Westward Heights Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident representative, hospital staff, and staff interview, the facility failed to ensure residents were allowed to return following acute hospitalization for 1 of 4 sample residents (#1) reviewed for transfer and discharge. The findings were: 1. Review of a discharge MDS assessment dated [DATE] showed resident #1 admitted to the facility on [DATE] and had an unplanned hospital discharge return not anticipated on 4/10/26. Review of progress notes dated 4/10/26 and timed 7:50 AM, 8/24 AM, and 1:01 PM showed at approximately 6 am the resident had increased agitation with behaviors. Further review showed the resident had an elevated blood glucose, was administered insulin per a sliding scale, and was transferred via EMS for evaluation and treatment. The following concerns were identified:a. Review of a progress note dated 4/10/26 and timed 1:28 showed LATE ENTRY Note Text: IDT team met with Westward Height's management company. That meeting included Director of Facility Operations,…

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 observation, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented during meal delivery and assistance during 2 of 3 meal observations in the main dining room. The census was 56. The findings were: 1. Observation on 3/24/25 beginning at 5:43 PM showed CNA #1 was assisting a resident to eat dinner. The CNA was observed touching the resident's shoulder, arm, and wheelchair wheel while assisting the resident. Without performing hand hygiene, the CNA moved around the table and was observed placing her ungloved hand on top of another resident's hamburger and using her other hand to cut the hamburger in half. After it was cut, the CNA picked up half the hamburger, using both hands, and handed it to the resident, which the resident ate. The CNA then used her ungloved hand to pick up a French fry, dip it in ketchup, and hand it to the resident, which s/he ate. The CNA again picked up the resident's hamburger and handed it to the resident before standing from the table at washing her hands at the sink in 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 medical record review, staff interview, and policy and procedure review, the facility failed to ensure a gradual dose reduction was performed for 1 of 5 sample residents (#28) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #28 had a brief interview for mental status score of 14 out 15, which indicated s/he was cognitively intact, and diagnoses which included end-stage renal disease and insomnia. Further review showed the resident used antidepressant medications during the look-back period. Review of the resident's physician orders showed s/he received trazodone (antidepressant) 50 mg by mouth at bedtime related to insomnia which was ordered on 7/21/23. The following concerns were identified: a. Review of the treatment administration records for January, February, and March 2025 showed the facility was monitoring the resident for restlessness at night and there were no documented episodes of restlessness indicated. b. Review…

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 medical record review, staff interview, facility incident review, and policy and procedure review, the facility failed protect the resident's right to be free from physical abuse by another resident for 1 of 3 sample residents (#2). Corrective measures were implemented prior to the survey and compliance was determined to be met on 8/9/24. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 5 out of 15, indicating severe cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. Review of the admission MDS assessment dated [DATE] showed resident #3 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. The following concerns were identified: a. Review of an incident report dated 7/20/24 and timed 5 PM showed both resident #2 and #3 were in the dining room when resident #3 was seen rubbing…

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 medical record review, staff interview, and review of incident and facility documentation the facility failed to provide care in accordance with physician's orders and professional standards of practice for 1 of 3 residents (#1) with change in condition including resident #1. The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 11/19/24. The following concerns were identified: 1. Review of complaint/grievance report dated 11/13/24 showed resident #1 did not get transported to an appointment after it was ordered by the physician. 2. Medical record review showed resident #1 had a physician's order for an x-ray of his/her hip dated 10/26/24. On 11/8/24 the nurse attempted to have facility scheduler transport the resident for the x-ray; however, the scheduler was unable to take the resident until 11/11/24. Further review showed the resident received hip x-ray on 11/13/24, 5 days after it was ordered. 2. Interview with the social services staff member #4 on 12/30/24 at 11 AM revealed the delay in time of…

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 observation, medical record review and staff and resident interviews, the facility failed to monitor the resident's access site upon return from dialysis treatment for 1 of 1 sample resident (#33) who received dialysis at an off-site dialysis center. The findings were: 1. Observation of resident #33 on 1/8/24 at 4:09 PM showed a bandage visible on his/her upper right chest. Interview with the resident at that time revealed s/he received dialysis three times a week at an off-site dialysis center. The following concerns were identified: a. Review of physician's orders showed the only order related to dialysis was for staff to record the resident's weight following dialysis. There lacked any orders related to the monitoring of the resident's dialysis access site. b. Review of the resident's care plan for hemodialysis initiated 8/23/23 showed Monitor/document/report PRN [as needed] signs/symptoms of infection to access site: redness, swelling, warmth or drainage and Monitor/document/report PRN for signs/symptoms of the following: bleeding, hemorrhage, bacteremia, septic shock.…

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 observation, staff interviews, review of manufacturer's instructions, and policy review, the facility failed to ensure infection prevention practices were followed by staff during 1 of 6 medication pass observations which affected residents (#5, #20). The findings were: 1. Continuous observation on 1/9/24 starting at 11:38 AM showed LPN #1 obtained a blood glucose level on resident #20. After the procedure was completed, the glucometer was returned to the medication cart without being disinfected by the LPN. At 12:23 PM LPN #1 obtained a blood glucose level on resident #5 using the same glucometer. After the procedure was completed, the glucometer was returned to the medication cart without being disinfected by the LPN. 2. Interview on 1/9/24 at 12:37 PM with LPN #1 confirmed she had not disinfected the glucometer between residents. 3. During an interview on 1/9/23 at 3:12 PM the infection control nurse and the MDS coordinator both confirmed the facility did not have any residents with known blood borne pathogens. 4. Interview on 1/10/24 at 2 PM with the DON and ADON…

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 medical record review and staff interview, the facility failed to ensure PRN orders for anti-psychotic medications were limited to 14 days for 1 of 3 sample residents (#95). The findings were: 1. Review of physician's orders for resident #95 showed an order dated 10/18/22 for Zyprexa (anti-psychotic) 5 mg every 24 hours as needed for agitation. Review of the MAR for October and November 2022 verified the medication was a PRN order, with a start date of 10/18/22. The resident received one dose on 10/27/22. 2. During an interview on 11/2/22 at 5:39 PM the DON confirmed the PRN order for Zyprexa was not limited to 14 days. She stated the medication order should have had a 14 day end date, but did not. She further stated the facility was aware that regulations required PRN orders for anti-psychotics be limited to 14 days and required the physician to evaluate the resident before renewing the order.