Deficiencies per Year
4
3
2
1
0
Unclassified
Inspection Report
Renewal
Census: 71
Capacity: 147
Deficiencies: 3
Feb 20, 2025
Visit Reason
The inspection was conducted as a renewal licensing study for Westwood Inn to assess compliance with regulatory requirements and determine eligibility for license renewal.
Findings
The facility was found to be noncompliant with ventilation requirements in multiple rooms, water temperature regulations at plumbing fixtures, and the requirement for reliable thermometers in refrigerators in residents' rooms.
Deficiencies (3)
| Description |
|---|
| Vents in Rooms 146, 157, 120, 115, 247, 238 and the janitor closet in memory care did not provide discernable air flow. |
| Hot water temperature at plumbing fixtures was not always within the required range of 105 to 120 degrees Fahrenheit; examples include Room 153 at 95.9°F, Room 157 at 122.5°F, and Room 146 at 121.3°F. |
| Refrigerators in residents’ rooms number 120 and 157 did not have reliable thermometers. |
Report Facts
Number of staff interviewed and/or observed: 12
Number of residents interviewed and/or observed: 71
Number of others interviewed: 4
Capacity: 147
Water temperature readings: 95.9
Water temperature readings: 122.5
Water temperature readings: 121.3
Number of excluded employees followed up: 3
Inspection Report
Renewal
Deficiencies: 0
Mar 14, 2024
Visit Reason
The document serves as a renewal notification for the Home for the Aged license following an administrative review of licensing activity for the past year.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brender L Howard | Health Surveyor | Signed the renewal notification letter. |
Inspection Report
Complaint Investigation
Capacity: 147
Deficiencies: 1
Nov 14, 2023
Visit Reason
The inspection was conducted following a complaint received on 10/13/2023 alleging that Resident A lacked care and protection, including neglect and abuse concerns.
Findings
The investigation substantiated that Resident A's care was not always consistent with her service plan, particularly regarding her preference to sleep in her bed and behavioral needs. However, there was insufficient evidence to substantiate abuse by staff. Communication with Resident A's family and hospice was documented, and corrective actions were recommended.
Complaint Details
Complaint received from Adult Protective Services on 10/13/2023 alleging neglect and abuse of Resident A, including being left in a chair overnight, soiled clothing mishandling, falls without timely notification, and allegations of physical abuse. The complaint was substantiated in part (lack of care and protection) and not substantiated regarding abuse.
Deficiencies (1)
| Description |
|---|
| Resident A's care was not always consistent with her service plan, including failure to follow her preference to sleep in her bed and failure to update the service plan to reflect behavioral needs. |
Report Facts
Capacity: 147
Complaint Receipt Date: Oct 13, 2023
Investigation Initiation Date: Oct 13, 2023
Inspection Date: Nov 14, 2023
Exit Conference Date: Dec 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Desiree Rasberry | Administrator | Interviewed during investigation; provided statements regarding Resident A's care and staff actions |
| Jessica Rogers | Licensing Staff | Conducted investigation and authored report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Complaint Investigation
Capacity: 147
Deficiencies: 1
Oct 6, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging inadequate protection and supervision for Resident A, who was dragged from her bed by another resident, Resident B.
Findings
The investigation confirmed that Resident B pulled Resident A into the hallway causing injuries. Resident B was returned to the facility without adequate supervision, and Resident A's service plan had not been updated to reflect increased protection needs. The facility was found not in compliance with applicable rules.
Complaint Details
The complaint alleged that on 8/26/2023, Resident A was dragged from her bed by Resident B causing severe wounds. The facility initially reported minor wounds and that Resident B was sent for psychiatric evaluation. The investigation confirmed the dragging incident and found inadequate supervision after Resident B returned to the facility. Resident A passed away on 9/03/2023.
Deficiencies (1)
| Description |
|---|
| Inadequate protection and supervision for Resident A resulting in injury after being dragged by Resident B. |
Report Facts
Capacity: 147
Complaint Receipt Date: Oct 5, 2023
Investigation Initiation Date: Oct 5, 2023
Inspection Date: Oct 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Desiree Rasberry | Executive Director | Interviewed regarding the incident and supervision of residents |
| Aida Moussa | Administrator/Authorized Representative | Present during interview and involved in facility administration |
| Aaron Clum | Licensing Staff | Author of the report and correspondence |
Inspection Report
Renewal
Deficiencies: 0
Mar 14, 2023
Visit Reason
The document serves as a renewal notification for the facility's Home for the Aged license following an administrative review of licensing activity over the past year.
Findings
The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Report Facts
License effective period: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brender Howard | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Original Licensing
Capacity: 147
Deficiencies: 0
Sep 1, 2021
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the Westwood Inn facility.
Findings
The study determined substantial compliance with licensing statutes and administrative rules, resulting in the issuance of a temporary license with a maximum capacity of 147 beds. The facility is newly constructed and designed to provide assisted living and memory care services.
Report Facts
Capacity: 147
Residential units: 118
Assisted living units: 80
Double occupancy assisted living units: 14
Memory care units: 38
Double occupancy memory care units: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aida Moussa | Authorized Representative | Named in relation to the licensing study and confirmation of compliance |
| Andrea Krausmann | Licensing Staff | Conducted the licensing study and signed the report |
| Russell B. Misiak | Area Manager | Approved the licensing study report |
| Paul Mullett | Bureau of Fire Services Inspector | Completed fire safety inspection |
| Kasra Zarbinian | Health Facilities Engineering Section Engineer | Submitted opening survey and occupancy approval |
| Anthony Marszalec | Senior VP, Architecture firm Alexander V. Bogaerts & Associates, PC | Confirmed installation of windowsill stops in memory care unit |
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