Woodbriar Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interview and facility policy review, it was determined that the facility failed to ensure the Minimum Data Set (MDS) was accurate and complete to facilitate the ability to plan and provide necessary care and services for three (Residents #4, #17 and #64) of three residents reviewed. The findings include:Resident #4Review of an admission Record indicated the facility admitted Resident #4 with diagnoses that included atherosclerotic heart disease (a buildup of fats and cholesterol in the artery walls, leading to narrowed or hardened arteries) and cerebral infarction (a stroke caused by blockage in an artery supplying blood to the brain).Review of a quarterly MDS with an Assessment Reference Date (ARD) of 02/09/2026 for Resident #4 revealed that the resident was taking medications that included an anticoagulant (medication that prevents or reduces the formation of blood clots) and an antiplatelet (medication that prevents blood platelets from sticking together. Review of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to protect a resident's right to be free from verbal and mental abuse for one (Resident #38) of four residents reviewed. The findings include: Review of Resident #38's admission Record revealed the facility admitted Resident #38 on 04/12/2022 with diagnoses that included dementia, mood disorder, bipolar disorder, limitations of activities due to disabilities, altered mental status, a sleeping disorder, and an excessive persistent thirst with an insatiable urge to drink fluids. Review of an annual Minimum Data Set with an Assessment Reference Date of 01/12/2026, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. The MDS indicated no acute altered mental status present, no behaviors had been displayed towards others, and no impairment to arms or legs. The MDS also revealed Resident #38 used a wheelchair for mobility and Resident #38's eating skills were indicated as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 1 (Residents #38) sampled resident whose care plan was reviewed. The findings are: 1. A review of an admission Record indicated the facility admitted Resident #38 with diagnoses of cerebral infarction (stroke), hypertension (high blood pressure), and congestive heart failure (a condition in which a person heart doesn't pump correctly). The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/2024 revealed Resident #38 had a Brief Interview Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. In Section N part N0415 subpart E Anticoagulant (blood thinner) revealed that it was marked as given within the last 7 days of ARD period. Review of Resident #38's Care Plan, with completed update on 10/9/2024, revealed the resident did not have anticoagulants nor the medication Eliquis (Blood thinner) care planned. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, employee record review, and document review, it was determined the facility failed to ensure five Nursing Assistants (NA) completed competency training and failed to complete the certification testing within 120 days from completion of their initial training. The findings are: Reviewed employee records of all reported full-time Nursing Assistants (NA) employed at the facility on10/09/2024 at 1:30 PM, all five NAs were hired within the last three months, and each had not yet completed the certification process. The only records provided were the certificates stating the completion of the initial 90-hour training. There were no records showing competencies from the initial training, nor any from the facility in which they were employed. During an interview on 10/09/2024 at 2:40 PM, the Human Resources/Social Services (HR/Social) confirmed the facility has five NAs which have not completed the requirements for certification. Records provided by the facility indicate the following are NAs awaiting testing certification and dates of completion of initial 90 hours of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure residents received oxygen therapy at the physician ordered flow rate. This failed practice affected 2 (Resident #17, #19) of 3 (Resident #17, #19, #34) sampled residents, residing on the 200 Hall who had orders for oxygen, according to a list provided by the Administrator on 08/17/2023 at 10:48 AM. The findings are: 1.The following observations were made of Resident #17: a. On 08/14/23 at 3:09 PM Resident #17 was sitting in her room in her wheelchair. Her oxygen was set at 1.5 liters per minute. b. On 08/16/23 at 8:42 AM Resident #17 was sitting at bedside in a wheelchair, with oxygen off. Concentrator on and set on 1.5 liters, nasal cannula in a bag dated, 08/13/23. I usually have that oxygen on. The Surveyor asked if she puts oxygen on and off by herself. No, the nurse or Certified Nursing Assistant [CNA] puts it on me. I cough a lot and need it since I had pneumonia. c. On 08/16/23 at 10:10 AM Resident #17 was sitting in a wheelchair resting with her eyes closed, Oxygen on at 1-1.5 liters per minute.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and policy and procedure review, the facility failed to prevent the potential for infection and cross contamination in the facility laundry processing area as evidenced by staff placing half consumed food and drinks on the laundry folding table next to clean, folded resident linens. This failed practice had the potential to effect 18 (Resident #1, #3, #4, #5, #8, #16, #17, #19, #20, #26, #34, #37, #39, #40, #46, #51, #54 and #59) sampled residents, and 62 residents who have their laundry done in the facility based on a list provided by the Administrator on 08/18/23 at 8:41 AM. The findings are: a. During a facility tour of the Laundry Room on 08/17/23 at 1:58 PM, the Surveyor observed a soft drink in a plastic bottle sitting on top of the folding counter surface next to a stack of clean, pink folded transfer pads. There was a clear, plastic cup half full of a brown colored liquid covered with a plastic lid with an exposed straw sitting near the right corner end of the stainless-steel countertop. There were 2 containers of salsa in Styrofoam cups with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and to care for residents in a manner to protect their right to a dignified existence and privacy. This failed practice affected 1 (Resident #16) of 3 (Resident #9, #16, #63), residents and had the potential to affect 10 residents residing on 100 Hall. The findings are: 1. During facility observations on 08/14/23 at 11:29 AM, Resident #16 pointed to her bathroom and said, They locked the bathroom door, and gave my roommate a bedside commode. If I want to use the bathroom, I must go down the hallway. It's a good bathroom. They said the bathroom was too small and we might get hurt. Can you help me get my door unlocked? Certified Nursing Assistant [CNA] #2 walked in and said, I could hear through the door, we locked her bathroom door. When she calls, we take her to the bathroom up front. Resident #16 said, They let my roommate use a bedside commode, but told me I could not use one. I do not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to secure confidential and private medical information on an open laptop. This failed practice had the potential to affect all 13 residents residing on 200 Hall according to a census of 200 Hall received from the Administrator [Admin] on 08/14/2023 at 11:20 AM. The findings are: 1. On 08/16/23 at 2:26 PM, during facility rounds on 200 Hall, the Surveyor observed an open laptop, sitting on a small table. The laptop was open with the 200-Hall Census, in clear view of anyone walking in the 200 Hallway. 2. On 08/16/23 at 2:27 PM, Registered Nurse [RN] #1 came out of a resident room. The Surveyor asked RN #1 if it was appropriate for a computer to be left on with resident information pulled up, and visible to anyone in the hallway. RN #1 said, No, it is absolutely not appropriate. The Surveyor observed RN #1 lock the computer screen. During the interview RN #1 said, The screen should be off or locked. Anyone, like yourself, could see medical information on any resident we have. It is Health Insurance Portability and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure fingernails were clean, groomed, and free from chipped nail polish to promote good personal hygiene and grooming for 1 (Resident #51) of 7 (Resident #4, #20, #37, #39, #46, #51 and #59) sampled residents that were dependent on staff for fingernail care on the Special Care Unit. This failed practice had the potential to affect 16 residents that lived on the Special Care Unit and were dependent on staff for nail care according to a list provided by the Administrator on 8/18/23 at 8:40AM. The findings are: 1. Resident #51 had a diagnosis of Alzheimer's Dementia, Anxiety, and Osteoarthritis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/2/23 documented that she scored 1 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance with dressing, toileting, personal hygiene, limited assistance with bed mobility, transfer, and supervision with eating.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.