Westwood Post Acute Care

In the surveyor’s words

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

• Immediate jeopardy, patternF755Jun 3, 2021

  Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided accurately and safely for 10 of 11 sampled residents (Residents 10, 11, 13, 15, 23, 31, 45, 56, 61, and 269). The facility failed to: 1. Verify the residents' identity prior to administering medications to Residents 10, 11, 13 and 269 2. Ensure residents' medications ordered by the physician were available in the medication cart for administration to Residents 10, 11, 13, and 269, and the physician was notified timely if the medication was unavailable or the resident refused to take it. 3. […]

• Immediate jeopardy, patternF760Jun 3, 2021

  Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents' medication regimen was free from significant medication errors (Residents 10, 11, and 269). This deficient practice jeopardized Residents 10, 11, and 269's health and safety by failing to administer necessary medications in accordance with the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/26/2021, at 5:57 p.m., the Director of Nurses (DON), Assistant Director of Nursing (ADON), and the Administrator (ADM) were verbally notified of an Immediate Jeopardy (IJ: a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation. […]

• Immediate jeopardy, patternF880Jan 8, 2021

  Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) for five of five residents (Residents 1, 2, 3, 4, 5), out of a total of 82 residents in the facility, had available PPE for staff use, in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan a reduce loss of life and impact of COVID-19 in the facility). The facility also failed to provide a safe environment for seven of 23 facility staff (RN 1, LVN1, Receptionist, Activity Assistant, CNA1, CNA 2, Housekeeper 1), who did not donn or doff appropriate PPE when required. […]

• Immediate jeopardy, isolatedF759Jun 3, 2021

  Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (5%). During the medication pass observation on 5/27/2021, eight medication errors were observed of a total of 30 opportunities for error (a total of 30 medications were observed administered or missed [omitted] for one of four sampled residents (Residents 10). Eight medications were not given within one hour from the scheduled 9 a.m. time (considered medication error), and two medications were omitted ([MEDICATION(S)] [Neurontin] medication to treat nerve pain and [MEDICATION(S)] KwikPen Pen Injector [Insulin pen to control blood sugar]) for a total of 10 medication errors. […]

• Actual harm, isolatedF678Aug 1, 2025

  Based on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped) in accordance with the American Heart Association (AHA - organization dedicated to fighting heart disease and stroke) guideline for one of three sampled residents (Resident 1). On [DATE] at 4:08 P.M., Resident 1 was found unresponsive (when a person is not reacting to shaking, touch, sound, or verbal commands and may or may not continue breathing) in the patio, facility staff transferred Resident 1 to his room to start the CPR. […]