Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westwood Nursing Center during CMS and state inspections, most recent first.
Incomplete Elopement Investigation After Resident Exited Through Window: A resident with schizoaffective disorder, delusional disorder, and PTSD was identified on admission as at risk for elopement, but no care plan or interventions were developed. After the resident exited through a second-story window and was hospitalized with injuries, the facility’s investigation did not document key findings about the window, staff interviews, environmental factors, or whether elopement prevention policies were followed, and it did not show a root cause analysis for why interventions were not in place.
Failure to Address Known Elopement Risk: A resident with schizoaffective disorder, delusional disorder, and PTSD was identified on admission as being at risk for elopement, but no care plan or interventions were developed. During the incident, an RN heard a noise, entered the room, and saw the resident climbing out of a window; the resident jumped out, fractured his leg, and required hospitalization.
Food service and support areas had multiple maintenance and sanitation issues observed by surveyors. A refrigerator light bulb was missing and its socket was loose and dangling, a microwave interior door face plate was etched and corroded, and a meat slicer and blade guard were soiled with encrusted food residue. In the janitor closet, a light was out, the lens cover was cracked and broken, a dead insect was found inside the cover, and the dish machine PSI gauge was non-functional. The facility’s sanitation policy required food service areas to be kept clean, sanitary, and free from pests.
Unsafe and unsanitary facility environment: Surveyors observed widespread cracked, broken, missing, and heavily soiled surfaces throughout resident areas, the laundry, dining rooms, shower rooms, clean linen rooms, and utility rooms. Findings included dust and lint buildup, damaged flooring, air drafts through doors and windows, missing plumbing and lighting components, a water leak, and uncapped or dripping pipes. The NHA stated housekeeping leadership had been removed, the maintenance tracking system was down due to non-payment, and the facility was in arrears.
A facility failed to maintain safe domestic hot water temperatures and comfortable ambient room temperatures. Multiple hand sinks and restroom sinks were measured below expected hot water levels, and several dining rooms and a resident room were recorded below the required 71 to 81 F range. Residents were observed waiting for lunch in a hallway outside a cold dining room, and one resident stated, "I am freezing."
Failure to Develop and Document Discharge Plan of Care: A resident admitted for short-term rehab with fx of the L fibula, HTN, dementia, cognitive communication deficit, hypothyroidism, and anemia said no one had talked with her about discharge, and she became tearful and anxious during the interview. The EHR had no discharge plan of care or SW progress notes related to discharge goals, even though the resident had a court-appointed guardian, mild cognitive impairment on MDS, and was expected to return to a group home after therapy.
A facility failed to provide adequate information during a resident's transfer to a hospital. The resident, with severe cognitive impairment and multiple diagnoses, was transferred for an abscess without the necessary eINTERACT form, face sheet, or medication list. Staff interviews confirmed that standard procedures for non-emergency transfers were not followed, and the receiving hospital did not receive the required information.
The facility failed to maintain records for controlled drugs in the back-up box, lacking a reconciliation log and proper documentation. The interim DON and current DON confirmed the absence of records, and attempts to contact the pharmacy were unsuccessful. This failure contravenes the facility's policy on controlled drug storage and discrepancy reporting.
A facility failed to complete and submit the PAS/ARR form for a resident with bipolar disorder and schizophrenia, who was prescribed psychoactive medications. The necessary documentation for screening mental illness and intellectual disability care needs was missing, and incomplete forms were presented without essential information. This oversight contradicts the facility's policy on ensuring comprehensive assessments and necessary behavioral health care.
Two residents with known contractures were not provided with their prescribed hand and elbow splints, as observed during a survey. Despite care plans requiring daily application of these splints to maintain ROM, staff failed to apply them consistently. The facility's policy emphasized maintaining residents' abilities, but staff did not adhere to this, as confirmed by the Therapy Manager and Nursing Home Administrator.
The facility failed to ensure accurate documentation of medication administration for a resident, leading to double doses of several medications. The issue was identified during a review of the resident's MAR, revealing that previous medication orders were not discontinued upon readmission, and new orders were not verified and entered correctly.
The facility failed to repair an unattached closet door for a resident, resulting in dissatisfaction and concern over the protection of personal belongings. The resident, with intact cognition, reported the issue had persisted for over two months, and personal items had been taken. The LPN was unaware of the issue, and the NHA acknowledged a lack of a maintenance checklist and was unaware of the problem prior to the survey.
The facility failed to maintain a clean bathroom and comfortable water temperatures for one resident and failed to maintain a clean bathtub in a tub room commonly used by residents for toileting. Observations revealed significant cleanliness issues and disrepair, and staff acknowledged the problems but were unaware or unable to address them effectively.
Incomplete Elopement Investigation After Resident Exited Through Window
Penalty
Summary
The facility failed to thoroughly investigate an elopement involving a resident admitted with Schizoaffective Disorder, Bipolar Type; Delusional Disorder; and PTSD, whose BIMS score was 13 and who was identified on admission as being at risk for elopement with a score of five. Despite that identified risk, the facility did not develop a care plan or implement interventions to address the resident’s elopement risk. According to the incident report, the resident exited the facility through a second-story window and landed on the ground, sustaining injuries that required emergency medical treatment and hospitalization. The investigation did not document findings about the resident’s ability to exit through the window without supervision or about the window safety mechanisms and functionality. It also did not include interviews with all staff involved, an evaluation of environmental factors, or a determination of whether facility policies and procedures regarding elopement prevention were followed. The ADON stated an incident investigation was completed, but could not provide evidence that it assessed why interventions were not implemented despite the resident being identified as at risk on admission. The Administrator stated he initiated the reporting process and acknowledged the investigation focused primarily on documenting the occurrence and reporting requirements. Record review did not identify evidence of a comprehensive root cause analysis or corrective actions addressing the lack of a care plan, absence of elopement interventions, staff monitoring practices, environmental safety concerns, or accountability related to the resident’s ability to exit through the window.
Failure to Address Known Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate safety interventions for one resident who was identified as being at risk for elopement. The resident was admitted with diagnoses including Schizoaffective Disorder, Bipolar Type; Delusional Disorder; and PTSD, and had a BIMS score of 13, indicating cognitive intactness. An elopement risk assessment completed on admission identified the resident as at risk for elopement with a score of five, but the facility did not develop a care plan or implement interventions to address that risk. During the incident, Nurse C heard a noise and entered the resident’s room, where she observed the resident climbing out of a window. Nurse C attempted to intervene, but the resident jumped from the window and landed on his feet in the yard below, fracturing his leg and requiring hospitalization. The incident report stated that EMS was contacted, the resident was assessed, pain and skin assessments were completed, neurological checks were initiated, and the physician and legal guardian were notified. Interviews with the ADON and Administrator confirmed that no care plan or interventions had been developed or implemented for the resident’s documented elopement risk.
Food Service Equipment and Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to clean and maintain multiple food service and support area items during survey observations of the kitchen and janitor closet. In the food service area, surveyors observed domestic hot water temperatures at two handwashing sinks, and both wall-mounted paper towel dispensers were non-functional. The refrigerator interior appliance light bulb was missing, and the light bulb socket assembly was loose and dangling from the interior refrigerator ceiling surface. The interior door face plate of a microwave oven was observed etched, scored, corroded, and particulate. Surveyors also observed the meat slicer and blade guard assembly soiled with accumulated and encrusted food residue. In the janitor closet, one of two overhead U-bulb lights was non-functional, the overhead light plastic lens cover was cracked and broken, and one dead insect carcass was observed within the overhead light lens cover. The mechanical dish machine pounds-per-square inch gauge was observed non-functional during the final rinse cycle. Record review of the facility’s sanitation inspection policy showed that food service areas were to be kept clean, sanitary, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. The cited observations showed that several pieces of equipment and facility fixtures in food service and related areas were not maintained in that condition at the time of survey.
Unsafe and unsanitary facility environment
Penalty
Summary
The facility failed to clean and maintain the physical plant in multiple areas of the building. During observations, cracked, broken, missing, stained, or heavily soiled flooring was noted in the entrance foyer, resident restroom areas, clean linen rooms, soiled utility rooms, shower rooms, dining rooms, and the laundry service area. Several surfaces were observed with accumulated dust, dirt, lint, grime, and debris, including dryer exteriors and safety shields, washer-adjacent flooring, return-air ventilation grills, door tracks, hallway corners, walls, ceilings, and dining room tables and chairs. Environmental conditions affecting resident areas were also observed. Dining rooms were cold, with air drafts coming through sliding glass doors and windows, and clear visqueen sheeting was used over several windows to reduce drafts. Several resident room and shower room features were damaged or missing, including cracked or missing ceramic and vinyl tiles, loose or missing plumbing components, a missing atmospheric vacuum breaker, a missing commode tank top, a loose commode seat, non-functional or flickering lights, and a moist ceiling tile from an active water leak. Additional observations included open or uncapped plumbing pipes, a dripping pipe, a warped and splintered plywood base under a laboratory specimen refrigerator, and a loose wooden flooring panel near an exit door. Record review showed the facility had policies requiring a safe, functional, sanitary, and comfortable environment and a preventative maintenance program, but the facility was not maintaining the environment in that condition. The Nursing Home Administrator stated the housekeeping and laundry director had been let go about a month earlier, that the maintenance work order system was down due to non-payment, and that the facility was in arrears for $8,000.00. The Maintenance Supervisor stated there were no records for flushing the water supply. The report identified these conditions as affecting 103 residents.
Unsafe Water Temperatures and Cold Dining/Resident Areas
Penalty
Summary
The facility failed to provide sufficient domestic hot water supply in resident care areas. During observations, hot water temperatures were measured at multiple hand sinks and restroom sinks, including readings of 80.0 to 90.0 degrees Fahrenheit, 85.0 to 95.0 degrees Fahrenheit, 89.9 degrees Fahrenheit, 85.0 degrees Fahrenheit, 73.7 degrees Fahrenheit, 80.7 degrees Fahrenheit, and 79.8 degrees Fahrenheit. The facility’s policy stated that water temperatures were to be maintained at appropriate levels in resident care areas, and staff were to report abnormal findings related to water temperature. The facility also failed to provide appropriate ambient room temperatures affecting 103 residents. The 2-North Dining Room was observed unoccupied with a cool/cold ambient air temperature, and residents were seen seated at bedside tables in the hallway outside the dining room while awaiting lunch. Air drafts were observed between the sliding glass door panels, and clear visqueen sheeting was noted on the triple panel window to reduce cold drafts. Temperature measurements in the 2-North Dining Room ranged from 61.0 to 68.0 degrees Fahrenheit, and the 1-North Dining Room ranged from 65.0 to 70.8 degrees Fahrenheit. Additional temperature checks showed the Memory Care Dining Room at 68.0 to 70.0 degrees Fahrenheit, a resident room at 68 to 70 degrees Fahrenheit, and the first floor Main Dining Room at 66 to 71 degrees Fahrenheit. Resident #49 stated, "I am freezing." The report cited Appendix PP and stated that facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 degrees Fahrenheit.
Failure to Develop and Document Discharge Plan of Care
Penalty
Summary
The facility failed to develop and implement a discharge plan of care for one resident who was expected to return to a group home after short-term rehabilitation. On 12/15/2025, the resident was observed in her room and stated that she was supposed to be discharged from the facility, but no one had spoken with her about the discharge process. During the interview, she became tearful and anxious and said she had only been supposed to be at the facility for short-term rehabilitation. Record review showed the resident was admitted with diagnoses including fracture of the left fibula, hypertension, cognitive communication deficit, dementia, hypothyroidism, and anemia. Her most recent admission date was 10/28/2025, and she had a court-appointed guardian. The MDS with ARD 11/18/2025 showed a BIMS score of 11, indicating mild cognitive impairment, and that she needed partial/moderate assistance with most ADLs. The EHR contained no discharge plan of care or social work progress notes related to discharge goals or planning. The Social Services Director stated the resident was planning to return to her group home after therapy but could not provide evidence of a discharge plan of care, and the NHA stated discharge planning starts on day one of admission and should be part of the medical record.
Failure to Provide Adequate Transfer Information
Penalty
Summary
The facility failed to ensure appropriate information was communicated to the receiving hospital for a resident during a transfer. The deficiency was identified when it was reported that the EMTs transporting the resident to the hospital were only provided with minimal information on a piece of paper, which included the resident's name, date of birth, physician's name, and facility's medical record number. The resident, who had severe cognitive impairment and diagnoses including dementia, unspecified psychosis, and delusional disorders, was transferred to the hospital for an abscess on the left upper back. However, the necessary transfer documentation, such as the eINTERACT form, face sheet, and medication list, was not completed or sent with the resident. Interviews with facility staff, including the Unit Managers and Acting Director of Nursing, confirmed that the standard procedure for non-emergency transfers was not followed. The eINTERACT form, which is crucial for ensuring continuity of care, was not completed, and there was no documentation to support that the receiving hospital received any pertinent information about the resident's condition or care needs. The facility's policy on transfers and discharges requires comprehensive information to be provided to the receiving provider, but this was not adhered to in this instance.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to maintain a proper record of receipt, disposition, or reconciliation of controlled drugs in the back-up box, which is a secured storage unit for controlled drugs. During an observation, it was noted that the back-up box had a red plastic lock, but there was no medication log or documentation to record the medications inside. The interim Director of Nursing (RN C) acknowledged the absence of a reconciliation log and mentioned that the keys to the locked medication cart, which might contain the log, were missing. The current Director of Nursing (DON) confirmed the lack of a reconciliation log and stated that they had recently placed the lock on the back-up box without knowing the status of the medications inside. Further observations revealed that the back-up box was later secured with a green plastic lock, but the situation remained unchanged with no reconciliation log available. The medication cart was still locked, and there were no pharmacy slips or records of medication deliveries. Attempts to contact the facility's pharmacy were unsuccessful, as no return call was received. The facility's Medication Storage policy requires controlled drugs to be stored under double-lock and key, and any discrepancies to be reported immediately. However, the facility was unable to account for the controlled drugs, leading to potential issues with drug diversion and availability for residents.
Failure to Complete PAS/ARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the completion and submission of the Preadmission Screening and Annual Resident Review (PAS/ARR) form for a resident with mental illness and intellectual disability care needs. The resident, who was admitted with diagnoses of bipolar disorder and schizophrenia, was prescribed psychoactive medications including Duloxetine and Sertraline. Despite these conditions, there was no PAS/ARR DCH-3877 form in the resident's electronic health record, and no evidence that the resident was screened for mental illness or intellectual disability care needs. Additionally, there was no documentation of a Level II determination evaluation for the resident's mental health care needs. The social worker confirmed the absence of the necessary documentation, acknowledging that the form was missed and suggesting that the resident might be exempt due to a hospital screening. However, the presented paper copies of the DCH-3877 form were incomplete, lacking essential information such as the physician's name, address, phone number, and signature. The facility's policy on Behavioral Health Service emphasizes the importance of comprehensive assessments and PASSAR screening to ensure residents receive necessary behavioral health care, which was not adhered to in this case.
Failure to Apply Ordered Splints for Residents with Contractures
Penalty
Summary
The facility failed to apply hand splinting as ordered for two residents, R18 and R81, who were reviewed for Range of Motion (ROM). This failure resulted in a potential loss of ROM for these dependent residents with known contractures. R18 was observed on multiple occasions without the prescribed right-hand splint, despite having a care plan that required daily application of the splint to prevent further contracture and maintain ROM. R18's medical records did not document any refusal to wear the splint, and the resident confirmed that staff did not always apply it. Similarly, R81 was observed without the prescribed right-hand and elbow splints on several occasions. The resident's care plan included daily application of these splints to manage contractures. During an observation, a Certified Nurse Assistant (CNA) failed to apply the splints after providing a bed bath, and the splints were not found in the resident's room. The Therapy Manager confirmed that both residents were supposed to wear their splints as ordered. The facility's policy on Restorative Nursing Programs emphasized the importance of maintaining or improving a resident's abilities to the highest practicable level, including the use of assistive devices. However, the staff did not adhere to this policy, as evidenced by the failure to apply the ordered splints for R18 and R81. The Nursing Home Administrator acknowledged the expectation for staff to apply the residents' ordered splints, highlighting a gap between policy and practice.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately documented the administration of prescribed medications. This deficiency was identified during an interview and record review for one resident (R101) out of three residents reviewed for medical record documentation. The review revealed that multiple medication orders for R101 were entered twice in the Medication Administration Record (MAR) for March 2024, leading to the administration of double doses of Briviact, metformin, topiramate, and pantoprazole sodium on several occasions. The Assistant Director of Nursing (ADON) and MDS Coordinator, Licensed Practical Nurse (LPN) I, confirmed that the previous medication orders had not been discontinued upon R101's readmission, and the new orders were not verified and entered correctly, which is a standard practice for nursing. Additionally, the MDS Coordinator, Registered Nurse (RN) J, stated that medications should be discontinued by nursing when a resident does not return within 24 hours from the hospital. The facility's policies on medical record documentation and medication administration were reviewed and found to require accurate and timely documentation and correction of discrepancies, which were not followed in this case. R101 had multiple readmissions and discharges within a short period, with diagnoses including foreign body of alimentary tract, unspecified intestinal obstruction, specified eating disorder, non-suicidal self-harm, schizoaffective disorder, anxiety disorder, and bipolar disorder. The Minimum Data Set (MDS) documented intact cognition for R101. The failure to accurately document and administer medications as prescribed resulted in the potential for staff and providers lacking accurate information to care for the resident. During the exit conference, the Nursing Home Administrator confirmed that there was no additional documentation or information to provide prior to the end of the survey.
Failure to Repair Unattached Closet Door
Penalty
Summary
The facility failed to repair an unattached closet door for one resident, resulting in dissatisfaction with the living environment and concern over the protection of personal belongings. The resident, who has intact cognition and is able to make all needs known independently, expressed unhappiness with the condition of the closet door and the exposure of personal belongings. The resident reported that the door had been in this condition since admission, over two months prior, and mentioned that personal items, such as a Coca Cola, had been taken due to the lack of a functional door. During the investigation, it was found that the Licensed Practical Nurse (LPN) was unaware of the missing closet door and acknowledged that the resident should have a functional door. The Nursing Home Administrator (NHA) stated that daily rounds are made by the Maintenance Supervisor, but there was no checklist for repairs needed, and the NHA was unaware of the issue prior to the survey. The Maintenance/Services Log Sheet reviewed did not contain any entry for the broken closet door, indicating a lapse in the facility's maintenance and repair processes. The facility's policy on accommodation of needs states that reasonable accommodations should be made to individualize the resident's physical environment, which was not adhered to in this case.
Failure to Maintain Cleanliness and Adequate Water Temperature
Penalty
Summary
The facility failed to maintain a clean bathroom and comfortable water temperatures for one resident and failed to maintain a clean bathtub in a tub room commonly used by residents for toileting. One resident expressed dissatisfaction with the cleanliness of the facility, specifically mentioning the tub room. An observation of the tub room revealed a dry dark green, thick substance covering the area just above the drain and splattered dark green and brown areas throughout the tub. The housekeeper acknowledged the tub had been in this condition for at least two weeks, and the Maintenance Supervisor was unaware of the issue. The Nursing Home Administrator stated that daily rounds are made by the Maintenance Supervisor and Housekeeping Supervisor, and that Housekeeping has a checklist for cleaning, but the issue persisted regardless. Another resident had complained to the state agency's complaint hotline about the lack of hot water and cleanliness in their bathroom. An observation of the bathroom revealed a loose sink fixture, a slow drip of hot water that did not get warm, dried dark-colored solid material on the toilet seat, and other signs of disrepair. The Maintenance Supervisor acknowledged that the bathroom should not be in such a state and mentioned that the facility no longer uses the electronic maintenance database that would notify when repairs are required. The Nursing Home Administrator confirmed that daily rounds are made by the Maintenance Supervisor and that the facility is working to get the electronic maintenance database back, but maintenance does not have a checklist for repairs needed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| The Orchards At Northwest | 0.5 mi | ★★★★★ | 22 | 0 |
| Sheffield Manor Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 15 | 0 |
| Hartford Nursing & Rehabilitation Center | 0.9 mi | ★★★★★ | 23 | 0 |
| Oakpointe Senior Care And Rehab Center | 1.3 mi | ★★★★★ | 0 | 0 |
| The Villa At Great Lakes Crossing | 2.7 mi | ★★★★★ | 8 | 0 |
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