Inspection Reports for
Westwood Nursing Center
16588 Schaefer Highway, Detroit, MI 48235, Detroit, MI, 48235
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Inspection Report — Feb 20, 2025
Complaint Investigation
Date: Feb 20, 2025
Visit Reason
Investigation of a complaint received on 2025-02-09 about failure to transfer resident information to hospital.
Complaint Details
Failure to transfer resident information to hospital: established.
Findings
The facility failed to ensure appropriate information was communicated to the receiving hospital for one resident transferred on 2025-02-09.
Deficiencies (1)
F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. The facility failed to complete and send the required eINTERACT transfer form and other necessary resident information to the receiving hospital for resident R105's transfer on 2/9/25.
Inspection Report — Oct 11, 2024
Complaint Investigation
Date: Oct 11, 2024
Visit Reason
Investigation of a complaint received on 2024-10-08 about failure to complete PASARR screening, failure to apply ordered hand splints, and failure to maintain pharmaceutical records.
Complaint Details
PASARR screening not completed for one resident: established. Failure to apply ordered hand splints for two residents: established. Failure to maintain controlled drug records: established.
Findings
Three deficiencies were found: failure to ensure PASARR screening for mental disorders or intellectual disabilities, failure to apply ordered hand splints for two residents resulting in potential loss of range of motion, and failure to establish a record of receipt, disposition, or reconciliation of controlled drugs in the facility's back-up box.
Deficiencies (3)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities: the facility failed to ensure the PAS/ARR DCH-3877 form was completed and sent for evaluation for one resident, resulting in no screening or evaluation for mental disorder or intellectual disability care needs.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM): the facility failed to apply ordered hand splints for two residents, resulting in potential loss of ROM and decline in health status.
F 0755 Provide pharmaceutical services to meet the needs of each resident: the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs in the back-up box, resulting in inability to account for medications and potential drug diversion.
Inspection Report — Mar 29, 2024
Date: Mar 29, 2024
Visit Reason
Investigation of a complaint regarding inaccurate medication administration documentation.
Findings
The facility failed to ensure the resident's medical record accurately documented the administration of prescribed medications, resulting in potential risk to resident care.
Deficiencies (1)
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to ensure resident #101's medication administration records were accurate, with multiple duplicate medication orders and failure to discontinue old orders upon readmission.
Inspection Report — Mar 7, 2024
Complaint Investigation
Date: Mar 7, 2024
Visit Reason
Investigation of complaints received on 2024-01-08 about facility maintenance, cleanliness, and water temperature.
Complaint Details
Closet door unattached: established. Bathroom cleanliness and hot water issues: established.
Findings
The facility failed to repair an unattached closet door, maintain a clean bathroom and bathtub, and provide adequate hot water, resulting in resident dissatisfaction and potential risk to resident belongings and comfort.
Deficiencies (2)
F 0558 Reasonably accommodate the needs and preferences of each resident: the facility failed to repair an unattached closet door for resident R905, exposing personal belongings and causing resident dissatisfaction.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to maintain a clean bathroom and bathtub and did not provide adequate hot water for resident R902, resulting in dissatisfaction with cleanliness and comfort.
Inspection Report — Nov 15, 2023
Complaint Investigation
Date: Nov 15, 2023
Visit Reason
Investigation of a complaint received on 2023-11-15 about failure to notify resident representative of change in condition and hospital transfer.
Complaint Details
Failure to notify resident representative of change in condition and hospital transfer: established.
Findings
The facility failed to inform the resident representative of a change in condition and transfer to the hospital, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
F 0580 Notification of Change: the facility failed to promptly inform the resident's representative when there was a change requiring notification, specifically the transfer of resident R901 to the hospital without family notification.
Inspection Report — Aug 31, 2023
Complaint Investigation
Date: Aug 31, 2023
Visit Reason
Investigation of complaints received about abuse allegations, medication administration, care planning, medication storage, food service sanitation, staffing data reporting, and facility maintenance.
Complaint Details
Abuse allegations for residents R385, R536, R537, and R2: not established. Medication administration errors: established. Baseline care plan deficiency for R9: established. Medication storage issues with insulin: established. Food service sanitation and maintenance issues: established. Staffing data reporting failure: established. Facility maintenance and sanitation deficiencies: established.
Findings
Multiple deficiencies were found including failure to timely report and investigate abuse allegations, failure to develop baseline care plans, medication administration errors, improper medication storage, unsanitary food service conditions, failure to report staffing data, and poor facility maintenance resulting in unsafe and unsanitary conditions.
Deficiencies (8)
F 0584 Honor the resident's right to a safe, clean and homelike environment: the facility failed to provide adequate storage for residents' personal belongings and maintain clean rooms for residents #33 and #67.
F 0609 Timely report suspected abuse, neglect, or theft: the facility failed to timely report and investigate abuse allegations for residents R385, R536, R537, and R2.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to develop dialysis and ADL baseline care plans for resident R9.
F 0658 Ensure services provided meet professional standards of quality: medication administration errors occurred for residents #30, #40, and #284 including late administration and incorrect dosing.
F 0761 Ensure drugs and biologicals are labeled and stored properly: expired and undated insulin was found in a medication cart.
F 0812 Procure food from approved sources and maintain food service equipment and kitchen physical plant: multiple sanitation and maintenance issues were found including soiled equipment, leaking faucets, broken tiles, missing light bulbs, and insect presence.
F 0851 Electronically submit complete and accurate direct care staffing information: the facility failed to submit Payroll-Based Journal data for Q2 2023.
F 0921 Make sure the nursing home area is safe, easy to use, clean and comfortable: extensive facility maintenance and sanitation deficiencies were observed throughout the building including soiled surfaces, broken fixtures, missing ceiling tiles, insect presence, and cross-connections between potable and non-potable water supplies.
Inspection Report — Aug 31, 2023
Complaint Investigation
Date: Aug 31, 2023
Visit Reason
Investigation of complaints received about abuse allegations, medication administration, food service sanitation, and facility maintenance.
Complaint Details
Failure to maintain clean environment and storage: established. Failure to timely report and investigate abuse allegations: established. Medication administration errors: established. Food service sanitation failures: established. Physical plant maintenance failures including water cross-connections and sanitation: established.
Findings
Multiple deficiencies were found including failure to timely report and investigate abuse allegations, medication administration errors, unsanitary food service conditions, and poor maintenance of the physical plant resulting in safety and sanitation hazards.
Deficiencies (5)
F 0584 Honor the resident's right to a safe, clean and homelike environment: the facility failed to maintain a clean environment and provide adequate storage for residents' personal belongings, resulting in unsanitary conditions and missing personal items for residents #33 and #67.
F 0609 Timely report suspected abuse, neglect, or theft: the facility failed to timely report and investigate abuse allegations for residents R385, R536, R537, and R2, resulting in delayed investigations and reporting to the State Agency.
F 0658 Ensure services meet professional standards: medication was not administered timely or accurately for residents #30, #40, and #284, including late administration and incorrect dosing.
F 0812 Procure food from approved sources and maintain food service equipment: the facility failed to effectively clean and maintain food service equipment and the kitchen physical plant, including leaking faucets, soiled ovens, cracked tiles, missing light bulbs, and accumulated dust and dirt, increasing risk of contamination.
F 0921 Maintain a safe, clean, and comfortable environment: the facility failed to maintain the physical plant, resulting in cross-contamination risks, bacterial harborage, decreased illumination, and cross-connections between potable and non-potable water supplies, with numerous maintenance and sanitation issues throughout the building.
Inspection Report — Jul 12, 2023
Complaint Investigation
Date: Jul 12, 2023
Visit Reason
Investigation of a complaint received about failure to provide adequate personal care, medication administration, and proper disposal of garbage.
Findings
Three deficiencies were cited: failure to provide adequate hair grooming for one resident, failure to ensure vital signs were consistently obtained and documented for one resident, failure to ensure timely administration of prescribed medications for one resident, and failure to properly dispose of garbage and maintain cleanliness of the outside garbage area and stairwell.
Deficiencies (3)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide hair grooming for one resident (R102), resulting in untimely and unmet care needs regarding personal grooming.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to ensure vital signs were consistently obtained and documented according to physician's orders for one resident (R106), and failed to ensure timely administration of prescribed medications, resulting in potential unmet health care needs.
F 0814 Dispose of garbage and refuse properly: the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area and an outside stairwell, resulting in a visually unappealing property and potential harborage of pests.
Inspection Report — May 16, 2023
Complaint Investigation
Date: May 16, 2023
Visit Reason
Investigation of a complaint received on 2023-05-16 about failure to ensure legal guardian consent for resident leave of absence.
Complaint Details
Failure to obtain legal guardian consent for resident #301's leave of absence: established.
Findings
The facility failed to ensure the legal guardian consented for one resident to leave the facility on a leave of absence, resulting in the inability of the guardian to exercise rights regarding the resident's care and activity decisions.
Deficiencies (1)
F 0551 Give the resident's representative the ability to exercise the resident's rights: the facility failed to obtain legal guardian consent for resident #301's leave of absence on 5/3/2023.
Inspection Report — Sep 8, 2022
Renewal
Date: Sep 8, 2022
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
Multiple deficiencies were cited including failure to ensure residents' rights regarding advance directives, failure to notify legal guardians of changes in condition or room changes, failure to provide notice of Medicare non-coverage, failure to maintain a safe, clean, and homelike environment, failure to ensure freedom from physical restraints, failure to submit timely Minimum Data Set assessments, failure to coordinate PASARR assessments, failure to develop comprehensive care plans, failure to provide appropriate treatment and care, failure to provide range of motion interventions, failure to provide appropriate catheter and colostomy care, failure to maintain sufficient nursing staff, failure to ensure nurse aide competencies, failure to provide dementia care and social services, failure to respond to pharmacist medication recommendations, failure to provide timely laboratory services, failure to properly sanitize kitchenware, failure to administer the facility effectively, failure to ensure staff COVID-19 vaccination compliance, failure to maintain clean emergency equipment, and failure to provide working call systems in resident areas.
Deficiencies (23)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: The facility failed to ensure competent residents and/or the resident's legal representatives were involved in the formulation of an advance medical directive for 9 residents, potentially denying their rights to formulate an advance medical directive.
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: The facility failed to notify Legal Guardians/Resident Representatives of a change in condition or room change for eight residents, resulting in unawareness of changes and inability to participate in care decisions.
F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: The facility failed to provide evidence that a resident was issued a Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice, resulting in the resident not being fully informed of Medicare rights or potential liability.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: The facility failed to ensure residents' bed linens were clean, rooms free from odors, and furniture maintained, resulting in resident displeasure and non-homelike environment.
F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment: The facility failed to periodically release a secured table top restraint for one resident, restricting freedom of movement.
F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment: The facility failed to submit Minimum Data Set assessments in a timely manner for 4 residents, delaying time sensitive information used to monitor resident decline or progress.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: The facility failed to complete PASARR Level I screening and/or Level II evaluation for 4 residents, risking unmet mental health and psychiatric care needs.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: The facility failed to develop and implement comprehensive person-centered care plans for two residents, resulting in potential unmet psychosocial and urinary catheter care needs.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: The facility failed to ensure timely treatment and monitoring for a resident with projectile vomiting of coffee ground emesis, resulting in delayed medical treatment and potential unmet care needs.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: The facility failed to implement interventions to address range of motion concerns for one resident, risking contracture development.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: The facility failed to provide appropriate supra-pubic indwelling urinary catheter care for one resident, resulting in potential injury, dislodgement, and urinary tract infection.
F 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services: The facility failed to obtain physician's orders and provide care for a colostomy for one resident, risking skin excoriation and infection.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: The facility failed to maintain sufficient nursing staff to administer medications for 5 residents, risking compromised health and well-being.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: The facility failed to ensure nursing competencies were performed for 5 nurse aides, risking unmet care needs.
F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia: The facility failed to provide social service assessment, treatment, and individualized dementia care interventions for one resident, resulting in lack of identification of needs and treatments.
F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life: The facility failed to timely complete comprehensive social service assessments for 23 residents, risking unmet resident needs related to advocacy, grievance assistance, mental health, education, referrals, financial and legal matters, and discharge planning.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: The facility failed to respond timely to monthly medication regimen review recommendations for six residents, resulting in unnecessary and unmonitored medication use.
F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents: The facility failed to ensure labs were obtained per physician orders for two residents, risking ineffective therapeutic drug levels and treatment.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: The facility failed to properly implement the three-step manual warewashing procedure, risking foodborne illness.
F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently: The facility's managing corporation failed to effectively administer daily operations, resulting in insufficient weekend staff, and inability of DON and Social Service Director to perform duties.
F 0888 Ensure staff are vaccinated for COVID-19: The facility failed to track staff COVID-19 vaccination status and ensure all staff were fully vaccinated, risking spread of COVID-19 infection.
F 0908 Keep all essential equipment working safely: The facility failed to ensure resident emergency crash cart was clean and free of contamination, risking injury due to lack of equipment maintenance.
F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area: The facility failed to provide alternate means of alerting staff when the resident call system was non-functional on two nursing units, risking delayed staff response to resident needs.
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