West Woods of Niles

Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident of 22 (Resident #27) reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.Findings include: Resident #27: Review of an admission Record revealed Resident #27 was a female with pertinent diagnoses which included stroke, contractures (a permanent tightening of muscles, tendons, skin caused the joint to shorten and become very stiff) right elbow, right hand, and right ankle; contractures left elbow, hand, and ankle; abnormalities of breathing, epilepsy, and tube feeding due to a persistent vegetative state. Review of Care Plan for Resident #27 revised on 11/12/24 revealed the focus, . (Resident #27 is dependent on the staff for all ADL cares related to her persistent vegetative state. She has contractures to bilateral upper extremity joints and bilateral ankles. with the intervention .FALL - RISK MANAGEMENT: * Low bed in lowest position except with…

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 This citation pertains to intake #2715364. Based on interviews and record review, the facility failed to identify an acute change in condition for 1 (Resident #121) of a total sample of 22 residents reviewed for quality of care resulting in a delay in treatment for Resident #121 who was sent to the hospital on 1/8/26 and diagnosed with altered mental status and septic shock (life-threatening condition caused by a severe infection) from necrotic (death of cells in tissue) sacral ulcer with osteomyelitis (infection in a bone). Findings include: Resident #121Review of an admission Record revealed Resident #121 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of sacral region stage 4, and need for assistance with personal care. Review of Resident #121's Care Plan revealed, (Resident #121) has the potential for an acute condition change with cardiopulmonary, metabolic or infectious complicationsrelated to atrial fibrillation (irregular heart rhythm) and…

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, interview and record review, the facility failed to adequately supervise, reduce hazards, and ensure the safety of 2 (Resident #109 and Resident #32) of 7 residents reviewed for accidents/hazards resulting in an elopement and a fall. Findings include: Resident #109 (R109) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R109's initial admission date was 5/2/2025 with pertinent diagnoses including anxiety, post-traumatic stress disorder, bipolar disorder (intense mood swings ranging from extreme highs and lows), mild cognitive impairment and depression. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R109 cognition was moderately impaired. Review of R109's incident report dated 1/1/2026 revealed Nursing Description: (R109) exited the building at 1855 (6:55 PM). The main entrance door alarm was sounding and (R109) was outside sitting on the sidewalk between the main entrance and the office entrance. (R109) was wearing a…

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, interview and record review the facility failed to maintain sufficient hydration and consistent nutritional status monitoring and re-evaluation by a nutrition professional of residents at risk for altered hydration and nutritional status for 3 of 4 residents (Resident #18, #98, #32) reviewed for hydration/nutrition resulting in the potential for dehydration, weight loss, and unmet resident needs.Findings include: Resident #18: Review of an admission Record revealed Resident #18 was a female with pertinent diagnoses which included diabetes, paralysis left side, stoke, dementia, need for assistance with personal care, and stroke. Review of Care Plan for Resident #18 revised on 1/7/25, revealed the focus, .(Resident #18) has the potential for an altered nutritional status primarily related to her diagnoses of dementia and type 2 DM (diabetes). This may lead to diminished cures of hunger or thirst and a decreased understanding of the importance of eating as well as altered blood sugars. with…

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 interview and record review, the facility failed to ensure pre-dialysis assessments were completed for 1 (Resident #19) of 4 residents reviewed for dialysis services, resulting in the potential for miscommunication, inadequate documentation of resident's clinical conditions, and unmet care needs. Findings include: Resident #19Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and end stage renal disease (final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment). Review of Resident #19's Care Plan revealed, Focus: Hemodialysis required to remove urea & other toxic products from the blood: At risk for loss of vascular access; clotting, hemorrhage(bleeding), infection. At risk for exacerbation of heart failure with inadequate dialysis or increased hypervolemia (fluid overload). Date Initiated: 10/14/2025. Interventions: Assess fluid…

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 interview and record review, the facility failed to ensure the physician documented review of pharmacy recommendations timely for 1 resident (Resident #5) of 6 residents reviewed for unnecessary medications resulting in the potential for medication side effects to occur and/or unnecessary medications for residents.Findings include:Resident #5 (R5)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R5's initial admission date was 10/30/2023 with pertinent diagnoses including depression, delusions (delusions are false beliefs that persist despite evidence to the contrary), bipolar disorder (intense mood swings ranging from extreme highs and lows), dementia (decline in cognitive abilities severe enough to interfere with activities of daily life) and chronic pain. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R5 cognition was moderately impaired. Review of R5's active physician orders revealed Olanzapine (Zyprexa, antipsychotic…

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 interview and record review, the facility failed to ensure 1 (Resident #114) resident of 6 reviewed for unnecessary medications was prescribed a controlled medication, resulting in the use of a controlled addictive substance without adequate diagnosis or indications of use with potential for adverse side effects including negative physical and psychosocial side effects. Findings include: .Use of Adderall can create psychological dependence, physiological dependence, and tolerance may occur with amphetamine; dextroamphetamine therapy. Abrupt discontinuation or a significant dose reduction of CNS (central nervous system) stimulants after prolonged use may produce withdrawal symptoms that include dysphoria, depression, fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. Signs and symptoms of chronic amphetamine abuse include severe dermatoses (skin defect or lesion of the skin), marked insomnia, irritability, hyperactivity, personality changes, and psychosis with features indiscriminate from…

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, interview and record review, the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for 1 (Resident #103) of 1 resident reviewed for management of skin and wounds, resulting in lack of assessment, monitoring, and the potential for a decline in overall health status.Findings include:Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included diabetes and edema. Review of Care Plan for Resident #103, revealed a focus of .(Resident #103) has the potential with acute condition change with cardiopulmonary, metabolic or infectious complications Diabetes Mellitus, Sterocoral Colitis, (serious inflammation of the colon caused by severe chronic constipation and impaction) Bilateral (both sides) hearing loss, and Hypertension (high blood pressure). with the intervention .Assess and document edema, breath sounds, circumoral (blueish tint around the mouth due to poor oxygen) or nail bed cyanosis (blueish tint on the nail bed). Review of admission Assessment…

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, interview, and record review the facility failed to ensure proper infection control protocols and practices for 2 (Resident #103 & #105) of 3 residents reviewed for infection control, resulting in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include: Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi drug resistant organisms) to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection…

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, interview, and record review the facility failed to 1) implement transmission-based precautions for 1 (Resident #35) of 18 residents reviewed for isolation precautions, 2) properly clean and sanitize resident shared equipment and 3) ensure proper use of personal protective equipment (PPE) resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: Review of CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, published 4/12/24 by the Centers for Disease Control and Prevention revealed: Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered .core practices include: clean and disinfect .frequently touched surfaces .ensure proper use of personal protective equipment .implement additional precautions (i.e., Transmission-Based Precautions) .…

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 interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program. Findings include: Review of the facility's Infection Prevention and Control Program with a reference date of 3/2020, revealed: It is the policy of this facility to implement the Infection Prevention and Control Program utilizing a systematic, coordinated and continuous approach guided by OSHA regulations, and pertinent state, federal and local regulations pertaining to infection control. The Infection Prevention Manager has the authority to institute any surveillance, prevention, or control measure indicated. Review of a Facility Assessment with a reference date of 10/23/24 revealed: Evaluation of Infection Prevention and Control Program: .The Infection Preventionist is a dedicated position to the role. In an interview on 1/8/25 at 1:13pm, Infection…

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 interview and record review, the facility failed to ensure COVID-19 immunizations were offered to 10 residents reviewed for COVID-19 immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors. Findings include: Review of the facility's Covid-19 Vaccine Administration policy, with a reference date of May 2023 revealed: It is the policy of this facility to facilitate through partnership with the local health department, consulted pharmacy, and contracted pharmacy to provide the COVID-19 Vaccine according to standards set forth by the Center for Disease Control and Prevention. In an interview on 1/8/25 at 1:13pm, Infection Preventionist (IP) J reported she was behind on several of her responsibilities including offering covid 19 vaccinations to some residents. IP J reported the facility offered a round of covid vaccinations in October 2024, but there had not been follow up for residents who could not receive the vaccination at that time due to the lack of a consent form, or who were…

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 interview and record review the facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) and Notice of Medicare Non-Coverage (NOMNC) to 2 (Resident #26 and Resident #291) of 3 residents reviewed for proper notification related to Medicare A insurance coverage. Findings include: Resident #26 Review of an admission Record revealed Resident #26 had pertinent diagnoses which included: Chronic combined systolic (congestive) and diastolic (congestive) heart failure (increased fluid influences the heart's ability to pump), anxiety disorder, and dementia. Resident #291 Review of an admission Record revealed Resident #291 had pertinent diagnoses which included: spinal stenosis of the cervical region with surgical aftercare (surgical procedure on the neck). On 1/6/2025 at 10:22 AM., during entrance conference, a list of all discharged residents during the past 6 months, from Medicare A insurance coverage was requested from Nursing Home Administrator (NHA) A. On 1/6/2025 at 4:46 PM., NHA A provided an electronic copy of a list of…

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, interview and record review, the facility failed to provide consistent, meaningful and person centered activities for 1 (Resident #29) of 2 reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of wellbeing, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort. Findings include: Resident #29 Review of an admission Record revealed Resident #29 was originally admitted to the facility on [DATE] with pertinent diagnoses which included persistent vegetative state. Review of Resident #29's Care Plan revealed, Per Social service interview: (Resident #29) . worked in fast food and retail. She enjoys music and church. (Resident #29) is dependent on staff for all activities and needs. Activity staff provide manicures, pedicures, music, church on TV or tablet. Date initiated: 4/9/20. Goal: In room activities of choice which include: Music, manicures, Reading books/magazines to her. Date…

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 This citation pertains to intake MI00147700. Based on interview and record review, the facility failed to prevent the elopement and ensure the safety in 1 (Resident #238) of a total sample of 18 reviewed for accidents resulting in Resident #238 exiting the facility from a staff exit door and getting 30 feet away from the building before staff found her with the potential for serious harm, injury, and/or death. Findings include: Resident #238 Review of an admission Record revealed Resident #238 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking. Review of Resident #238's Wandering Risk Assessment Scale dated 9/19/24 indicated that Resident #238 was identified as a high risk to wander, and the facility staff placed a wander guard device on her prophylacticly. Review of incident report dated 10/7/24 revealed, (Resident #238) exited the building and was accompanied by staff back into the facility. (Resident #238) was observed outside in the courtyard, in…

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 interview and record review, the facility failed to ensure that that QAA (quality assessment and assurance) meetings had the Medical Director as a mandatory attendee at least quarterly resulting in the potential for the Medical Director to not be notified of quality deficiencies occurring in the facility. Findings include: Review of the facility's Quality Assurance Performance Improvement Program policy last revised January 2015 revealed, Policy: With the support of the governing body and administration, it is the policy of this facility, to implement and maintain a Quality Assessment and Performance Improvement Program (QUAPI). QUAPI activities will involve members at all levels of the facilities organization to identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor the effectiveness of actions . 2. Governance and Leadership: a. The Quality Assurance Committee meets a minimum of monthly and is designated as the steering committee to oversee QUAPI and provide opportunity…

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.

This citation pertains to intake MI00144494 Based on interview and record review the facility failed to develop care plan interventions to prevent the development of and/or worsening of pressure ulcers and develop interventions for wound vac (a device that applies gentle pressure to assist with wound healing) use for 1 (Resident #101) of 2 residents reviewed for care plan interventions related to pressure wounds resulting in Resident #101's existing pressure ulcer worsening, and the development of additional pressure wound. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: pressure ulcer of the sacral region stage 4, osteomyelitis of the vertebra, sacral and sacrococcygeal region (infection of the vertebra bone in the sacral region), and functional quadriplegia (the complete inability to move). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 4/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #101 was cognitively intact.…

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, interview, and record review the facility failed to ensure infection control practices were maintained during wound care dressing change in 1 (Resident #102) of 1 resident reviewed for wound care dressing changed resulting in the potential for the introduction of infection, cross-contamination, and disease transmission. Findings include: Resident #102 Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: pressure ulcer of the sacral region stage 4, osteomyelitis of the vertebra, sacral and sacrococcygeal region (infection of the vertebra bone in the sacral region), and muscle weakness (generalized). Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #102 was cognitively intact. Review of Physician Orders for Resident #102 revealed . enhanced barrier precautions during high contact resident activities every shift for . wound care active on 3/28/24 .Wound care: coccyx- cleanse with normal…

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.

This citation pertains to intake number MI00143279. Based on interview and record review the facility failed to ensure medications were administered in a dignified manner for 1 resident (Resident #5) when a nurse attempted to administer medications to a resident who was naked, suspended in a shower sling and having a bowel movement. Findings: Resident #5 (R5) Review of an admission Record reflected R5 admitted to the facility with diagnoses that included, muscle weakness, difficulty walking, mild dementia, mixed anxiety disorder and adjustment disorder with depressed mood. Review of a Care Plan initiated on 1/25/2023 reflected that R5 had altered functional mobility and ADL's (Activities of Daily Living) and was totally dependent on staff for bathing and transfers with a mechanical lift. During an interview on 3/14/24 at 10:17 a.m., the Director of Nursing (DON) reported she knew about an incident of undignified care for R5 from Licensed Practical Nurse (LPN) U as witnessed and reported by Certified Nursing Aides (CNA's) R and Q in September of 2023. The DON reported the concern…

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 This citation pertains to Intake # MI00142068. Based on interview, and record review, the facility failed to respond to an alarming exit door per policy/procedure to ensure resident safety in 1 of 3 residents (Resident #101) reviewed for wandering/supervision, resulting in an elopement and the potential for injury. Findings include: Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included heart failure, high blood pressure, diabetes, obstructive lung disease, dementia, stroke, muscle weakness, and difficulty walking. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/28/23, revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Wandering Risk Assessment Scale for Resident #101, dated 11/28/23, revealed .(Resident #101) is alert and oriented with confusion and forgetfulness at times. He is independent with wheelchair…

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, interview and record review the facility failed to ensure ADL (activities of daily living) care plan interventions were implemented for 1 (Resident #29) of 21 residents reviewed for care plans, resulting in pain and frustration due to inadequate assistance for bed mobility during incontinence care. Finding include: Review of an admission Record revealed Resident #29 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 11/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #29 was cognitively impaired. Review of Resident #29's Care Plan revealed, .altered functional mobility and ADL's .Interventions: .Bed Mobility: assist of two. Date initiated: 1/25/23 . In an interview on 11/27/23 at 01:13 PM, Resident #29 reported that she often times has a wet or soiled brief for…

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 interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided timely/as scheduled per resident preference and plan of care for 2 (Residents #42 and #54) of 4 residents reviewed for Activities of Daily Living (ADL) care, resulting in Resident #42 being left on the commode for an extended period, Resident #54 not consistently receiving showers as scheduled, and the potential for dissatisfaction with care. Findings include: Resident #42 Review of an admission Record revealed Resident #42 was a female, with pertinent diagnoses which included: chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, chronic respiratory failure with hypoxia (not enough oxygen in the tissues), and orthostatic hypotension (low blood pressure upon standing). Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 11/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #42 was cognitively intact. Further review of said MDS…

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, interview, and record review the facility failed to provide adequate supervision for 1 (Resident #449) of 4 residents reviewed for accidents/hazards, resulting in the potential for resident to sustain a fall with injury. Findings include: Resident #449: Review of an admission Record revealed Resident #449 was a male with pertinent diagnoses which included dementia, stroke, muscle weakness, reduced mobility, need for assistance with personal care, delirium, anemia, attention and concentration deficit, frontal lobe and executive function deficit (difficult to start or complete tasks), aphasia (loss of the ability to understand or express speech caused by brain damage, like with a stroke), dysphagia (damage to the brain responsible for production and comprehension of speech), and memory deficit. Review of current Care Plan for Resident #449, revised on 11/7/2023, revealed the focus, .(Resident #449) has altered functional mobility and ADLs related to: CVA (cerebral vascular accident- stroke)…

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, interview, and record review, the facility failed to provide timely incontinence care and perform hand hygiene in accordance with standard infection control practices in 1 (Resident #29) of 1 resident reviewed for UTI's (urinary tract infections), resulting in the potential for skin breakdown and recurrent infection. Findings include: Review of an admission Record revealed Resident #29 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 11/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #29 was cognitively impaired. Review of Resident #29's Care Plan revealed, .altered functional mobility and ADL's .Interventions: .Elimination: Wears incontinence products, check and change before and after meals, HS (bedtime) with rounds and prn (as needed), assist when verbal and…

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, interview, and record review the facility failed to follow physician orders related to the application of a Continuous Positive Aireway Pressure (CPAP - used to treat sleep apnea) in the evening in 1 (Resident #63) of 1 resident reviewed for CPAP use, resulting in the potential for respiratory distress while sleeping. Findings include: Review of an admission Record revealed Resident #63 had pertinent diagnoses which included obstructive sleep apnea, morbid obesity, and a history of Covid-19. Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 10/31/23 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #63 was cognitively intact. During an observation and interview on 11/27/23 at 1:33 PM., Resident #63 reported she could not remember the last time she wore her CPAP at night. Resident #63 reported that the staff did not put her CPAP on her at night. Resident #63's CPAP mask was observed in a bag on top of the CPAP machine, under a red towel on the bedside table. Resident #63 reported…

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 interview and record review, the facility failed to ensure necessary clinical treatments were ordered and/or documented in 2 (Resident #77 & #448) of 2 residents reviewed for quality of care, resulting the potential for residents not receiving appropriate interventions. Findings include: Resident #77: Review of an admission Record revealed Resident #77 was a male with pertinent diagnoses which included pseudocyst of pancreas (fluid collection surrounded by a wall of fibrous & granulation tissue), acute kidney failure with medullary necrosis ( a disorder of the kidneys in which all or part of the openings of the collecting ducts enter the kidney and where urine flows inot the ureters), moderate protein calorie malnutrition, gall stones, pancreatitis (inflammation of the pancreas), spinal cord damage, heart failure, and muscle weakness. Review of current Care Plan for Resident #77, revised on 10/30/23, revealed the following interventions, .PHYSICIAN ORDERS: admission orders implemented as noted on the…

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.