Westwood Center

Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to provide supervision to prevent an accident for 1 of 2 resident records reviewed. (Resident #1)

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff follow physician's orders for 2 of 22 residents, Resident #9 and Resident #63.

Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, the facility staff failed to provide supervision to prevent accidents for 2 of 6 closed record reviews, Resident #55 and Resident #209. This resulted in actual harm for resident #55 cited at past non-compliance. For resident #209, the facility failed to implement safety measures resulting in an elopement.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste.

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer or discharge to the resident and the resident's representative(s) and failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for four (4) or 22 sampled residents and/or residents' representatives, (Resident #30, Resident #17, Resident #5, and Resident #35).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide residents and/or residents' representatives with the facility bed hold policy upon transfer for four (4) of 22 sampled residents, (Resident #30, Resident #17, Resident #5, and Resident #35).

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility document review, the facility staff failed to ensure that residents and/or resident representatives had the opportunity to develop an advanced directive for 3 of 22 residents in the survey sample, residents # 32, # 44 and # 39.

Inspectors wroteBased on staff interview, clinical record and facility document review the facility staff failed to ensure an accurate minimum data set for 1 of 6 closed record reviews, Resident #56.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure a level I preadmission screening and resident review (PASARR) was completed for 2 of 22 residents, Resident #21 and Resident #32.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to develop and/or implement a comprehensive person-centered care plan for 1 of 6 closed record reviews, Resident #55.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one (1) of 22 sampled residents, (Resident #5).

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide activities of daily living (ADL) care for 2 of 22 residents, Resident #39 and Resident #7.

Inspectors wroteBased on staff interview, clinical record review and facility document review facility staff failed to provide treatment and services to prevent and/or heal pressure ulcers for 1 of 22 residents in the survey sample, Resident #44.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review the facility staff failed to provide adequate respiratory care for 1 of 22 residents in the survey sample, (Resident #63).

Inspectors wroteBased on observation, staff interview, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 1 of 22 residents, Resident #43.

Inspectors wrote2. For Resident #29 the facility failed to ensure Resident #29 was free of an unnecessary medication, Novolin. (Novolin is a medication used to treat diabetes.) Resident #29's diagnosis list indicated diagnoses that included, but were not limited to, Lung Cancer, Type 2 Diabetes Mellitus, Atrial Fibrillation, Fibromyalgia, Anxiety Disorder, Depression, and Chronic Kidney Disease-Stage 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/14/24, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #29 was cognitively intact. Resident #29's clinical record included a Nursing Report, that read in part, Includes the following Classifications: MRR (medication regimen review) For Recommendations Created Between 7/25/2024 And 7/25/2024 Includes Routings for: [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 22 residents was free from unnecessary psychotropic medications, Resident # 43.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 22 residents was free from significant medication errors.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to appropriately store, prepare and/or serve resident food items.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to provide basic life support, including cardiopulmonary resuscitation to one of 57, residents, Resident #2.

Inspectors wroteBased on observation, staff interview, resident interview, family interview, clinical record review, facility document review, the facility staff failed to provide wound management as evidenced by the absence of assessments, monitoring, and/or treatment for of 5 out 33 residents. This resulted in wound infections and/or wound deterioration for Resident #10, Resident #4, Resident #42, Resident #36, and Resident #149. The facility also failed to implement provider orders at the time they were ordered for 1 of 33 residents reviewed, Resident #199. On 3/15/23 at 3:50 PM, the surveyors notified the facility of the Immediate Jeopardy determination, Level IV Pattern. The facility staff implemented an abatement plan that was verified by the survey team through additional observations, interviews, and document reviews. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide the necessary treatment and services to promote wound healing and prevent infection for four of 33 residents in the survey sample, Resident #37, 42, 299, 199. Resident #37 experienced harm due to the development of osteomyelitis and the subsequent invasive treatment procedures that were required.

Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to obtain physician ordered labs for 4 of 33 residents, Resident #4, Resident #42, Resident #11, and Resident#199.

Inspectors wroteBased on interviews and document review, the facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification for one (1) of three (3) residents selected for SNF Beneficiary Notification Review (BNR) (Resident #2).

Inspectors wroteBased on interviews and record reviews, the facility staff failed to ensure one (1) of 33 residents had orders, at the time of admission, to guide care (Resident #46).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 33 residents, Resident #4.

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to initiate a care plan within 48 hours that addressed the resident's clinical needs for 2 of 33 residents, Resident #36 and #149 1. For Resident #36, facility staff failed to implement a baseline care plan to address the resident's needs as evidenced by failure to address surgical wounds on the care plan within 48 hours of admission. [...]

Inspectors wroteBased on staff interview, family interview and clinical record review, the facility staff failed to initiate interventions to address the resident's wound care needs for 1 of 33 residents reviewed (Resident #149). Resident #149 was admitted to the facility with diagnoses to include encounter for orthopedic aftercare following surgical amputation, diabetes mellitus due to underlying condition with diabetic nephropathy, atrial fibrillation, hypertensive heart disease with heart failure, asthma, infection following a procedure-superficial incisional surgical site-subsequent encounter, muscle weakness, and difficulty walking. The minimum data set assessment (MDS) with the assessment reference date 1/19/2023 was reviewed. The resident scored 13/15 on the brief interview for mental status, and was assessed as without signs of delirium, psychosis, or behaviors affecting care. [...]

Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to review and revise the comprehensive person-centered plan of care for 1 of 33 residents in the survey sample, Resident #299.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice for the notification and assessment of critical laboratory test results for 2 of 33 Residents, Resident #10, and Resident #14

Inspectors wroteBased on interviews and document review, the facility staff failed to ensure that admission orders included nutrition and fluid orders for one (1) of 33 residents, Resident #46. Resident #46 received their nutrition and fluids via enteral means. Resident #46 was not able to intake nutrition and/or fluids orally. (Enteral nutrition is a way of providing nutrition, via tube, directly to an individual's stomach or small intestine.)

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and physician's orders for 1 of 33 residents in the survey sample, Resident #38.

Inspectors wroteBased on interviews and document review, the facility staff failed to ensure Medication Regimen Reviews (MRRs) were addressed by a medical provider for three (3) of five (5) residents selected for unnecessary medication review (Resident #14, Resident #17, and Resident #26).

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to ensure one out of 21 residents were free from medication errors, Resident #104.

Inspectors wrote2. The facility staff failed to promptly notify a medical provider of Resident #14's critically low blood glucose level. A blood glucose test is a blood test that measures the level of sugar (glucose) in the blood. Low blood sugar (also called hypoglycemia) has many causes, including missing a meal, taking too much insulin, taking other diabetes medicines, exercising more than normal, and drinking alcohol. Blood sugar below 70 mg/dL is considered low . Low blood sugar can be dangerous and should be treated as soon as possible. (Downloaded from https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html on 3/16/23) Resident #14's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/16/22, was dated as being completed on 12/29/22. Resident #14 was assessed as sometimes able to make self understood and as sometimes able to understand others. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to discard an out-of-date food item and failed to label opened food items in the refrigerator.

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical record/documentation for four of 21 sampled residents, Resident #103, Resident #108, Resident #117, and Resident #106.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure a Quality Assurance and Performance (QAPI) Program to meet the needs of the facility as evidenced by repeated deficiencies in the area of Quality of Care related to wound management.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to perform hand hygiene after cleaning the wound and placing a clean dressing for 1 of 33 residents in the survey sample, Resident #36. Resident #36 was admitted to the facility with diagnoses including (by listed date of diagnosis) type 2 diabetes mellitus with diabetic polyneuropathy,peripheral vascular disease, morbid obesity, obstructive sleep apnea,muscle weakness, hypertensive heart and chronic kidney disease with heart failure, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, chronic obstructive pulmonary disease with acute exacerbation, atrial fibrillation, sepsis due to escherichia coli, bacteremia. [...]

Inspectors wroteBased on staff interview, employee record review and facility documentation review, the facility staff failed to obtain verification of licensure from the Department of Health Professions prior to hire for 2 (Employees # 15 and # 24) of 5 Registered Nurses, for 1 (Employee # 13) of 5 Licensed Practical Nurses and the facility staff failed to ensure a criminal background check was obtained timely for 1 (Employee # 26) of 27 employees in the Employee Records Check sample.

Inspectors wrote19. For Resident 196, the facility staff failed to administer a PPD per the physicians orders. A (PPD) purified protein derivative skin test is a test that determines if you have (TB) tuberculosis. The face sheet in Resident 196 clinical record included the diagnosis degenerative diseases of basal ganglia, hemiplegia, epilepsy, and hypertension. Resident 196 was a new admit and had no completed MDS assessment. Resident 196 was unable to communicate with the surveyor. Resident 196's (EHR) electronic health record included an order dated 05/06/2021 for tuberculin PPD solution inject 0.1 ml intradermally one time only for screening. This was a verbal order that had been confirmed by the (DON) director of nursing. 05/08/2021 the nursing staff documented that they would obtain information regarding the residents previous PPD from another nursing facility. [...]

Inspectors wroteBased on staff interview, clinical record review, facility document review, and during the course of a complaint investigation, facility staff failed to inform the resident's responsible party and physician of a change in skin status for 1 complaint resident (Resident #246).

Inspectors wroteBased on observation, staff interview, resident interview, and clinical record review, facility staff failed to determine that an assessment needed to completed for a significant change regarding the development of what was stated to be a deep tissue injury for 1 of 12 residents in the survey sample (Resident #6).

Inspectors wroteBased on staff interview, resident interview, and clinical record review during review of a complaint, facility staff failed to provide necessary care and services for prevention and treatment of pressure ulcers for 1 of 12 residents in the survey sample (Resident #246).

Inspectors wroteBased on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure a resident's respiratory/oxygen equipment was appropriately changed for one (1) of 15 sampled residents (Resident #40).

Inspectors wroteBased on interviews, the review of documents, and during the course of a complaint investigation, it was determined the facility staff failed to ensure the competition of orientation was documented for a staff member (Licensed Practical Nurse (LPN) #21) prior to the staff member being scheduled to work independently.