Deficiency Records for Westwood Post Acute Care
Updated as of June 01, 2019
This is not the most recent data for Westwood Post Acute Care. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 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 ne | 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 |
| 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 | Y |
| 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 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-02-12 | 2019-03-12 | 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 | 2019-02-12 | 2019-03-12 | Y |
| 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 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-13 | 2019-03-04 | N |
| Have protected exits that allow the resident to escape the building. | 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 other general requirements that are deficient. | 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-21 | 2018-12-31 | 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 | 2018-06-23 | 2018-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-09 | 2018-04-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-04-09 | 2018-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-27 | 2018-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-27 | 2018-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2018-02-26 | 2018-03-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-02-23 | 2018-03-06 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Establish methods for sharing information. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-29 | 2018-02-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-30 | 2018-02-19 | N |
| 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 | 2018-01-30 | 2018-02-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-01-30 | 2018-02-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-30 | 2018-02-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-30 | 2018-02-19 | 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 | 2018-01-30 | 2018-02-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-30 | 2018-02-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-01-30 | 2018-02-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-01-30 | 2018-02-19 | 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 | 2018-01-30 | 2018-02-19 | 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 ne | Health | 2018-01-30 | 2018-02-19 | 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 | 2018-01-30 | 2018-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-30 | 2018-02-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-30 | 2018-02-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-30 | 2018-02-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-30 | 2018-02-19 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-03 | 2017-11-13 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-06-01 | 2017-09-29 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-12 | 2017-04-25 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2017-01-25 | 2017-02-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-01-25 | 2017-02-22 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-01-27 | 2017-02-22 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-27 | 2017-02-22 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-01-27 | 2017-02-22 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-01-27 | 2017-02-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-27 | 2017-02-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-27 | 2017-02-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-01-27 | 2017-02-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-01-30 | Not Fixed | N |
