Westwood Health and Rehab, Inc

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a resident's transfer or discharge was reported to the ombudsman for two (Resident #1 and Resident #3) of two residents reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the comprehensive person-centered care plan included an objective for monitoring a resident with wandering behaviors who was at risk for resident-to-resident altercations for 1 (Resident #44) of 3 residents reviewed for abuse. The lack of effective interventions resulted in Resident #44 having resident-to-resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. All of the incidents took place on the locked unit and Resident #44 had been kicked, hit in the face, hit in an unknown area, pushed, punched in the hand, struck in the hand, punched in the stomach, pushed down numerous times, and hit in the head. The last incident resulted in a broken hip. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure that resident to resident events were reported within 24 hours even if no serious bodily injury occurred for 1 (Resident #9) of three residents reviewed for abuse and neglect.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that the resident received prompt treatment after noticing a change in condition for 1 (Resident #112) of 4 residents reviewed for abuse and/or neglect. Specifically, Resident #112 showed signs of a stroke and was not sent to the emergency room until approximately 4 hours after noticing the change in condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to (1) properly transfer 1 (Resident #41) of 9 residents reviewed for accidents; (2) ensure keys were not left in the janitor closet door unattended where chemicals were stored for 1 (100 hall) of 4 halls observed; (3) ensure the rear casters/wheels of the mechanical lift were in the unlocked position when raising and lowering residents affecting 1 (Resident #8) of 9 residents reviewed for accidents; (4) ensure the beauty shop on the secured unit was locked when not in use or when there were no staff present.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure garbage and refuse was disposed of properly for one of one dumpster observed.

Inspectors wroteBased on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure hand hygiene was performed during one of one meal service observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident was free from resident-to-resident abuse for 1 (Resident #44) of 3 sampled residents reviewed for abuse. The lack of effective behavior monitoring resulted in Resident #44 having resident to resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. Of those incidents, Resident #9 was the physical aggressor for 3 instances. On 12/07/2024, Resident #9 hit Resident #44 in the stomach. On 12/20/24, Resident #9 pushed resident #44, resulting in the resident falling. On 01/08/2025, Resident #9 pushed Resident #44, resulting in the resident falling. Resident #44 was sent to the emergency room and was found to have a fractured hip. [...]

Inspectors wroteBased on record review and interview, the facility failed to acquire a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, as required, for 1 of 1 facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 (Resident #13) of 1 sampled resident was provided a weighted cup for fluids to prevent dehydration.

Inspectors wroteBased on observation, interview, and policy review the facility failed to post, in a form and manner accessible and understandable to residents, contact information for pertinent State agencies and advocacy groups for 15 residents residing in the facility's Secure Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident rooms in a safe, functional, homelike manner for 3 (Rooms 114, 119, 121) rooms, as evidenced by trim disconnected from the walls and built in drawers failed to open and close safely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 2 (Residents #32 and #34) of 15 (Residents #2, #3, #4, #8, #13, #21, #31, #32, #35, #38, #43, #45, #48, #105, and #106) sampled residents who were dependent on staff for fingernail care and facial hair was removed from 1 (Resident #105) of 10 (Residents #50, #105, #13, #45, #35, #41, #32, #38, #5, and #8) sampled residents who were dependent on staff for personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities for 15 residents in the facility's Secure Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that hazardous fluids were stored in a safe manner in 3 (rooms [ROOM NUMBER]) resident rooms located in the facility's secure unit. This failed practice had the potential to affect 10 residents identified as ambulatory by a list provided by the Administrator on 01/24/2024 at 04:00 PM.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 (Resident #13) of 12 (Residents #50, #105, #13, #3, #45, #106, #35, #5, # 4, #8, #31, and #48) sampled residents who were dependent on staff for hydration always had fluids available.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the oxygen tubing, humidifier mask, and/or an oxygen water bottle were dated for 2 (Residents #3 and #13) of 6 (Residents #3, #13, #28, #50, #105, and #106) sampled residents who had a physician's order for oxygen.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items and expired food items were promptly removed/discarded by the expiration or use by dates to prevent potential for food bone illness. These failed practices had the potential to affect 66 residents who received meals from the kitchen and 21 residents who received snacks from the unit (total census: 66), as documented on a list provided by the Dietary Supervisor on 10/19/2022.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 (Resident #17) of 7 (Residents #2, #17, #27, #36, #43, #46 and #59) sampled residents who were dependent for nail care.