Westwood Hills Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews with resident, staff, Pharmacy Manager and the Medical Director, the facility failed to implement effective systems to safeguard a resident's controlled medication from misappropriation (30 tablets of oxycodone 15 milligrams) for 1 of 1 resident reviewed for misappropriation of property (Resident #22).The findings included:Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome.Review of Resident #22's physician orders dated 10/30/24 revealed an order for oxycodone15 mg by mouth every six hours for pain.Review of Resident #22's Medication Administration Record for 08/2025 revealed he was given oxycodone 15 mg by mouth every six hours as ordered.Review of a pharmacy packing slip revealed Resident #22's oxycodone 15 mg /120 tablets were delivered to the facility on [DATE] and were counted in by Nurse #3 and Nurse #4. The packing slip indicated the count was correct.Review of Resident #22's quarterly Minimum Data Set assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to remove 63 expired nutritional shakes from their dry storage area which resulted in 3 of the expired nutritional shakes making it to the service line and prepared for service to residents.The findings included:An observation made of the facility's dry storage area on 11/16/25 at 9:50 AM revealed 48 mixed berry flavored nutritional supplement shakes with an expiration date of 08/01/25 and 18 vanilla flavored nutritional shakes, with an expiration date of 06/20/25, sitting in the dry storage room on the top shelf.A follow-up observation of the kitchen, completed on 11/18/25 at 12:21 PM revealed the 48 mixed berry nutritional supplements with an expiration date of 08/01/25 to still be on the shelf in the dry storage area. However, there were only 15 vanilla flavored nutritional supplements with an expiration date of 06/20/25 in the dry storage area.An observation of the tray service line on 11/18/25 at 12:25 revealed 3 vanilla flavored nutritional shakes with an expiration date of 06/20/25 to be in an ice bin on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, facility policy, Center for Disease Control guidance, Statewide Program for Infection Control and Epidemiology (SPICE) representative, local health department, and staff interviews the facility failed to identify the need for and implement broad based testing during a Covid-19 outbreak when the interventions implemented failed to halt transmission of Covid-19 which spread to 2 of 5 hallways (100 and 200) and affected 11 residents on the 100 hall and 1 resident on the 200 hall (Resident #97). The findings included: Guidance from the Center for Disease Control (CDC) website updated 03/18/24 read in part, Responding to a newly identified SARS-CoV-2 infected health care personnel or resident: the approach to an outbreak investigation could involve either contract tracing or a broad-based approach; however a broad based (e.g., unit, floor, or other specific area (s) of the facility) approach is preferred if all potential contracts cannot be identified or managed with contract tracing or if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure a residents (Resident #92) code status election was accurate throughout the medical record for 1 of 1 residents reviewed for advance directives. The findings included: Resident #92 was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #92 was severely cognitively impaired. A care plan last revised on 07/16/24 read: End of Life/Advance Directive and contained the following interventions Cardio-pulmonary resuscitation/Full Code. A physician order dated 08/12/24 read: Do Not Resuscitate (DNR). Nurse #1 was interviewed on 08/21/24 at 9:17 AM. She stated that code status election was done upon admission with the resident and family and then discussed at each care plan meeting. If the resident or family wished to change the advance directive then she would get help from the Unit Manager (UM) at getting the new forms completed, obtaining the physician order, and updating the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family, staff, and Nurse Practitioner interviews the facility failed to prescribe an antibiotic that would effectively treat a urinary tract infection (Resident #29) for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #29 was severely cognitively impaired and was frequently incontinent of bowel and bladder. A urinalysis laboratory report dated 08/17/24 indicated that Resident #29 was positive for greater than 100,000 bacteria and the culture report attached indicated that it was resistant to Ciprofloxacin (Cipro is an antibiotic). The report was signed by the Nurse Practitioner. Resident #29's family member was interviewed on 08/18/24 at 11:55 AM. The family member stated that Resident #29 had recently had 2 falls and the staff thought she may have a urinary tract infection and the medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications (Resident #85), discharge (Resident #101) and restraints (Resident #27) for 3 of 21 residents reviewed for MDS accuracy. The findings included: 1. Resident #85 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction. A review of Resident #85's physician orders dated 05/26/23 revealed an order for Zoloft (antidepressant) 50 milligrams (mg) by mouth once a day for anxiety. A review of Resident #85's Medication Administration Record for 06/2023 revealed the Resident received the Zoloft 50 mg by mouth at 5:00 PM every day of the month. A review of Resident #85's Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was not coded as receiving an antidepressant in the look back period. An interview was conducted with the Minimum Data Set (MDS) Nurse #1 on 07/11/23 at 2:50 PM who explained that she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews the facility failed to remove expired medications from 2 of 5 medications carts reviewed for medication storage (Yellow Hall and Orange Hall). The findings included: 1a. An observation of Yellow Hall medication cart was conducted on 07/09/23 at 2:15 PM along with Medication Aide (MA) #1. The observation revealed an open bottle of Calcium 250 milligrams (mg) with Vitamin D3 that expired on 06/23 that was on the medication cart and available for use. The observation further revealed an open bottle of Atropine 1% (used to dry secretions) that expired 02/23 on the medication cart available for use. An interview was conducted with MA #1 on 07/09/23 2:21 PM and revealed that she generally worked on the Blue Hall Medication cart and the Yellow Hall medication cart was not her normal medication cart to work. She stated that she was here about two to three weeks ago and the pharmacy had gone through the Blue Hall medication cart, but she was not sure that they had gone through the Yellow Hall medication cart. She added that MA #2 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the administration, and governing body failed to ensure the facility followed their abuse policies and procedures when a corporate nurse consultant stated the facility did not need to complete a 24 hour or 5 working day report to the state agency after a nurse aide grabbed a resident (Resident #87) by the wrists during incontinence care resulting in three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with agitation and anxiety disorder. Resident #87's admission Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no psychosis, rejection of care, or instances of wandering. Resident #87 was coded as having other behavioral symptoms not directed towards others (physical symptoms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey that occurred on 12/16/21. This failure was for 1 deficiency originally cited in the area of Resident Assessment (F641). The repeat deficiency during two surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F641: Based on observation, record reviews, and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications (Resident #85), discharge (Resident #101), and restraints (Resident #27) for 3 of 21 residents reviewed for MDS accuracy. During the recertification survey on 12/16/21 the facility failed to accurately code the Minimum Data Set assessment to reflect a resident received dialysis therapy, this was evident for 1 of 1 resident reviewed for dialysis. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.