Westwood Nursing Center

Inspectors wroteThis citation is based on Intake#2993239. Based on interview and record review, the facility failed to thoroughly investigate and elopement for one Resident (R304) of three reviewed for accidents.

Inspectors wroteThis citation pertains to intake #2993239. Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate safety interventions for one Resident (R304) of three residents reviewed for accidents, resulting in the resident to have jumped out of a two-story window, fracturing (breaking) their leg and required hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to clean and maintain food service equipment affecting 102 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant affecting 103 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) provide sufficient domestic hot water supply, and (2) provide appropriate ambient room temperatures affecting 103 residents, resulting in the increased likelihood for resident discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a discharge plan of care for one (R66) of six residents reviewed for discharge planning.

Inspectors wroteThis citation pertains to Intake MI00150156. Based on interview and record review, the facility failed to ensure appropriate information was communicated to the receiving hospital for one resident (R105) out of five residents reviewed for transfer.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was completed and sent to the local state agency for an evaluation for a Level II determination for one (R1) of six residents reviewed for PASSARs, resulting in R1 not being screened for mental disorder or intellectual disability care needs and the potential for R1's care needs being unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply hand splinting as ordered for two (R18 amd R81) of five residents reviewed for Range of Motion (ROM), resulting in a potential loss of ROM to dependent residents with known contractures and the potential for decline in overall health status.

Inspectors wroteThis citation pertains to Intake MI00143461. Based on interview and record review, the facility failed to ensure resident's medical record accurately documented the administration of prescribed medications for one resident (R101) out of three residents reviewed for medical record documentation, resulting in the potential for staff and providers lacking accurate information to care for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to repair an unattached closet door for one resident (R905) of three residents reviewed for environment, resulting in resident dissatisfaction with the living environment and concern over protection of personal belongings. Findings Include: On 3/7/24 at 10:10 AM, R905 was observed pointing at the closet door reserved for R905's belongings. The door was off the hinges and in front of the open closet. The closet items were visible. R905 expressed unhappiness with the condition of the closet door and the exposure of personal belongings. The resident said having the door unattached was upsetting because anyone could come inside the room and see and take personal belongings. The resident stated My Coca Cola was taken. [...]

Inspectors wroteThis citation pertains to intakes MI142286 and MI141954. Based on observation, interview, and record review, the facility failed to maintain a clean bathroom and comfortable water temperatures for one resident (R902) and failed to maintain a clean bathtub (in a tub room commonly used by residents for toileting) to include R905, resulting in dissatisfaction with facility cleanliness and resident comfort. Findings Include: On 3/7/24 at 10:10 AM R905, was interviewed and expressed dissatisfaction with the cleanliness of the facility, specifically mentioning the tub room, I won't go in there now. Review of the clinical record of R905 admitted [DATE] according to the MDS (MDS (Minimum Data Set) dated 1/22/24 documented that resident has intact cognition. Resident is able to make all needs known independently. [...]

Inspectors wroteThis citation pertains to intake MI00140622. Based on interview and record review the facility failed to inform the resident representative for R901 of a change in condition out of three residents reviewed for hospitalization, resulting in R901's representative being unaware of a change in condition and transfer to the hospital. Findings Include: During an interview on 11/15/23 at 12:45 PM with Concerned Family Member A, it was reported that R901 was sent to the hospital on [DATE] and the facility did not make the family aware. Record review of Nursing Progress Notes dated 10/22/23 noted the following: Writer spoke with Dr (name redacted), regarding resident having diarrhea, and decreased appetite, patient is malaise (with discomfort). Resident stated he feels very ill. Resident requested to go to hospital. [...]

Inspectors wroteThis citation pertains to Intake MI00133617. Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively maintain the food production kitchen physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteThis citation pertains to Intake MI00133617 and MI00134554. Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteThis ciations pertains to Intake numbers MI00137230 and MI00137425. Based on observation, interview, and record review the facility failed to maintain a clean and homelike environment by providing storage space to put personal belongings in and remove trash and food off the floor for two residents (#33, #67) reviewed for safe, clean, comfortable homelike environment resulting unsanitary living conditions and the opportunity for missing personal items.

Inspectors wroteThis citation pertains to Intakes #MI00137110 and MI00137114. Based on interview, and record review, the facility failed to timely investigate and submit to State Agency reports of abuse for 4 residents (R385, R536, R537, R2) out of 23 sampled residents for abuse resulting in the potential for further allegations of abuse to not be investigated timely.

Inspectors wroteBased on interview and record review, the facility failed to develop a dialysis and activity daily living (ADLS) baseline care plan for one (R9) of one residents reviewed for baseline care plans, resulting in the potential for unmet needs of ADLS and dialysis care.

Inspectors wroteThis citation pertains to intake MI00137425. Based on observation, interview, and record review, the facility failed to ensure medication was administered timely and accurately per physician's orders for three residents (#30, #40, #284) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not administered properly.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper storage of insulin and disposal of expired insulin in one of two medication carts reviewed during inspection of medication carts, resulting in the potential for residents to receive expired medications with altered potency and efficacy.

Inspectors wroteBased on interview and record review, the facility failed to report staffing data to the Payroll-Based Journal (PBJ) with the potential to affect all 80 residents residing in the building. This deficient practice resulted in the potential for staffing concerns leading to quality of care concerns.