St Mary Of The Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, facility policy review, and interview, the facility failed to ensure staff followed physician orders when administering Resident #26's and Resident #44's respiratory aerosol treatments. This affected two residents (#26 and #44) out of three residents reviewed for respiratory care. The facility census was 43. Findings include:1. A review of Resident #44's clinical record revealed an admission date of 02/18/26 with diagnoses including chronic obstructive pulmonary disease, emphysema, high blood pressure and cholesterol, atherosclerotic heart disease, esophagitis, peripheral vascular disease, stage IV chronic kidney disease, hyperparathyroidism secondary to renal origin, radiculopathy (spinal nerve compression), cataract, malaise, pupillary abnormality, and dysphagia (trouble swallowing). Resident #44 was discharged from the facility to her private residence on 02/25/26.A review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #44 was alert…

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, policy review, and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 32 out of 36 residents who ate meals in the facility's kitchen. Four residents (Residents #1, #4, #10 and #24) received enteral nutrition and did not receive meals from the kitchen. The facility census was 36. Observations during the initial tour of the kitchen on 08/25/25 from 10:27 A.M. through 10:50 A.M. revealed the wall behind the grill and stove had grease built-up with food spattered, the deep [NAME] shield on the side of the deep [NAME] had half inch thick grease built up. The hood screens above the grill and stove had heavy grease buildup and the stove had burnt food and flood splatter all over it. The shelf under the steam table had grease buildup and food particles, also, the nine casserole dishes on the shelf were dirty with dried food. The reach-in cooler floor was wet with food particles on the floor and water was dripping from…

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 medical record review, interviews, and review of facility policy, the facility failed to ensure the resident personal privacy and confidentiality of medical records was maintained. This affected one resident (#63) of two residents reviewed for medical record release. The facility census was 36. Findings include: Interview with Resident #58's Family Member (FM) on 08/27/25 at 1:32 P.M. revealed she received Resident #58's medical records as requested from the facility, however; it also included another Resident's (#63) personal information, date of birth , insurance, diagnoses, and complete care plan. Review of medical record package sent to Resident #58's FM by facility verified Resident #63's private information and medical information were included in the packet for Resident #58. Interview with the Director of Nursing (DON) on 08/27/25 at 1:15 P.M. verified the medical record requested for Resident #58 also contained Resident #63's personal private and clinical information sent from the facility. The DON also informed Resident #63's family of the breech in confidentiality…

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 record review, staff interviews, and facility policy, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and facility policy. This affected one resident (#58) of three residents reviewed for oxygen administration. The facility census was 36.Review of medical record for Resident #58 revealed an admission date of 04/01/25 with diagnoses of acute respiratory failure with hypoxia, Parkinson's disease, heart failure with ejection fraction of 42%, dysphagia, history of falls, hypertension, myocardial infarction, and cognitive deficits.Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 04/04/25 revealed the resident had cognitive decline as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require some assistance for Activities of Daily Living (ADLs) but maximum assistance with hygiene/toileting needs related to shortness of breath with minimal exertion. Resident also required continuous oxygen per nasal cannula at two to three liters per…

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, record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one resident (#17) out of three residents reviewed for an indwelling urinary catheter. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/25/22 with diagnoses including type II diabetes mellitus, chronic kidney disease, and calculus of kidney. Review of Resident #17's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/22, revealed Resident #17 was cognitively intact. Resident #17 required the extensive assistance of two staff members for bed mobility and transfers. Resident #17 had an indwelling catheter for urine and was always continent of bowel. Review of the plan of care, dated 04/26/22, revealed the resident had an indwelling urinary catheter due to urinary retention. Interventions included positioning catheter bag below level of bladder, manipulating tubing…

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,record review, and review of facilities policy, the facility failed to notify and obtain physician orders for the use of oxygen for one resident (Resident #14) of three residents reviewed. The facility census was 45. Findings include: Record review for Resident #14 revealed an admission date of 04/21/22. Diagnoses include unspecified fracture of shaft of right fibula, subsequent encounter for closed fracture with routine healing, mild cognitive impairment and unspecified dementia without behavioral disturbance. Record review of the Minimum Data Set (MDS) for Resident #14 dated 06/02/22 revealed resident had moderately impaired cognition and required extensive assistance for bed mobility transfers and mobility. Record review of the progress note dated 06/19/22 at 10:29 A.M. completed by Licensed Practical Nurse (LPN) #906 revealed State Tested Nursing Assistant (STNA) was toileting (Resident #14) and while washing (Resident #14) hands with the STNA, (Resident #14) knees felt weak and was lowered to ground. STNA called for the nurse, and nurse assessed…

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 record review, observation, and staff interview, the facility failed to maintain a drainage bag for an indwelling urinary catheter in a manner to ensure the dignity of one (#285) out of three residents reviewed for personal privacy. The census was 48. Findings include: Review of Resident #285's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, enterocolitis due to clostridium difficile, sepsis, and chronic kidney disease. Observation of Resident #285 on 05/28/19 at 8:50 A.M. and 3:43 P.M., on 05/29/19 at 10:20 A.M., 11:50 A.M.,1:09 P.M., and 2:23 P.M., and on 05/30/19 at 8:50 A.M. revealed the resident was in his room lying in bed. Resident #285's catheter bag was attached to the bed frame facing the open door and without a cover. Interview on 5/30/19 at 8:50 A.M., with the Director of Nursing verified the observation of Resident #285's catheter bag being in view of the hallway and not covered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop an initial baseline plan of care for one (#288) of 12 residents reviewed for initial baseline plans of care. The facility census was 48. Findings include: Review of Resident #288's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to thrombosis of left anterior cerebral artery, Antiphospholipid Syndrome (a disorder in which the immune system mistakenly attacks normal proteins in the blood. It causes blood clots, can cause organ damage and death), epilepsy, thrombocytopenia, chronic kidney disease, stage 3, bipolar disorder, and vascular dementia without behavioral disturbance. The record contained no evidence Resident #288 had an Initial Baseline Plan of Care developed until 05/29/19. Interview with the Director of Nursing (DON) on 05/29/19 at 10:20 A.M. verified she could not find any documented evidence the facility developed a baseline plan of care for Resident #288.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, staff interview and record review, the facility failed to provide assistance with activities of daily living of bathing, hygiene, and opening food packets for one (#291) of 12 residents reviewed for showers. The facility identified 48 residents who required staff assistance or were dependent for bathing and 26 residents who required assistance or were dependent for eating. The facility census was 48. Findings include: Review of Resident # 291 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, pneumonitis, ischemic cardiomyopathy, chronic stage 4 kidney disease, and type 2 diabetes mellitus. Review of Resident # 291's plan of care, dated 05/22/19, revealed the resident had limited ability to perform his activities of daily living, including bathing, hygiene, and eating. The goal was for the resident to be well-groomed and dressed appropriately with proper hygiene maintained.…

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 record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure pain medication were available and administered timely for one (#187) of two residents reviewed for pain. The facility identified 27 residents who required pain management. The facility census was 48 residents. Findings include: Review of the medical record revealed Resident #187 was admitted to the facility on [DATE]. Diagnoses included status post bilateral knee replacement surgery, critical illness polyneuropathy, complex regional pain syndrome, osteoarthritis, obesity and depression. Review of the baseline care plan included improving pain and ambulation. Review of the nurses' note dated 05/25/19 at 2:40 P.M. revealed Resident #187 arrived to the facility status post bilateral knee replacement surgery and was three days post-operation. Review of the May 2019 Medication Administration Record (MAR) revealed upon admission [DATE] Resident #187 was prescribed Lyrica (for nerve and muscle…

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 record review, observation, staff interview, visitor interview, and review of facility policy, the facility failed to ensure information signage was properly posted on the door of a room with contact isolation and failed to ensure visitors were educated on the need for precautions when visiting one (#285) three residents on contact isolation precautions. The facility census was 48. Findings include: Review of Resident #285 medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, enterocolitis due to clostridium difficile, sepsis, chronic kidney disease, severe protein-calorie malnutrition, and atherosclerotic heart disease. Resident #285 was on contact isolation for clostridium difficile (C-Diff). Review of Resident #285's Initial Base Line Plan of Care dated 05/20/19, revealed the resident was on isolation for clostridium difficile, (C-Diff). Interventions included gown, gloves and handwashing. Observation of Resident #285 on 05/28/19 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.