Arbors at Woodsfield

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure residents with reclining wheelchairs were assessed for possible restraint use. This affected two (Resident #12 and #34) of two residents reviewed for possible restraint use.

Inspectors wroteBased on record review and interview the facility failed to ensure comprehensive assessments were accurate. This affected two residents (Resident #9 and #48) of 12 residents reviewed for accurate assessment.

Inspectors wroteBased on record review and interview the facility failed to ensure residents had appropriate indication for use of medications and did not have duplicate medication therapy without appropriate justification. This affected one (Resident #46) of five residents reviewed for medication use.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store and prepare foods in a sanitary manner. This had the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure all residents received a dignified dining experience when residents seated at a table were not served their meals at the same time. This affected four residents (#2, #8, #47, and #161) of 20 residents observed in the dining room. The facility census was 55.

Inspectors wrote3. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, type II diabetes, acute kidney failure, and major depressive disorder. Review of MDS completed on 01/24/24 revealed Resident #20 had moderately impaired cognition. Record review revealed no evidence a baseline care plan was completed within 48 hours of admission or that a copy was given to Resident #20. Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. [...]

Inspectors wroteBased on observation, medical record review, review of menus, and interview, the facility failed to ensure food was palatable. This affected four residents (#37, #49, #58 and #263) of six residents reviewed for food concerns and one additional resident (Resident #36).

Inspectors wroteBased on record review and interviews, facility failed to conduct care conferences with residents in conjunction with minimum data set (MDS) assessments. This affected two residents (#24 and #49) of three residents reviewed for care planning. The facility census was 55.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure recommendations for restorative ambulation programs were implemented to maintain a resident's ambulatory status. This affected one resident (#37) of three residents reviewed for activities of daily living.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide oral care for a resident who is dependent on staff for personal care. This affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 55.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure interventions to prevent pressure ulcers were in place per orders. This affected one resident (#39) of two residents reviewed for pressure ulcers. The facility census was 55.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to implement fall prevention interventions for a resident with a history of falls. This affected one resident (#27) of three residents reviewed for accidents.

Inspectors wroteBased on observation and interview, the facility failed to prepare pureed foods to meet the needs of residents requiring a pureed diet. This affected two residents (#5 and #19) of two residents who received a pureed diet. The facility census was 55.

Inspectors wroteBased on observations, record review, review of a food preference form, and interview, the facility failed to ensure a resident received food according to assessed food preferences/dislikes. This affected one resident (#58) of 24 residents reviewed for food/nutrition.

Inspectors wroteBased on record review, review of facility infection reports, review of inservice records, staff interview, and policy review, the facility failed to ensure antibiotics were not used unless criteria was met for the treatment of urinary tract infections. This affected one resident (#11) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, review of medical nutrition therapy recommendations, facility policy and procedure review and interview the facility failed to timely address significant weight loss and/or communicate weight loss recommendations to appropriate staff. Actual Harm occurred on 05/25/22 when Resident #41 was assessed to have a 11.2 pound/11.07% severe weight loss in less than thirty days following her admission on [DATE]. During this time period, the facility failed to implement timely comprehensive, individualized and effective interventions to prevent the weight loss, promote weight gain, communicate dietary recommendations to the physician and ensure an ordered dietary supplement was being consumed by the resident. This affected three residents (#20, #32 and #41) of six residents reviewed for nutrition/weight loss. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure residents had a monthly resident council meeting and failed to ensure adequate and timely responses to residents' concerns. This affected 13 residents (#1, #4, #5, #9, #14, #21, #23, #31, #32, #37, #44, #45 and #155) of 50 residents residing in the facility who had voiced concerns through resident council.

Inspectors wroteBased on review of resident personal fund account records, facility policy and procedure review and interview the facility failed to ensure quarterly bank statements were provided to residents/responsible parties and available for review. This affected 30 resident (#1, #2, #3, #4, #5, #6, #7, #8, #9, #16, #18, #19, #20, #21, #23, #24, #26, #27, #28, #29, #30, #34, #35, #36, #37, #38, #43, #44, #47 and #155) of 30 residents who had personal fund accounts maintained by the facility. The facility census was 50.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs and/or preferences of all residents. This affected four residents (#6, #7, #10 and #15) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting during the survey who voiced concerns related to activities. The facility census was 50.

Inspectors wroteBased on record review and interview the facility failed to employ a qualified activity professional as required. This affected four residents (#10, #15, #7 and #6) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting who voiced concerns regarding activities. The facility census was 50.

Inspectors wroteBased on observation, review of the facility menu, review of the National Dysphagia Diet Level documentation, completion of a test tray and interview the facility failed to ensure pureed diets were prepared at the appropriate consistency. This affected four residents (#8, #15, #26 and #39) of four residents identified to receive pureed diets.

Inspectors wroteBased on observation and interview the facility failed to ensure food was prepared in a sanitary manner to prevent contamination. This affected four residents (#8, #15, #26 and #39) of four residents identified to receive pureed diets.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to maintain adequate infection control practices, including the proper use of personal protective equipment (PPE) to prevent the spread of infection including COVID-19. This affected one resident (#248) who was in transmission based/droplet precautions and had the potential to affect 22 residents (#2, #3, #9, #11, #14, #15, #17, #19, #20, #21, #22, #25, #26, #27, #28, #29, #30, #35, #39, #41, #44, and #151) who resided on A Hall. The facility census was 50.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #20's physician was notified timely following weight loss and the resident's family request for an appetite stimulant. This affected one resident (#20) of six residents reviewed for nutrition.

Inspectors wroteBased on closed record review, facility policy and procedure review and interview the facility failed to ensure Resident #50 was provided a notice of the facility bed hold policy and ability to return to the facility upon admission and prior to a hospital transfer. This affected one resident (#50) of one resident reviewed for hospitalization.

Inspectors wroteBased on medical record review, facility policy and procedure review and interview the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) screening for residents with newly added mental health diagnoses. This affected two residents (#44 and #17) of two residents reviewed for PASARR reviews.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to develop comprehensive and individual care plans for Resident #44 related to psychoactive medication, Resident #12 related to restorative nursing services and Resident #6 related to activities. This affected three residents (#6, #12 and #44) of 25 residents whose care plans were reviewed.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure comprehensive and individualized care plans were revised for Resident #19 related to advance directives and Resident #43 related to medication administration. This affected two residents (#19 and #43) of 25 residents reviewed for care planning.

Inspectors wroteBased on closed record review, facility policy and procedure review and interview the facility failed to ensure a comprehensive discharge summary was completed for Resident #49 as required. This affected one resident (#49) of two residents reviewed for transfer/discharge.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #15, who required staff assistance for activities of daily living care received adequate and timely assistance with nail care to maintain proper hygiene. This affected one resident (#15) of two residents reviewed for activities of daily living.

Inspectors wroteBased on observation, record review and interview the facility failed to assess and timely notify the physician of an identified skin alteration for Resident #17. This affected one resident (#17) of one resident reviewed for non-pressure skin alterations.

Inspectors wroteBased on observation, record review, manufacturer guidelines review, facility policy and procedure review and interview the facility failed to ensure pressure ulcer interventions were provided in accordance with manufacturer guidelines and to meet the needs of Resident #15. This affected one resident (#15) of two residents reviewed for pressure ulcers. The facility identified three residents who had pressure ulcers.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to provide a restorative program as scheduled for Resident #12. This affected one resident (#12) of four residents reviewed for restorative programs.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #5, who had a history of falls in the facility had fall interventions in place as planned and education to prevent additional falls. This affected one resident (#5) of four residents reviewed for accidents.

Inspectors wroteBased on observation, record review, meal ticket review and interview the facility failed to ensure Resident #32 received a dysphagia diet as ordered. This affected one resident (#32) of ten residents reviewed for dining.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure residents received timely COVID-19 vaccination after receiving consent for administration. This affected one resident (#248) of one resident reviewed for transmission based precautions.