Westwood Health and Rehabilitation

Inspectors wroteBased on record reviews, and staff, Pharmacy Consultant, and Medical Director interviews, the facility failed to administer scheduled medications as ordered by the physician for 6 of 32 residents on the D and E halls that were reviewed for medication administration (Residents #4, #5, #6, #7, #8 and #9).

Inspectors wroteBased on record review, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to ensure there was sufficient nursing staff in the facility on 5/16/26 from 1:00 PM to 5:00 PM to administer medications as ordered to the D and E halls for 6 of 32 residents reviewed for medication administration (Resident's #4, #5, #6, #7, #8 and #9).

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to discard expired medications and date open multiple-dose medications in 2 of 3 medication carts (A and D medication carts) and 1 of 1 medication storage room observed.

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date food items and maintain food in sealed containers in the kitchen. Specifically, the facility did not label and date cups of orange juice in 1 of 1 walk-in cooler; did not seal and label a box of frozen biscuits with the date opened in 1 of 1 walk-in freezer; did not keep a small container of pimento cheese sealed in 1 of 1 reach-in refrigerator; and seal and label a box of rice with the date opened in the dry storage area. These practices had the potential to affect the safety and quality of food served to residents.

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility failed to treat a resident in a dignified manner when there was a delay in answering a resident 's call light for 1 of 4 residents (Resident #21) reviewed for dignity.

Inspectors wroteBased on record review and resident, friend and staff and local Law Enforcement Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of resident's property. This affected 1 of 1 resident reviewed for misappropriation (Resident #19).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of accidents (Resident #11), and medications (Residents #49 and #21). This was for 3 of 24 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, observation, Medical Wound Provider and staff interviews, the facility failed to assess a newly identified pressure ulcer that included the pressure ulcer stage, characteristics, and presence of pain and failed to complete pressure ulcer treatments as ordered 3 out of 5 days. This was for 1 of 5 (Resident #2) residents reviewed for pressure ulcer care.

Inspectors wroteBased on record review, observation, and interviews with staff and Medical Director, the facility failed to provide behavioral healthcare services to a resident with diagnosed mental health disorders and behavioral symptoms for 1 of 1 resident (Resident #21) reviewed for behavioral and emotional needs.

Inspectors wroteBased on record review, Medical Director and staff interviews, the facility failed to hold a blood pressure medication as ordered by the physician for 1 of 6 residents whose medications were reviewed (Resident #49) for unnecessary medication.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to post the most recent survey of the facility in the survey results notebook. This occurred for 2 of 4 days of the survey (2/15/26 and 2/17/26).

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 22 out of 46 days (1/6/26, 1/7/26, 1/10/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/24/26, 1/25/26, 1/28/26, 1/30/26, 1/31/26, 2/1/26, 2/2/26, and 2/3/26).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain evidence of ongoing communication with the dialysis treatment center in the medical record for 1 of 2 residents reviewed for dialysis (Resident #65).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to protect a resident's right to be free from resident to resident sexual abuse when Medication Aide #2 observed Resident #1, a male resident, fondle a severely cognitively impaired female resident (Resident #2) when he lifted both of Resident #2's breasts out of the neckline of her V-neck shirt and caressed them with both hands and when Medication Aide #1 observed Resident #1 holding the hand of Resident #2 and rubbing her hand over his pants in his crotch area. Resident #2 did not have the cognitive capacity to consent to this intimate sexual contact. This deficient practice affected 1 of 3 residents reviewed for resident-to-resident abuse (Resident #2).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to date opened vials of insulin and insulin pens stored 2 of 2 medication carts (B and C hall cart, and D and E hall cart) the facility failed to keep a medication refrigerated per manufacturer guidelines in 1 of 2 medication carts (B and C hall cart), and also failed to discard expired medications in 1 of 1 medication storage room.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to honor a resident's request for his hair to be trimmed to his preferred length by not coordinating a hair cut despite staff's knowledge of the resident's preference. This deficient practice affected 1 of 2 residents reviewed for choices (Resident #48).

Inspectors wroteBased on record reviews, observations and interviews with residents and staff, the facility failed to provide routine hair trimming as part of basic hygiene services for residents whose payor source was Medicaid. This was for 2 of 6 residents reviewed for Activities of Daily Living (ADL) (Residents #16 and #26).

Inspectors wroteBased on record review, observations, resident and staff interviews the facility failed to implement interventions to prevent further falls for Resident #6. This was for 1 of 3 residents reviewed for accidents (Resident #6).

Inspectors wroteBased on observations, record reviews, Nurse Practitioner, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 29 opportunities, resulting in a medication error rate of 6.9% for 2 of 3 residents (Resident #5 and Resident #16) during the medication administration observation.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to disinfect a glucometer (used to check a resident's blood glucose level) after using per manufacturer's guidelines for 1 of 1 resident (Resident #29). The glucometer was individually assigned to Resident #29 and stored in the medication cart.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide the resident and their Responsible Party (RP) a written notification of the bed hold policy upon a resident's transfer to the hospital for 2 of 2 residents (Resident #37 and & 30) reviewed for hospitalization. This practice had the potential to impact 54 of 54 residents at the facility.

Inspectors wroteBased on record review, and staff interviews, the facility failed to provide the resident and/or the Responsible Party with a written notification of the reason for a hospital transfer for 2 of 2 residents reviewed for hospitalization (Residents #37 & #30).

Inspectors wroteBased on record reviews, and staff interviews, the facility failed to have complete and accurate documentation for wound care (Residents #30, #55 and #56). This was for 3 of 35 resident records reviewed.

Inspectors wroteBased on record reviews, observation, and resident, staff, and transportation driver interviews, the facility failed to provide safe transportation for Resident #1 when she was being transported by a contracted van transport company from dialysis back to the facility on 5/25/24. Resident #1's wheelchair was not secured to the floor securement system per the manufacturer's instructions. When Driver #1 accelerated the vehicle, Resident #1's wheelchair tipped backward, and the resident hit the right back side of her head. Driver #1 pulled the transportation van over to the shoulder of the road and called 911. Emergency Medical Services (EMS) arrived, assessed the resident, and determined she needed to go to the hospital for evaluation for her complaints of head pain. The accident occurred post hemodialysis and Resident #1 was prescribed and received Plavix (anticoagulant medication). [...]

Inspectors wroteBased on record reviews, staff and Physician interviews, the facility failed to maintain complete and accurate medical records in the area of hospital readmission and medication changes for 1 (Resident #1) of 14 medical records reviewed.

Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #24 and #44). This was for 2 of 6 residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on record reviews, observations and staff and resident interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Residents #31).

Inspectors wroteBased on record reviews, observations, resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey completed on 04/12/22. This was for two deficiencies that was cited in the areas of Activities of Daily Living Care Provided for Dependent Residents and Respiratory/Tracheostomy Care and Suctioning. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program.

Inspectors wrote2) Resident #36 was admitted to the facility 04/13/23 with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke) and Gastroesophageal Reflux Disease. Resident #36's care plan dated 05/16/23 indicated a focus area of Resident #36 had a Percutaneous Endoscopic Gastrostomy (PEG) tube due to dysphagia from a stroke. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was not coded as having a feeding tube. On 8/15/23 at 2:45 PM, an interview occurred with the Dietary Manager. She verified she had completed the nutritional section for Resident #36's 07/28/23 MDS assessment. She stated she knew Resident #36 had a feeding tube, and she should have marked Resident #36's MDS as having a feeding tube. She stated the incorrect coding was due to human error. [...]