Westwood Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF684May 15, 2026

  Based on interview and record review, the facility failed to provide services according to professional standards for one of one resident (Resident 1) when licensed nurses had no documentation of Resident 1's use and care of sequential compression device (SCD - a pair of inflatable leg wraps connected to a machine that acts as a massager for the legs to prevent blood clots while inactive, a compression therapy) and there was no care plan (a summary of a person's health conditions, goals, specific care needs, and current treatments) developed for the SCD's use.These failures resulted in multiple fluid filled blisters (a small, raised bubble on the skin filled with clear, water liquid, blood, or pus) and pain on Resident 1's bilateral (affecting two sides) lower extremities… […]

• Actual harm, isolatedF684Apr 21, 2026

  Based on interview and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when registered nurse A (RN A) and licensed vocational nurse B (LVN B) re-inserted Resident 1's gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without proper training and demonstration of competency in this procedure, using a bigger size of GT and did not have a detailed confirmation of GT placement (verifying if the tube is in the stomach using methods like checking for stomach contents, easy rotation of the tube, and lack of leakage. […]

• No harm, potential for more than minimal, widespreadF880Apr 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure their infection prevention practices were implemented when: 1. A urinary catheter (a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drainage bag touched the floor; 2. Hand hygiene (the practice of cleaning your hands to prevent the spread of germs and illness) and the removal/change of isolation gowns (a type of personal protective equipment (PPE) used in healthcare settings to protect healthcare personnel and patients from the spread of infection or illness, particularly from contact with blood and body fluids) was not completed between tasks; 3. […]

• No harm, potential for more than minimal, widespreadF700Nov 21, 2023

  Based on observation, interview, and record review, the facility failed to follow their bed rails (side rails, safety rails and grab/assist bars) policy for 34 of 35 sampled residents (Residents 117, 121, 159, 104, 89, 65, 134, 175, 99, 3, 125, 49, 43, 101, 26, 53, 81, 131, 11, 78, 105, 149, 617, 618, 6, 9, 32, 172, 154, 206, 1016, 35, 193, and 79). The survey team expanded the sample and identified that a total of 198 residents had bed rails. The facility failed to follow their bed rails policy when: 1. There was no documentation that alternatives were attempted prior to installing bed rails for 198 of 198 residents; 2. […]

• No harm, potential for more than minimal, widespreadF800Nov 21, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure: 1. Resident 35 with a wheat allergy received nourishing and palatable meals to meet their needs; 2. The overall day-to-day food and nutrition services operations were carried out in a safe and sanitary manner for food service, preparation, storage, and delivery; equipment sanitation; kitchen staff competency; ineffective pest control; and acceptable parameters of nutrition care to prevent significant and severe resident weight loss for two sampled residents (Residents 104 and 175), according to standards of practice and facility policy. […]