Complete Care at Woodlands

Inspectors wroteComplaint # 2648672Based on observation, interview, and record review, it was determined that the facility failed to: a.) change an arterial ulcer treatment dressing in accordance with a physician order, b.) failed to document appropriately in accordance with professional standards of practice, c) failed to notify the physician that resident refused dressing change. This deficient practice was identified for 1 of 3 residents reviewed with pressure ulcers (Resident #2), and was evidenced by the following:A review of Resident #2's electronic medical record. The admission Record reflected that Resident #2 had diagnoses which included but were not limited to; Polyosteoarthritis, Type 2 Diabetes Mellitus, and Atherosclerosis of native arteries of right leg with ulceration of other part of foot. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy and manufacturer's instructions, the facility failed to ensure a medication error rate below five percent. During medication administration for one (Resident (R)133) of seven residents, two medication errors occurred out of 31 opportunities for error, or a medication error rate of 6.45%. This failure had the potential to increase or decrease the effectiveness of these medications.

Inspectors wroteComplaint#: NJ00175265 Based on observation, interview, review of medical records and other pertinent facility documentation on 09/24/24 and 09/25/24, it was determined that the failed to maintain an accurate and complete medical record in accordance with acceptable standards and practice by not documenting a registered nurse's (RN) assessment of a resident that presented with a change in condition. The facility also failed to follow it's Charting and Documentation policy. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed and was evidenced by the following: On 09/24/24, at 11:11 A.M., the surveyor observed the resident seated in a wheelchair beside the bed. The resident stated that staff was sometimes responsive to resident's needs. [...]

Inspectors wroteBased on record review, interview, review of the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure ten residents out of 27 sampled resident's (Resident (R)16, R62, R6, R42, R44, R97, R72, R78, R2, R15) Minimum Data Set (MDS) assessments were transmitted in a timely manner.

Inspectors wrote4. Review of the undated admission Record under the Profile tab in the EMR revealed R45 was admitted to the facility on [DATE] with the diagnosis of stage four pressure ulcer, cerebral infarction, and hypertension. Review of R45's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/23 coded the resident of having a Brief Interview for Mental Status (BIMS) score of three out of a possible score of 15. This represents R45 was severely cognitively impaired. Review of R45's EMR revealed the resident did not have a base line care plan developed within 48 hours of admission to the facility. R45 was admitted on [DATE]. During an interview on 02/01/24 at 1:11 PM, UM1 reviewed the EMR and stated, There isn't a base line care plan that was started for [R45] . We have a care plan meeting, but it is done when they are here for 72 hours. 5. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide one of 27 sampled residents (Resident (R) 87) a dignified dining experience. Specifically, the facility failed to provide regular silverware to R87, who was not assessed to be a danger to herself or others, for 14 months.

Inspectors wroteBased on observation, staff interview, and record review, the facility staff failed to follow professional standards of practice and left medications at the bedside that were not ordered to be self-administered for one of one resident (Resident (R) 98).

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure a safe discharge for residents that left Against Medical Advice by ensuring agencies in the community were made aware the resident was returning to the community prior to a planned discharge and that prescriptions for care and medications were provided to ensure continuity of care for two of two (Resident (R) 107 and R105) residents reviewed for unplanned discharge.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to accurately screen residents for elopement risk and have measures in place to ensure residents with a wander guard had documented exit seeking behaviors prior to use for one of one resident (Resident (R)76) reviewed for wander guards.

Inspectors wroteBased on staff interview and medical record review, the facility staff failed to obtain a physician order when change in treatment occurred and failed to obtain a physician order for wound care when a resident was admitted to the facility for two of five residents (Resident (R) 45 and R32) reviewed for pressure injuries.

Inspectors wroteComplaint #: NJ00157992 Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one of nine sampled residents (Resident (R)4).

Inspectors wroteComplaint #: NJ00168238 Based on interview, document review, and policy review, the facility failed to implement their COVID-19 outbreak policy to mitigate the spread of COVID-19 when one of four employees (Certified Nursing Assistant (CNA) 1) tested positive for COVID-19, was at home for five days and did not test negative twice within 48 hours prior to returning to work.

Inspectors wroteComplaint #:NJ00168734 Based on observation, interview, document review and policy review, the facility failed to ensure the bedrails were clean in one of 28 resident rooms (room [ROOM NUMBER]-B) on the Oakwood Unit.

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner for 1 of 1 nurse observed providing a wound care treatment, to 1 of 1 resident, (Resident #51); b) perform proper hand hygiene during meal service for 1 of 3 dining rooms observed; and c.) perform proper hand hygiene to maintain sanitation in a safe and consistent manner to prevent food borne illness. 1. On 08/11/21 at 11:09 AM, the surveyor observed Resident #51 lying in bed, which had a pressure-relieving device attached to the end of the bed. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow acceptable standards of clinical practice related to wound care administration and accurate implementation of physician's orders. This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #51), and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: [...]

Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 08/11/21 from 09:25 AM to 10:18 AM, the surveyor toured the kitchen in the presence of the Account Manager (AM) and observed the following: 1. The surveyor washed hands at handwashing sink #1 and observed that the foot pedal trash can was not lined with a trash bag and both trash and food debris were observed in the can. [...]