Woodcrest At Blakeford

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure staff honored residents' rights related to self-determination, which affected 1 (Resident #31) of 1 resident reviewed for dignity concerns. The findings include: An undated facility policy titled, Resident Rights And Responsibilities, revealed, The resident has the right to, which included, Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal, and Exercise his or her rights without being subjected to discrimination or reprisal. An admission Record revealed the facility admitted Resident #31 on 10/26/2023. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified dementia, severe with agitation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was…

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, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 (Resident #31) of 1 resident reviewed for abuse. Specifically, CNA #18 failed to report an allegation of staff-to-resident abuse that occurred on 09/06/2024 until 09/13/2024. The findings include: A facility policy titled, Abuse, Neglect, Misappropriation Protocol, revised 04/2025, revealed, 1. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. An admission Record revealed the facility admitted Resident #31 on 10/26/2023. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified severe dementia with agitation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of facility policy, and review of the American Heart Association Adult Basic Life Support Algorithm, the facility failed to have documented evidence that Emergency Medical Services (EMS or 911) was contacted or that an Automated External Defibrillator (AED) was utilized when cardiopulmonary resuscitation (CPR) was provided for 1 resident (Resident #78) of 2 residents reviewed for CPR, who had a physician's order for a full code (a medical directive indicating that if a person's heart stops or they stop breathing, healthcare providers will use all available life saving measures to revive them). The findings include: A facility policy titled, CPR - Do Not Resuscitate - DNR POST Form, revised 07/2025, revealed, Cardiopulmonary Resuscitation (CPR) shall be defined as the administering of any means or device to restore or support resuscitative functions in a resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal…

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 facility policy review, record review, facility document review, and interview, the facility failed to activate a resident's physician orders for blood glucose monitoring and sliding scale insulin that were listed in the medication administration software queue, which caused staff to not monitor blood glucose levels or provide insulin according to the order. The deficiencies affected 1 (Resident # 78) of 2 residents reviewed for diabetes management. The facility implemented corrective actions to correct the identified deficient practice from [DATE] to [DATE], to include a change in electronic health record software, staff training, and ongoing audits; thus, past noncompliance was cited. The findings include: An undated facility policy titled, Insulin Administration indicated its Purpose was, To provide guidelines for the safe administration of insulin to residents with diabetes. The policy revealed Preparation included, 3. The type of insulin, dosage requirements, strength, and method of administration…

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 facility policy review, medical record review, and interview, the facility failed to perform Interdisciplinary Team (IDT) Care Plan meetings for 10 of 29 sampled residents (Resident #2, #3, #9, #12, #17, #21, #22, #28, #29, and #43) and the facility failed to revise the Care Plan for 1 of 29 sampled residents (Resident #2). The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with revision date 9/20/2021 revealed .the Interdisciplinary Team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .the IDT must review and update the care plan .when there has been a significant change in the resident's condition .when the desired outcome is not met .when the resident has been readmitted to the facility from 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.

Based on facility documentation and interview the facility failed to have at least 8 hours of Registered Nurse (RN) coverage in the facility. The findings include: Review of the facility daily staffing revealed in November 2020 the facility had 5 days of no 8 hour RN coverage. December 2020 the facility had 3 days of no 8 hour RN coverage; January 2021 the facility had 1 day of no 8 hour RN coverage; February 2021 the facility had 3 days of no 8 hour RN coverage; March 2021 the facility had 1 day of no 8 hour RN coverage; May 2021 the facility had 1 day of no 8 hour RN coverage; June 2021 the facility had 1 day of no 8 hour RN coverage; July 2021 the facility had 3 days of no 8 hour RN coverage; August 2021 the facility had 2 days of no 8 hour RN coverage; December 2021 the facility had 1 day of no 8 hour RN coverage. During a telephone interview on 3/24/2022 at 10:24 AM, the Administrator confirmed there was no 8 hour RN coverage for the specific days in November and December 2020; January, February, March, April, May, June, July, August, and December 2021.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to notify family of a change of condition for 1 of 29 sampled residents (Resident #2) related to a significant weight loss. The findings include: Review of the facility policy titled, Guidelines for Notifying Physicians/Family of Clinical Problems, with revision date of 2/2021 revealed, .all significant changes in resident status are assessed and documented in the medical record and family notified . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Dementia, Anemia, and Adult Failure to Thrive. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive abilities. Continued review of the MDS revealed weight loss with no physician prescribed weight-loss regimen. Review of the weights for Resident #2 revealed a weight of 125.8 pounds…

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 facility policy review, medical record review, observation, and interview, the facility failed to maintain privacy for 4 of 29 sampled residents (Resident #9, #11, #12, and #17) related to swallowing difficulties. Review of the facility's undated policy, titled, Notice of Privacy Practices, revealed, .Our Responsibilities .Maintain the privacy of your health information . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Dysphagia, Oropharyngeal phase. Review of Resident #9's Physician Order dated 6/23/2021 and 6/28/2021 revealed, .ST (Speech Therapy) eval [evaluate] and treat as indicated .SLP (Speech Language Pathologist) to treat for dysphagia to increase swallow safety skills and symbolic language treatment to increase to communication/cognition for ADLs [Activities of Daily Living] safety, as indicated . Review of Resident #9's Care Plan dated 6/23/2021, revealed, .Nutritional Status .nutritional risk r/t [related to] Dysphagia…

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 facility policy review, medical record review, and interview, the facility failed to implement a care plan for 1 of 29 sampled residents (Resident #29) reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 9/2021, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Personal History of Urinary Tract Infections. Review of Resident #29's Physician Orders dated 3/17/2022, revealed, .Nitrofurantoin monohydrate/macrocrystasis 100 mg [milligram] capsule 100 mg by mouth twice daily for UTI [Urinary Tract Infection] . Review of Resident #29's Medication Administration Record dated 3/2022, revealed the resident received Nitrofurantoin 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 facility policy review, medical record review, observation, and interview, the facility failed to store medications and biologicals appropriately for 4 of 29 sampled residents (Resident #10, Resident #33, Resident #47, and Resident #304) reviewed receiving medications and biologicals. The findings include: Review of the facility's policy titled, Storage of Medications, revised April 2007 revealed, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Compartments .containing drugs and biologicals shall be locked when not in use .items shall not be left unattended if opened or otherwise potentially available to others . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Age-Related Osteoporosis w/o [without] Current Pathological Fracture. Review of the Physician's Orders for Resident #10 revealed an order dated 8/26/2021 for wound care per protocol as indicated. Review of the Quarterly Minimum Data…

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 facility documentation, medical record review, observation and interview the facility failed to serve a therapeutic diet during the lunch meal for 1 of 29 sampled residents (Resident #12) observed. The findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Dysphagia, Oropharyngeal Phase. Review of Resident #12's Physician Orders dated 8/24/2021, revealed .MS [mechanical soft] Ground, NAS [No added salt] . Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #12 required a mechanical altered diet. Review of the lunch meal ticket dated 3/22/2022, revealed .MS [mechanical soft] Deluxe Hamburger . Observation in Resident #12's room at 12:07 PM, revealed Resident #12 had a lunch tray with hamburger and steamed broccoli. Continued observation revealed the Certified Nurse Assistant (CNA) #3 looked at the meal ticket and identified the meal which was delivered was not a mechanical soft diet. During 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.

Based on facility policy review, observations, and interview, the facility failed to maintain dietary equipment in a sanitary manner in the dietary department during 1 of 3 observations. The findings include: Review of the facility's policy titled, Sanitation and Infection Prevention/Control, dated 1/2021, revealed, .detailing daily and weekly (as needed) cleaning for all areas and equipment in the department . Observation in the dietary department on 3/21/2022 at 10:35 AM, revealed the pan under the stove burners had a moderate amount of black burned particles on the surface. During an interview on 3/21/2022 at 10:36 AM, the Certified Dietary Manager (CDM) confirmed the pan under the stove burners had a moderate amount of black burned particles on the surface and she stated she did not know when it had been cleaned.

Based on review of the facility policy, review of the manufacturer's recommendation, observation, interview and review of the Dishware/Warewashing Machine Temperature Log, the facility failed to operate the dish machine wash cycle within the recommended minimum 160 degrees Fahrenheit (F) in 1 of 6 observations. The findings include: Review of the undated facility policy, Dish-Machine Temperatures, revealed .Temps [temperatures] are taken daily and documented if they aren't to standard-Chef or Dietary Director must be informed immediately. Wash Tank Temp must be 160 degrees F. Final Rinse Temp must be 180 degrees F .If findings aren't to standard, Maintenance and Ecolab [chemical supplier, monitored dish machine operation] will be informed to correct any problems . Review of the dish machine manufacturer's recommendation revealed the minimum wash temperature was 160 degrees F. Observation on 4/15/19 at 7:38 AM in the dietary department dishroom revealed the dish machine was in operation. Further observation revealed various pots, pans, utensils, and sheet pans were processed through…

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.