Westwood Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Westwood Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF686Apr 12, 2022

  Based on observations, record reviews, and interviews with resident's, staff, Nurse Practitioner #1, Physician, and wound Physician, the facility failed to complete scheduled weekly skin sweeps (a head-to-toe skin assessment), provide daily wound care treatments as ordered, and failed to thoroughly complete a comprehensive assessment on 3/5/22 for a change in wound status. All of these actions contributed to the facility failing to identify when Resident #32 developed an unstageable pressure area. […]

• Immediate jeopardy, patternF835Apr 12, 2022

  Based on record reviews, observations, Nurse Practitioner #1, Physician, Orthopedic Surgeon, Orthopedic Nurse, Wound Physician, resident and staff interviews, the facility administration failed to provide effective oversight to ensure practitioners were notified when a change in a pressure area was identified, weekly skin sweeps were completed as ordered, and daily wound care was completed as ordered to a resident that developed an unstageable pressure area (Resident #32). In addition, the facility administration also failed to provide effective oversight to ensure wound care for pressure and non-pressure related wounds were completed as ordered (Residents #9, #40, #48, #95, #3 and #195), and residents were transported to scheduled appointments or had appointments rescheduled (Residents #… […]

• Immediate jeopardy, isolatedF689Aug 22, 2024

  Based on record reviews, observation, and resident, staff, and transportation driver interviews, the facility failed to provide safe transportation for Resident #1 when she was being transported by a contracted van transport company from dialysis back to the facility on [DATE]. Resident #1's wheelchair was not secured to the floor securement system per the manufacturer's instructions. When Driver #1 accelerated the vehicle, Resident #1's wheelchair tipped backward, and the resident hit the right back side of her head. Driver #1 pulled the transportation van over to the shoulder of the road and called 911. Emergency Medical Services (EMS) arrived, assessed the resident, and determined she needed to go to the hospital for evaluation for her complaints of head pain. […]

• Immediate jeopardy, isolatedF580Apr 12, 2022

  Based on record review, Nurse Practitioner #1, Physician and staff interviews, the facility failed to notify the Physician or Nurse Practitioner of a change in wound condition to Resident #32's right heel on 3/20/22. This was for 1 of 8 residents reviewed for pressure ulcers. Immediate Jeopardy began on 3/20/22 when staff had failed to notify the physician or Nurse Practitioner (NP) of a change in wound status for Resident #32's right heel which progressed to an unstageable pressure ulcer. Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of the Immediate Jeopardy removal. […]

• Actual harm, patternF689Apr 12, 2022

  Based on observations, record reviews, and staff interviews, the facility failed to thoroughly investigate falls and implement interventions to prevent further falls (Resident #195). Resident #195 sustained a [CONDITION(S)] requiring sutures and sustained multiple skin tears as a result of repeated falls. The facility also failed to implement a fall intervention for a resident with a history of falling (Resident #36). This was for 2 of 3 residents reviewed for accidents. The findings included: 1) Resident #195 was admitted to the facility on [DATE] with diagnoses that included a nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), repeated falls, muscle weakness, unsteadiness on feet, history of a stroke with deficits to the left side, [CONDITION(S)], and… […]