Woodlands Skilled Nursing And Therapy

Based on observation and interview, the facility failed to honor resident's choice of entertainment for one (#11) of two sampled residents who was reviewed for choices. The DON identified 58 residents resided in the facility. Finding: Res #11 had diagnoses which included recurrent depressive disorders and diabetes mellitus with diabetic polyneuropathy. A significant change assessment, dated 12/27/23, documented the resident was moderately impaired with cognition and required assistance with most ADLs. On 02/12/24 at 10:37 a.m., an observation was made of Res #11 having a television mounted on the wall approximately four foot from another television mounted on the wall for the other resident which resided in the same room. The resident stated the remote control operates both televisions in the room. They stated every time the other resident utilizes their remote control for their television it operates both televisions. Res #11 stated they could not watch what they wanted related to their television being controlled by the other resident's remote. On 02/14/24 at 3:42 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#44) of 24 residents whose code status was reviewed. The administer identified 55 residents who resided in the facility. Findings: Res #44 had diagnoses which included diabetes mellitus, dependence on renal dialysis, chronic kidney disease, and congestive heart failure. An advanced directive acknowledgment form, dated [DATE], documented the resident did not have a DNR. An admission assessment, dated [DATE], documented the resident was intact with cognition and required substantial to maximal assistance with most ADLs. A care plan, dated [DATE], documented the resident had full code status. On [DATE] at 11:29 a.m., a red name tag was observed on the outside of the resident room. A review of the EHR, documented the resident's code status was full code. A DNR was not found in the resident's hard chart. On [DATE] at 3:29 p.m., LPN # 3 stated when a resident had a red…

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 and interview, the facility failed to ensure a resident received the necessary services to maintain their scheduled baths for one (#42) of one sampled resident for assistance with bathing. The administrator identified 55 residents who resided in the facility. Findings: Res #42 had diagnoses which included history of falling, reduced mobility, and osteoarthritis. A quarterly assessment, dated 12/21/23, documented the resident was intact with cognition and required partial to moderate assistance with bathing. A care plan, revised 12/28/23, documented the resident has a self care deficit related to impaired balance and pain. The care plan documented the resident required limited physical help from staff participation with bathing. The residents bathing schedule was bath on Monday and Thursday on the 7 to 3 shift. The resident should have received baths on 01/15, 01/18, 01/22, 01/25, 01/29, 02/01, 02/05, 02/08, and 02/12. A review of the bathing sheet for 30 days documented the resident had a bath on 01/23, refused on 01/24, refused on 01/29, was bathed on 02/01,…

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, and interview, the facility failed to ensure wound care treatments were completed as ordered for one (#17) of three sampled resident reviewed for pressure ulcers. The DON identified 55 residents resided in the facility. Res #17 had diagnoses which included dementia without behavioral disturbances, atrial fibrillation, arthropathy, chronic pain, and stage II pressure ulcer. Weekly skin assessment, dated 10/27/23, documented there was no skin problems with res #17. Weekly skin assessment, dated 11/10/23, documented there was no skin problems with res #17. A physician order, dated 11/16/23, documented apply skin prep to spine every day and evening shift for wound management/prevention. A skin assessment summary documented on 11/22/23, the resident had a pressure ulcer. There was also documentation of a wound consultant visit on this day. A physician order, dated 11/22/23 documented cleanse mid back with normal saline, pat dry, apply medihoney, cover with calcium alginate, and secure with bordered foam every day shift, Monday, Wednesday, Friday, related 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 record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 55 residents resided in the facility. Findings: A document titled Time & Attendance Detail, date range: 11/01/23 through 01/31/23, documented an RN was not in the facility for eight hours on 12/16/23. On 02/15/24 at 3:07 p.m., the corporate nurse stated on 12/16/23 there was only 6.50 hours for RN coverage.

Based on record review and interview, the facility failed to ensure nursing staff completed required competency demonstrations annually for one (CMA #2) of five staff reviewed for annual competency. The administrator identified 55 residents resided in the facility. Findings: On 02/15/24 at 11:42 a.m., competency documentation was requested. On 02/15/24 at 1:43 p.m., HR stated they did not have an annual competency for CMA #2. On 02/15/24 at 2:54 p.m., the DON stated CMAs competencies were to be completed annually.

Based on observation and interview, the facility failed to ensure staff did not stand while feeding residents for two (#14 and #206) of 24 sampled residents. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: On 01/04/23 at 8:26 a.m., LPN #1 was observed standing at the bedside while feeding Res #206. On 01/04/23 at 8:30 a.m., CNA #1 was observed standing at bedside while feeding Res #14. On 01/04/23 at 5:12 p.m., a staff member was observed standing at bedside while feeding Res #14. On 01/09/23 at 10:16 a.m., the DON stated that the staff should be eye level with the resident or seated while assisting them to eat.

Based on record review and interview, the facility failed to act upon grievances presented during resident council meetings or provide rationale as to why concerns could not be met. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: The resident council minutes were reviewed for 02/11/22, 03/23/22, 04/27/22, 05/23/22 and 09/30/22, which were all of the meeting minutes provided for review for the last 12 months. There was no documentation the residents' grievances had been acted upon. On 01/05/23 at 1:33 p.m., a resident group meeting was conducted with nine residents attending. During the meeting, residents stated that they were not sure who the grievance official was, but they thought it was the administrator. They stated none of the staff, including the administrator, ever responded to their concerns or gave a reason as to why the concerns were not addressed. On 01/05/23 at 3:40 p.m., the president of the council was asked if he was allowed to have council meetings without a staff member present. He stated several…

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 and interviews, the facility failed to provide mail delivery to residents on Saturdays. The Resident Census and Conditions of Residents identified 56 residents who resided in the facility. Findings: On 01/05/23 at 1:33 p.m., a group meeting was held with nine alert and oriented residents. They all agreed the mail came to the facility but did not get distributed every day and especially not on Saturdays. They stated the mail is distributed by social services. On 01/05/23 at 2:48 p.m., social services was observed delivering the mail to residents. On 01/05/23 at 4:03 p.m., the social services director stated the mail usually came to the facility and they would put it in her mail slot. She stated she then would separate the mail by resident and deliver the mail to the residents on the days she is schedule to work, when she had time.

Based on record review and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for 2 (#12 and #33) of 18 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: 1. Res #33 had diagnoses which included dementia and delusional disorder. A significant change assessment, dated 11/09/22, documented the resident was severely impaired with cognition and required extensive to total assist with activities of daily living. The assessment documented the resident had no behaviors and received an antipsychotic medication. The assessment documented the resident had a physician documented contraindicated GDR on 10/26/22. The resident's medical record did not document a contraindication for a reduction of the antipsychotic medication on 10/26/22. On 01/06/23 at 1:37 p.m., MDS coordinator #1 stated she got the date in October from a mental health progress note which documented to continue current medication. 2. Res #12 had a physician order, dated…

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 and interview the facility failed to ensure one of three medication carts were locked when unattended. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: On 01/03/23 at 1:23 p.m., an observation was made of an unlocked medication cart on hall 200. The staff member was in a room administering medication to a resident. The cart was between rooms and the drawers were facing the hall way. A resident in a wheel chair was in the hall by the medication cart. The CMA came out of the room and closed the drawer and locked the cart. 01/03/23 at 1:25 p.m., CMA #1 stated she thought she had locked the medication cart. On 01/09/23 at 3:30 p.m., the DON stated all medication carts should be locked at all times when not occupied by staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to serve appealing options for alternative food items for residents who choose not to eat food that is initially served or who request a different meal choice. The Resident Census and Conditions of Residents report, documented 50 residents who resided in the facility. Findings: 1. On 01/03/23 at 4:40 p.m., the evening meal was observed. On the steam table the dietary staff were serving 6 oz of chicken spaghetti, 4 oz of mixed vegetables and 4 oz of broccoli, a slice of white bread and a pre packaged oatmeal cream cookie . On 01/03/23 at 4:54 p.m., the DM stated the kitchen staff came out and talked to the residents to see what they wanted to eat. She stated they always have a soup and sandwich of some kind. The DM stated if a resident is not feeling well and they and want chicken noodle we will fix that for them. On 01/03/23 at 5:10 p.m., the dinner meal was observed written on the board outside the kitchen door. The menu documented 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 observation and interview, the facility failed to ensure food was stored and served in a sanitary manner. The Resident Census and Conditions of Residents report documented 50 residents who resided in the facility. Findings: 1. On 01/03/23 at 1:28 p.m., an initial tour of the kitchen was conducted and the following was observed: Two plates of food covered with plastic wrap and three drinks on the counter by the hand washing sink with two open with no lid covering, Four sandwiches and gelatin were observed in the refrigerator not dated, A cut onion in a bag tied in a knot in the refrigerator was not labeled or dated, A bowel of tamales were not labeled or dated, A plate of food in a plastic bag not labeled or dated. Five 20 pound rolls of hamburger meat were observed thawing in the refrigerator with a bag of fajita chicken laying on top of the thawing meat, On 01/03/23 at 1:36 p.m., cook #1 stated she was the evening cook and did not know when the tamales were cooked or the onion cut up and placed in the refrigerator. [NAME] #1 stated they should be labeled and dated before…

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 and interview, the facility failed to conduct COVID-19 testing at a frequency which was consistent with current CDC guidance/standard of practice for conducting testing during an outbreak. The Resident Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: The CDC website, read in parts, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Updated Sept. 23, 2022 .3. SETTING-SPECIFIC CONSIDERATIONS .NURSING HOMES .Responding to a newly identified SARS-CoV-2-infected HCP or resident .Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 .If no additional cases are identified during contact tracing or the broad-based testing,…

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 and interview, the facility failed to notify the OHCA of a resident with a new serious mental illness for one (#33) of two sampled residents reviewed for PASRR evaluations. The Resident Census and Conditions of Residents report, documented six residents who received antipsychotic medications. Findings: Res #33 was admitted to the facility on [DATE]. A PASRR level I was completed on 03/21/22 and documented the resident did not have a serious mental illness. On 05/04/22, Res #33 received a new diagnosis of delusional disorders. A significant change assessment, dated 11/09/22, documented the resident was severely impaired with cognition and required extensive to total assist with activities of daily living. The assessment documented the resident had no behaviors and received an antipsychotic medication. On 01/06/23 at 9:07 a.m., the business office person stated she had been doing the PASRR I for the past three weeks. She stated she had not been fully trained and educated on what to do if a…

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 interview, it was determined the facility failed to revise care plans to meet the needs of one (#21) of 18 residents whose care plans were reviewed. The director of nursing (DON) identified 56 residents who resided in the facility. Findings: 1. Resident #21 was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, intrinsic eczema, and hypertension. An annual assessment, dated 03/04/22, documented the resident's cognition was intact and was total assist with transfers, dressing, toilet use, and did not walk. The care plan, last revised on 03/21/22 documented the resident required interventions to minimize skin breakdown in general. A quarterly assessment, dated 10/21/22, documented the resident's cognition was intact and was a total assist with transfers, dressing, toilet use, and did not walk. A nurse note, dated 05/11/22 at 2:51 p.m., documented a CNA alerted 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 record review, observation, and interview, the facility failed to perform appropriate hand hygiene during wound care for one (#16) of two residents sampled for pressure ulcers. The Resident Census and Conditions of Residents report, documented one resident who had a pressure ulcer. Findings: Res #16 had diagnoses which included COPD, diabetes mellitus, hemiplegia and hemiparesis. A physician order, dated 10/30/22, documented to cleanse buttocks, pat dry, apply hydrophilic, and leave open to air every day and evening shift. A quarterly assessment, dated 12/07/22, documented the resident was severely impaired with cognition, required extensive to total assistance with ADLs, and did not have a pressure ulcer. A care plan, last reviewed 12/23/22, documented to cleanse buttocks, pat dry, apply hydrophilic leave open to air. The care plan documented daily during daily ADL care, to observe the residents skin for redness, open areas, scratches, cuts or bruises, and report changes to the nurse. A weekly skin assessment, dated 01/03/23, documented the resident had no new skin issues.…

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, observation and interview, the facility failed to provide physician ordered monthly weights for one (#16) of one resident reviewed for nutrition. The Resident Census and Conditions of Residents report, documented 50 resident who resided in the facility. Findings: Res #16 had diagnoses which included COPD, diabetes mellitus, hemiplegia and hemiparesis. A physician order, dated 01/16/22, documented to weigh the resident on day shift the 16th of every month. The weight record, dated 10/16/22, documented the resident's weight as 250 pounds. This was the last weight documented in the resident's EHR. A quarterly assessment, dated 12/07/22, documented the resident was severely impaired with cognition and required extensive to total care for ADLs except eating which he was independent. The assessment documented the resident's weight was 250 pounds. A care plan, last reviewed 12/23/22, documented Res #16 had potential nutritional/weight problem related to dysphagia and impaired mobility. On 01/03/23 at 2:32 p.m., Res #16 was observed in his room in the bed and his…

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, observation and interview, the facility failed to ensure the physician responded to a pharmacist recommendation for one (#14) of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents report documented 50 residents resided in the facility. Findings: Res #14 had diagnoses which included brief psychotic disorder, anxiety disorder, major depressive disorder, and dementia without behavioral disturbance. A MRR, dated 05/11/22, documented a request to attempt a reduction in the following medications: Zoloft 50mg every day, valproic acid 250mg three times a day, Seroquel 50mg twice a day, and Buspar 7.5mg three times a day. The physician response for May's MRR was not documented in the resident record. On 01/09/23 at 10:51 a.m., the pharmacist stated the facility could not find the physician response for May's MRR. She stated the medication had not been changed at that time. She stated she should have followed up better after the MRR was sent.

Based on record review, observation, and interview, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (#33) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, documented six residents in the facility who are receiving antipsychotic medications. Findings: Res #33 had diagnoses which included dementia, senile degeneration of the brain, and delusional disorders. A MRR, dated 03/18/22, documented Res #33 was admitted on Seroquel 12.5mg at bedtime for insomnia. The MRR documented the antipsychotic had a black box warning for increased risk of death in elderly patients with dementia. The MRR documented if insomnia was the intended diagnosis the recommendation would be to taper off the medication. The provider documented an agreement to the recommendation on 03/24/22. The MARs for March and April 2022 were reviewed. Res #33 continued to receive the Seroquel at 12.5mg until 04/24/22. A significant change assessment, dated 11/09/22, documented the resident was severely impaired 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.