Westwood Post Acute

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#45) of three residents reviewed out of 29 sample residents. Resident #45 was admitted on [DATE] for long-term care with a diagnosis of bipolar (mental illness), borderline personality disorder, intellectual disability and dysphagia/oropharyngeal phase (difficulty in swallowing due to issues in the part of the throat located behind the mouth). On 3/18/25 Resident #45 had an episode of choking after she grabbed a handful of leftover refried beans and shoved them into her mouth before the staff could stop her and she aspirated. The resident required the Heimlich maneuver (abdominal thrusts used to remove food or particles stuck in the airway) and suctioning. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement contained the required components. Specifically, the facility failed to: -Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and, -Provide for the selection of a neutral arbitrator agreed upon by both parties.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to personal funds, survey results, bedholds, re-admissions, PASSAR recommendations, quality of care, activities of daily living, activities, ancillary services, accidents/hazards, respiratory, dialysis, mental/psychosocial concerns, drug regimen, dental, hydration, snacks, arbitration, immunizations, safe and comfortable environment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that personal funds accounts were managed adequately for four (#19, #22, #27 and #42) of 10 residents out of 31 sample residents. Specifically, the facility failed to have Resident #19, Resident #22, Resident #27 and Resident #42 sign a new resident fund management service (RFMS) authorization and agreement form to handle the residents' funds when the facility underwent a name change.

Inspectors wroteBased on record review and interview, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for four (#9, #13, #16 and #35) of five residents reviewed for unnecessary medications out of 31 sample residents. Specifically, the facility failed to: -Have a monthly medication review (MMR) completed for Resident #9, Resident #13, Resident #16, and Resident #35; and, -Failed to have licensed pharmacist signature on monthly medication review (MMR).

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for six residents (#5, #35, #47, #48, #49 and #53) of six resident out of 31 sample residents. Specifically, the facility failed to ensure Resident #5, Resident #35, Resident #47, Resident #48, Resident #49 and Resident #53 consistently had access to water to ensure proper hydration.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide snacks in one of one nourishment rooms for residents who required bedtime snacks and residents who wanted snacks during off hours. Specifically, the facility failed to ensure residents were offered and provided nourishing snacks in accordance to their needs and preferences.

Inspectors wroteBased on record review and interviews, the facility failed to provide notice of bed hold policy and return for two (#35 and #211) of four residents reviewed for hospital transfers out of 31 sample residents. Specifically, the facility failed to provide Resident #35 and #211 with a written notice of bed hold policy and return when transferred to the hospital to address acute care needs.

Inspectors wroteBased on record review and interviews, the facility failed permit a resident to return after a hospitalization or therapeutic leave for one (#212) of three residents out of 31 sample residents. Specifically, the facility failed to reassess Resident #212's status at the time the resident sought to return to the facility after a transfer to the hospital, and did not allow the resident to return to the facility, based upon her status at the time of her transfer to the hospital.

Inspectors wroteBased on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#40) of two residents reviewed for PASRR out of 31 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #40.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for one (#20) of three residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #20, who had a diagnosis of diabetes, had his fingernails cut by staff who were trained to perform the task.

Inspectors wroteIV. Resident #20 A. Resident status Resident #20, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, quadriplegia, contractures of the left and right hands, diabetes and anoxic brain injury. The 3/19/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident had impairments of both upper extremities, used a wheelchair to ambulate and was always incontinent of bowel and bladder. The resident was dependent on staff for eating, toileting, personal hygiene, shower, dressing and transfers. B. Resident observation During a continuous observation on 4/7/25, beginning at 11:41 a.m. and ending at 2:49 p.m., the following was observed: At 11:41 a.m. the resident was sitting in his wheelchair in the dining room. At 12:33 p.m. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide one (#30) out of five residents out of 31 residents with an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically the facility failed to ensure Resident #30 received a personalized activity program.

Inspectors wroteBased on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#30) of one resident reviewed for vision out of 31 sample residents. Specifically, the facility failed to follow up on Resident #30's referral for cataract surgery.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#9) of three residents who required respiratory care received care consistent with professional standards of practice out of 31 sample residents. Specifically, the facility failed to follow physician's orders to maintain, clean, sanitize and store Resident #19's continuous positive airway pressure (CPAP) mask and machine.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#112) of one resident reviewed for dialysis care out of 31 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure the resident's arteriovenous fistula (AVF) shunt was assessed on a daily basis.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#40 and #42) of four residents reviewed out of 31 sample residents. Specifically, the facility failed to: -Identify Resident #40 and Resident #42's history of trauma and identify triggers which may retraumatize them; and, -Ensure services and individualized care approaches were provided for Resident #40 and Resident #42.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide one resident (#30) with professional quality of care out of 31 residents. Specifically, the facility failed to ensure Resident #30 received timely dental service.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#30) of five residents reviewed for immunizations out of 31 sample residents. Specifically, the facility failed to ensure consent was obtained from Resident #30's representative prior to administering the pneumococcal vaccination.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the residents' shower room was maintained in a safe and sanitary condition.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facilities most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically the facility failed to provide three years worth of survey and investigation findings in a prominent location for public viewing.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents were free of any significant medication errors for one (#6) of four residents out of 29 sample residents related to anticoagulants and insulin management. Resident #6 had several significant health conditions requiring close monitoring with personal care services including physician services and nursing assessment with medication and treatment administration to ensure the resident's highest optimal health condition possible. Resident #6 was at high risk for the development of life threatening blood clots that could cause blockages in the heart, lungs and other vital organs potentially shutting the organs down. The facility's nursing staff were to administer physician ordered medication (warfarin) in proper dosages as calculated by the resident physician based on results of regularly assessed lab work. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (#15) of four residents reviewed for ADL care assistance out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with diagnoses of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). The resident was dependent on staff for all of his ADLs. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#15 and #11) of three residents reviewed for catheter care out of 29 sample residents. Resident #15 admitted to the facility for long term care on 2/28/22 with a diagnosis of depression, quadriplegia (decreased or no movement of all four limbs), neurogenic bowel (decreased bowel movements), neuromuscular dysfunction of bladder (decreased bladder movement) and colostomy status (an opening into the colon from the outside of the body). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#11 and #4) of two residents out of 29 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #11 was admitted to the facility for long term care on 5/17/23 for long term care with diagnoses of quadriplegia (decreased or no control of all four limbs), neuromuscular dysfunction of the bladder (decreased movement of the bladder), hypoglycemia (low blood sugar), type I diabetes mellitus, neurogenic bowel (decreased bowel movement) and anxiety. Upon admission, Resident #11 weighed 188 pounds (lbs) and he reported he preferred to eat vegetarian meals. Resident #11 was started on Glucerna (diabetic nutritional supplement) once a day on 7/20/23. On 7/6/23, Resident #11 weighed 182.4 lbs. Resident #11 had lost 5. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication errors.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity. Specifically, the facility failed to provide residents with a dignified existence by ensuring that call lights were consistently answered in a timely manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding meals, staff cell phone usage, batteries not being charged and trash not being taken out.

Inspectors wroteIV. Falls A. Facility policy and procedure The Fall Risk Assessment policy, revised March 2018, was provided by CNC #1 on 2/19/24 at 4:30 p.m. It read in pertinent part, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure certified nurse aides and licensed nurses were able to demonstrate competency skills and techniques necessary to care for residents' needs. This placed all residents at the facility at risk of receiving inadequate care. Specifically, the facility failed to conduct staff competency evaluations for all certified nurse aides (CNA), licensed practical nurses (LPN) and registered nurses (RN). Cross-reference F677: failure to provide adequate assistance for activities of daily living for a resident who was dependent on staff for all care. Cross-reference F684: failure to provide diabetic care per standards of care. Cross-reference F689: failure to ensure the needs of a resident with substance use disorder. Cross-reference F690: failure to provide catheter care per standards of care. Cross-reference F691: [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance.

Inspectors wroteBased on record review, observations and interview, the facility failed to ensure a clean, safe and homelike environment for two (#19 and #11) of 29 sample residents. Specifically, the facility failed to: -Ensure a system was implemented to clean and maintain Resident #19's chew and spit discarded food bucket; and, -Maintain a clean room environment for Resident #19 and Resident #11, who were roommates.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#4) of three residents out of 29 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #4's grievance, which he had communicated to staff on multiple occasions, regarding the resident's missing cigarettes and money.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#4) of three sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan of 29 sample residents. Specifically, the facility failed to provide regular and consistent supervised guidance to assist Resident #4 to make educated decisions on determining an appropriate sliding scale insulin dose based on blood glucose assessment and carbohydrate intake and document those efforts per physician's orders.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. for two (#15 and #11) of two residents reviewed for colostomy care out of 29 sample residents. Specifically, the facility failed to ensure Resident #15's and Resident #11's colostomy bags were maintained per physician's guidance and professional standards of practice.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to: -Follow correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow recipe modifications for the texture modified diets.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for one (#11) of three residents out of 29 sample residents. Specifically, the facility failed to ensure Resident #11's requests and preferences for a vegetarian diet were served to him.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Follow aseptic technique when replacing Resident #15's suprapubic catheter; and -Follow aseptic technique when performing Resident #18's wound care.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure two (#272 and #7) residents out of 28 sample residents were free from significant medication errors. Resident #272, was admitted on [DATE] for long term care with a goal to return home. The resident was prescribed medication of Ativan for his anxiety disorder. The facility ran out of the prescribed medications and he missed 18 doses of Ativan across six days from 9/4/23 to 9/9/23. The facility failed to implement effective interventions to prevent the resident from running out of his medications (discovered on 9/4/23) from progressing to the resident experiencing withdrawal symptoms and subsequently being hospitalized on [DATE] (six days after the facility identified the medication was out of stock). In addition, the facility failed to: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#32, #41 and #272) of five residents reviewed for psychotropic medications out of 28 sample residents had the right to be informed of, and participate in, his or her treatment including the right to be informed, in advance, of the care to be furnished. Specifically the facility failed to ensure Resident #32, #41 and #272 were made aware of the risk/benefit and side effects of prescribed psychotropic medications.

Inspectors wroteBased on observations and interviews the facility failed to provide a homelike environment, including but not limited to receiving treatment and support for daily living safely in two out of two units. Specifically, the facility failed to: -Ensure smoking residents smoked in designated areas; -Ensure non-smoking residents were protected from smoking odors.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of three medication carts. Specifically, the facility failed to ensure medications were properly labeled with open dates for insulin (medication used for blood glucose management) pens and vials.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Ensure Insulin (medication used for blood glucose management) pens and vials were properly cleaned prior to drawing up medications; -Ensure wound care was provided in a hygienic manner; and, -Ensure hand hygiene was performed when changing gloves.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen. Specifically, the facility failed to: -Ensure the kitchen and food equipment was clean; -Prevent potential contamination; -Ensure proper food temperatures were taken for tray line service.

Inspectors wroteIII. Appropriate clothing for the weather A. Resident #49 Resident #49, age [AGE], was admitted on [DATE]. According to the January 2020 computerized physician orders (CPOs), diagnoses included multiple sclerosis, anxiety disorder, and nicotine dependence to cigarettes. According to the 12/7/19 minimum data set (MDS) assessment, the resident had minimum cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision for activities of daily living (ADL's) such as dressing that required additional time to complete. The care plan initiated 6/26/18 identified Resident #49 as a safe smoker and capable of smoking without physical assistance but must be supervised. B. Observation 2/25/2020 -At 8:35 a.m., Resident #49 was observed through windows sitting outside in the courtyard, the temperature was 27 degrees with 12 mile per hour wind. [...]

Inspectors wroteBased on observation and interviews the facility failed to ensure infection control practices were followed to prevent the spread of infection. Specifically the facility failed to: -Follow proper hand hygiene with glove use when working between dirty to clean processes.

Inspectors wroteBased on observation, record review and interviews the facility failed to provide an ongoing program of activities to meet the interests of and support the wellbeing of one (#46) out of three residents out of 31 sample residents reviewed. Specifically the facility failed to -Provide a resident centered activity program for Resident #46

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to ensure one (#57) of one out of 31 sample residents received treatment and care in accordance with professional standards of practice, comprehensive care plan and resident choices. Specifically, the facility failed to: -Ensure proper wheelchair positioning to address improper postioning for Resident #57.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure the hydration needs were met for one (#46) out of three residents out of 31 total sampled residents reviewed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#39) of two residents out of 31 sample residents received respiratory treatments in a manner of care consistent with professional standards of practice. Specifically the facility failed to: -Follow physician oxygen orders -Clean and store the continuous positive airway pressure (CPAP) equipment properly