The Suites at Western Home Communities

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) practices during a routine transfer for 1 of 1 resident reviewed for pressure ulcer (Resident #4). The facility reported a census of 70.Findings include:The Minimum Data Set (MDS) dated [DATE] revealed that Resident #4 had one unstageable pressure injury presenting as a deep tissue injury that was not present on admission.The Care Plan initiated on 3/15/24 indicated that Resident #4 required EBP related to wounds. It directed staff to wear gloves and gown for transferring the resident. It also indicated that he had an actual skin impairment related to the left heel and directed staff to provide wound care per Medical Doctor (MD) orders.The Physician's Order dated 11/18/25 indicated to use EBP due to wound to the left heel every shift. In another order dated 9/24/25 it directed staff to apply Betadine topically to the left heel ulcer at bedtime.The Electronic Health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, the Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) Assessment within 14 days of hospice election for 2 of 2 residents reviewed on hospice services (Residents #45 and #4). The facility reported a census of 71 residents. Findings include: 1. A Progress Note dated 5/30/24 at 5:02 PM documented Resident #45 admitted to hospice care services. A Hospice Benefit Election Statement signed by Resident #45's family member documented the start of service date as 5/30/24. The Care Plan Focus revised 6/14/24 reflected Resident #45 started hospice care on 5/30/24. The SCSA MDS assessment dated [DATE] documented Resident #45 with long/short term memory impairment and moderately impaired (required cues) decision making ability. The MDS listed diagnoses of metabolic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, document review, the Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the care status of 4 out of 5 residents reviewed (Residents #33, #45, #53, and #70). The MDS failed to accurately reflect Resident #33's fall with major injury, Resident #45 received hospice services, Resident #53's use of restraints, and Resident #70 discharged home and not to the hospital. The facility identified a censes of 71 residents. Findings include: 1. The Incident Note dated 9/5/24 at 3:30 PM documented by Staff F, Licensed Practical Nurse (LPN), indicated they heard Resident #33 calling out for help and she entered her apartment. Resident #33 laid on the bathroom floor with her hand placed under her buttocks, wearing gripper socks, and her walker next to her. Resident #33 walked to the bathroom…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview the facility failed to follow a physician order to place washcloths in the hands of 1 of 1 resident reviewed for range of motion (ROM) (Resident #45). The facility identified a census of 71 residents. Findings include: Resident #45's Minimum Data Set (MDS) assessment dated [DATE] listed Resident #45 as rarely/never understood with long- and short-term memory impairment. Resident #45 had an upper extremity (shoulder, elbow, wrist, hand) functional impairment on both sides. The MDS reflected Resident #45 depended upon staff for activities of daily living (ADLs). The MDS included diagnoses of metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness. You may make a full recovery if you receive a diagnosis and treatment quickly, but permanent brain damage is possible), stroke, Alzheimer's dementia and non Alzheimer's dementia. The MDS documented Resident #45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview the facility failed to serve meals in a therapeutic form necessary to meet residents' needs. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #59 dated 12/22/23 documented a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. The MDS documented diagnoses including: stroke, traumatic brain dysfunction (occurs as a result of a severe injury to the head with immediate or delayed symptoms which may include confusion, blurry vision, and concentration difficulty), traumatic spinal cord dysfunction (a spinal cord injury which may cause a loss of strength, sensation, and function below the site of the injury), and progressive neurological conditions (continued decline in functioning). The Resident's Care Plan, revised 10/06/23, contained interventions including: staff to follow Speech Therapy (ST) progress and recommendations; the resident is to have their diet as (physician) ordered; all foods to be cut into small bites or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview the facility failed to serve meals under sanitary conditions and at safe temperatures to prevent food-borne illness. The facility reported a census of 61 residents. Findings include: During an observation of the noon meal on 2/27/24 from 11:45 AM to 12:55 PM Staff A, Certified Nursing Aide (CNA) observed setting the serving scoops face down on the counter top without a barrier. Staff A then placed the scoops into the food that was served out to multiple residents. Staff A placed a blender lid face down directly onto the counter top and then used the blender to grind food for two residents before serving them. Staff A placed the serving tongs directly on the dirty stovetop surface multiple times, then used the tongs to plate egg rolls for multiple residents. Pre-meal temperatures taken at 12:05 PM revealed the ground beef and broccoli heated to 120.7 degrees Fahrenheit (F) prior to meal service without a reheat to 165 degrees performed. Staff A plated the ground beef and broccoli and served it out at the noon meal to multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview, the facility failed to implement care planned interventions for toileting and to prevent falls for 2 of 20 sampled residents (#3 and #19). The facility identified a census of 61 residents. Findings include: 1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] showed Resident #19 with a long/short term memory impairment and severely impaired daily decision-making ability. The MDS documented Resident #19 as dependent upon staff for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS documented Resident #19 as always incontinent of urine and frequently incontinent of bowel. The MDS listed diagnoses of unspecified dementia, end stage renal disease, and muscle weakness. The Care Plan, revised 1/25/24, documented a focus problem of bladder incontinence and directed the staff to: a. Encourage/assist to void at least routinely and more often…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview the facility failed to follow standards of practice when staff failed to observe residents swallowed their medication per facility policy, per physician orders, and standard of practice for 2 of 2 sampled residents (#13 and #39). The facility identified a census of 61 residents. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating mild cognitive impairment. The MDS documented Resident #13 independent with eating with a diagnosis of metabolic encephalopathy (metabolic encephalopathies comprise a series of neurological disorders not caused by primary structural abnormalities; rather, they result from systemic illness, such as diabetes, liver disease, renal failure, and heart failure). The Care Plan revised 2/19/24 lacked documentation Resident #13 could self-administer his own medications. A Review of the 2/28/24 Physician Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure resident with limited range of motion (ROM) received restorative exercises as planned for 1 of 1 resident sampled (Resident #32). The facility reported a census of 61 residents. Findings include: Resident #32's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 8/15 indicating a mild cognitive impairment. The MDS detailed the Resident had a lower body impairment on both sides of the body and a diagnosis of muscle weakness and Parkinsonism (Parkinsonism is a term used to describe a collection of movement symptoms associated with several conditions - including Parkinson's disease (PD). These symptoms include slow movements along with stiffness, walking and balance issues and/or tremors). The MDS documented Resident #32 received 54 minutes of physical therapy one time in the seven-day look-back period. The Care Plan revised 1/08/24 directed staff to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interviews the facility failed to keep resident respiratory equipment in sanitary condition for 1 of 1 residents reviewed (Resident #5). The facility reported a census of 61 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented a Brief Interview for Mental Status of 14/15 indicating no cognitive impairment. The MDS documented diagnoses including: cancer, heart failure, pneumonia, chronic obstructive pulmonary disease, and respiratory failure. The Resident's Care Plan, revised 1/23/24, detailed Resident #5 required the use of oxygen due to heart failure and contained an intervention to provide oxygen therapy via nasal canula/mask. Physician Orders dated 1/23/24 instructed the resident to be on oxygen at 3 liters continuous and for the tubing to be changed and dated weekly. During observations on 2/26/24 at 10:45 AM and on 2/29/24 at 8:28 AM the filter on the resident's oxygen concentrator was found to be matted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, policy review, resident and staff interview, the facility failed to answer call lights within 15 minutes for 2 of 3 residents reviewed (Resident #5 and #44). The facility identified a census of 61 residents. Findings include: 1. Resident #44's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating mild cognitive impairment. The MDS documented Resident #44 as dependent upon staff for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement); dependent upon staff for lower body dressing (the ability to dress and undress below the waist, including fasteners; does not include footwear) and required substantial to maximal assist with toilet transfers (the ability to get on and off a toilet or commode). The MDS listed diagnoses of Dystonia (a disorder that causes the muscles to contract involuntarily), Parkinsonism (unspecified),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.