Westward Heights Care Center

In the surveyor’s words

From the most serious findings on record at Westward Heights Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Mar 27, 2025

  Based on observation, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented during meal delivery and assistance during 2 of 3 meal observations in the main dining room. The census was 56. The findings were: 1. Observation on 3/24/25 beginning at 5:43 PM showed CNA #1 was assisting a resident to eat dinner. The CNA was observed touching the resident's shoulder, arm, and wheelchair wheel while assisting the resident. Without performing hand hygiene, the CNA moved around the table and was observed placing her ungloved hand on top of another resident's hamburger and using her other hand to cut the hamburger in half. […]

• No harm, potential for more than minimal, isolatedF627May 22, 2026

  Based on medical record review, resident representative, hospital staff, and staff interview, the facility failed to ensure residents were allowed to return following acute hospitalization for 1 of 4 sample residents (#1) reviewed for transfer and discharge. The findings were: 1. Review of a discharge MDS assessment dated [DATE] showed resident #1 admitted to the facility on [DATE] and had an unplanned hospital discharge return not anticipated on 4/10/26. Review of progress notes dated 4/10/26 and timed 7:50 AM, 8/24 AM, and 1:01 PM showed at approximately 6 am the resident had increased agitation with behaviors. Further review showed the resident had an elevated blood glucose, was administered insulin per a sliding scale, and was transferred via EMS for evaluation and treatment. […]

• No harm, potential for more than minimal, isolatedF758Mar 27, 2025

  Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a gradual dose reduction was performed for 1 of 5 sample residents (#28) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #28 had a brief interview for mental status score of 14 out 15, which indicated s/he was cognitively intact, and diagnoses which included end-stage renal disease and insomnia. Further review showed the resident used antidepressant medications during the look-back period. Review of the resident's physician orders showed s/he received trazodone (antidepressant) 50 mg by mouth at bedtime related to insomnia which was ordered on 7/21/23. The following concerns were identified: a. […]

• No harm, potential for more than minimal, isolatedF600Jan 14, 2025

  Based on medical record review, staff interview, facility incident review, and policy and procedure review, the facility failed protect the resident's right to be free from physical abuse by another resident for 1 of 3 sample residents (#2). Corrective measures were implemented prior to the survey and compliance was determined to be met on 8/9/24. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 5 out of 15, indicating severe cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. […]

• No harm, potential for more than minimal, isolatedF684Jan 14, 2025

  Based on medical record review, staff interview, and review of incident and facility documentation the facility failed to provide care in accordance with physician's orders and professional standards of practice for 1 of 3 residents (#1) with change in condition including resident #1. The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 11/19/24. The following concerns were identified: 1. Review of complaint/grievance report dated 11/13/24 showed resident #1 did not get transported to an appointment after it was ordered by the physician. 2. Medical record review showed resident #1 had a physician's order for an x-ray of his/her hip dated 10/26/24. […]