Woodward Skilled Nursing And Therapy

Based on observation, record review, and interview, the facility failed to ensure sufficient staffing was available:a. to turn and reposition residents at risk for pressure ulcers for 1 (#3); andb. to prevent dependent residents from being taken to the dining room one hour before meals for 1 (#9) of 3 sampled residents reviewed for staffing. The DON identified 15 dependent residents resided in the facility.Findings: 1. On 07/14/26 from 8:49 a.m. to 11:39 a.m., during continuous observation, Resident #3 was observed lying on their right side in bed throughout the observation period. Staff was not observed to check on Resident #3 or reposition the resident during the continuous observation.An admission assessment for Resident #3, dated 06/16/26, showed the resident's cognition was severely impaired with a BIMS score of 0. The assessment showed the resident was at risk for developing pressure ulcers.A care plan for Resident #3, dated 06/12/26, showed the resident was to be turned every two hours, heels offloaded with pillows, and required assistance with turning and repositioning…

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 annual nurse aide skill reviews was conducted for 2 (CNA #2 and CNA #3) of 2 nurse aides sampled for employee training review. The administrator identified 35 residents resided in the facility. Findings: 1. CNA #2's employee file showed they had a hire date of 10/16/24. There was no documentation to show CNA #2 had an annual skills review completed in or after 10/2025. 2. CNA #3's employee file showed they had a hire date of 01/08/25. There was no documentation to show CNA #3 had an annual skills review in or after 01/2026. On 07/16/26 at 12:51 p.m., the administrator stated the required annual skills review for CNA #2 and CNA#3 were not conducted.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests.The administrator identified 35 residents resided in the facility. Findings:On 07/14/26 at 10:57 a.m., during an observation of the lunch meal service, three flies were observed on the dining table while residents drank coffee.On 07/14/26 at 11:34 a.m., during an observation of the lunch meal service, eight flies landed on top of the steam table while food was being prepared and served from the steam table.On 07/14/26 at 11:36 a.m., during an observation of the lunch meal, there was a blue light hung in the dining room on the wall.On 07/14/26 at 11:56 a.m., during an observation of the lunch meal service, flies were observed landing on residents' plates containing food.On 07/16/26 at 9:57 a.m., during a wound care observation, multiple flies were observed landing on the clean wound care supplies.A policy titled Pest Control, dated 10/2008, read in part, It's 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 ensure an allegation of physical abuse was reported to the State Agency within the two hour required timeframe for 1 (#3) of 3 sampled residents reviewed for abuse.The administrator identified 35 residents resided in the facility Findings:On 07/14/26 at 1:18p.m., Resident #3 was observed sitting in a wheelchair with four round purple and yellow areas of circular bruising on their left upper arm.A policy titled Resident Abuse, Neglect and Misappropriation of Property, dated 07/2018, read in part, All allegations and incidents of abuse, neglect or misappropriation of residents' property, must be reported to Quality Assurance Performance Improvement committee, appropriate Federal and State Agencies including OSDH and investigated to establish a reasonable conclusion about the validity of the allegation .Immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.An admission assessment for Resident #3, dated 06/16/26, showed the resident had a BIMS score of…

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

Based on observation, record review, and interview, the facility failed to ensure a resident received pressure ulcer prevention interventions to include repositioning every two hours for 1 (#3) of 2 sampled residents reviewed for pressure ulcers.The DON identified three residents with pressure ulcers. Findings:On 07/14/26 from 8:49 a.m. to 11:39 a.m. during continuous observation, Resident #3 was observed lying on their right side in bed throughout the observation period. Staff was not observed to check on resident.A policy titled Skin Integrity/ Wound Care, revised 07/2024, read in part, To promote healing of pressure ulcers.Use Proper positioning, transferring, and turning techniques.A Braden Scale for Resident #3, dated 06/10/26, showed:mobility (ability to change and control body position) as very limited, andfriction and shear (require moderate to maximum assistance in moving).A care plan for Resident #3, dated 06/12/26, showed an intervention to turn the resident every two hours, offload heels with pillows, and assist with turning and repositioning frequently. An admission…

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 ensure urinary catheter bags were not placed on trash cans or allowed to touch the floor for 1 (#7) of 1 sampled resident reviewed for urinary catheters.The DON identified two residents with urinary catheters resided in the facility.Findings: On 07/15/26 at 8:52 a.m., Resident #7 was observed in their room sitting in their recliner. Resident #7's urinary catheter bag was observed hanging on a small trash can beside the recliner and touching the floor. On 07/16/26 at 9:53 a.m., Resident #7's urinary catheter bag was observed hanging on a small trash can beside their recliner and touching the floor. A policy titled Catheter Care Guideline, dated 03/01/25, read in part, Ensure care aligns with safe and effective management of urinary catheters and reduce the risk of infection and promote resident comfort and dignity. A physician's order for Resident #7, dated 07/02/26, showed catheter care every shift and as needed. A significant change assessment for Resident #7, dated 07/04/26, showed the resident's cognition…

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 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.