Sholom Home West

In the surveyor’s words

From the most serious findings on record at Sholom Home West, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF628Mar 19, 2026

  Based 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. Findings include: R73's comprehensive Minimum Data Set (MDS), dated [DATE], indicated R73 was cognitively intact, and diagnoses included chronic kidney disease, and neuralgia and neuritis (general nerve pain or inflammation). R73's progress note, dated 2/16/26 at 5:43 p.m., indicated R73 was sent to the hospital for blood emesis and loss of consciousness. […]

• No harm, potential for more than minimal, patternF585Jan 8, 2025

  Based 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. Findings include: On 1/7/25 at 1:37 p.m., a resident council meeting was held with four residents which included R26 R26, R35, R102 and R104. During the resident council meeting, all four residents indicated they were not aware how to file a grievance form. R35 stated she thought there was a form at the front door that could be filled out and turned into a nurse. R35 further stated she did not think the form could be filled out without the help of a nurse. […]

• No harm, potential for more than minimal, patternF657Jan 8, 2025

  Based 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. Findings include: R14's facesheet printed on 1/8/25, included diagnoses of Alzheimer's disease, dementia, depression, chronic kidney disease, diabetes, and congestive heart failure (heart doesn't pump as it should). R14's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R14 was cognitively intact, had clear speech, could understand and be understood. […]

• No harm, potential for more than minimal, patternF803Jan 8, 2025

  Based 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. Findings include: R241's facesheet printed on 1/8/25, included diagnoses of chronic kidney disease and congestive heart failure (heart doesn't pump as it should). R241's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R241 was cognitively intact, had clear speech, could understand and be understood. R241 required supervision for most activities of daily living (ADL) and could eat independently after set-up help. R241's orders dated 12/17/24, indicated a heart healthy diet. […]

• No harm, potential for more than minimal, patternF550Oct 14, 2022

  Based on observation, document, and interviews, the facility failed to promote dignity of its residents when a resident's family member found TikTok videos made by a nurse who was working in the facility and wearing her employee badge. The nurse created and posted social media videos on TikTok that disrespected residents of the facility who were prescribed medications for psychiatric illness and/or neurological illness. Findings include: Upon interview on 10/11/22, at 9:52 a.m. A resident's family member (FM)-A provided TikTok videos made by a facility licensed practical nurse (LPN)-A that FM-A found disturbing. […]