Focused Care At Westwood

The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions while performing pressure ulcer treatment on 11/5/25.

These failures could place residents at risk of cross-contamination and development of infection.Finding include:

Record review of Resident #1's face sheet reflected, the date of admission was 11/20/21 and was readmitted on [DATE]. Resident #1 had diagnoses which included history of neuromuscular dysfunction of bladder, (the nerves controlling your bladder are damaged and can no longer coordinate properly with the bladder muscles), constipation (bowel movements that are infrequent, hard ,dry or difficult to pass), , orthostatic hypotension (sudden drop blood pressure), bacterial infection, unspecified, cognitive communication deficit need for assistance with personal care.

Record review of Resident #1's quarterly MDS assessment, dated 10/20/2025, Section C (Cognitive Patterns) reflected BIMS score was 04 which indicated severely impaired cognitively.

Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #1's functional status revealed he was dependent with supervision of staff with bed mobility, transfer, and toilet use.

Further review revealed Resident #1 had a supra pubic Foley catheter.Record Review of Resident's #1's care plan dated 9/28/2025 reflected I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days.Observation on 11/5/25 at 11:59 AM, revealed Resident #1 lying in bed, a EBP sign was posted inside the room. LVN A entered Resident #1's room without donning PPE and performed pressure ulcer treatment to Resident #1.

Interview with the LVN A on 11/5/25 at 12:30 PM revealed she forgot to don PPE. LVN A said she realized she should have donned PPE to protect the resident and herself for infection.

She knew not donning PPE could cause infection. LVN A said she would be more careful. In an interview with the DON on 11/5/25 at 5:15 PM, she stated any resident who had wounds, contact isolation, Gastrostomy tube feeding, or Foley catheter was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's.

She stated signage was posted inside the head of Resident #1's bed, which explained what PPE was to be worn and for what task the PPE was to be worn for.

She stated any contact with a resident with pressure ulcer required the use of gown and gloves.

She stated the staff received training on the use of Enhanced Barrier Precautions.

Record review of the facility's policy revised, 04/01/2024, on Enhanced Barrier Precautions, reflected the following: Policy Statement: Enhanced barrier precautions (EBPs) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes, EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO or who have open wound or indwelling medical device.

Record review of CDC guidelines reflected: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown.

Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment.

Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

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