A list of the most recent deficiencies for Westwood Nursing Center. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-15 | 2023-12-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-31 | 2023-10-20 | 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 | 2023-08-31 | 2023-10-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-08-31 | 2023-10-20 | 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 | 2023-08-31 | 2023-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-31 | 2023-10-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-31 | 2023-10-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-10-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-31 | 2023-10-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Develop a communication plan. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-30 | 2023-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-12 | 2023-08-04 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-07-12 | 2023-08-04 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-05-16 | 2023-06-09 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-08 | 2022-10-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-08 | 2022-10-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-08 | 2022-10-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-08 | 2022-10-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-08 | 2022-10-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-08 | 2022-10-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-08 | 2022-10-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-08 | 2022-10-03 | 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 | 2022-09-08 | 2022-10-03 | 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 | 2022-09-08 | 2022-10-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-09-08 | 2022-10-03 | 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 | 2022-09-08 | 2022-10-03 | 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 | 2022-09-08 | 2022-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-08 | 2022-10-03 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-08 | 2022-10-03 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-08 | 2022-10-03 | N |
| Keep all essential equipment working safely. | Health | 2022-09-08 | 2022-10-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-09-08 | 2022-10-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-08 | 2022-10-03 | Y |
| 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 | 2022-09-08 | 2022-10-03 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-09-08 | 2022-10-03 | 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 | 2022-09-08 | 2022-10-03 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-08 | 2022-10-03 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-09-08 | 2022-10-03 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-09-02 | 2022-10-01 | 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 | 2022-09-02 | 2022-10-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-02 | 2022-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-02 | 2022-10-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-02 | 2022-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-02 | 2022-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-02 | 2022-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-29 | 2022-05-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-26 | 2021-11-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-02 | 2021-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-02 | 2021-11-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-17 | 2021-11-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-17 | 2021-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-17 | 2021-11-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-17 | 2021-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-17 | 2021-11-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-17 | 2021-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-11-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-26 | 2021-09-10 | 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 | 2021-06-09 | 2021-09-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-06-09 | 2021-08-05 | 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 | 2021-06-09 | 2021-08-05 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-09 | 2021-08-05 | 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 | 2021-06-09 | 2021-08-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-09 | 2021-08-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-17 | 2021-07-26 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-06-17 | 2021-07-26 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-06-17 | 2021-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-17 | 2021-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-26 | 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 | 2021-06-17 | 2021-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-17 | 2021-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-07-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-17 | 2021-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-17 | 2021-07-26 | 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 | 2021-06-17 | 2021-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-26 | N |
| Dispose of garbage and refuse properly. | Health | 2021-06-17 | 2021-07-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-06-17 | 2021-07-26 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-06-17 | 2021-07-26 | 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 | 2021-06-17 | 2021-07-26 | 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 | 2021-06-17 | 2021-07-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-06-17 | 2021-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-06-17 | 2021-07-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-06-17 | 2021-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-17 | 2021-07-26 | 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 | 2021-06-17 | 2021-07-26 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-17 | 2021-07-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-21 | 2021-07-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-07-21 | 2021-07-25 | Y |
| 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 | 2021-07-21 | 2021-07-25 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-07 | 2021-07-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-02 | 2021-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-02 | 2021-07-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-02 | 2021-07-01 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-06-02 | 2021-07-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-02 | 2021-07-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-03 | 2021-05-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-03 | 2021-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-03 | 2021-03-27 | Y |
