Westwood Post Acute

actions that can be measured.

common sleep disorder that can make it hard to fall asleep or stay asleep) care plan.

This failure had

titled, admission Record, indicated Resident 1 was admitted with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (a type of stroke caused by a blockage in brain blood vessels, resulting in a lack of oxygen and brain cell death) affecting right dominant side (the side of the body that a person prefers, uses more frequently, and is stronger or more skillful with), aphasia (a disorder that makes it difficult to speak), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental illness that causes constant fear) and insomnia.Review of Resident 1's order summary report, it indicated an order dated 9/16/2023, Zolpidem Tartrate [Ambien, brand name - a prescription sedative-hypnotic medication for insomnia] Tablet 5 MG [milligram - unit of measurement] Give 1 tablet by mouth as needed for Insomnia for 14 days May give 1 to 2 tablets as needed.Review of Resident 1's care plan for insomnia, date initiated 9/12/2023, indicated, Indicate & provide non-pharmacological intervention: 1.

Reposition/limb elevation 2.

Snacks/drinks 3.

Redirect/reassurance/emotional support.8 Deep breathing/relaxation exercises.Monitor and record number of hours of sleep.Try non-pharmacological measures: avoid heavy meals, caffeine, large fluid intake before sleep and offer milk.Review of Resident 1's September 2023's nursing progress notes and medication administration record (MAR -a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), indicated there was no documentation of Resident 1's monitoring of hours of sleep and no documentation that the non-pharmacological interventions were provided.During a concurrent interview with the infection preventionist (IP) nurse and record review on 3/26/2026 at 1:15 p.m., the IP reviewed Resident 1's September 2023 nursing progress notes and MAR and stated there was no documentation of hours of sleep monitoring and no documentation that the non-pharmacological interventions were provided.

The IP confirmed Resident 1's insomnia care plan was not implemented.During a phone interview with the director of nursing (DON) on 4/2/2026 at 10:43 a.m., the DON stated if it was care planned that nurses should monitor residents' hours of sleep and should provide non-pharmacological interventions, nurses should have implemented these interventions.

The DON further stated the intervention provided to residents should have been documented in nurse's notes or MAR.During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, date revised March 2022, indicated, .a person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE