West Woods of Niles

Inspectors wroteThis citation pertains to intake #3052734 and #3065589Based on interview and record review the facility failed to ensure quality of care and obtain physician orders to manage and monitor a JP Drain (Jackson Pratt drain- a surgical suction device that removes fluid from a wound to promote healing and reduce infection risk) and drain insertion/wound site for 1 (Resident #9) of 3 resident reviewed for quality of care resulting in a lack of managing, a lack of monitoring, and unmet care needs.

Inspectors wroteThis citation pertains to intake #3052734 and #3065589Based on interview and record review the facility failed to obtain treatment orders for pressure ulcers and prevent the development of an additional pressure ulcer for 1 (Resident #9) of 3 residents reviewed for pressure ulcers resulting in Resident #9 not receiving wound care timely and the development of a stage 1/DTI (a non-blanchable redness or discoloration over intact skin/ Deep Tissue Injury).

Inspectors wroteThis citation pertains to intake # 2715364. Based on interview and record review, the facility failed to provide quality wound care to promote healing and prevent the deterioration of a pressure ulcer for 1 (Resident #121) of 3 residents reviewed for wound care resulting in an Immediate Jeopardy when on 1/8/26, Resident #121 was hospitalized with altered mental status and septic shock (life-threatening condition caused by a severe infection) from a necrotic (death of cells in tissue) sacral ulcer (pressure ulcer at the base of the spine) with osteomyelitis (infection in a bone) requiring surgical intervention and bone debridement.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual performance evaluations for certified nursing assistants were completed, resulting in the potential for the delivery of nursing and related services that does not support or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food and drink at a palatable temperature in 2 (R32 and R72) of 22 residents reviewed for palatability among all residents. This deficient practice has the potential to result in decreased food consumption and potential nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain complete and accurate medical records for 2 (Resident #121 and #19) of 22 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain effective infection control practices for 6 residents (#90, #76, #32, #8, #13 and #27) of 6 sampled for infection control; as evidenced by failure to 1. Properly implement transmission-based precautions and complete testing on symptomatic residents; 2. Ensure resident shared equipment was properly cleaned; and 3. Ensure the cleanliness of a tube feeding pole/pump and the surrounding surfaces.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe and sanitary environment, for 2 (Resident #4 and Resident #103) including a dusty and broken oscillating fan and an unkept resident room resulting in the potential for unsafe and uncomfortable resident environment.

Inspectors wroteBased on interview and record review the facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) to 3 (Resident #123, Resident #124, and Resident #125) of 3 residents reviewed for proper notification related to Medicare A insurance coverage and facility care costs.

Inspectors wroteThis citation pertains to intake #2735016. Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a staff member.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of potential neglect (elopement) to the State Agency for 1 resident (Resident #109) of 1 resident reviewed for reportable incidents resulting in the potential for additional reportable incidents to not be reported and cause a delay in the investigative process.

Inspectors wroteBased on interview and record review the facility failed to ensure proper procedure for a facility-initiated discharge for 1 (Resident #120) of 1 resident reviewed for facility-initiated discharge resulting in the unapproved discharge of the resident from the facility.

Inspectors wroteBased 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.

Inspectors wroteThis 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteThis citation pertains to intakes: 2659614 & 2661255Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #100) of 7 residents reviewed for medication errors, resulting in a change in condition, emergent transfer, and hospitalization for Resident #100.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteThis 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.

Inspectors wroteBased 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.

Inspectors wroteThis citation pertains to intake MI00143902 Based on interview and record review the facility failed to ensure a timely assessment for a change in condition in 1 (Resident #100) of 1 resident reviewed for timely assessment for a change in condition resulting in the delay of communication with a provider, delay of transfer to acute care setting for evaluation and a delay of treatment.

Inspectors wroteThis citation pertains to Intake MI00144494 Based on interview and record review the facility failed to prevent the worsening of a pressure ulcer in 1 (Resident #101) of 2 residents reviewed for pressure ulcers resulting in Resident #101 being sent to the hospital for evaluation and/or treatment.

Inspectors wroteThis 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.

Inspectors wroteBased 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.

Inspectors wroteThis citation pertains to intake numbers MI00143061 and MI00143279. Based on interview and record review the facility failed to ensure that staff followed care planned interventions and professional standards of care for 2 residents (Resident #1 & #3) out of 5 residents reviewed for accidents and hazards, resulting in major injuries (fractures) after avoidable falls.

Inspectors wroteThis 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.

Inspectors wroteThis 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.