Woodland Manor Nursing Center

Based on observation, interview, and record review, the facility failed to follow infection control precautions by not changing gloves or washing hands during resident care for four residents (Residents #7, #11, #103, and #134) out of six sampled residents, by not following enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for five residents (Residents #7, #41, #103, #104, and #134) out of five sampled residents, and during medication administration for three residents (Residents #38, #104 and #141) out of seven sampled residents. The facility census was 126.Review of the facility's policy titled, Policy and Procedure - Enhanced Barrier Precautions, dated 04/01/24, showed: - Whenever a resident has an infection regardless of their MDRO status, the community will utilize EBP for any time that physical contact is…

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 provide showers for three residents (Resident #1, #2, and #5) out of six sampled residents. The facility's census was 124.Review of the facility's policy, Showers, dated January 5, 2017, showed:- It is the policy of the facility to provide showers on a bi-weekly basis;- Requests for more frequent showers will be granted and addressed via the plan of care;- Shower sheets will be reviewed by the charge nurse;- The charge nurse will forward all completed shower sheets to the clinical nurse managers;- Clinical nurse managers will ensure a shower sheet is received for each shower and ensure interventions are in place for any areas identified during showers and track the area weekly on the weekly skin or pressure report;- Shower sheets will be kept in the clinical managers' office for a period of two weeks.Review of the Certified Nursing Assistant (CNA) Meeting notes, dated November 25, 2025, showed:- Showers need to be completed in a timely manner, not at the end of a shift. Day shift - after breakfast and Evening…

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 interview and record review, the facility failed to notify the physician and resident representative of a fall for one resident (Resident #1) out of five sampled residents. The facility census was 122. 1. Review of the facility policy titled, Following a Resident Fall, dated 04/29/25, showed: - The licensed nurse assess the resident for injuries (including neuro checks if indicated) and provides necessary treatment and initiates the Situation, Background, Assessment, Recommendation (SBAR - a structured communication tool used to improve the clarity and efficiency of information exchange between healthcare professionals, especially when reporting a change in a resident's condition); - The physician and resident's representatives are notified; 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 03/05/2025, showed: - admitted to facility on 02/21/23; - Cognition impaired; - Diagnoses of dementia (a general term for a decline in mental ability severe enough to interfere 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.

Based on interview and record review, the facility failed to provide their final investigation in a timely manner after a report of sexual abuse for one resident (Resident #1) of three sampled residents. On 4/5/2025, Resident #1 reported Registered Nurse (RN) A had sexually assaulted him/her on 04/3/25. As of 04/15/25, the facility had not completed the investigation. The census was 130. Review of the facility's Abuse Policy and Procedures/Investigation Protocols dated 12/14/18 showed: - Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor, the Administrator (ADM) or the Director of Nurses (DON); - Once the ADM/DON determine that there is possible mistreatment, the ADM or DON will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident; - The person in charge of the investigation will report the conclusions of the investigation to the ADM or DON designee within five working days of the reported incident.…

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 interview and record review, the facility failed to ensure a code status was consistently documented throughout the medical record for two residents (Residents #17 and #92) out of 21 sampled residents and for two residents (Residents #33 and #53) outside the sample. The facility census was 127. Review of the facility's policy titled, Advance Directives, not dated, showed: - Upon admission, every resident or resident representative is asked to determine code status; - Full Code - cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) performed when the resident experiences a catastrophic event such as cardiac/respiratory arrest or Do Not Resuscitate (DNR - does not want CPR); - The resident's code status will be reviewed with the resident and/or the resident representative annually; - The resident has the right to change their code status at any time. Review of facility's Code Status book (a book that gives…

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 interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when 13 residents (Residents #7, #17, #30, #34, #37, #39, #48, #50, #92, #101, #105, #121, and #126) out of 13 sampled residents transferred to the hospital. The facility's census was 127. Review of the facility policy titled, Hospital Transfer and Bed Hold Policy, undated, showed: - If the attending physician orders his/her patient to be transferred to the hospital, the family or responsible party will be notified and arrangements will be made; - Before there is a transfer of a resident to a hospital or a resident goes on a therapeutic leave, the resident and family or Durable Power of Attorney (DPOA) will be notified twice. The first will be during the admission process by the reading of the Bed Hold Policy. The second notice will be provided to the resident and family or DPOA at the time of the transfer to the hospital. A copy of this policy will be…

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 interview and record review, the facility failed to inform the resident and/or legal representative in writing of their bed hold policy at the time of transfer to the hospital for 12 residents (Resident #7, #17, #30, #34, #37, #48, #50, #92, #101, #105, #121, and #126) out of 13 sampled residents. The facility's census was 127. Review of the facility policy titled, Hospital Transfer and Bed Hold Policy, undated, showed: - In the event that you are transferred to a hospital, a copy of the bed hold policy will be sent with you. If you are a Medicaid recipient, you have access to Therapeutic Leave. You have 12 days leave between January and June and 12 days between July and December of each year; - Before there is a transfer of a resident to a hospital or a resident goes on a therapeutic leave, the resident and family or Durable Power of Attorney (DPOA) will be notified twice. The first will be during the admission process by the reading of the Bed Hold Policy. The second notice will be provided to the…

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 interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for two residents (Residents #3 and #17) out of 21 sampled residents. The facility census was 127. Review of the facility's policy titled, Care Plan Section Responsibility, March 2024, showed: - A care plan will be developed upon admission per Centers for Medicare and Medicaid Services (CMS) guidelines. It will be updated quarterly, and annually per CMS guidelines to ensure that there is a continuity of care, and is in accordance with the individual's needs. Care plan will also be updated with a significant change of condition; - The care plan must be based upon the resident assessment, choices and advance directives, if any. As the resident's status changes, the facility, attending practitioner, and the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. 1. Review of Resident #3's medical record showed: - An admission date of 09/27/24; - Diagnoses of urinary tract…

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 monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents and failed to update the care plan with new interventions to prevent additional falls for two residents (Residents #3 and #39) out of two sampled residents. The facility also failed to prevent resident access to liquor in an unlocked office. This had the potential to affect all residents who were able to move freely around the facility. The facility census was 127. Review of the facility policy titled, Falls, dated 09/22/21, showed: - The Minimum Data Set (MDS - a federally mandatory assessment completed by facility staff) defines a fall as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force; - Procedure following a fall includes…

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 assess residents for the use of side rails prior to installation or use, the facility failed to obtain informed consent from the resident or if applicable, the resident representative, and the facility also failed to provide on-going monitoring, supervision, and routine maintenance of the beds with side rails in use for eight residents (Residents #3, #7, #48, #50, #105, #111, #127, and #389) out of eight sampled residents. The facility's census was 127. The facility did not provide a policy for side rails. 1. Review of Resident #3's admission Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 10/04/24, showed: - Intact cognition; - Dependent with bed mobility; - Diagnoses of falls, difficulty walking, morbid obesity (overweight), pain, heart failure (the heart does not pump blood as well as it should), and atrial fibrillation (abnormal heart beat). Review of the resident's care plan, revised…

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 diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for two residents (Residents #108 and #115) out of three sampled residents. The facility census was 127. The facility did not provide a policy regarding dementia care. 1. Review of Resident #108's medical record showed: - An admission date of 08/13/24; - Diagnosis of unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 09/16/24, showed: - Diagnosis of dementia; - Able to understand others and to be understood. Review of the resident's…

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 maintain an error rate of less than five percent (%) during medication administration. There were 31 opportunities with two errors made, for an error rate of 6.45%, which affected two residents (Residents #48 and #71) out of two sampled residents. The facility census was 127. Review of the facility's policy titled, Medication Administration General Guidelines, revised May 2021, showed: - Medications are administered as prescribed in accordance with manufacturers' specifications; - Personnel authorized to administer medications do so only after having familiarized themselves with the medication. Review of the insulin lispro (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) KwikPen (insulin in a pen-type device) Manufacturer Instructions for use, revised July 2023, showed: - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; - Not priming before each injection may…

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 four vials of Tubersol (a solution used during a tuberculosis (a serious bacterial infection that mainly affects the lungs) test were dated when opened. This had the potential to affect all residents. The facility's census was 127. Review of the facility's policy titled, Storage of Medications, revised 07/22/24, showed: - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs should be returned to the dispensing pharmacy or destroyed; - Did not address dating vials when opened. Review of the manufacturer's recommendations for Tubersol, revised 03/18/24, showed the solution should discarded 30 days after date opened. Observation on 12/06/24 at 8:51 A.M., of the medication refrigerator in the Terrace medication room showed: - Two opened vials of Tubersol solution not dated. Observation on 12/06/24 at 9:15 A.M., of the medication refrigerator in the Pavilion medication room showed: - Two opened vials of Tubersol solution not dated. During an interview on…

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 follow infection prevention precautions for one resident (Resident #48) out of six sampled residents by not performing proper hand hygiene and glove changing techniques during care and failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for two residents (Residents #71 and #389) out of two sampled residents. The facility census was 127. Review of the facility policy titled, Personal Protective Equipment (PPE) Usage (Glove Policy), undated, showed: - Wash hands in between glove changes. Review of the facility policy titled, EBP, dated 04/01/24, showed: - EBP will be utilized by the staff for any residents with chronic wounds or indwelling medical devices during any high-contact with that resident. 1. Review of Resident #48's medical record showed: - Resident on contact precautions (wear a gown and gloves to prevent the spread of a bacteria or virus when entering the resident's room) for…

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, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for eight residents (Residents #3, #7, #48, #50, #105, #111, #127, and #389) out of eight sampled residents. The facility's census was 127. The facility did not provide a policy on inspections of side rails. 1. Review of Resident #3's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 12/03/24 at 11:10 A.M., the resident rolled side to side holding on to the bilateral quarter side rails in the upright position while staff performed incontinence care; - On 12/06/24 at 10:30 A.M., the resident lay in bed with the bilateral quarter side rails in the upright position. 2. Review of Resident #7's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 12/03/24 at 11:30 A.M., and 12/05/24 at 9:30 A.M., the resident lay in bed with the bilateral quarter side rails in the…

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 interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year for two certified nurse aides (CNA R and CNA S) and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for one CNA S out of two CNA's sampled. The facility census was 127. The facility did not provide a CNA in-service training policy. Review of the facility assessment, dated October 31, 2017, showed: - Required in-service training for nurse's aides must: 1. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; 2. Include dementia management training and resident abuse prevention training; 3. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents to as determined by the facility staff; 4. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively…

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 interview and record review, the facility failed to maintain the surety bond (a purchased bond for the security of the residents' personal funds) for at least one and one half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from September 2022 through August 2023. The facility census was 138. The facility did not provide a surety bond policy. Review on 09/13/23 of the residents' personal funds account for the last 12 consecutive months from September 2022 through August 2023 showed: - The facility's approved bond amount equaled $100,000.00; - The average monthly balance of the residents' personal funds equaled $97,043.77; - An average monthly balance of $97,043.77 rounded to the nearest thousand equaled $97,000.00, at one and one half times would equal the required bond amount of at least $145,500.00. During an interview on 09/13/23 at 4:06 P.M., the Business Office Manager (BOM) said the surety bond was not sufficient for the residents' personal funds. The surety bond had recently been increased from $50,000.00 to…

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 staff offered residents a bedtime snack (HS) for two residents (Resident #81 and #90) out of 27 sampled residents and seven residents (Resident #2, #,15, #23, #38, #58, #64, and #69) outside of the sample. This practice had the potential to affect all residents in the facility. The facility's census was 138. Review of the facility's policy titled, Snacks, not dated, showed the facility's meals were based on the natural awakening and snacks will be available throughout the day and staff will offer snacks at HS to all resident unless the resident could have nothing by mouth or the physician orders state otherwise. During a resident group interview on 09/14/23 at 2:00 P.M., Resident #2, #15, #23, #38, #58, #64, #69, #81, and #90 collectively said HS snacks were not offered by the staff. Sometimes there was a tray of sweet snacks at the nurses' stations, but not always. If a resident could physically get to the nurses' stations when there were snacks there, then that resident might get something, if 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 maintain an effective pest control program to control the fly population in the facility. This deficient practice had the potential to affect all residents in the facility. The facility census was 138. The facility did not provide a pest control policy. Observations on 09/12/23 at 12:20 P.M., 2:38 P.M., 09/12/23 and 4:38 P.M.; 09/13/23 at 7:59 A.M., and 1:22 P.M.; and 09/14/23 at 8:02 A.M., and 10:52 A.M., of the Oak Hall shower, located across from the biohazard room, showed: - Several flies flew outside the biohazard room door; - Two flies on a shower curtain that lay on the floor located next to the shower stall; - Three flies on a shower chair located against the wall by the shower stall; - No fly control devices on Oak Hall. Observations on 09/12/23 at 2:36 P.M., and 4:38 P.M., of Oak Hall showed: - Three flies flew throughout the nurse's station; - Two flies on the nurse's station counter; - No fly control devices on Oak Hall. Observations on 09/12/23 at 2:36 P.M., 09/13/23 at 2:08 P.M., and 09/14/23 at…

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 interview and record review, the facility failed to ensure a code status was consistently documented throughout the medical record for three residents (Resident #27, #82 and #115) out of 27 sampled residents. The facility census was 138. Review of the facility's policy titled, Advance Directives, not dated, showed: - Upon admission, every resident or resident representative is asked to determine code status; - Full Code - cardiopulmonary resuscitation (CPR) (an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) performed when the resident experiences a catastrophic event such as cardiac/respiratory arrest or Do Not Resuscitate (DNR) (does not want CPR); - The resident's code status will be reviewed with the resident and/or the resident representative annually; - The resident has the right to change their code status at any time. 1. Review of Resident #27's medical record showed: - An admission date of [DATE]; - A hospice admission date 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 138. Review of the facility's policy titled, Housekeeping, revised 03/30/19, showed: - Daily cleaning and supplying resident rooms, nursing stations, lounges, bathrooms, offices and any other areas assigned in accordance with standard procedures of the housekeeping department and in accordance with nursing home objectives; - Perform duties in assigned areas following established schedules and using prescribed methods; - Empty waste baskets; - Clean and wipe sinks; - Clean and dry toilets; - Dry and wet mop floors of rooms and offices; - Clean up urine where needed; - Wipe off chairs; - Perform any other tasks which may be assigned. Observations on 09/12/23 at 12:20 P.M., 2:38 P.M., and 4:38 P.M.; 09/13/23 at 7:59 A.M., and 1:22 P.M.; and 09/14/23 at 8:02 A.M., and 10:52 A.M., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when seven residents (Resident #14, #30, #45, #51, #63, #93 and #100) out of seven sampled residents transferred to the hospital. The facility census was 138. The facility did not provide a policy regarding hospital transfer notifications. 1. Review of Resident #14's medical record showed: - Resident transferred to the hospital for medical evaluation on 06/19/23 and readmitted to the facility on [DATE]; - Resident transferred to the hospital for medical evaluation on 07/29/23 and readmitted to the facility on [DATE]; - Resident transferred to the hospital for medical evaluation on 08/12/23 and readmitted to the facility on [DATE]; - No documentation of the written notifications to the resident and/or the resident's representative of the resident's transfers to the hospital on [DATE], 07/29/23, and 08/12/23. Review of Resident #30's medical record…

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 interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federal mandated assessment to be filled out by the facility staff, within 14 days of a resident's admission to hospice. This affected one resident (Resident #113) out of five sampled residents. The facility census was 138. The facility did not provide a MDS significant change policy. 1. Review of Resident #113's medical record showed the resident admitted to hospice on 05/19/23. Review of the resident's MDS assessments showed: - No significant change completed on or after 14 days of the resident's admission to hospice on 05/19/23; - The facility failed to complete and submit a significant change MDS assessment within 14 days after the resident admitted to hospice. During an interview 09/14/23 at 3:38 P.M., the Director of Nursing (DON) said she would expect a significant change to be completed within 14 days of when a resident was admitted to hospice. During an interview on 09/15/23 at 10:52 P.M., the MDS Coordinator said he/she would expect a significant change MDS…

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 interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASARR) (a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder, to determine the level of care needed)for two resident (Resident #30 and #90) out of 27 sampled residents. The facility census was 138. The facility did not provide a policy for PASARR. 1. Review of Resident #30's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of Asperger's syndrome (development disorder affecting socialization and communication), Alzheimer's disease (disease that destroys memory and other mental functions), and major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest); - No documentation of the Level I/II screening completed. During an interview on 09/14/23 at 4:07 P.M., the Social Services Director (SSD) said Resident #30 was transferred to the facility from another…

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 interview and closed record review, the facility failed to ensure a discharge planning process was in place which addressed goals and needs and involved the resident and/or the resident's legal guardian and the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) in developing a discharge plan for one resident (Resident #50) out of three sampled discharged residents. The facility census was 138. The facility did not provide a discharge planning policy. Review of Resident #50's closed medical record showed: - admission date of 07/26/23; - Diagnoses of hypertension (high blood pressure), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), gastroesophageal reflux disease (stomach acid being forced back into the throat region), and osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae); - A family member as the legal guardian; - No documentation which addressed the…

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 interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #50) out of three sampled discharged residents. The facility census was 138. The facility did not provide a discharge summary policy. Review of Resident #50's closed medical record showed: - The resident discharged to another facility on 09/06/23; - No documentation of a comprehensive discharge summary. During an interview on 09/14/23 at 3:33 P.M., Medical Records said there should be a comprehensive discharge summary completed when a resident was discharged . The facility needed to be more proactive with the discharge summary process. During an interview on 09/14/23 at 3:47 P.M., the Director of Nursing (DON) said there should be a comprehensive discharge summary completed when a resident was discharged . The facility needed to do a better job with the discharge summary process. During an interview on 09/15/23 at 8:13 A.M., the Social Service Director (SSD) said a comprehensive discharge summary including a recapitulation of the resident's stay,…

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 provide resident care for activities of daily living (ADL's) when the residents did not receive a minimum of two showers per week for two residents (Resident #15 and #64) outside the sampled 27 residents. The facility census was 138. Review of the facility's policy, titled, Showers, dated January 2017, showed: - It is the policy to offer showers on a bi-weekly basis; - Requests for more frequent showers will be granted and addressed via the plan of care; - A shower schedule will be maintained at each nurse's station for each division reflecting days for each resident's shower to be completed. Review of the Resident Shower List showed: - Resident #15 scheduled for showers two times weekly on Tuesdays and Thursdays; - Resident #64 scheduled for showers two times weekly on Mondays and Thursdays; 1. Review of Resident #15's medical record showed: - An admission date of 02/09/23; - Diagnoses of hypertension (high blood pressure), and heart…

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 implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility also failed to provide a safe and sanitary environment by failing to wash or sanitize hands prior to medication administration and disinfect the glucometer (a device used to measure blood sugar) per the manufacturer's instructions and failed to sanitize hands for six sampled residents (#10, #56, #59, #81, #97, and #117). The facility's census was 138. Review of the facility's policy titled, Water Management Program, undated, showed: - The water management team consists of owners, administration, the local water department, maintenance director, and a local plumbing service; - The water management program consists of the water management team, a detailed description of the water system in the facility, identification of areas that could encourage the growth and spread…

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 interview and record review, the facility failed to provide the required annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions), and Abuse and Neglect of a resident to two Certified Nurse Aides (CNA) (CNA M and CNA N) out of two sampled CNAs, which had the potential to affect all residents. The facility's census was 138. The facility did not provide a policy in regards to the required annual competencies for CNAs. 1. Review of CNA M's in-service record showed: - A hire date of 12/18/18; - No documentation of the annual Dementia Care training provided for September 2022 through September 2023; - No documentation of the annual Abuse and Neglect training provided for September 2022 through September 2023. Review of CNA N's in-service record showed: - A hire date of 07/18/17; - No documentation of the annual Dementia Care training provided for September 2022 through September 2023; - No documentation of the annual Abuse and Neglect training provided for September 2022 through September 2023. During an interview…

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.