The family member discovered the unauthorized vaccination only when the resident complained her arm hurt after a visit. When she called the facility, a nurse confirmed the resident had received the Prevnar 20 vaccine on March 26.
The consent form, dated five days earlier, bore the signature of the infection preventionist rather than the resident's representative. The document falsely claimed the signer had "authority to complete this registration process and to make healthcare decisions for the named patient."
Resident 30 had severe cognitive impairments with a mental status score of three out of 15 points. Her January assessment noted she was not current on pneumonia vaccination because it had been "offered and declined."
The representative told inspectors on April 8 that she was never notified about the vaccination and never gave consent. She had taken the resident out for a visit when the woman complained of arm pain from receiving a shot. Only then did the family member learn what had happened.
The facility's director of nursing admitted the infection preventionist had "incorrectly signed the consent" and said the responsible party should have given permission. She promised to provide additional training.
But the vaccination consent violation represented just one of multiple oversight failures inspectors documented during their April visit.
The facility's quality assurance committee met monthly to review eight to ten areas, according to the nursing home administrator. Yet the committee had failed to identify problems with CPAP machine cleaning, medication review schedules, and snack distribution that inspectors discovered during their survey.
The administrator told inspectors the facility had changed its snack distribution six months earlier due to residents hoarding food. But he only learned during the inspection that there were not enough snacks available to residents.
Similarly, he was unaware that required monthly pharmacy medication reviews were not occurring until inspectors brought it to his attention.
The facility's shower room presented another sanitation concern. Black residue covered grout lines around the perimeter of the communal shower that residents used daily.
Resident 30's representative, who had complained about the vaccination consent issue, also told inspectors the shower room was not clean and "needed to have a good cleaning." She said it had been in that condition for some time.
The maintenance director initially claimed housekeeping staff cleaned the shower daily and performed deep cleaning weekly. When pressed about the black residue, he speculated it could be soap, though the body soap in the shower was orange, or splattered caulking, though the actual caulking was gray.
Unable to identify the substance, facility officials requested emergency mold testing. The maintenance director first said he had professional commercial shower sanitizer, then admitted he could not test for mold, only sanitize.
Environmental testing the following day revealed "potential water damage, potential visual growth and excessive humidity and moisture" in the shower. Laboratory results showed common allergens were present, though no fungal growth was detected.
The shower violations highlighted broader quality oversight gaps at the facility. The nursing home administrator said infection control was discussed at all quality committee meetings, yet staff had missed obvious sanitation problems in the primary bathing area for residents.
The facility's quality assurance process appeared designed more for documentation than actual problem identification. The administrator described a system where the committee reviewed resident council minutes, grievances, and incident trends to find root causes and develop performance improvement plans.
Yet this systematic approach had failed to catch fundamental care issues: medication reviews running behind schedule, inadequate snack availability, and a moldy shower room that residents used daily.
The vaccination consent violation struck at a core principle of nursing home care — the right of residents and their representatives to make informed healthcare decisions. Federal regulations require facilities to obtain proper consent before administering vaccines, particularly for residents with cognitive impairments who cannot consent for themselves.
The infection preventionist's decision to sign consent documents for a resident represents a serious breach of medical ethics and federal requirements. The false claim of decision-making authority could have exposed both the facility and the staff member to legal liability.
For the 86-year-old resident's family, the unauthorized vaccination represented a violation of trust. The family member had specifically been designated to make healthcare decisions, yet staff bypassed that authority entirely.
The facility's promise to provide additional training to the infection preventionist suggested the violation was treated as an educational matter rather than a serious breach of resident rights and medical consent requirements.
The multiple oversight failures documented during the April inspection painted a picture of a facility where systematic quality review processes existed on paper but failed to identify obvious problems in daily operations.
Residents at Westwood Post Acute faced the consequences of these oversight gaps — from potentially unsafe shower conditions to unauthorized medical procedures performed without proper consent or family notification.
The facility's inability to identify the black residue in its shower room until inspectors arrived raised questions about staff training and basic sanitation protocols. The subsequent discovery of water damage and excessive moisture suggested the problem had persisted for some time.
The 86-year-old resident with dementia, meanwhile, had received a medical intervention she or her family had previously declined, administered by staff who forged consent documents to circumvent proper authorization procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Post Acute from 2025-04-25 including all violations, facility responses, and corrective action plans.