Westwood Manor Nursing Home, Inc

Inspectors wroteBased on observation and interview, the facility failed to ensure medications and biologicals were stored and labeled properly in accordance with currently accepted professional principles. The facility failed to ensure:1. Expired medications were not available for use/administration to Resident #20;2. Resident #48's medication was properly labeled; and3. Residents (#15, #29, #72, and #77)'s insulin pen/vials were properly labeled after opening and discarded after 28days of opening.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 90 residents that received meals prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received reasonable needs for 1 (Resident #32) of 1 residents reviewed for accommodation of needs. The facility failed to ensure Resident #32 received a Geriatric chair as requested.

Inspectors wroteBased on record review and interview, the facility failed to transmit an admission MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #33) of 1 sampled residents with a MDS record over 120 days old.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's comprehensive care plan was revised after each assessment for 1 (Resident #22) of 30 sampled residents. Review of Resident #22's medical record revealed an admission date of 03/26/2018 with diagnoses including Alzheimer's Disease, Epilepsy, Gastrostomy, and Quadriplegia. Review of Resident #22's Discharge with Return Anticipated MDS with ARD of 07/15/2025 revealed a BIMS Score was not conducted. Resident #22 did not receive Oxygen. Review of Resident #22's previous physician's orders revealed Oxygen at 2-4L NC PRN SOB and O2 sat below 95% RA as needed was discontinued on 01/29/2025. Review of Resident #22's care plan revealed the following interventions: Oxygen settings: O2 via NC at 2-4L PRN SOB or O2 less than 95% on RA; and Oxygen: Administer as ordered. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide nail care for 1 (#5) out of 30 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were not available for administration to residents in 1 (Room A) of 1 medication room checked for safe and secure storage. Observation of Room A on 07/29/2025 at 10:00 a.m. accompanied by S14 LPN revealed Room A was used to store medications and supplements to be provided to residents. Observation revealed 2 unopened bottles of Ocuvite Adult 50+ Soft Gels with an expiration date of 06/2025, and 3 DiabetiSource AC Complete Nutrition 250mL supplements with an expiration date of 05/23/2025. An interview was conducted at this time with S14 LPN who confirmed expired medications and supplements were in Room A, but should not have been. Interview with S3 ADON on 07/29/2025 at 10:45 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received and the facility provided liquids consistent with resident needs for 1 (Resident #52) resident investigated for hydration. The sample size was 30 residents. Review of Resident #52's medical record revealed an admission date of 12/16/2020 with diagnoses including, in part. Dementia, Mild Protein-Calorie Malnutrition, and Aphasia. Review of Resident #52's Quarterly MDS with ARD of 06/06/2025 revealed a BIMS Score of 99. Resident #52 required substantial/maximal assistance with eating and did not have a swallowing disorder. Review of Resident #52's active physician's orders revealed the following: 09/03/2024: 360mL fluid of choice po TID with med pass; and 09/03/2024: Give 360mL fluid of choice po BID at snack times. Review of Resident #52's care plan revealed the following: 12/01/2021: [...]

Inspectors wroteBased on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 95 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 1 (#96) of 2 (#45, #96) Residents reviewed for dignity in a total sample of 29. The facility failed to ensure Resident #96 was dressed appropriately.

Inspectors wroteBased on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#96) of 2 (#96, #352) Residents reviewed for advance directives. The total sample size was 29. The facility failed to ensure all medical records regarding code status consistently reflected the Resident's wishes to be a DNR (Do Not Resuscitate).

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment, by failing to ensure a resident's bed linens were clean for 1 (Resident #18) of 4 (Resident #10, Resident #18, Resident #49 and Resident #55) sampled Residents. Total sample size was 29.

Inspectors wroteBased on interview and record review, the facility failed to ensure a prompt resolution of an allegation of missing property for 1 (Resident #13) of 1 resident reviewed for grievances by failing to initiate a grievance for Resident #13. Total sample size was 29.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a CPOC (Comprehensive Person Centered Care Plan) to meet Resident's medical needs for 2 (#47, #96) of 29 sampled residents. The facility failed to: 1. Ensure Resident #47 was transferred with a mechanical lift by 2 person assist as specified in the resident's physician's orders and CPOC, and 2. Ensure Resident #96 had a CPOC to address the Resident's code status of DNR.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (#47, #49) of 2 residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on record review and interview the facility failed to administer the Pneumococcal Vaccine after receiving consent for 1 (#45) of 5 (#2, #45, #57, #66 and #352) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations.