Woodward Skilled Nursing And Therapy

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a significant change assessment for one (#37) of 12 sampled residents reviewed for assessments. The Long Term Care Application, dated 10/01/24, documented 46 residents resided in the facility. Findings: A RAI manual, dated October 2023, read in part, .Significant change MDS completion date must be no later than 14 days from the ARD and no later than 14 days after the determination that the criteria for an SCSA were met . Resident #37 had diagnoses which included depression with psychotic features, anxiety, and diabetes mellitus. A significant change assessment, dated 09/15/24, was not completed by the ARD date. On 10/04/24 at 8:22 a.m., the MDS coordinator was asked what was the policy for completing a MDS in a timely manner. They stated there was no policy and they referred back to the RAI manual for instructions. They were tasked to review the significant change assessment dated [DATE]. They were asked if the significant change had been…

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 ensure resident assessments were accurately coded for one (#11) of 12 sampled residents reviewed for assessments. The Long-Term Care Facility Application, dated 10/01/24, documented 45 residents resided in the facility. Findings: 1. Resident #11 had diagnoses which included coronary artery bypass, heart disease with heart failure, and congestive heart failure. A physician's order, dated 10/04/24, documented clopidogrel bisulfate (Plavix) (antiplatelet medication). A significant change assessment, dated 07/10/24, doucmented Plavix as a anticoagulant and not as a antiplatelet. On 10/04/24 at 11:40 a.m., the MDS coordinator was asked what was the facility policy on accuracy of assessments. They stated they followed physician orders. They were asked to review the significant change assessment dated [DATE]. They were asked if Resident #11 was on a anticoagulant or a antiplatelet medication and if the medication coding was correct on the significant change…

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 care plan was revised and updated for one (#36) of 12 sampled residents reviewed for care plans. The Long-Term Care Facility Application, dated 10/01/24, documented 45 residents resided at the facility. Findings: Resident #36 had diagnoses which included insomnia, anxiety, acute kidney, urethritis, chronic urinary tract infection, and history of urinary retention. A care plan, dated 12/23/23, documented the resident would not have a decline in functional status. The care plan did not document any further updates for a decline in ADL status. A quarterly assessment, dated 07/26/24, documented staff assistant with ADLs was supervision to moderate assist. A significant change assessment, dated 08/23/24, doucmented the resident required maximum assist with ADLs. No revision or update to the ADL careplan was noted on current care plan. On 10/03/24 at 12:29 p.m., Corporate Nurse Consultant #1 was asked the facility policy for revising and updating care plans. They stated they would have to look at the RAI manual to 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.

Based on record review and interview, the facility failed to ensure medications were given as ordered for one (#5) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 47 residents resided in the facility. Findings: A Medication Administration-General Guidelines policy, effective January 2022, read in part, .For residents not in their rooms or otherwise unavailable to receive medication on the pass .After completing the medication pass, the nurse returns to the missed resident to administer the medication . Resident #5 was scheduled to receive the following medications during the 7 a.m.-11 a.m. time slot: Aspirin Low Dose 81 mg, Pantoprazole Sodium 40 mg, Polyethylene Glycol 3350 Powder 17 gm, Docusate Sodium 100 mg, Ipratropium Bromide Solution 0.06% 2 sprays in both nostrils, Metoprolol Tartrate 25 mg, Mucinex ER 600 mg, Propranolol HCL 10 mg , Seroquel 50 mg, and Hydrocodone-Acetaminophen 5-325 mg. The June 2023 MAR for Resident #5 documented medications scheduled to be given during 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, record review, and interview, the facility failed to prevent the use of a chair alarm to prevent falls from becoming a restraint for one (#45) of nine sampled residents reviewed for restraints. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 47 residents resided in the facility. The Regional Nurse Consultant reported there were 9 residents with chair alarms. Findings: A Restraint and Non-Restraint Devices policy, revised 12/14/22, read in parts, .Non-restraint devices are devices that do not restrict the resident's freedom of movement .A Monthly Restraint/non-restraint Assessment .will be completed .to determine the continued need for the use of the restraint/non-restraint . Resident #45 had diagnoses that included history of falling, syncope and collapse, unspecified dementia of unspecified severity, with anxiety. A quarterly assessment, dated 05/24/23, documented Resident #45 was cognitively intact and required extensive assistance of 2 people for positioning, transfers, and ambulation. A Restorative Note, dated 06/26/23,…

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 report an alleged violation of verbal abuse and neglect for two (#5 and #11) of three sampled residents reviewed for abuse allegations. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: A policy and procedure titled, Resident Abuse, Neglect and Misappropriation of Property, dated September 2016, read in part, .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . Identification/Reporting/Protection .The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation .The nurse should take immediate steps to protect the resident from further incident during this time .The licensed nurse .shall then complete an incident report reflecting any and all findings from the assessment of the resident following the incident . Resident #5 was admitted with diagnoses which included depressive disorder, hypothyroidism, and arthritis.…

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 investigate allegations of abuse for one (#10) of three sampled residents reviewed for abuse. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: A policy and procedure titled, Resident Abuse, Neglect and Misappropriation of Property, dated September 2016, read in part, .The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion . Investigation .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 .The preliminary report .shall at the minimum, include: who, what, when and where; and measures taken to protect the resident(s) during the investigation .preliminary information .preliminary findings of the investigation . Resident #10 was admitted with hypotension, depressive disorder, and atrial fibrillation. An OSDH incident report, dated 05/10/21, read in part,…

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 complete a significant change assessment for one (#11) of two sampled residents reviewed for PASRR's. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: Resident #11 was admitted with diagnoses which included unspecified intellectual disabilities, unspecified fracture of right arm, depressive disorder, and seizures. An admission assessment, dated 10/04/21, documented Resident #11 required limited assistance with transfers, dressing, and personal hygiene. A quarterly assessment, dated 01/11/22, documented Resident #11 required extensive assistance with transfers, dressing, and personal hygiene. On 06/23/22 at 12:05 p.m., the case manager was asked to review Resident #11's admission and quarterly assessments. They were asked if the resident had a decline in two or more care areas, what should have been done. They stated, a significant change.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the state authority of new mental health diagnoses for one (#36) of two sampled residents reviewed for PASRR's. The Resident Census and Conditions of Residents report, dated 06/22/22, documented 48 residents resided in the facility. Findings: A level I PASRR screen, dated 07/01/19, documented Resident #36 was screened and a level I was completed. It was documented there were no indicators for a level II PASRR. Resident #36 was admitted to the facility on [DATE] with no diagnoses which included a serious mental illness. On 06/18/21, the resident had a new diagnosis of unspecified psychosis not due to a substance or known physiological condition. On 12/02/21, the resident had a new diagnosis of generalized anxiety disorder. There was documentation the state authority had been notified of the resident's new diagnoses to see if a level II PASRR was required. On 06/23/22 at 4:25 p.m., the case manager was shown Resident #36's level I PASRR where no…

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.