Inspection Reports for
Westwood Nursing Center
16588 Schaefer Highway, Detroit, MI 48235, Detroit, MI, 48235
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging the facility failed to provide adequate transfer information to a hospital for a resident.
Complaint Details
The complaint was substantiated. An anonymous complainant reported that EMTs transporting resident R105 received only minimal information on a piece of paper instead of the required transfer documentation.
Findings
The facility failed to ensure appropriate transfer documentation was provided to the receiving hospital for one resident. The required eINTERACT transfer form was not completed or sent with the resident during transfer.
Deficiencies (1)
F 0622: The facility failed to transfer a resident to the hospital with adequate documentation and specific information as required. The transfer form (eINTERACT) was not completed or provided to the receiving hospital for resident R105.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager, Licensed Practical Nurse (LPN) D | Provided information about transfer procedures and the use of the eINTERACT form. | |
| Unit Manager, LPN E | Described the procedure for gathering information and completing the eINTERACT form prior to transfer. | |
| Acting Director of Nursing (ADON) | Confirmed no transfer form was completed for resident R105 and no documentation was provided to the receiving hospital. | |
| Nursing Home Administrator (NHA) | Stated the facility should send resident information to the hospital and participated in the exit conference. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, range of motion care, and pharmaceutical services in the nursing facility.
Findings
The facility failed to complete and send required PASARR screening forms for mental disorders or intellectual disabilities for one resident. The facility also failed to apply ordered hand splints for two residents, risking loss of range of motion. Additionally, the facility did not maintain proper records for controlled drugs in the medication back-up box, resulting in inability to account for medication receipt and disposition.
Deficiencies (3)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities was not completed or sent for one resident, resulting in potential unmet care needs.
F 0688 The facility failed to apply ordered hand splints for two residents, risking loss of range of motion and potential decline in health status.
F 0755 The facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs in the back-up box, risking drug diversion and unavailability of medications.
Report Facts
Residents reviewed for PASARR screening: 6
Residents reviewed for Range of Motion: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker B | Social Worker | Confirmed missing PASARR screening forms and incomplete documentation |
| RN C | Interim Director of Nursing | Acknowledged lack of reconciliation log for controlled drugs |
| Therapy Manager E | Therapy Manager | Confirmed ordered splints for residents R18 and R81 |
| Nursing Home Administrator | Nursing Home Administrator | Stated expectation for staff to apply ordered splints |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 29, 2024
Visit Reason
The inspection was conducted based on a complaint intake MI00143461 regarding the facility's failure to accurately document the administration of prescribed medications for one resident.
Complaint Details
This citation pertains to Intake MI00143461. The complaint was substantiated based on findings that the facility failed to accurately document medication administration for one resident.
Findings
The facility failed to ensure the medical record accurately documented medication administration for Resident #101, with multiple medication orders duplicated and not properly discontinued upon readmission, posing a risk of inaccurate information for staff and providers.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain accurate medical records for Resident #101, resulting in duplicated medication orders and improper discontinuation of previous orders upon readmission.
Report Facts
Medication orders duplicated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Registered Nurse (RN), MDS Coordinator | Provided interview stating medications should be discontinued if resident does not return within 24 hours. |
| I | Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) and MDS Coordinator | Provided interview and record review regarding medication documentation failures. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 7, 2024
Visit Reason
The inspection was conducted in response to complaints regarding facility maintenance issues, including a broken closet door, lack of hot water, and cleanliness concerns.
Complaint Details
The complaint was submitted on 2024-01-08 alleging lack of hot water and unclean conditions. The complaint was substantiated based on observations and interviews.
Findings
The facility failed to repair an unattached closet door for one resident, maintain a clean bathroom and bathtub, and provide adequate hot water, resulting in resident dissatisfaction and potential risk to personal belongings and comfort.
Deficiencies (2)
F 0558: The facility failed to repair an unattached closet door for one resident, exposing personal belongings and causing resident dissatisfaction.
F 0584: The facility failed to maintain a clean bathroom and bathtub and did not provide adequate hot water for one resident, resulting in dissatisfaction with cleanliness and comfort.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor A | Maintenance Supervisor | Interviewed about bathroom disrepair and maintenance rounds |
| Housekeeper E | Housekeeper | Interviewed about tub cleanliness and cleaning attempts |
| LPN B | Licensed Practical Nurse | Interviewed about closet door condition |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about maintenance rounds and facility conditions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 15, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to inform a resident's representative about a change in condition and transfer to the hospital.
Complaint Details
The complaint was substantiated as the facility did not notify the resident representative when R901 was transferred to the hospital.
Findings
The facility failed to notify the resident representative for R901 about the resident's change in condition and hospital transfer. Interviews and record reviews confirmed no documentation or communication was made to the family.
Deficiencies (1)
F 0580: The facility failed to inform the resident representative of R901 about a change in condition and transfer to the hospital. This resulted in the representative being unaware of the resident's hospitalization.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 31, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, medication administration, abuse reporting, environmental safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, untimely reporting and investigation of abuse allegations, lack of baseline care plans for dialysis and ADLs, medication administration errors, improper storage and disposal of insulin, inadequate cleaning and maintenance of food service equipment and physical plant, and failure to submit accurate staffing data to CMS.
Deficiencies (8)
F 0584: The facility failed to maintain a clean and homelike environment by not providing adequate storage for personal belongings and not removing trash and food from floors for two residents, resulting in unsanitary conditions.
F 0609: The facility failed to timely report suspected abuse and neglect to the State Agency for four residents, resulting in delayed investigations.
F 0655: The facility failed to develop baseline care plans for dialysis and activities of daily living for one resident within 48 hours of admission, risking unmet care needs.
F 0658: The facility failed to ensure timely and accurate medication administration for three residents, including late doses and incorrect dosages.
F 0761: The facility failed to ensure proper storage and disposal of insulin in medication carts, including undated and expired insulin, risking administration of ineffective medication.
F 0812: The facility failed to effectively clean and maintain food service equipment and the food production kitchen, resulting in bacterial harborage, cross-contamination risks, and decreased illumination affecting many residents.
F 0851: The facility failed to electronically submit complete and accurate direct care staffing information to CMS for a fiscal quarter, potentially affecting all residents.
F 0921: The facility failed to maintain a safe, clean, and comfortable physical environment, with widespread issues including soiled surfaces, damaged flooring, missing ceiling tiles, malfunctioning lights, insect infestations, and cross-connections between potable and non-potable water supplies affecting many residents.
Report Facts
Residents affected: 80
Expired insulin items: 13
Missing ceiling tiles: 53
Non-functional overhead light fixtures: 26
Residents reviewed for medication administration: 6
Residents reviewed for abuse reporting: 23
Inspection Report
Routine
Deficiencies: 5
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, abuse reporting, food service sanitation, and facility maintenance.
Findings
The facility was found deficient in maintaining a clean and homelike environment, timely reporting and investigating abuse allegations, accurate and timely medication administration, proper food service sanitation, and maintaining the physical plant and environment in good repair, affecting resident safety and comfort.
Deficiencies (5)
F 0584: The facility failed to maintain a clean and homelike environment by not providing adequate storage for personal belongings and not promptly cleaning spills for residents #33 and #67, resulting in unsanitary conditions.
F 0609: The facility failed to timely report and investigate suspected abuse for four residents, including R537 and R385, resulting in potential delays in addressing abuse allegations.
F 0658: The facility failed to ensure medication was administered timely and accurately per physician orders for residents #30, #40, and #284, including late administration and incorrect dosing.
F 0812: The facility failed to effectively clean and maintain food service equipment and the food production kitchen, resulting in bacterial harborage, cross-contamination risk, and decreased illumination affecting 80 residents.
F 0921: The facility failed to effectively clean and maintain the physical plant, including resident rooms and common areas, resulting in bacterial harborage, cross-contamination risk, decreased illumination, and unsafe water supply cross-connections affecting many residents.
Report Facts
Residents reviewed for medication administration: 6
Residents affected by food service sanitation issues: 80
Residents affected by physical plant maintenance issues: 80
Residents sampled for abuse reporting: 23
Inspection Report
Routine
Deficiencies: 4
Date: Jul 12, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards, including activities of daily living assistance, medication administration, and facility maintenance.
Findings
The facility failed to provide adequate hair grooming for one resident, failed to consistently obtain and document vital signs and timely administer prescribed medications for another resident, and failed to properly dispose of garbage and maintain cleanliness of the outside garbage area and stairwell, potentially affecting all residents.
Deficiencies (4)
F 0677: The facility failed to provide hair grooming for one resident dependent on staff for activities of daily living, resulting in unmet care needs and resident dissatisfaction.
F 0684: The facility failed to ensure vital signs were consistently obtained and documented according to physician's orders for one resident, resulting in lack of clinical information and potential unmet care needs.
F 0684: The facility failed to ensure timely administration of prescribed medications for one resident, resulting in potential unmet health care needs.
F 0814: The facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area and stairwell, resulting in a visually unappealing property and potential pest harborage.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) O | Admitted resident's hair was matted and unkempt | |
| Certified Nurse Aide (CNA) P | Observed resident's hair condition as matted | |
| Director of Nursing (DON) | Provided expectations for resident hair care and medication/vital sign monitoring | |
| Unit Manager/Licensed Practical Nurse (UM/LPN) H | Described vital sign monitoring practices and concerns | |
| Maintenance Director (MD) L | Reported debris and trash in outside dumpster area | |
| Nursing Home Administrator (NHA) | Stated maintenance responsibilities for grounds cleanliness |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure the legal guardian consented for a resident (#301) to leave the facility on a leave of absence (LOA).
Complaint Details
This citation pertains to Intake number MI00136275. The complaint was substantiated as the facility failed to obtain legal guardian consent for the resident's LOA on 5/3/2023.
Findings
The facility failed to obtain documented consent from the resident's legal guardian for the resident's LOA on 5/3/2023. The resident left with his girlfriend and did not return as expected, and the legal guardian was not informed or did not provide consent to the facility.
Deficiencies (1)
F 0551: The facility failed to ensure the resident's legal guardian consented for the resident to leave the facility on a leave of absence. Documentation confirming guardian consent was not found for the LOA on 5/3/2023.
Report Facts
Residents Affected: 1
Inspection Report
Routine
Deficiencies: 23
Date: Sep 8, 2022
Visit Reason
Routine state inspection survey of Westwood Nursing Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights regarding advance directives, failure to notify legal guardians of condition changes, inadequate environment cleanliness, improper use of physical restraints, delayed Minimum Data Set submissions, incomplete PASARR screenings, deficient care planning, delayed medical treatment, inadequate range of motion interventions, improper catheter and colostomy care, insufficient nursing staff coverage, lack of nurse aide competency documentation, incomplete dementia care, untimely social service assessments, failure to follow pharmacist medication recommendations, improper dish sanitization, poor administrative oversight, incomplete COVID-19 vaccination tracking, unclean emergency crash cart, and non-functioning resident call systems during power outage.
Deficiencies (23)
F578: Facility failed to ensure residents or legal representatives were involved in formulating advance directives for 9 residents, resulting in potential denial of resident rights.
F580: Facility failed to notify legal guardians or resident representatives of changes in condition or room changes for 8 residents, preventing participation in care decisions.
F582: Facility failed to provide notice of Medicare non-coverage and appeal rights to one resident, resulting in lack of informed Medicare rights.
F584: Facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, including unclean rooms, odors, and damaged furniture.
F604: Facility failed to periodically release a physical restraint (secured table top on recliner) for one resident, restricting freedom of movement.
F640: Facility failed to submit Minimum Data Set assessments timely for 4 residents, delaying monitoring of resident status.
F644: Facility failed to complete PASARR Level I screening and/or Level II evaluation for 4 residents, risking unmet mental health and psychiatric care needs.
F656: Facility failed to develop and implement comprehensive person-centered care plans for medical and psychosocial needs for 2 residents, risking unmet care needs.
F684: Facility failed to ensure timely monitoring and treatment for a resident with projectile vomiting of coffee ground emesis, resulting in delayed medical care.
F688: Facility failed to implement interventions to maintain or improve range of motion for one resident, risking contracture development.
F690: Facility failed to provide appropriate supra-pubic indwelling urinary catheter care for one resident, risking injury, dislodgement, and infection.
F691: Facility failed to obtain physician's order and provide care for colostomy for one resident, risking skin excoriation and infection.
F725: Facility failed to maintain sufficient nursing staff to administer medications for 5 residents, risking compromised health and well-being.
F726: Facility failed to ensure nurse aides had documented competencies, risking unmet care needs.
F744: Facility failed to provide social service assessment, treatment, and individualized dementia care for one resident, risking inadequate care.
F745: Facility failed to timely complete social service assessments for 23 residents, risking unmet resident needs related to advocacy and psychosocial health.
F756: Facility failed to respond timely to pharmacist medication regimen review recommendations for 6 residents, risking unnecessary and unmonitored medication use.
F770: Facility failed to ensure timely laboratory services for 2 residents per physician orders, risking ineffective treatment.
F812: Facility failed to properly implement three-step manual warewashing procedure in kitchen, risking foodborne illness.
F835: Facility failed to effectively administer daily operations including staffing, medication review follow-up, and social service functions, risking resident well-being.
F888: Facility failed to track and ensure staff COVID-19 vaccination status, risking potential spread of infection.
F908: Facility failed to maintain clean and well-maintained emergency crash cart, risking injury due to equipment contamination.
F919: Facility failed to provide alternate alerting means when resident call system was non-functional on two nursing units during power outage, risking delayed staff response.
Report Facts
Residents reviewed for assessments: 24
Residents affected by staffing shortage: 73
Nurses called off: 100
Residents not receiving medications: 5
Days overdue for Social Service Evaluation: 211
Days overdue for Social Service Evaluation: 206
Days overdue for Social Service Evaluation: 160
Days overdue for Social Service Evaluation: 124
Days overdue for Social Service Evaluation: 87
Days overdue for Social Service Evaluation: 131
Days overdue for Social Service Evaluation: 144
Days overdue for Social Service Evaluation: 206
Days overdue for Social Service Evaluation: 169
Days overdue for Social Service Evaluation: 87
Days overdue for Social Service Evaluation: 124
Days overdue for Social Service Evaluation: 131
Days overdue for Social Service Evaluation: 160
Days overdue for Social Service Evaluation: 206
Days overdue for Social Service Evaluation: 211
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