Memorial Woodland Village Nursing Center

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and confidentiality by posting personal health information on the resident's wall for one (1) of twenty-three (23) sampled residents, Resident #82.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to a resident having a restraint, when no restraint had been ordered or used, for one (1) of twenty-three (23) residents reviewed. Resident #99.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to acknowledge and honor the documented food preferences of one (1) of twenty-three (23) sampled residents, Resident #88.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to follow safe food storage and handling practices on one (1) of four (4) survey days. Specifically, the facility failed to properly store, label, and date frozen food items that were opened, discard expired bakery rolls and refrigerate lemon juice in accordance with manufacturer instructions.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to properly store, label, and date food items and discard expired food on an annual recertification survey on 2/29/24 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F812. Findings Include: [...]

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to follow appropriate infection control practices when a Certified Nurse Aide (CNA) placed soiled linens on the floor of a resident's room after incontinent care for one (1) of twenty-three (23) sampled residents, Resident #97.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain an effective pest control program related to ants for one (1) of twenty-three (23) sampled residents, Resident #49.

Inspectors wroteBased on interviews, record review, and review of resident council monthly meeting minutes, the facility failed to resolve grievances regarding food complaints for five (5) of eight (8) months reviewed.

Inspectors wroteBased on interviews, record review, and the facility policy review the facility failed to offer residents in the facility a bedtime snack for (3) of 23 sampled residents. (Resident #94, Resident #95, and Resident #107). Findings Include: A review of the facility's policy, Offering/Serving Bedtime Snacks, revised 4/20/23, revealed, .It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis .Policy Explanation and Compliance Guidelines .1. The nursing staff offers bedtime snacks to all residents . Resident #94 On 02/27/24 at 01:30 PM, in an interview with Resident #94, she explained she has not noticed the staff offering snacks to residents in the facility, or taking bedtime snacks to residents who are unable to leave their room. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement care plan approaches related to an indwelling catheter care for one (1) of 23 sampled residents.

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to provide showers for residents who require assistance for three (3) of (23) sampled residents. (Residents #74, #78 and #97) Findings Include: Review of the facility's policy, Activities of Daily Living (ADL's), revised 11/28/2023, revealed .The facility will, based on the residence comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate .Care and services will be provided for the following activities of daily living .1. Bathing, dressing, grooming . Review of the facility policy, Resident Showers, revised 11/29/23, revealed, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene .Policy Explanation and Compliance Guidelines .1. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent complications for one (1) of one of seven (7) residents with urinary catheters.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to store food and engage in sanitary practice in accordance with professional standards for food service safety related to food items not dated with a use-by-date, no identifying label, expired foods, improperly stored and exposed food for one (1) of three (3) kitchen observations.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of property for one (1) of 23 sampled residents.

Inspectors wroteLevel II Based on interview, and record review, the facility failed to provide a pest free living environment for one (1) of 23 sampled residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for a resident taking an antipsychotic medication for one (1) of 20 residents sampled for MDS accuracy. Resident #74. A record review of the signed statement by the Nursing Home Administrator revealed the facility used the Resident Assessment Instrument (RAI) for coding the MDS. A record review of the Face Sheet revealed the facility admitted Resident #74 on 06/16/21, with diagnoses including Personal History of Traumatic Brain Injury, and Personal History of Other Mental and Behavioral Disorders. A record review of Resident #74's Physician Orders List revealed a physician order with a start date of 06/16/21 for Zyprexa 5 milligram (mg) tablet one (1) tablet by mouth (PO) every hour sleep (QHS). [...]

Inspectors wroteBased on record review, facility policy review, and staff interviews, the facility failed to act upon a Consultant Pharmacy (CP) recommendation for one (1) resident of seven (7) residents reviewed for unnecessary medications. Resident #22 A record review of the facility's policy, Medication Regime Reviews with a revised date of April 2007 revealed, .7. The Consultant Pharmacist will document his/her findings and recommendations . A record review of the Note to Attending Physician/Prescriber revealed .Please consider if GDR (Gradual Dose Reduction) is appropriate for: Lexapro 10 mg (milligrams) po (by mouth) daily .RECOMMENDATION: If a gradual dose reduction is appropriate, please consider reducing dose to Lexapro 5 mg po daily .Physician/Prescriber Response .Agree. The recommendation was signed by the Nurse Practitioner (NP) and dated 10/13/21. [...]