The Woodlands Health And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, the facility staff failed to obtain physician orders for the care of an implanted cardiac defibrillator for one of 21 residents, Resident #153. Findings were: Resident #153 was admitted to the facility with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia cardiomegaly, atherosclerotic heart disease, mitral valve insufficiency, presence of automatic implantable cardiac defibrillator (AICD), heart failure, dysphagia, and hypertensive heart disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/27/2023 assessed Resident #153 as cognitively intact, with a summary score of 13 out of 15. The clinical record was reviewed on 04/12/2023, beginning at approximately 11:00 a.m. Review of the physician orders did not contain orders regarding the care and or monitoring of the implanted cardiac defibrillator. The Nursing Admission/readmission assessment dated [DATE] included the following information in section O.…

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 staff interview and clinical record review, the facility staff failed to provide a baseline care plan for one of 21 residents in the survey sample. Resident #53 was not presented with a completed copy of the baseline care plan. This was a closed record review. The Findings Include: Diagnoses for Resident #53 included; Dementia, anxiety, depression, epilepsy, insomnia, and muscle wasting. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/19/21. Resident #53 was assessed with a cognitive score of 15 indicating cognitively intact. On 4/12/23 review of Resident #53's clinical record evidenced that a baseline care plan was completed on 8/14/21 after the admission on [DATE]. A form titled Safe Transition Meeting dated 8/16/21 documented a meeting with the facility staff and Resident #53, and indicated that the baseline care plan was reviewed during the meeting. The form was electronically signed by the social worker, however there was not a place…

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, staff interview, and clinical record review, the facility staff failed to develop comprehensive care plans for two of 21 residents. Resident # 153 did not have a care plan in place for nutrition and a physician ordered treatment was not listed on the care plan for pressure ulcers. Resident #119 did not have a care plan for the use of a life vest. Findings were: 1. Resident #153 was admitted to the facility with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia cardiomegaly, atherosclerotic heart disease, mitral valve insufficiency, presence of automatic implantable cardiac defibrillator (AICD), heart failure, dysphagia, and hypertensive heart disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/27/2023 assessed Resident #153 as cognitive intact with a summary score of 13 out of 15. The clinical record was reviewed on 04/12/2023 beginning at approximately 11:00 a.m. Review of the admission MDS Section V indicated that Resident #153 had triggered for nutrition and should be care…

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, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 21 residents. Resident # 14's care plan was not updated to include the use of a specialty mattress. Findings were: Resident #14 was admitted to the facility with the following diagnoses, including but not limited to: Vascular dementia, urine retention, hypertension, Parkinson's disease, and cerebrovascular disease. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date of 01/23/2023. Resident #14 was assessed as having problems with both long and short term memory, as well as daily decision making skills. ON 04/11/2023 at approximately 10:00 a.m., during initial tour of the facility, Resident #14 was observed sitting in a geri chair in his room. Resident #14 was non verbal except for the repetitive sound of la la la la. The sides of the mattress on Resident #14's bed were higher than the rest of the mattress. The clinical record was reviewed on 04/12/2023 at approximately 10:00 a.m.…

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 medication pass and pour observation, staff interview, and facility document review, the facility staff failed to follow professional standards of nursing practice during medication pass on the back hall. Findings were: A medication pass and pour observation was conducted on the back hall of the facility on 04/12/2023 at approximately 8:00 a.m. with LPN (licensed practical nurse) #1. LPN #1 removed two plastic bags from the medication cart and explained that the pharmacy packed the medication for each resident in separate labeled bags. The bags were labeled with the resident name, room number and time of day for the medications to be administered. Listed on each bag were the blister packs of medication that were in the bag and the resident was to receive. LPN #1 removed the bags for Resident #45 and compared the medications listed on the outside of the bag to the electronic MAR (medication administration record). then opened the bags and placed the blister packs on the top of the medication cart. LPN #1 popped each pill from the blister packs into the medication cup. LPN #1…

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 closed clinical record review, and staff interview, the facility failed to maintain a complete and accurate clinical record for one of 21 residents in the survey sample (Resident # 54). Facility staff failed to document the resident's bathing for the period [DATE] through [DATE]. The findings were: Resident # 54 was admitted to the facility with diagnoses that included Alzheimer's Disease, anemia, coronary artery disease, hypertension, renal insufficiency, diabetes mellitus, anxiety disorder, Non-Alzheimer's Dementia, benign prostatic hyperplasia, urinary retention, chronic prostatitis, gastroesophageal reflux disease, hypertensive chronic kidney disease, and arteriosclerotic heart disease. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of [DATE], Resident # 54 was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 03 out of 15. Under Section G (Functional Status), the resident was assessed as…

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, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices to prevent the potential spread of COVID-19 on one of two units, the west unit. Droplet precautions were not implemented at the time of entry for an unvaccinated new admission, facility staff was not aware of the proper PPE (personal protective equipment) to wear while in contact with a resident on droplet precautions, and one staff member was not aware of where to find proper PPE. Findings were: Initial tour of the facility was conducted on 07/26/2021 beginning at approximately 7:00 p.m. Observed outside of Resident #205's room was a white trifold, cloth covered partition. The partition was not around the door but sitting at an angle. RN (registered nurse) #1 was asked what the partition was for. She stated, I don't know why that is there .the resident in the room is a new admission but she was COVID negative when she left the hospital today. There was 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.

Based on observation, staff interview, and clinical record review, the facility staff failed to administer oxygen per physician order for one of 15 residents in the survey sample: Resident # 29. Resident # 29's oxygen was observed being administered above the parameters ordered by the physician. Findings include: Resident # 29 was admitted to the facility 7/11/20 with a readmission date of 9/21/20. Diagnoses for Resident # 29 included, but were not limited to: COPD, respiratory failure, congestive heart failure, and GERD. The most recent MDS (minimum data set) was an annual review dated 6/12/21. Resident # 29 was coded as having moderate impairment in cognition with a score of 06 out of 15. On 7/28/21 at 10:30 a.m. Resident # 29 was observed in bed. The oxygen concentrator beside the bed was observed delivering oxygen to the resident via nasal cannula at 4.5 LPM (liters per minute). The clinical record was reviewed at 10:45 a.m. and was noted to include an order for O2 (oxygen) at 4 LPM via nasal cannula for diagnosis of COPD and chronic respiratory failure. The order was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, facility staff failed to provide care and services for use of an indwelling catheter for one of 17 residents in the survey sample, Resident #203. Facility staff failed to ensure Resident #203 had an acceptable diagnosis for use of an indwelling catheter (Foley) and failed to provide privacy for resident's urinary drainage bag. Findings included: Resident #203 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Chronic Kidney Disease, Congestive Heart Failure, and Atrial Fibrillation. Resident #203 did not have a completed MDS (minimum data set) at the time of the survey. According to clnical record progress notes, Resident #203 was assessed as alert and oriented to person, place and time. During initial tour of the facility on 04/02/2019 at 8:08 a.m., Resident #203 was observed lying in bed with his Foley catheter drainage bag hanging from the side of the bed. No privacy bag was observed.…

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, staff interview and facility document review, the facility staff failed to ensure Tuberculin PPD (purified protein derivative) solution was dated when opened and stored per pharmacy recommendation in the refrigerator of the facility's medication room. One multi-dose vial of PPD solution was observed opened and stored in the top of a medication cart on the front hall of the facility. The vial was not labeled with the date that it had been opened. Findings were: On 04/03/2019 at approximately 9:45 a.m., the refrigerator in the facility's medication room was inspected with LPN (licensed practical nurse) # 1. There were no vials of Tuberculin PPD solution observed in the refrigerator. LPN #1 was asked what was used for Tuberculosis testing for newly admitted residents. She stated, We use PPD solution .I used it this morning, it's still in the top of my cart. The opened vial of PPD solution was located on top of the medication cart and observed. The date the vial was opened was not written on the vial. LPN #1 was asked when the vial had been opened. She stated, I…

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.