Westwood Specialty Care

Inspectors wroteBased on clinical record review, resident interview, staff interviews, and facility record review, the facility failed to provide safe and adequate mechanical lift transfer to prevent an injury to the resident's forehead for 1 out of 3 residents reviewed (Resident #18). The facility reported a census of 77 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 4/15/26 regarding deficiency F689 with a scope and severity of a Level G. The facility provided evidence of education to the staff member directly involved in the facility incident that occurred on 4/15/26. The remainder of the nursing staff received education on 4/16/26. The facility was found to be in substantial compliance of F689 during the annual survey process that occurred on 4/19/26 through 4/29/26.

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to assist residents with activities of daily living for 5 of 8 residents reviewed (Residents #3, #1, #11, #27, and #85). The facility reported a census of 77 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to properly secure and store medications to minimize loss or access for 1 of 4 medication carts. The facility reported a census of 77 residents.

Inspectors wroteBased on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 77 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 2 of 15 residents (Residents #3, and #94) reviewed. The facility reported a census of 77 residents.

Inspectors wroteBased on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene during catheter care for 2 of 3 residents reviewed (Resident #12 and #15). The facility reported a census of 77 residents.

Inspectors wroteBased on observation, infection control policy and staff interview, the facility failed perform proper hand hygiene and adhere to infection control guidelines during medication pass for 4 of 4 residents observed (Resident #1, #4, #7 and #8) The facility reported a total census of 77 residents.

Inspectors wroteBased on observations, facility policy review and staff interview the facility failed to cover exposed catheter bags for 3 of 3 residents reviewed (Resident #1, #5 and #6). The facility reported a census of 77 residents

Inspectors wroteBased on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance as scheduled for 3 of 3 residents reviewed for bathing (Resident #2, #3 and #6). The facility reported a census of 77 residents.

Inspectors wroteBased on record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered daily weights 1 of 1 residents reviewed (Resident #2). The facility reported a census of 77 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to provide safe transfers of residents with transfers 2 of 3 residents reviewed (Resident #4 and #13). The facility reported a total census of 77 residents.

Inspectors wroteBased on observations and staff interview, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 2 of 3 residents observed (Resident #1 and #4). The facility reported a census of 77 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to provide and maintain accurate resident records to reflect an incident occurring in the facility for 1 of 3 residents (Residents #4). The facility reported a census of 77 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to assure residents were free from significant medication errors for 1 of 3 resident reviewed (Resident #1). The facility reported a census of 77 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a diagnosis of heart failure, renal insufficiency and stroke. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The Medical Diagnosis report for Resident #2 showed no diagnosis of Diabetes [NAME]. The Clinical Physician Orders for Resident #2 showed no orders of jardiance or gabapentin. The Progress Note dated 11/3/25 at 7:30 AM for Resident #1 documented the following:Resident received wrong AM medications this AM. Spit out most of all medications. Received jardiance and gabapentin, but medications not ordered. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to provide and maintain accurate resident records to reflect an incident occurring in the facility for 2 of 2 residents (Residents #2 and #4). The facility reported a census of 77 residents.

Inspectors wroteBased on observation, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 1 of 3 residents observed (Resident #6). The facility reported a census of 80 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch, PASARR recommendations, oxygen usage and fluid restrictions for 4 out of 20 sampled residents reviewed for comprehensive care plans (Resident #20, #45, #72 and #231). The facility reported a census of 87 residents.

Inspectors wroteBased on observation, document review, resident interview, staff interview, and policy review the facility failed to follow the menu and prepare food to meet the nutritional needs for 19 of 81 residents reviewed. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 4 of 5 residents reviewed ( Residents #4, #28, #36, and #50). The facility reported a census of 81 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 81 residents.

Inspectors wroteBased on record review, interview, and facility policy the facility failed to have the minimum number of required members for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 87.

Inspectors wroteBased on observation, Electronic Health Record (EHR) review, policy review, resident interview and staff interview the facility failed to provide appropriate infection prevention practices by not donning appropriate Personal Protective Equipment (PPE) and failed to provide appropriate infection prevention practices during administration of medications for 3 of 8 residents reviewed (Resident #51, #57, and #72). The facility reported a census of 81 residents.

Inspectors wroteBased on policy review, document review, and staff interview the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. The facility reported a census of 81 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, staff interviews, resident interview and policy review the facility failed to provide an opportunity for bath or shower to 1 of 4 residents reviewed (Resident #21). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent falls for 1 of 3 residents reviewed (Resident #231). The facility reported a total census of 87 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to identify non-pharmacological interventions related to high risk medications in 1 out of 5 sampled residents reviewed (Resident #20). The facility reported a census of 87 residents.

Inspectors wroteBased on resident interview, resident family interviews, staff interview, electronic health records (EHR), document review and policy review the facility failed to maintain medical records on each resident that were complete and accurate by failing to document a fall in the electronic health records and not keeping an accurate up to date resident inventory list for 2 of 8 residents reviewed (Resident #21 and #231). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, record review, hospital staff, staff and family interview the facility failed to follow physician's orders for 1 of 3 (Resident #1) residents reviewed. The facility also failed to appropriately enter a physician's order in to the Electronic Health Record (EHR) for 1 of 3 (Resident #2) residents reviewed. The facility reported a census of 76 residents.

Inspectors wroteBased on observations, record review, resident, staff and hospital staff interview and policy review the facility failed to ensure 1 of 3 residents (Resident #2) reviewed were assisted with cleaning their dentures and that her peri-area was adequately cleansed appropriately prevent moist associated skin damage (MASD). The facility reported a census of 76 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to ensure all residents had their call light within reach in their rooms for 1 of 1 resident reviewed, (Resident #31). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, resident interview and facility policy, the facility failed to ensure bed hold notice was sent to resident and or the resident's responsible person after giving a verbal consent when residents transferred out of the facility for 1 of 3 residents reviewed, (Residents #18). The facility reported a census of 68 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to resubmit Preadmission Screening and Resident Review (PASRR) after a 180 day short stay approval expired on [DATE] for 1 of 1 residents reviewed for PASRR requirements, (Resident #45). The facility reported a census of 68 residents.

Inspectors wroteBased on record review, resident interview, and staff interviews the facility failed to provide professional standards of care by not following physician orders and by not entering orders into the electronic health record for 1 of 21 residents reviewed, (Resident #36). The facility reported a census of 68 residents.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to notify the primary care provider (PCP) for worsening of a deep tissue injury (Resident #16) as well a delay in initiating wound care treatment on a newly identified deep tissue injury (#4) for 2 of 4 resident identified with a pressure injury. The facility reported a census of 68.

Inspectors wroteBased on observations, record review and interviews the facility failed to properly use a mechanical lift, low bed positions and ensure proper footwear and gait belt used to avoid hazards and prevent accidents for 3 of 21 residents reviewed, (Resident #6, #63 and #74). The facility reported a census of 68 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to update and liberalize a diet order, as discussed during a Standards of Care meeting (SOC) to improve nutritional intake, for 1 of 1 residents reviewed (Resident #66). The facility reported a census of 68.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to follow the prescribed oxygen order for 1 of 2 residents reviewed, (Resident #16). The facility reported a census of 68.

Inspectors wroteBased on staff documentation, staff interview, policy review, and observations, the facility failed to ensure the blade on the manual can opener in the kitchen was clean and free of residue to reduce the risk of bacteria growth and cross contamination. The facility reported a census of 68 residents.

Inspectors wroteBased on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene after catheter care and medication administration for 2 of 21 residents reviewed, (Resident #21 and #74). The facility reported a census of 68 residents. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #74 documented the Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. The MDS showed Resident #74 used a walker and wheelchair for mobility and required partial or moderate assistance for bed to chair transfers. The MDS diagnoses included dementia, heart failure and renal insufficiency. Observation on 6/4/24 at 3:05 PM of Resident #74 showed Staff A, Certified Nursing Assistant (CNA) applied personal protective equipment including goggles, gown, mask and gloves. [...]

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to provide professional standards of care by following physician ordered wound treatment for 1 of 4 residents reviewed (Resident #24). The facility reported a census of 70 residents.

Inspectors wroteBased on observation, interviews, and record review the facility failed to reposition residents according to their needs for 2 of 3 residents reviewed (Resident #2 & Resident #15). The facility reported a census of 70 residents.

Inspectors wroteBased on observations, interview, and record review the facility failed to use adequate infection control measures to mitigate the spread of pathogens for 2 of 4 residents reviewed (Resident #5 and Resident #24). The facility reported a census of 70 residents.

Inspectors wroteBased on clinical record review and facility policy review the facility failed to implement new interventions and adequate interventions, including adequate supervision, consistent with the resident's needs and cognitive status to mitigate the risk of falls and injuries for 1 out 3 residents reviewed (Resident #6).

Inspectors wroteBased on facility personnel record review, resident, and staff interviews, the facility failed to consistently answer call lights within a reasonable amount of time (defined as 15 minutes or less). Residents reported they had to wait over 15 minutes for someone to answer their call light for 6 out 6 residents reviewed (Residents #17, #18, #19, #20, #21, #22).

Inspectors wroteBased on facility record review, the facility failed to sustain an effective quality assurance and performance improvement plan (QAPI) program in place to assist in the provision of quality care for residents. The facility identified a census of 78 residents.

Inspectors wroteBased on observation, infection control policy, clinical record review and staff interview, the facility failed to complete hand hygiene while providing incontinence care for 2 of 3 residents observed. In addition, the facility failed to pass food in a sanitary manner. The facility reported a total census of 78 residents.

Inspectors wrote2. On [DATE] at 11:51 AM, observed Staff I, Certified Nursing Assistant (CNA), and Staff J, Certified Medication Assistant (CMA), assist Resident #14 with perineal care. At the start of the observation noted the curtain open approximately 15 inches. The curtain remained open during the entire observation. Interview on [DATE] at 1:19 PM, Resident #14 revealed she didn't even notice the curtain open. Resident #14 revealed it happened all the time and she has gotten used to it. The Resident Rights policy revised [DATE] instructed employees to treat all residents with kindness, respect and dignity. The policy continues federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's rights to privacy. 3. Interview on [DATE] at 3:46 PM, Resident #15 said she would like to have 3 baths a week. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the physician the resident continued to refuse supplements, resulting in a continued to lose weight for 1 of the 3 residents reviewed (Residents #5).

Inspectors wroteBased on facility record review, family and staff interviews and policy review the facility failed to ensure people could file a grievance form without fear. In addition, the facility failed to follow-up on all grievances.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 resident (Resident #1) reviewed for PASRR requirements.

Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to revise a resident's Care Plan to include appropriate interventions for a cognitively impaired resident to prevent repeated falls and injuries for 1 out of 3 residents reviewed (Resident #6).

Inspectors wroteBased on record review and staff interviews the facility failed to pass medications as ordered by the physician for 2 of 21 residents reviewed (Resident #5 and #11).

Inspectors wroteBased on clinical record review, resident interview, staff interview, and facility policy review the facility failed to give a bath twice a week and/or per the resident's preference for 3 of 3 residents reviewed for bathing (Resident #3, #7 and #9).

Inspectors wroteBased on clinical record review, staff interviews, and policy the facility failed to complete assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff failed to complete vital signs and neurological assessments for 1 out 3 residents reviewed for falls (Resident#6).

Inspectors wroteBased on interviews and record review, the facility failed to provide a restorative program to a resident with mobility concerns for 1 of 3 residents reviewed (Residents #7).

Inspectors wroteBased on resident observations, resident record reviews and interviews the facility failed to prevent pain during medical procedures for 1 out of 1 resident (Resident #13) reviewed.

Inspectors wroteBased on clinical record and staff interview, the facility failed to ensure a resident had an adequate diagnosis for psychotropic medications for 1 of 3 resident's reviewed (Resident #1).

Inspectors wroteBased on observation, clinical record, facility policy, Medline Plus, and staff interview, the facility failed to administer medications in the correct form and 1 hour or more before a meal for 1 of 7 residents reviewed (Resident #16).

Inspectors wroteBased on observation, facility record, pharmacy record, and staff interviews, the facility failed to keep narcotic medication secure to prevent diversion. The facility reported 78 residents.

Inspectors wroteBased on record reviews, facility policy review, resident, staff, and medical facility interviews, the facility failed to ensure 2 out of 2 residents reviewed (Resident #3 and Resident #13) received transportation to their appointments, causing them to have to be rescheduled.

Inspectors wroteBased on clinical record review, interviews, facility policy and procedures, the facility failed to provide adequate transfers for 2 out of 3 residents observed to ensure a safe transfer according to the facility policy (Resident #17 and Resident #20). The facility also failed to implement effective interventions to prevent multiple falls involving a wheelchair and self-transfer for 1 out of 3 residents reviewed (Resident #13).

Inspectors wroteBased on resident, and staff interviews, the facility failed to provide enough staff to meet the needs of the residents who resided in the facility for 4 out of 8 residents reviewed (Residents #3, #4, #9, and #10). Residents reported that the staff could not answer their call light within 15 minutes due to the lack of staff.

Inspectors wroteBased on facility record and policy review, and resident, staff, and pharmacy interview, the facility failed to obtain and provide routine and emergency drugs for 4 out of 4 residents reviewed (Residents #3, #4, #8, and #9). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, facility policy, resident and staff interviews, the facility failed to ensure food preferences were honored for 5 out of 7 residents (Residents #3, #4, #8, #9 & #23). This deficient practice had the potential to result in decreased intake for the residents. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, resident and staff interview, facility identified meal times and facility policy review, the facility failed to meet the resident's preferences regarding meal times for 4 out 6 residents reviewed (Residents #3, #9, and #23). In addition, the facility failed to provide afternoon and bedtime snacks on a routine basis.

Inspectors wroteBased on observation, and facility policy review, the facility failed to display respect and dignity for 1 out of 3 residents (#22) who required assistance with eating.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to notify the physician of a significant change in condition and when a resident refused to follow physician orders for 1 of 3 residents reviewed (Resident #6). The facility failed to report the following: 1. Notify the Physician of a weight gain of 3 pounds in one day. 2. Notify the Physician when Resident #6 refused to wear TED hose (specialized stockings to prevent clots and swelling). 3. Notify the Physician when Resident #6 refused to wear CPAP machine (Continuous Positive Airway Pressure) (machine used to keep airways open while asleep)

Inspectors wroteBased on record review, policy review, and resident and staff interviews, the facility failed to meet professional standards by failing to administer medications as prescribed by the physician for 3 out of 5 residents reviewed (Residents #3, #6, and #8). The facility reported a census of 81 residents.

Inspectors wroteBased on facility chart review, resident and staff interview, and policy review, the facility continued to fail to provide bathing or showering per resident preference for 1 of 7 residents reviewed (Residents #4).

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to assess and provide interventions necessary for the care and services, to maintain the residents' highest practical physical well-being for 2 of 4 residents reviewed (Residents #6, #13). The facility failed to assess/document skin impairments for Resident #6 and a fall for Resident #13.

Inspectors wroteBased on clinical record review, resident and staff interviews, observations and policy review, the facility failed to provide appropriate oxygen services for 2 of 4 resident (Residents #6, #11) reviewed for respiratory services. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, facility policy, and procedures, resident and staff interviews, the facility failed to identify, intervene and alleviate physical pain in a timely manner for 1 out of 2 residents reviewed for neglect (Resident #18).

Inspectors wroteBased on staff interviews, clinic record review, and policy review, the facility failed to administer insulin medication appropriately for 1 out of 8 residents (Resident #4) reviewed.

Inspectors wroteBased on record reviews, resident, staff, and medical facility interviews, the facility failed to ensure 3 out of 3 residents reviewed, (Residents #3, #10, and #14) received transportation to their appointments, causing them to have to be rescheduled.

Inspectors wroteBased on resident documentation and interview, and staff interview, the facility failed to provide food that was palatable, appetizing, and attractive to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 81 residents.

Inspectors wroteBased on facility policy review, observations, resident, and staff interviews, the facility failed to provide fresh ice water for 3 out 7 residents reviewed for hydration (Residents #3, #9, and #10).

Inspectors wroteBased on resident interview and documentation, and staff interview, the facility failed to follow proper sanitation practices to prevent the outbreak of foodborne illness for 1 of 1 residents reviewed (Resident #10). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interviews and representative interviews, the facility failed maintain an accurate and complete resident clinical records for resident's personal possession for 1 out of 3 resident's reviewed (Residents #7 and #17). In addition, the facility failed to maintain an accurate and complete record related to a resident falling out of his wheelchair for 1 out of 3 resident's reviewed (Resident #13).