Embassy of Woodview

Inspectors wroteBased on observations and staff interviews the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and the public. This had the potential to affect all residents who reside in the facility. The census was 64.

Inspectors wroteBased on record review and interview, the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day and 7 days a week. This deficiency had the potential to affect all 68 residents. The facility census was 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food services. This had the potential to affect 68 residents who eat food from the kitchen. The facility census was 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a water heater to ensure residents had access to hot water. This affected all residents residing on the coral area of the facility (Residents #3, #4, #5, #6, #8, #12, #13, #14, #15, #17, #18, #20, #23, #26, #27, #28, #29, #30, #31, #35, #36, #38, #40, #43, #47, #48, #51, #52, #54, #60, #64, #65, #81, and #82). The facility census was 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #31's bathroom was clean; the facility failed to ensure a packaged terminal air conditional (PTAC) was functional in Resident #2's room; and the facility failed to ensure the hallway floor was clean between rooms [ROOM NUMBERS]. This affected two (Resident #31 and #2) and had the potential to affect all residents residing in the facility. The facility census was 68.

Inspectors wroteBased on medical record review, Self-Reported Incidents (SRI) review, interviews, and facility policy, the facility failed to complete thorough investigations following allegations of abuse. This affected four residents (#01, #73, #88, and #89) of four residents reviewed for abuse. The facility census was 68.

Inspectors wroteBased on record reviews, observations, interviews, and facility policies, the facility failed to ensure staff practiced hand hygiene. This affected two (Residents #7 and #62); The facility failed to have signage posted for residents on enhanced barrier precautions. This affected two (Resident #4 and #11); The facility failed to ensure a nurse wore a gown during wound care for a resident on enhanced barrier precautions. This affected one (Resident #67); The facility failed to ensure a catheter bag was off the floor to prevent contamination. This affected one (Resident #12). This deficient practice affected six (Residents #7, #62, #4, #11, #67, and #12) of six residents reviewed for infection control. The facility census was 68.

Inspectors wroteBased on record review, observations, interviews, and facility policies, the facility failed to provide a fitted sheet for a resident to promote a homelike environment. This affected one (Resident #30) of one resident reviewed for environment. The facility census was 68.

Inspectors wroteBased on review of medical records, review of Self-Reported Incidents (SRI), interviews, and policy review, the facility failed to report an allegation of neglect when a resident eloped to the State Agency (SA). This affected one (Resident #85). Additionally, the facility failed to report an allegation of resident-to-resident physical abuse to the SA. This affected two (Residents #35 and #59). This affected three (Residents #85, #35, and #59) of three residents reviewed for abuse. The facility census was 68.

Inspectors wroteBased on medical record review, review of care conferences, and interviews, the facility failed to complete care conferences quarterly. Additionally, the facility failed to ensure care plans reflected a resident's current status. This affected one (Resident #05) of one resident reviewed for care planning. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete weekly skin assessments as ordered. This affected one (Resident #48) of three residents reviewed for skin. The facility census was 68.

Inspectors wroteBased on record review, interview and observation the facility failed to ensure weekly skin assessments were completed as ordered to potentially prevent pressure ulcers. This affected one resident (#57) of four residents reviewed for pressure ulcers. The census was 68.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure staff accompanied residents to smoking. This affected two (Residents #35 and #32) of three residents observed for smoking. The facility census was 68.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide timely incontinence care for one resident (#21). This affected one (Resident #21) of one resident observed for incontinence care. The facility census was 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen as ordered to Resident #23 and Resident #48. This affected two (#23 and #48) of three residents investigated for respiratory care. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to monitor a resident's blood glucose levels and oxygen saturations as physician ordered. This affected one (Resident #150) of three residents revied for changes in condition. The facility census was 74.

Inspectors wroteBased on interviews, record reviews, hospital documentation, observation and review of facility policy, the facility failed to initiate treatment and complete an accurate assessment for a suspected deep tissue injury (SDTI) [persistent non-blanchable deep red, maroon or purple discoloration of the skin] to the bilateral buttocks upon admission on [DATE] for Resident #174. Actual Harm occurred on 05/07/25 when Resident #174's SDTI to the bilateral buttocks worsened to four stage III pressure ulcers (full thickness skin loss in which the fat is visible in the ulcer and granulation tissue as well as rolled wound edges are often present) due to not following the Wound Certified Nurse Practitioner's recommendations. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to implement enhanced barrier precautions for Resident #174. This affected one resident of one resident reviewed for enhanced barrier precautions and had the potential to affect all 23 residents on the hall. The facility census was 70.

Inspectors wroteBased on observations, resident interviews, staff interviews and record review, the facility failed to ensure there was a sufficient supply of washcloths, hand towels and bath towels to complete resident care. This shortage affected two residents (#8 and #21) and had potential to affect all 70 residents residing in the facility. The facility census was 70.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one (Resident #47) had access to her personal property a motorized wheel chair. This affected one (#47) of two reviewed for personal property. The facility census was 70.

Inspectors wroteBased on observations, medical record review, staff interview, and facility policy review, the faciltiy failed to monitor and provide timely/adequate treatments and care for non-pressure skin issues. This affected two (Resident #27 and #47) of six residents reviewed for skin issues. The census was 70. Findings Include: 1. Review of the medical record for Resident #27, revealed an admission date of 3/30/25. Diagnoses included but were not limited to dementia, cerebral infarction, muscle weakness, anxiety disorder, and chronic kidney disease stage III. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 09 suggested moderate cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide proper parameters for as needed pain medications. This affected two (Resident #3 and #48) of five residents reviewed for medications. Also, the facility failed to follow parameters prior to administering medications. This affected two (Residents #48 and #5) of five residents reviewed for medications. The census was 70. Findings Include: 1. Resident #3 was admitted to the facility on [DATE]. His diagnoses were alcoholic cirrhosis of liver, hypertension, hyperlipidemia, depression, anemia, adult failure to thrive, alcohol dependence, schizoaffective disorder, personal history of traumatic brain injury, diabetes mellitus, type II diabetes, dementia, cognitive communication deficit, dysphagia, and bipolar II disorder. [...]

Inspectors wroteBased on record reviews, staff interviews, review of a Medication Error form, and review of facility policy, the facility failed to ensure residents medications were administered as ordered. This affected four (#42, #50, #63 and #71) out of the seven residents reviewed for medication administration. The facility census was 70.

Inspectors wroteBased on record reviews, staff interview, review of a Medication Error form, and review of facility policy, the facility failed to ensure accurate and complete documentation was maintained in residents medical records. This affected three (#50, #63, and #71) out of the seven residents whose medical records were reviewed. The facility census was 70.

Inspectors wroteBased on observation, medical record review, review of hospital records, review of physician's notes and wound assessments, appointment reminder notice review, interviews with residents, family, outside entities, and staff, and policy review, the facility failed to provide adequate, timely and necessary care and services, including timely re-scheduling of vascular surgeon appointments for Resident #100, who had vascular wounds to meet the resident's total care needs. [...]

Inspectors wroteBased on staff and resident interview, medical record review, and policy review, the facility failed to ensure a resident's preference for showers was honored. This affected one (#110) of six resident reviewed for choices. The facility census was 72.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to timely notify a resident's family of a change in condition. This affected one (#58) of six residents reviewed for notification of change in condition. The facility census was 72.

Inspectors wroteBased on medical record review, staff interview, family interview, resident interview, and policy review, the facility failed to ensure Resident #110's family and the Office of the State Long-Term Care Ombudsman was timely notified of the resident's facility-initiated 30-day discharge notice, emergency transfer and subsequent emergency discharge. This affected one (#110) of three residents reviewed for discharges. The facility census was 72.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure safe and sanitary infection control practices were maintained during a dressing change. This affected one (#27) and had the potential to affect sixteen residents who the facility identified as receiving wound care. The facility census was 72.

Inspectors wroteBased on closed record review and interview, the facility failed to provide written notice of discharge to two residents when they transferred to the hospital. This affected two residents (#13, #87) of three residents reviewed for hospitalization with the potential to affect all 73 residents as facility does not have a process in place for discharge or transfer notices. The facility census was 73.

Inspectors wroteBased on closed record review and interview, the facility failed to offer bed hold notices to two residents. This affected two residents (#13, #87) of three residents reviewed for hospitalization with the potential to affect all 73 residents as the facility does not have a process in place for bed hold notices. The facility census was 73.

Inspectors wroteBased on observation of video footage, record review, and interviews, the facility failed to ensure one resident (#66) was treated with respect and dignity. This affected one (Resident #66) of three residents reviewed for dignity. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. [...]

Inspectors wroteBased on medical record review, observation of video footage, staff interviews, and review of facility policy and procedure, the facility failed to ensure a resident was free from abuse. This affected one (#66) of three residents reviewed for abuse. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#66), who was dependent on staff received routine nail care. This affected one (Resident #66) of three residents reviewed for activities of daily living (ADL). The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. [...]

Inspectors wroteBased on observation of video footage, record review, interviews, and facility policy review, the facility failed to ensure one resident (#66) who was at high risk for falls and had a history of falls received the care and supervision for safe transfers. This affected one (Resident #66) of three residents reviewed for transfers. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. [...]

Inspectors wroteBased on observations, review of menus, staff interview, and facility policy review, the facility failed to ensure the menu was followed to meet the nutritional needs of the residents. This had the potential to affect all 64 residents who received meals from the kitchen. The facility identified two residents (Resident #5 and Resident #30) who did not eat anything by mouth. The facility census was 66.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure food was stored and dated properly. This had the potential to affect all 64 residents who received meals from the kitchen. The facility identified two residents (Resident #5 and Resident #30) who did not eat anything by mouth. The facility census was 66.

Inspectors wroteBased on record review, resident, family and staff interviews, and policy review, the facility failed to include residents in the care planning process. This affected five ( #22, #24, #28, #38 and #117) of five reviewed for care planning.

Inspectors wroteBased on observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure the residents resided in a safe, sanitary and homelike environment when there was wallpaper missing on the walls of a resident room affecting two (#59 and #24) and the facility failed to repair a hole in the back hallway floor, that was utilized by residents this had the potential to affect the 52 residents the facility identified as not being bedfast. The total facility census was 66.

Inspectors wroteBased on observations, resident interview, staff interviews, and medical record review, the facility failed to ensure a bed rail was installed as ordered to assist with bed mobility. The deficient practice affected one (#61) of one record reviewed for accommodations of needs. The facility census was 66.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide an appropriately completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). This affected one (#61) of the three residents reviewed for Beneficiary Notices. The facility census was 66.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure residents received accurate bed hold notices/reserve bed payment information and establish a written bed-hold and reserve bed payment policy. This affected two (#35 and #44) of the three residents reviewed for bed hold notices/ reserve bed payment. The facility census was 66.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to ensure assessments accurately reflected resident's condition. This affected two (#59 and #65) of 22 resident assessments reviewed. The total facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to completed an updated PASARR screening when a Resident was diagnosed with a new mental illness. This affected one (#36) of the three residents reviewed for accurate PASARR screenings. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to complete a full resident review for a resident who enter the facility under the hospital exemption and remained in the facility longer than 30 days. This affected one (#59) of two residents reviewed for preadmission screening. The total facility census was 66.

Inspectors wroteBased on observation, record review, staff interviews, and policy review, the facility failed to ensure residents had comprehensive care plans developed to addressed their individualized needs. This affected four ( #49, #59, and #38) of 22 residents reviewed for care plans. The total facility census was 66.

Inspectors wroteBased on record review, resident and staff interview, and policy review the facility failed to timely address a resident's constipation. This affected one (#117) of one reviewed for constipation. The facility census was 66.

Inspectors wroteBased on medical record review, resident, family and staff interviews, and policy review, the facility failed to ensure vision services were arranged and received timely. The deficient practice affected two (#28 and #38) of two residents reviewed for communication and sensory services. The facility census was 66.

Inspectors wroteBased on medical record review, observation of wound care, resident and staff interview, and review of hospice notes, National Pressure Injury Advisory Panel (NPIAP) guidelines review, the facility failed to identify a new pressure area, assess the wounds, and provides treatments. The deficient practice affected one (#61) of one reviewed for pressure ulcers. The facility census was 66.

Inspectors wroteBased on medical record review, observations, family and staff interviews, and review of therapy notes, the facility failed to ensure a resting hand splint was applied as ordered. This affected one (Resident #5) of three residents reviewed for position and mobility. The facility census was 66.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure emergency tracheostomy supplies were readily available. This affected one (#49) of two residents reviewed for tracheostomy services. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide psychiatric services and/or alcohol counseling services as care planned for a resident with substance seeking behavior. This affected one (Resident #58) out of the one resident reviewed for behavioral health services. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to adequately monitor residents who received psychotropic medications. This affected one (#59) out of five residents reviewed for unnecessary medications. The facility census was 66.

Inspectors wroteBased on medical record review, facility staff interview, and policy review, the facility failed to perform laboratory tests as ordered. This affected one (#22) out of five residents reviewed for unnecessary medications. The facility census was 66.

Inspectors wroteBased on observation, medical record review, family and staff interview, and policy review, the facility failed to provide timely dental services. This affected one (#22) of three residents reviewed for dental services. The facility census was 66.

Inspectors wroteBased on observations and staff interviews, the facility failed to have the resident rights posted in the facility. This had the potential to affect 66 of 66 residents in the facility.

Inspectors wroteBased on activity calendar reviews, staff interview, and policy review, the facility failed to ensure meaningful activities were offered to residents daily and at various times throughout the day. The deficient practice affected had the potential to affect 66 of 66 residents residing in the facility. The facility census was 66. Findings Include: Review of activity calendars dated from August 2022 through November 2022 revealed no activities were scheduled on the weekends in November 2022 and no activities were scheduled after 2:00 P.M. in the afternoon, there were not any evening activities offered. Interview on 11/16/22 at 1:30 P.M., with Activity Director (AD) #300 revealed she was the only activities staff person at the facility currently due to the activities aide quitting. AD #300 stated she worked Mondays through Friday until 5:00 P.M. [...]