St. Therese of Woodbury LLC

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure safe use of a wheelchair without foot pedals and added cushions was assessed for 1 of 2 residents (R28) reviewed for falls. This resulted in actual harm when R28 fell from the wheelchair during transport, sustained a right leg fracture and required hospitalization. The facility had implemented actions to prevent recurrence prior to survey on 5/26/26, therefore the citation was issued at past noncompliance. Furthermore, the facility failed to provide supervision with meals for 1 of 1 resident (R61) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that a resident's call light was accessible and within reach while the resident was in the shower for 1 of 1 resident (R47) reviewed for call light accessibility. This failure had the potential to impact all residents who use the shower.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was preserved for 1 of 1 resident (R50) reviewed for dignity.

Inspectors wroteBased on interview and document review, the facility failed to ensure provider orders were transcribed accurately into the electronic medical record (EMR) for 2 of 2 residents (R25,R61) and failed to ensure verbal orders were received accurately for 1 of 1 resident (R15), for residents reviewed for order accuracy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure facial hair was covered when plating food for delivery and failed to ensure dishwasher temperatures were maintained at required temperatures needed for proper sanitization. Furthermore, the facility failed to ensure refrigerated items were removed after expiration from 1 of 2 unit kitchens reviewed. This had the potential to impact all residents who reside in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 2 residents (R147, R198) reviewed for Physician Orders for Life Sustaining Treatment (POLST) had the correct code status (i.e. full code, do not resuscitate-DNR) information outlined within the medical record. This could cause R147 and R198 to receive resuscitation efforts (i.e. cardiopulmonary resuscitation-CPR) against their wishes.

Inspectors wroteBased on interview and document review the facility failed to ensure bowel monitoring for 1 of 1 resident (R33) reviewed for constipation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure recommendations were followed to minimize risk of aspiration for 1 of 1 residents reviewed for nutrition.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure meal choices were provided as ordered for 1 of 2 (R147) residents reviewed for choices.

Inspectors wroteBased on interview and document review the facility failed to ensure monitoring was in place for 1 of 1 resident (R9) reviewed who had an urinary tract infection (UTI).

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm for 2 of 3 residents when (R1) admitted with a stage 1 pressure ulcer that developed into an unstageable pressure ulcer and R2 admitted with a stage 2 pressure ulcer that developed into an unstageable pressure ulcer resulting in ongoing pain.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 1 of 1 resident (R3) observed for short term stay. The facility further failed to offer an alternate meal option. This had the potential to affect all 16 of 16 residents identified to reside on the unit where the meal was served.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP)-(an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented for management of a pressure ulcer wound and a peripherally inserted central catheter (PICC) to reduce the risk of infection to others for 1 of 1 resident (R2). Further the facility failed to implement hand hygiene for 1 of 1 resident (R2) observed during incontinence care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 1 residents (R360) colonized with a multidrug resistant organism (MRDO) was placed on enhanced barrier precautions (EBP). This had the potential to impact all residents who reside in the facility. Furthermore, the facility failed to ensure proper hand hygiene and glove use was utilized for 1 of 1 residents (R360) observed during personal cares.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 2 of 2 residents (R15, R360) observed with medications at bedside.

Inspectors wroteR355's admission MDS dated [DATE], indicated R355 had sever cognitive impairment and diagnoses of a hip fracture and spine fractures. R355's care plan dated 5/5/24, lacked indication R355 required a back brace. R355's [NAME] dated 5/5/24, lacked indication R355 required a back brace. R355's provider order dated 5/5/24, directed staff to have brace on when elevated above 30 degrees or up and active. An observation on 5/21/24 at 1:23 p.m., nursing assistant (NA)-B entered R355's room to assist him back to bed. R355 was sitting in the wheelchair with a black brace that went around his torso with straps over the shoulders. After NA-B was assisted back to bed, NA-B assisted R355 to remove the back brace. When interviewed on 5/21/24 at 1:55 p.m., NA-B- stated R355 had a back brace for when R355 was out of bed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure weekly wound assessments were completed to monitor wound healing and evaluate the residents response to interventions for 1 of 1 residents (R30) reviewed for non- pressure related wounds.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure range of motion (ROM) exercises and a left hand splint was applied as ordered for 1 of 1 resident (R16) reviewed for range of motion.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents oxygen was adminstered according to doctor's orders for 1 of 1 resident (R305) reviewed for respiratory therapy.

Inspectors wroteBased on observation, interview, and document review the facility failed to complete weekly comprehensive skin assessments, failed to follow physician ordered treatments, and failed to revise the care plan for new ulcer development for 1 of 4 residents (R2). Additionally failed to complete an admission comprehensive skin assessment, develop a baseline care plan for pressure ulcers, and failed to implement pressure ulcer interventions for 1 of 4 residents (R4) reviewed for pressure ulcers.