A list of the most recent deficiencies for Medilodge of Westwood. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-18 | 2024-01-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-18 | 2023-06-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-18 | 2023-06-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-18 | 2023-06-14 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-18 | 2023-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-18 | 2023-06-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-18 | 2023-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-18 | 2023-06-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-05-18 | 2023-06-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-18 | 2023-06-14 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-05-18 | 2023-06-14 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-05-18 | 2023-06-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-05-18 | 2023-06-14 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-05-18 | 2023-06-14 | N |
| Provide training in compliance and ethics. | Health | 2023-05-18 | 2023-06-14 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-05-18 | 2023-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-18 | 2023-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-18 | 2023-06-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-18 | 2023-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-18 | 2023-06-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-18 | 2023-06-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-18 | 2023-06-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-18 | 2023-06-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-18 | 2023-06-14 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-01 | 2023-06-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-22 | 2023-06-14 | 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 | 2023-05-22 | 2023-06-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-22 | 2023-06-14 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-05-18 | 2023-05-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-18 | 2023-02-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-03 | 2022-06-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-03 | 2022-06-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-03 | 2022-06-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-06-28 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-01-28 | 2022-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-28 | 2022-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-28 | 2022-03-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-28 | 2022-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-28 | 2022-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2022-01-28 | 2022-03-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-28 | 2022-03-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-01-28 | 2022-03-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-28 | 2022-03-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-28 | 2022-03-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-28 | 2022-03-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-22 | 2021-05-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-22 | 2021-05-14 | 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 | 2021-04-22 | 2021-05-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-22 | 2021-05-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-22 | 2021-05-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-10-30 | 2020-12-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-10-30 | 2020-12-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-10-30 | 2020-12-01 | 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 | 2020-10-30 | 2020-12-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2020-10-30 | 2020-12-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-10-30 | 2020-12-01 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2020-10-30 | 2020-12-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-30 | 2020-12-01 | N |
| Respond appropriately to all alleged violations. | Health | 2020-10-30 | 2020-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-30 | 2020-12-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-30 | 2020-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-30 | 2020-12-01 | 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 | 2020-10-30 | 2020-12-01 | 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 | 2020-10-30 | 2020-12-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-30 | 2020-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-30 | 2020-12-01 | N |
