A list of the most recent deficiencies for Westwood Post Acute Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-26 | 2024-02-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-10 | 2023-12-14 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-18 | 2023-09-27 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-08-09 | 2023-08-24 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-05-17 | 2023-06-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-05-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-10 | 2023-05-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-24 | 2023-04-08 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-24 | 2023-04-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-15 | 2023-01-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-09 | 2022-08-16 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-06-02 | 2022-07-10 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-06-03 | 2022-05-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-12 | 2022-04-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-24 | 2021-11-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-03 | 2021-09-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-03 | 2021-09-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-03 | 2021-09-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-03 | 2021-09-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-15 | 2021-09-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-08-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-24 | 2021-07-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-24 | 2021-07-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-24 | 2021-07-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-03 | 2021-07-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-03 | 2021-07-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-03 | 2021-07-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-03 | 2021-07-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-03 | 2021-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-03 | 2021-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-03 | 2021-07-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-03 | 2021-07-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-03 | 2021-07-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-06-03 | 2021-07-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-03 | 2021-07-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-03 | 2021-07-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-03 | 2021-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-03 | 2021-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-03 | 2021-07-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-03 | 2021-07-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-18 | 2021-07-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-18 | 2021-07-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-08 | 2021-06-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-08 | 2021-06-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-05-28 | 2021-06-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-07 | 2021-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-28 | 2021-04-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-22 | 2021-04-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-15 | 2021-03-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-03-31 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-25 | 2020-03-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-02-25 | 2020-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-25 | 2020-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | 2020-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-25 | 2020-03-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-02-24 | 2020-03-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-24 | 2020-03-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-24 | 2020-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-24 | 2020-03-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-24 | 2020-03-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-02-24 | 2020-03-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-24 | 2020-03-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-24 | 2020-03-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-24 | 2020-03-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-02-24 | 2020-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-24 | 2020-03-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-24 | 2020-03-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-02-24 | 2020-03-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-02-12 | 2019-03-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-02-12 | 2019-03-12 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-12 | 2019-03-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-12 | 2019-03-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-12 | 2019-03-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-12 | 2019-03-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-12 | 2019-03-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-02-12 | 2019-03-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-12 | 2019-03-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-02-12 | 2019-03-12 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-02-12 | 2019-03-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-12 | 2019-03-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-02-12 | 2019-03-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-02-12 | 2019-03-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-12 | 2019-03-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-12 | 2019-03-12 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-02-12 | 2019-03-12 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-02-12 | 2019-03-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-12 | 2019-03-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-02-12 | 2019-03-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-23 | Not Fixed | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-23 | Not Fixed | N |
