West Woods of Bridgman

In the surveyor’s words

From the most serious findings on record at West Woods of Bridgman, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 16, 2026

  This 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.Findings include:The immediate jeopardy began on [DATE] and was identified on [DATE] due to the facilities failure to assess for an acute change in condition, follow physician orders for medical laboratory testing, and notify 911 EMS when Resident #1 was found unresponsive, lethargic, hypotensive and… […]

• Actual harm, isolatedF686Jun 30, 2026

  This 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).Findings include: Resident #5Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had… […]

• Actual harm, isolatedF725Jan 16, 2026

  This 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.Findings include: Review of an admission Record revealed Resident #1 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: bipolar disorder (a mental health disorder characterized by significant mood swings), dementia (a syndrome characterized by a decline in cognitive function affecting memory, thinking,… […]

• Actual harm, isolatedF940Jan 16, 2026

  Based 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. Findings include:Resident #1Review of Interdisciplinary Documentation for Resident #1 dated [DATE] at 03:16 AM (3:16 am) and authored by Registered Nurse (RN) V at 8:19 am on [DATE] revealed .PA (physician assistant) notified of patient's change in condition, including hypotension (83/56 BP Blood pressure).lethargy, cool skin, significant bilateral lower-extremity edema, and blue-to purplish fluid-filled blisters on posterior heels bilaterally. […]

• Actual harm, isolatedF689Aug 20, 2025

  Based 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.Findings include: Resident #1 Review of an admission Record revealed Resident #1 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior). […]