Als Woodstock Inc

Inspectors wroteBased on record review, observation, staff and resident interview, document review and policy review, the facility failed to ensure a physician ordered specialized bed was provided for a resident with Multiple Sclerosis. This affected one (Resident #37) out of three residents reviewed. The facility census was 42. Findings Included:Review of the medical record revealed Resident #37 was admitted on [DATE]. Diagnoses included progressive multiple sclerosis (MS), bipolar disorder, type two diabetes, ileostomy, colostomy, chronic pain, and arthropathy. Review of the plan of care dated 08/08/25 revealed Resident #37 would remain in the facility for long term care. Interventions included allow Resident #37 to voice preferences regarding care and schedule as requested. Resident #37 was at risk for acute and chronic pain related to generalized pain. [...]

Inspectors wroteBased on record review, observation, staff interviews and policy review, the facility failed to follow infection control protocol when changing a wound dressing. This affected one (#19) of three residents reviewed for wound care. The facility census was 42.

Inspectors wroteBased on record review, review of a facility self-reported incident (SRI) and staff interviews, the facility failed to develop a plan of care to address a resident's behaviors. This affected one (#11) of three residents reviewed for care planning. The facility census was 42.

Inspectors wroteBased on observations, staff and resident interviews, review of the facility activity calendar, and review of the facility policy, the facility failed to ensure group activities were conducted as scheduled. This had the potential to affect 22 residents residing in the facility who regularly attend group activities, the facility identified 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities. The facility census was 39.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to notify a resident representative of change of condition. This affected one (#39) out of the three residents reviewed for change of condition. The facility census was 39.

Inspectors wroteBased on staff interviews, employee file reviews, and review of the facility Activity Director (AD) job description, the facility failed to ensure the employee in the role of AD was qualified as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39.

Inspectors wroteBased on medical record review, resident and staff interview, review of dental visit documentation, review of hospital documentation, and review of facility policy, the facility failed to ensure residents were provided with timely dental services to address non-restorable and decaying teeth. Actual harm occurred to Resident #33 when the dentist identified the resident's teeth required extraction (removal) and the facility failed to follow up with a referral to an oral surgeon. This resulted in the resident developing fever and chills which prompted a visit to the emergency department where the resident was diagnosed with system inflammatory response syndrome and bacteremia caused by a tooth infection. This affected one (#33) of one residents reviewed for dental services. The census was 35.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure sufficient smoking assessments were completed to determine resident capabilities and deficits regarding smoking safety. This affected four (#2, #13, #16, and #26) of five residents reviewed for smoking. The facility census was 35.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were reviewed and responded to timely from the physician. This affected four (#2, #7, #9, and #33) of five residents reviewed for unnecessary medications. The current census was 35.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans as required. This affected one (#31) of three residents reviewed for care plans. The facility census was 35.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the failed to ensure physician orders were in place to address wound treatments. This affected one (#31) of one residents reviewed for wounds. The facility census was 35.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure psychotropic as needed medications had an appropriate stop date or rationale for extending the usage as required. This affected one (#9) of five residents reviewed for unnecessary medications. The census was 35.

Inspectors wroteBased on medical record review, resident and staff interview, pharmacy delivery document review, and policy review the facility failed to administer an antibiotic as ordered by the physician. This affected one (#7) of one resident reviewed for urinary tract infections. The facility census was 35.

Inspectors wroteBased on observations, staff interviews, review of the medical record, review of the police report, review of the hospital documentation, and review of the facility's wandering and exit-seeking policy and procedure, the facility failed to provide a safe environment and adequate supervision to prevent Resident #8 from exiting the facility without staff knowledge. This affected one (Resident #8) of three residents reviewed for elopement. The facility identified six residents (Resident #8, #19, #20, #23, #25, and #33) at risk for elopement. The facility census was 39.

Inspectors wroteBased on resident and staff interviews, and record review, the facility failed to ensure resident concerns brought up at the resident council meeting were addressed timely and appropriately. This affected nine (#05, #07, #10, #13, #14, #18, #30, #32, and #36) residents in regular attendance of the resident council meetings. The Facility census was 39.

Inspectors wroteBased on resident interview, staff interview and record review, the facility failed to ensure resident's representatives were notified when a change in condition occurred. This affected two (#16 and #21) of three residents reviewed for change in condition. The facility census was 39.

Inspectors wroteBased on observation, resident and interviews, and record review, the facility failed to maintain a home like environment for one (#16) of three residents reviewed for physical environment. The facility census was 39.

Inspectors wroteBased on resident interviews, staff interviews and record review, the facility failed to ensure dependent residents received showers as scheduled. This affected two (#16 and #21) of three residents reviewed for activities of daily living (ADLs). The Facility census was 39.

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to ensure resident's call lights were answered timely. This affected one (#23) of the three residents reviewed for call lights. The facility census was 39.

Inspectors wroteBased on observation, staff interviews, resident interview, and record review, the facility failed to ensure residents received their diet as ordered. This affected one (#35) of three residents reviewed for nutrition. The facility census was 39.

Inspectors wroteBased on observation, staff interviews, resident interview, and record review, the facility failed to ensure a resident was provided with the appropriate assistive devices for dining. This affected one (#16) of three residents reviewed for assistive devices for dining. The facility identified eight (#05, #7, #14, #16, #17, #19, #36, and #39) residents with orders for adaptive equipment. The facility census was 39.

Inspectors wroteBased on staff interview, review of timecard punches, and review of facility schedule, the facility failed to ensure Registered Nurse (RN) coverage was maintained for eight consecutive hours, seven days a week. This had the potential to affect all 39 residents. The facility census was 39.

Inspectors wroteBased on observation, record review, interview with staff and residents, and review of daily menus, the facility failed to follow menus plan to provide nutritious and well-balanced meals. This had the potential to affect all 39 residents who the facility identified as receiving food from the kitchen. The facility census was 39.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policy, the facility failed to provide a clean and sanitary environment for the residents. This affected Resident #36 and #43 and had the potential to affect all 39 residents who resided in the facility.

Inspectors wroteBased on staff interviews, review of facility policy, and record reviews, the facility failed to maintain full and complete accounting records for the residents. This affected one (#45) of four resident reviewed for facility management of funds. The facility identified 24 residents that the facility manages residents funds. The facility census was 39.

Inspectors wroteBased on resident and staff interviews and record reviews, the facility failed to provide residents a diet order to meet their daily nutritional needs. This affected two (Residents #30 and #45) of four residents reviewed for therapeutic diets. The facility census was 39.

Inspectors wroteBased on resident and staff interviews, review of facility policy, and record reviews, the facility failed to provide a written physicians order for specialized rehabilitative services for a resident. This affected one (Resident #30) of four residents reviewed for specialized rehabilitative services. The facility census was 39.

Inspectors wroteBased on record reviews, staff interviews, and review of the facility policy, the facility failed to provide signed and dated current physician orders for the month of October 2023. This affected four (Residents #30, #42, #45, and #47) of four residents reviewed for physician orders. This had the potential to affect all 39 residents residing in the facility that received physician services at the facility.

Inspectors wroteBased on resident record review, staff interview, and review of Centers for Medicare and Medicaid Services (CMS) waiver guidance; the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon transfer to the hospital. This affected one (#30) of one residents reviewed for hospitalization. The census was 34.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure diagnoses were accurate for the use of antipsychotic medications and failed to ensure adverse side effects from said medications were monitored. This affected one (Resident #4) of five residents reviewed for unnecessary medications and four review. The facility also failed to ensure adverse side effects from psychotic medications were monitored for four (Residents #30 #34, #25 and #15) of four residents reviewed for psychotropic drug use. The facility census was 37.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment with all current diagnoses. This affected one (Resident #30) of three residents reviewed for accurate assessments. The facility census was 37.

Inspectors wroteBased on record review and interview, the facility failed to ensure that care plans were developed for activities. This affected one (Resident #20) of two residents reviewed for activities.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an assessment for activities and an activity calendar were provided for residents. This affected two (Resident #1 and Resident #20) of two residents reviewed for activities. The census was 37.

Inspectors wroteBased on observation, record review, interview and review of recommendations and manufacturer's guidelines for side rails and motorized wheelchairs, the facility failed to ensure there was safe distance between the side rail and the mattress on a bed and failed to ensure a motorized wheelchair was set at a safe speed . This affected one (Resident #1) of three residents reviewed for side rails and one (Resident #2) of five residents who operated a motorized wheelchair. The facility identified there were 22 ambulatory residents of which the speed of the motorized wheelchair could potentially affect. The census was 37. 1. Medical record review for Resident #1 revealed an admission date of 12/30/09. Medical diagnoses included anxiety, depression and Schizophrenia. Review of annual Minimum Data Set (MDS) assessment, dated 01/02/19, revealed he was cognitively intact. [...]

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure side rail assessments were completed for two (Residents #1 and #10) of eight residents reviewed for side rails. The census was 37.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure side rails were properly installed. This affected three (Residents #1, #5 and #7) of three residents who had reviewed for side rails. The census was 37.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure reference checks for new employees were completed prior to hire. This affected four (Employees #10, #12, #19 and #29) of nine personnel files reviewed. This had the potential to affect all 37 residents. The facility census was 37.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided a transfer/discharge notification upon transfer and failed to notify the Ombudsman. This affected two (Residents #1 and #19) of two residents reviewed for hospitalization. This had the potential to affect all residents in the facility. The census was 37.

Inspectors wroteBased on record review and interview, the facility failed to ensure a bed hold notice was given to a resident upon transfer to the hospital. This affected one (Resident #19) of two residents reviewed for bed hold notification. This had the potential to affect all residents in the facility. The census was 37. Medical record review for Resident #19 revealed an admission date of 10/10/16. Review of progress notes for Resident #19 revealed on 02/01/19 the resident was sent out to a behavior hospital and returned to the facility on [DATE]. The record contained no documentation the resident was provided with a bed hold notification. Interview with Social Worker Designee #35 on 04/24/19 at 12:32 P.M. revealed she didn't have a bed hold notice for the resident. She stated she was doing them prior to 12/01/19, but when the new company took over she didn't have one for the new company. [...]