West Woods of Bridgman

Inspectors wroteThis citation pertains to intake #3045701Based on observation, interview, and record review the facility failed to monitor and prevent the worsening of a pressure ulcer for 1 (Resident #5) and prevent the development of a pressure injury/ulcer in 1 (Resident #7) of 3 residents reviewed for pressure injuries/ulcers resulting in Resident #5 stage IV pressure wound (most severe, deep open wound that extends through the skin, underlying tissue, muscle and bone) worsening, and Resident #7 developing a stage II pressure injury (shallow, wound that affects both top layers of skin, and park of the under layer, appearing red, pink sore or blister).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain activities of daily living (ADLs) specifically showers for 1 (Resident #5) of 8 sampled residents, resulting in an unkempt appearance and the potential for unmet care need.

Inspectors wroteThis citation pertains to intakes 3056471 and 3056531. Based on interview and record review facility staff failed to notify a nurse and ensure a post-fall assessment was completed timely for 1 (Resident #6) of 3 residents reviewed for falls resulting in a delay in an assessment following a staff assisted fall and the potential for an injury and/or an increase in pain to go unaddressed.

Inspectors wroteThis citation pertains to intake #3045701Based on interview and record review the facility failed to ensure complete and accurate medical records of 3 (Resident #5, Resident #7, and Resident #6) of 8 sampled residents resulting in incomplete and inaccurate documentation and the potential for a diminished medical outcome.

Inspectors wroteThis citation pertains to intake #2698524Based on interview and record review the facility failed to adequately assess and treat a resident experiencing an acute change of condition timely for 1 (Resident #1) of 3 residents reviewed for quality of care, resulting in an immediate jeopardy when, on [DATE], Resident #1 was found unresponsive, lethargic, hypotensive (low blood pressure) and 911 EMS (emergency medical services) were not immediately contacted. Resident #1 subsequently died.

Inspectors wroteThis citation pertains to Intake # 2698524Based on interview and record review the facility failed to ensure sufficient staffing to meet the needs and maintain the highest practicable well-being of 1 (Resident #1) of 1 resident reviewed for sufficient staffing, resulting in a delay in treatment for Resident #1, who experienced an acute change in condition and was not transported timely to an acute care facility and subsequently died.

Inspectors wroteBased on interview and record review the facility failed to ensure that an effective training program for newly hired nurses was provided and monitored for all newly hired nurses in 1 of 1 resident (Resident #1) reviewed for training, resulting in a delay in treatment and emergent hospital transfer for Resident #1.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a person-centered care plan for 1 (Resident #2) of 3 residents reviewed for person centered care planning resulting in the potential for injury and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were free from significant medication errors in 1 (Resident #1) of 1 resident reviewed for significant medication error resulting in the potential for Resident #1 to experience lethargy (decreased alertness and response), dizziness, and an increased risk for falls.

Inspectors wroteBased on interview, and record review, the facility failed to complete an annual performance review for 2 Certified Nursing Assistants (CNAs) (CNA's F and DD) of 5 CNA's reviewed for annual performance evaluations, resulting in the potential for unidentified CNA performance concerns, a lack of training related to staff performance review outcomes, and the potential for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nurse Assistants (CNA's) completed the required 12 hours of in-service training to ensure continued competency in 1 of 5 CNA's reviewed for in-service training, resulting in the potential for a decrease in resident safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and implement interventions to prevent falls for 2 residents (Resident #1 and Resident #16) of 7 sampled residents reviewed for accidents, resulting in Resident #1 falling and sustaining a pelvic fracture, along with severe pain, and Resident #16 falling and hitting his head during an improper transfer.

Inspectors wroteThis citation pertains to Intake 1210578. Based on interview and record review, the facility failed to provide care and services to promote dignity and respect in 4 of 5 residents (Resident #31, #3, #17, #16) reviewed for dignity/respect, and 7 of 12 residents from the confidential group meeting, resulting in the potential for unmet care needs and feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to employ an Activity Director with the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact the residents who choose to participate in structured activities and/or are dependent for their leisure needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate infection control practices that included 1.) proper hand hygiene during medication administration for 4 (R27, R6, R52, and R3) residents observed during medication administration, 2.) resident-shared equipment not being cleaned prior to use for 1 (R6) of 18 residents and, 3.) adequate Enhanced Barrier Precautions (EBP) for 2 (R3, R5) of 2 residents observed for infection control practices, resulting in the potential of cross-contamination and the harborage of pathogens leading to infection among a vulnerable population.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 8/18/25 at 10:59 AM, observation of the kitchen hand sink, near the dish machine area, found that the soap and the paper towel dispenser for the hand sink are on the opposite wall as the hand sink. Further observation found the paper towel dispenser over an area used for drying clean pots, pans, and utensils. On 8/18/25 at 1:25 PM, An interview with Maintenance Director (MD) I found that the facility is in good repair, however there are a few roof leaks that pop up when the rain gets heavy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level II Exemption Form 3878 (Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification Level II Screening) was completed timely for 1 resident (Resident #2) of 3 residents reviewed for PASARR, resulting in the lack of the local Community Mental Health Services Program (CMHSP) to have a complete picture of the resident status.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (activities of daily living) care, to include nail care, to a dependent resident in 1 (Resident #36) of 4 residents reviewed for ADL care, resulting in the potential for Resident #36 to experience feelings of embarrassment and diminished self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 18 Residents (Resident #1) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, anxiety and boredom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate care and appropriate treatment for 2 residents (Resident #3 and Resident #16) of 18 sampled residents reviewed for quality of care, resulting in the potential for development of new wounds and infection.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide services to prevent the development of and promote healing of pressure ulcers/injuries for 1 (Resident #8) of 3 residents, resulting in the development of pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide tracheostomy emergency care equipment (Ambu bag, trach device and obturator (Key component used during the insertion or change of a tracheostomy tube (trach; inserted into the stoma (opening in the trachea to maintain an open airway and facilitate breathing) at the bedside for 1 (Resident #8) of 1 resident reviewed for respiratory care, resulting in the potential of serious negative outcome if Resident #8 were to need emergent tracheostomy replacement.

Inspectors wroteBased on observation, interview and record, the facility failed to ensure proper labeling of medications in 1 of 1 medication cart (South medication cart) reviewed for medication storage, resulting in the potential for residents to receive medications with altered potency and decreased efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 1 of 18 residents (Resident #3) reviewed for accuracy of medical records, resulting in inaccurate treatment records and the potential for providers to not have an accurate picture of resident status and condition.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman of residents who transferred from the facility, with the reason for a transfer.

Inspectors wroteThis citation pertains to Intake MI00152539 Based on interview and record review the facility failed to ensure that a therapy evaluation (a process to determine a resident's need for therapy services) was completed at the time of re-admission to the facility following an inpatient hospital stay for 1 (Resident #2) of 3 residents reviewed for therapy evaluation at the time of re-admission, resulting in the potential for the inability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop person centered care plan for 2 Residents (#8 & #32) of 16 residents reviewed for person centered care plans.

Inspectors wroteThis citation pertains to MI00146198. Based on interview and record review, the facility failed to update the transfer status of one resident (Resident #268) of 16 residents reviewed for comprehensive care plans resulting in a skin tear.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to dependent residents in 1 of 16 residents (Resident #8) reviewed for activities of daily living needs.

Inspectors wroteThis citation pertains to MI00146198. Based on observation, interview, and record review the facility failed to implement gait belt use for safety during transfers of 2 of 8 residents (Resident #268, Resident #61) reviewed for transfer status resulting in the potential for injury during transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers and implement interventions to mitigate triggers for 1 of 1 residents (Resident # 32) reviewed for trauma informed care, resulting in the potential for previous traumas to be retriggered causing mental distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Quality Assessment and Process Improvement (QAPI) 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper use of personal protective equipment (PPE) for enhanced barrier precautions in 2 (Resident #1 and Resident #18) of 8 residents reviewed for implementation of enhanced barrier precautions, resulting in the potential for the spread of infection, cross contamination and disease transmission.

Inspectors wroteThis citation pertains to intake: MI00143833 Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice to ensure accurate transcription of medications and monitoring of potentially dangerous medications in 1 of 2 residents (Resident #84) reviewed standards of practice, resulting in an overdose of blood thinner medication and potential bleeding.

Inspectors wroteThis citation pertains to intake MI00143833 Based on interview and record review, the facility failed to ensure medications were administered at the correct dose per the physician's order for 1 of 2 residents (Resident #100) reviewed for significant medication errors, resulting in the potential for adverse effects of an overdose of an anticoagulant medication.

Inspectors wroteBased on observations, interview, and record review the facility failed to maintain safe and sanitary conditions in the kitchen for all residents who receive food prepared or stored in the kitchen resulting in the potential for biological contamination and the potential for the development of food borne illnesses.

Inspectors wroteThis citation pertains to intake #MI00137460 Based on interviews and record review the facility failed to follow posted menus for two residents (Resident #3 and #45), resulting in the potential for decline in nutritional intake and a potential for weight loss.

Inspectors wroteThis citation pertains to MI00130808 Based on observation, interview and record review the facility failed to ensure proper infection control measures were implemented for cleaning and disinfecting resident shared equipment, properly storing a nebulizer mask for Resident #59, and ensuring Resident #44's bedside fall mat had a cleanable surface area resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population.

Inspectors wroteThis citation pertains to intake #MI00130808 & MI00130380 Based on observation, and interview, the facility failed to maintain a sanitary, home-like environment, resulting in the potential for pest harborage conditions and a non-home-like environment.

Inspectors wroteBased on observation and interview, the facility failed to maintain dignity for one resident (R17) of 18 residents reviewed for dignity, resulting in the likelihood of feelings of embarrassment and humiliation based on the reasonable person concept.

Inspectors wroteBased on interview and record review, the facility failed to notify a Responsible Party of a change in care/condition for 1 of 18 residents (Resident #71) reviewed for notification of change, resulting in the Responsible Party not participating in medical decisions regarding care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 residents of 18 (Resident #8) reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) follow professional standards of nursing practice for physician notification of a change in condition, 2) complete assessments when an injury occurs, 3)notify of incident to nursing staff and kitchen personnel and 4) administer treatment with an order for 1 of 18 residents (Resident #42) reviewed for accidents, resulting in the potential for further injury and the affected resident not maintaining or achieving their highest practical physical well-being.

Inspectors wroteResident #42: Review of an admission Record revealed Resident #42 was a male with pertinent diagnoses which included ataxic gait (unsteady, staggering gait, poor balance, widened base of support), diabetes, muscle weakness, need for assistance with personal care, kidney disease, dysphagia (impairment in the production of speech resulting from brain disease or damage), and cognitive communication deficit, and unsteadiness on feet. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 5/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated Resident #42 was moderately cognitively impaired. Review of current Care Plan for Resident #42, revised on 2/21/23, revealed the focus, .(Resident #42) has altered functional mobility and ADLs related to blindness, age-related debility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommended laboratory diagnostic services were followed and completed for one resident (R17) reviewed for laboratory services, resulting in the potential of delayed treatment and impaired coordination of care.