Westwood Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, patternF684Mar 30, 2023

  Based on clinical record review, staff, paramedic, and physician interviews, the facility failed to complete a timely assessment and interventions for 5 of 18 residents reviewed (Residents #143, #42, #59, #38 and #62). This failure resulted in a death, several hospitalization s, and visits to an emergency room for treatment for the residents, therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 3:57 PM. […]

• Immediate jeopardy, isolatedF689Jul 19, 2021

  Based on observations, clinical record and policy review, resident and staff interview, the facility failed to adequately supervise residents at risk for elopement for 1 of 3 residents reviewed (Resident #1). On 6/27/21, the resident left the facility without staff knowledge and propelled himself in in his wheelchair to the south side of the facility and down a hill. On 7/10/21, the resident again left the facility in his wheelchair without staff knowledge (a second elopement) through the kitchen service door. The facility also failed to provide adequate supervision for residents during active construction in the resident hallways for 1 of 3 residents reviewed (Resident #4) who fell due to torn up flooring from construction. […]

• Actual harm, patternF689Feb 28, 2024

  Based on clinical record review and facility policy review the facility failed to implement new interventions and adequate interventions, including adequate supervision, consistent with the resident's needs and cognitive status to mitigate the risk of falls and injuries for 1 out 3 residents reviewed (Resident #6). Findings included: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6's cognitive skills for daily decision making as moderately impaired. The MDS included diagnoses of Parkinson's Disease, dysphagia (difficulty swallowing), altered mental status, and repeated falls. Resident #6's Incident Reports from a look back period starting 8/20/23 reflected she fell 38 times. […]

• Actual harm, isolatedF689Apr 29, 2026

  Based on clinical record review, resident interview, staff interviews, and facility record review, the facility failed to provide safe and adequate mechanical lift transfer to prevent an injury to the resident's forehead for 1 out of 3 residents reviewed (Resident #18). The facility reported a census of 77 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 4/15/26 regarding deficiency F689 with a scope and severity of a Level G. The facility provided evidence of education to the staff member directly involved in the facility incident that occurred on 4/15/26. The remainder of the nursing staff received education on 4/16/26. […]

• Actual harm, isolatedF686Mar 30, 2023

  Based on observations, interviews and record review the facility failed to monitor and prevent the development of pressure ulcers for 3 of 4 residents reviewed (Residents #29, #60, and #129). Resident #29 developed an open pressure on his right gluteal. As his wound declined the staff failed to document or contact the physician. Resident #60 had infected toes that eventually required amputation. The chart lacked documentation of the initial discovery of the sore or monitoring. The facility reported a census of 80 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]