On May 18, 2023, Medilodge Of Westwood received 37 citations for deficiencies related to resident care. Those deficiencies included:

1. Failing to ensure timely care and services to promote dignity, treat residents with dignity/respect, and ensure a dignified environment for eight residents, resulting in long call light wait times, a cluttered, noisy environment, and the potential for feelings of diminished self-worth, sadness, and frustration.
2. Failing to ensure call lights were within reach for two residents, resulting in the inability to call staff for assistance and the potential for unmet care needs.
3. Failing to honor two residents’ choices in regard to activities and schedules that were significant to the residents, resulting in dissatisfaction with care provided and the potential for frustration.
4. Failing to inform the physician and family/guardian of a change in condition for two residents, resulting in the physician and family/guardian not being notified of resident change in condition and the potential for delayed medical intervention and care.
5. Failing to maintain an environment with comfortable sound levels for a resident, resulting in the loss of a comfortable home like environment affecting the resident’s quality of life.
6. Failing to provide and document evidence of prompt resolution of grievances of 11 residents, resulting in unresolved grievances and the potential to experience frustration, apprehension, helplessness, and a negative psychosocial outcome for the residents impacting their quality of life.
7. Failing to provide an environment free from verbal abuse for one resident, resulting in the resident exposed to profanity, angriness and irritableness creating a hostile environment, and presenting themselves in an unprofessional manner.
8. Failing to immediately report allegations of abuse and neglect for 2 residents, resulting in allegations of abuse that were not reported to the State Agency timely and the potential for further allegations of abuse and neglect to go unreported.
9. Failing to investigate an allegation of abuse, resulting in an allegation of abuse not being identified and thoroughly investigated allowing for the potential for future mistreatment and/or abuse.
10. Failing to ensure complete and accurate Minimum Data Set (MDS) assessments were completed for three residents, resulting in the potential for inaccurate care plans and unmet care needs.
11. Failing to ensure an annual Level II evaluation was completed, resulting in the potential for unmet mental health and psychiatric care needs.
12. Failing to develop a person centered, comprehensive care plan for two residents, resulting in the potential for re-traumatization, unmet care needs and inappropriate Resident care and services.
13. Failing to ensure showers/bed baths were provided per resident preference and plan of care for 8 residents, resulting in the potential for dissatisfaction with care, hygiene concerns, skin irritation, and low self-esteem.
14. Failing to provide immediate cardiopulmonary resuscitation (CPR) per the standards of practice and facility policy, resulting in an immediate jeopardy for a resident whose advanced directive indicated she was a full code. The resident was found by a Licensed Practical Nurse (LPN) without respirations or a pulse and did not receive CPR for at least 15 minutes, resulting in the resident’s death.
15. Failing to ensure licensed staff adequately assessed and communicated an acute change in condition to the medical provider, resulting in an immediate jeopardy when the CNA (certified nursing assistant) recognized a change of condition in a resident and notified the RN (Registered Nurse) who noted the change of condition but failed to contact the medical provider for further orders. The resident was transported to the local hospital when during a video chat her family member demanded that the facility send her to the hospital due to her lethargy and decreased responsiveness. The resident was evaluated at the local Emergency Department and was found to be actively having a myocardial infarction with a completely blocked coronary artery (STEMI). The resident was admitted to critical care with cardiogenic shock and urosepsis and died.
16. Failing to provide pressure ulcer care and treatment consistent with professional standards of practice, resulting in the potential for further skin breakdown and overall deterioration in health status.
17. Failing to properly identify and accurately assess residents to ensure safety and prevent an elopement, resulting in an Immediate Jeopardy when on May 13, 2023, a resident exited the facility at an unknown time, unbeknownst to staff, and was identified walking outside by a laundry staff member, between 6:30 pm – 7:00 pm.
18. Failing to ensure falls were identified and included the completion of post fall assessments and a comprehensive fall investigation, resulting in a delay in coordination of care post fall and incomplete documentation of an unwitnessed fall.
19. Failing to identify hazards and risks for 2 residents who were seated in specialty wheelchairs not recommended for transport use when transported by the facility to medical appointments, resulting in a fall, emotional distress, and a potential for more than minimal harm as the result of improper use of assistance devices.
20. Failure to provide coordination of care and services for a Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine) and maintenance of a suprapubic catheter (a tube inserted into the bladder through the abdominal wall to drain urine) according to professional standards of practice for urinary catheters for 2 residents, resulting in the potential for unnecessary use of a catheter and infections.
21. Failing to ensure care and services were provided to maintain sufficient hydration for a resident at risk for altered hydration status, resulting in the potential for dehydration, unmet resident needs, and unnecessary negative physical, mental, and psychosocial outcomes.
22. Failing to identify post traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident’s past trauma.
23. Failing to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being for 7 residents, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility.
24. Failing to prevent significant medication errors, resulting in the potential for infection and negative physical, mental, and psychosocial outcome.
25. Failing to securely store and label resident medications, resulting in the potential for the compromise of medications, and or the misappropriation of medications.
26. Failing to provide palatable food products for 14 residents, resulting in dissatisfaction with meals, decreased food acceptance, and the potential for nutritional decline.
27. Failing to monitor personal refrigerators for 2 residents, resulting in unsafe food storage and the potential for food borne illness.
28. Failing to ensure the facility was administered in a manner that maintains the safety and care of residents so residents may reach their highest practicable physical, mental, and psychosocial well-being for all 78 residents who reside at the facility, resulting in quality care not being provided to residents, insufficient management of facility staffing, a lack of follow-up in regard to concerns voiced by staff, and unresolved resident grievances.
29. Failing to maintain complete and accurate medical records for 4 residents, resulting in inaccurate and incomplete medical records and the potential for facility staff and providers not having all of the pertinent information to care for residents.
30. Failing to identify quality deficiencies and implement appropriate corrective action plans in a timely manner, resulting in the potential for negative physical and psychosocial outcomes and decreased quality of life.
31. Failing to maintain shared resident equipment, spa rooms, and general cleanliness of resident rooms for 3 residents, resulting in the potential for contamination, poor ventilation, and decreased satisfaction in living environment.
32. Failing to ensure the provision of effective communication training for 103 staff review for communication training. This deficient practice had the potential affect all 79 residents in the facility.
33. Failing to ensure the provision of training for compliance and ethics requirements for 81 employees out of 126 employees reviewed for resident rights training. This deficient practice had the potential to result in all resident rights and the facility’s responsibilities for care with the potential to affect all 79 facility residents.
34. Failing to provide annual required abuse prevention education for 27 employees. This has the potential to affect all 79 residents residing in the facility at the time of the survey.
35. Failing to complete Quality Assurance and Improvement (QAPI) training for 126 staff reviewed out of 126 staff, resulting in the potential for staff for lack of knowledge of the elements and goals of the facility’s QAPI program, their role and potential input, and unmet resident care needs due to an ineffective QAPI program.
36. Failing to ensure the provision of training for compliance and ethics requirements for 30 employees reviewed for compliance training. This deficient practice had the potential to result in unethical and unprofessional staff conduct, with the potential to affect all 79 facility residents.
37. Failing to ensure the provision of training for behavioral health care and services for 36 staff reviewed for behavioral health care training. This deficient practice had the potential to result in unmet behavioral health care needs and services for residents, with the potential to affect all 79 facility residents.

The facility was found to have created three different instances of immediate jeopardy: failing to provide CPR to a full-code resident who was found unresponsive, failing to communicate a resident’s heart attack to their physician, and failing to prevent a resident from existing the facility and eloping unbeknownst to staff. Immediate jeopardy is a situation in which the nursing home’s non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

Click here to read the full report.