Westwood Hills Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 25, 2023

  Based on record review and staff interviews, the facility failed to protect Resident #87 from physical abuse from Nurse Aide (NA #1). NA #1 grabbed Resident #87's wrists when the resident became combative during incontinent care and Resident #87 hit NA #1. Resident #87 was cognitively impaired and resided on the dementia care unit. Resident #87 had three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #87). Immediate Jeopardy began on 03/08/23 when Resident #87 was physically abused by NA #1. […]

• Immediate jeopardy, isolatedF607Jul 25, 2023

  Based on observations, record reviews, staff and resident interviews the facility failed to remove Nurse Aide (NA) #1 from a resident care assignment after Nurse #1 witnessed the NA holding both of Resident #87's wrists to prevent the resident from hitting him when the resident became combative during care. In addition, the facility failed to identify, thoroughly investigate, and to report abuse to the state agency, Adult Protective Services, and local law enforcement for 1 of 3 residents (Resident #87) reviewed for abuse. Immediate Jeopardy began on 03/08/23 when the facility allowed NA #1 to continue working a resident care assignment after Nurse #1 observed NA #1 physically abuse Resident #87. […]

• Immediate jeopardy, isolatedF693Dec 22, 2021

  Based on record review and staff and physician interviews the facility failed to follow a physician order to stop a tube feeding after 16 hours per the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused Resident #64 to vomit, have bilateral adventitious (abnormal) lung sounds and was in visible distress with an oxygen saturation level of 81% and necessitated an emergent transfer to the emergency room (ER) to be assessed for aspiration. The Findings Included: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #64's electronic physician orders revealed an order dated 11/08/21 for [MEDICATION(S)] (type of parental nutrition) 1.5, infuse at 75 milliliters per hour for a continuous 16 hours. […]

• Actual harm, isolatedF600May 27, 2026

  Based on record review, observations, and interviews with residents, facility staff, the Nurse Practitioner, and Psychiatric Provider, the facility failed to protect the resident's right to be free from resident-to-resident abuse for 1 of 3 residents reviewed for abuse (Resident #2) on 4/30/26. Resident #2 sustained a left hip fracture and a left olecranon (elbow) fracture. The findings included: Resident #3 was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, dementia, and anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired and required substantial assistance for toileting, dressing and showers. Resident #1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF604Jul 25, 2023

  Based on record review and staff interviews, the facility failed to protect Resident #87 from physical restraint from Nurse Aide (NA #1). NA #1 grabbed Resident #87's wrists when the resident became combative during incontinent care and Resident #87 hit NA #1. Resident #87 was cognitively impaired and resided on the dementia care unit. Resident #87 had three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. […]