedures for ensuring immediate reporting to the State Agency allegations of misappropriation of resident property (narcotics) and the investigation results to the State Agency within 5 working days, resulting in the potential for continued abuses to go unreported and for residents to not be protected from abusive individuals due to inaccurate investigations.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate post-fall assessment and monitoring for 1 (Resident #211) of 5 residents reviewed for falls, resulting in a delay of treatment for spinal fractures and the potential for unidentified neurological changes, when Resident #211 sustained an unwitnessed fall with reported head trauma, and staff did not implement spinal cord precautions (prevent movement of the spine) prior to transfer into bed, did not implement neurological checks and/or monitor vital signs.

Inspectors wroteThis citation pertains to intake #MI00137198. Based on observation, interview, and record review, the facility failed to provide scheduled showers/bathing for 2 (Resident #202 and Resident #203) of 3 residents reviewed for showers, resulting in the potential for skin irritation and breakdown and feelings of decreased dignity.

Inspectors wroteThis citation pertains to intake #MI00141496 Based on interview and record review the facility failed to provide adequate supervision during a mechanical lift transfer for 1 (Resident #201) of 3 residents reviewed for falls, resulting in the potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate monitoring and treatment for a resident experiencing symptoms of a Urinary Tract Infection (UTI), (confusion, painful and frequent urination, and cloudy urine with a strong odor) for 1 resident (Resident #211) out of 4 residents reviewed for urinary care, resulting in a lack of monitoring, a delay in the treatment of UTI (urinary tract infection), hospitalization, and the potential for sepsis (a life threatening complication of infection.)

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 1 out of 14 residents (Resident #211) reviewed for medical records, resulting in inaccurate fall risk assessment and incomplete fall documentation, and the potential for facility staff and providers not having all of the pertinent information to care for residents.

Inspectors wroteThis citation pertains to intake #MI00141735 Based on interview, and record review, the facility failed to assess a resident after a outpatient medical procedure in 1 (Resident #100) of 4 residents reviewed for quality of care, resulting in a delay of treatment for Resident #100, who ultimately passed away.