Westwood Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 19, 2022

  Based on policy review, facility investigation review, weather website review, medical record review, and interview, the facility failed to ensure a safe environment with adequate supervision to prevent elopement for 1 of 3 sampled residents (Resident #1) reviewed for elopement/wandering behaviors. The facility's failure to ensure residents were adequately supervised resulted in Immediate Jeopardy when Resident #1, who had severe cognitive impairment, exited the facility unsupervised and was found walking on the side of a 2-lane road by passersby. […]

• Actual harm, isolatedF600Jun 18, 2025

  Based on facility policy review, medical record review, facility document review, facility investigation review, employee file review, observation, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 4 (Resident #1) sampled residents reviewed for abuse which resulted in physical harm for Resident #1. The findings include: 1. Review of the undated facility policy titled, Skin and Wound Monitoring and Management, revealed, .A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable .The purpose to this policy is that the facility provides care and services to .Pressure Injury .The injury… […]

• No harm, potential for more than minimal, patternF812May 14, 2025

  Based on policy review, observation, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions when 1 of 2 ice machines were observed to have multiple black spots, when the container of sugar was out of date, and when wet nesting of dishware was observed. The facility had a census of 52, with all residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility policy titled, General Sanitation and Cleaning, dated 1/2025, revealed .Cleaning Instructions: Ice Machine and Equipment .Ice machine and equipment .will be cleaned and sanitized on a regular basis . Review of the facility policy titled, Food Storage, dated 8/2019, revealed .Foods shall be labeled, dated, and covered. […]

• No harm, potential for more than minimal, isolatedF609Jun 18, 2025

  Based on facility policy review, medical record review, hospital record review, and facility investigation review, the facility failed to ensure allegations of neglect were reported immediately, but not later than 2 hours after the allegation was made for 1 of 4 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, Skin and Wound Monitoring and Management, revealed, .A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable .The purpose to this policy is that the facility provides care and services to .Pressure Injury .The injury occurs as a result of intense and/or… […]

• No harm, potential for more than minimal, isolatedF689May 14, 2025

  Based on policy review, medical record review, and interview, the facility failed to follow interventions to prevent falls for 1 of 4 residents (Resident #21) reviewed for falls. The findings include: 1. Review of the facility policy titled, Fall Management System, dated 1/2025, revealed .It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs . 2. […]