Westwood Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF725Jun 17, 2021

  This citation pertains to intakes MI 127, MI 478, MI 985, MI 858, MI 550, and MI 492. This citation has 2 Deficiency Practice Statements. Based on observation, interview, and record review, the facility failed to ensure sufficient staffing was available to render care, pass meal trays, and meet resident needs for all 67 residents in the facility. An Immediate Jeopardy was determined on 6/15/2021 when on the following dates and times, there was only one licensed or registered nurse in the building: 5/4/2021 (census of 69) between 7:00 AM and 7:00 PM; 5/9/2021 (census of 65) between 7:00 AM and 2:30 PM; 6/4/2021 (census of 67) between 9:00 PM and 12:15 PM on 6/5/2021; and 6/5/2021 (census of 66) between 12:16 PM and 7:00 PM. […]

• Immediate jeopardy, isolatedF604Jul 7, 2021

  This citations pertains to intakes MI 896, MI 947, MI 996. Based on observation, interview, and record review, the facility failed to ensure resident remained free from physical restraints for the sole purpose of staff convenience in 1 of 4 residents (R501) reviewed for restraints, resulting in an immediate jeopardy when on 6/19/21 at approximately 4:39 PM, R501 who had severe cognition impairment and a history of wandering, was seen on video scooting out of the 2 South Dining Room while restrained to a chair by a bedsheet tied around her waist and two staff members visibly present. R501 was observed struggling to remove herself from the chair for eight minutes (4:39 PM - 4:47 PM) until R501 put her feet on the railing, pushed herself over, and fell on the floor still tied to the chair. […]

• Immediate jeopardy, isolatedF684Jun 17, 2021

  This citation pertains to MI 492. This citation has three deficient practices. Deficient practice #1. Based on observation, interview, and record review, the facility failed to provide physician ordered wound care treatments, assess and monitor resident's skin condition, and follow the wound care team's recommendations for oral and topical antibiotics for one resident (#27) reviewed for quality of care, resulting in an immediate jeopardy when the resident was sent to the hospital on 5/21/21 and was found to be septic (life threatening blood infection), developed a left foot abscess, and experienced excisional debridement of his left foot down to the level of muscle. […]

• Immediate jeopardy, isolatedF686Jun 17, 2021

  Based on observation, interview, and record review the facility failed to implement the wound care program for 1 of 22 residents (Resident #52) reviewed for pressure ulcers, who was admitted on [DATE] with a stage 4 (deep wound reaching into muscle and bone with extensive damage) pressure ulcer on Sacro coccyx (upper buttock-back area) and stage 4 right ischium (upper thigh) pressure ulcer and facility staff did not transcribe and implement the hospital wound care orders until 5/13/2021. Wound care was missed on 5/15/2021, 5/16/2021, and 5/21/2021. […]

• Immediate jeopardy, isolatedF684Mar 3, 2021

  This citation pertains to intake MI 114. Based on interview and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #601) out of four residents reviewed for anticoagulant use, resulting in bleeding from the mouth and nose and an emergent transfer to the hospital. The initial Immediate Jeopardy (IJ) was identified on 3/3/2021 at 8:30a.m. which began on 2/8/2021. The facility Administrator was notified of the IJ and a request for a written plan for removal occurred on 3/3/2021 at 8:30 AM. Findings include: Resident #601 Review of an Admission Record revealed, Resident #601 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]