Sholom Home West

Inspectors wroteBased on interview and document review, the facility failed to ensure the Ombudsman for Long Term Care (OMB - LTC) was notified of resident transfers or discharges for 3 of 5 residents (R73, R139, R141) reviewed for transfers or discharges from the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident records upon discharge were complete and accurate for 1 of 1 resident (R141) reviewed for discharge. Findings Include - R141's Face Sheet (undated) documented the diagnoses of sepsis due to methicillin susceptible staphylococcus aureus ( a germ found on people's skin ), pneumonia, acute and subacute infective endocarditis (inflammation of the heart's inner lining). R141's Minimum Data Set (MDS), with a registered nurse signing date of 2/07/26, documented R141 was moderately cognitively impaired and require set up to moderate assistance with all activities of daily living. R141's nurse progress notes on 2/08/26, indicated R141 had eloped from the facility and was later found wondering at Target. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to complete proper disinfection of a blood glucose monitor for 1 of 1 resident (R10) reviewed for glucose monitoring.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain resident equipment cleanliness of intravenous (IV) poles for 1 of 1 resident (R86) reviewed for tube feeding. R86's quarterly Minimum Data Set (MDS) dated [DATE], indicated R86 had severe cognitive impairment and was dependent on assistance from staff for activities of daily living (ADLs). R86 diagnoses included dysphagia (difficulty swallowing food or liquids) following stroke, hypertension, gastrostomy tube (tube into stomach for feeding), hemiplegia (paralysis on one side) and hemiparesis (muscle weakness) following stroke, and encephalopathy (group of conditions that cause brain dysfunction). On 3/17/26 at 8:40 a.m., observed IV pole in R86's room with tube feeding pump attached. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a call light to one of three residents (R2) reviewed for access to call lights when R2 did not have a functioning call light for an unknown number of weeks. Findings Include: R2's Minimum Data Set (MDS) admission assessment dated [DATE], indicated R2 was admitted to the facility on [DATE]. The MDS indicated R2 was continent of bowel and bladder, and independent with toileting. R2's brief interview for mental status (BIMS) was 15 indicating intact cognition. The census report, undated, indicated R2 moved to room [ROOM NUMBER] on 3/7/24. R2's Quarterly Review MDS dated [DATE], indicated R2 was frequently incontinent of bowel and bladder. R2's Significant Change in Status MDS dated [DATE], indicated R2 required moderate assistance with toileting. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R26, R35, R102 and R104) reviewed for grievances.

Inspectors wroteBased on interview and document review, the facility failed to hold care conference meetings with the resident and/or their representative to allow the resident and/or representative the opportunity to review and participate in the revision of the care plan for 5 of 5 residents (R14, R105, R6, R74,R97) reviewed for care planning.

Inspectors wroteBased on interview, observation and document review, the facility failed to provide a process by which residents could make their own food selections for meals for 6 of 6 residents (R241, R73, R6, R23, R104, R35) reviewed for food.

Inspectors wroteBased on interview and document review the facility failed to complete a level II preadmission screening and resident review (PASARR) for 1 of 2 residents (R95) reviewed with a new mental illness diagnosis.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were offered for 1 of 1 resident (R97) reviewed for activities.

Inspectors wroteBased on observation, interview and document review the facility failed to provide timely repositioning for 1 of 1 resident (R58) who was dependent upon staff for repositioning and high risk for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines by appropriately implementing measures to prevent the spread of infection when the facility failed to ensure personal protective equipment (PPE) was discarded prior to leaving resident rooms (R19 and R1), and failed to follow enhanced barrier precautions (EBP) for 1 of 1 resident (R58) who had an indwelling device present.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R24, R25, and R124) received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for change in condition.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess and monitor edema for 2 of 2 (R1, R3) residents reviewed with lower extremity edema.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R28) observed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide restorative walking program as ordered for 1 of 1 residents (R42) reviewed for range of motion (ROM).