The Suites at Western Home Communities

In the surveyor’s words

From the most serious findings on record at The Suites at Western Home Communities, in the surveyor’s own words.

• Actual harm, isolatedF658Feb 9, 2023

  Based on facility incident review, clinical record review, personnel file review, facility policy review and staff interview the facility failed to ensure competent, trained staff was passing medications to residents on the second floor of the facility. The facility reported a census of 16 residents on the second floor at the time of the occurrence. This failure resulted in harm to the resident when he had low blood pressure and a low heart rate requiring hospitalization (Resident #129). Finding include: Facility Incident report completed on 1/13/22 at 5:39 PM documented Resident #129 appeared to receive another resident's medication. The Incident Report did not state what medications the resident received. […]

• Actual harm, isolatedF689Jan 19, 2021

  Based on record review and staff interview the facility failed to provide adequate supervision to prevent a fall with injury in 1 of 3 residents reviewed (Resident #9). The facility reported a census of 79 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #9 [DIAGNOSES REDACTED]. Resident #9 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Resident needed extensive assist to total dependence of 2 staff with transfers, bed mobility, dressing, personal hygiene, and had a history of [REDACTED]. Fall Risk Evaluation dated 10/9/20 on Resident #9 initial admission revealed a score of 12, which indicated the resident at risk for falls. Incident Report dated 10/16/20 at 9:00 p.m. […]

• No harm, potential for more than minimal, patternF805Feb 29, 2024

  Based on observation, policy review, and staff interview the facility failed to serve meals in a therapeutic form necessary to meet residents' needs. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #59 dated 12/22/23 documented a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. The MDS documented diagnoses including: stroke, traumatic brain dysfunction (occurs as a result of a severe injury to the head with immediate or delayed symptoms which may include confusion, blurry vision, and concentration difficulty), traumatic spinal cord dysfunction (a spinal cord injury which may cause a loss of strength, sensation, and function below the site of the injury), and progressive… […]

• No harm, potential for more than minimal, patternF812Feb 29, 2024

  Based on observation, policy review, and staff interview the facility failed to serve meals under sanitary conditions and at safe temperatures to prevent food-borne illness. The facility reported a census of 61 residents. Findings include: During an observation of the noon meal on 2/27/24 from 11:45 AM to 12:55 PM Staff A, Certified Nursing Aide (CNA) observed setting the serving scoops face down on the counter top without a barrier. Staff A then placed the scoops into the food that was served out to multiple residents. Staff A placed a blender lid face down directly onto the counter top and then used the blender to grind food for two residents before serving them. […]

• No harm, potential for more than minimal, patternF812Feb 9, 2023

  Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing, preparing, and serving food. The facility reported a census of 74 residents. Findings include: During an initial observation of the second-floor kitchen on 2/06/23 at 9:55 AM, the following findings were identified. The front kitchen cabinets contained three loaves of undated bread that were tied in a knot and an open, undated carton of apple cider vinegar. The General Electric (GE) refrigerator in the front kitchen area had an open, undated tub of ice cream in the freezer compartment. The [NAME] freezer located in the rear kitchen area had an open, undated package of dough. […]