The Woods, a Nightingale Community

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure safety straps were placed on all four wheels of a resident's wheelchair before being transported in the facility van which resulted in one resident falling backwards from the wheelchair for one (Resident #1) of three residents reviewed for accidents and hazards.

Inspectors wroteBased on observations, record review, interviews, and facility policy review it was determined the facility failed to ensure meal service assistance was provided in a timely manner for one (Resident #4) sampled resident, and to ensure staff did not stand while assisting residents with meal service for three (Residents #4, #46, and #49) of nine residents observed for dining.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure meals were served in a method that maintained the appearance, nutritive value and taste of pureed foods that were acceptable to the residents to improve palatability and encourage good nutritional intake during two of two meals observed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure expired food items were promptly removed or discarded on or before the expiration or use by date to prevent the growth of bacteria, and dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for two of two meals observed.

Inspectors wroteBased on observations, record review, interviews and facility policy review it was determined the facility did not ensure infection control measures were used and staff wore the proper Personal Protective Equipment (PPE) when providing device care for one (Resident #41) of two residents with gastrointestinal feeding tubes reviewed for Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on record review and interviews, it was determined that the facility did not ensure a Care Plan was accurately revised to reflect a resident's elopement and/or wandering status after an incident that occurred in which a resident left the facility without staff knowledge for one (Resident #20) of one sampled resident reviewed for Care Plan accuracy.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility did not provide appropriate services and treatment to prevent complications for one (Resident #41) of two residents reviewed who received enteral feedings.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility did not ensure residents were not provided the code to entrance/exit doors to safeguard residents and prevent residents from eloping from the facility for one (Resident #20) sampled resident. The IJ began on 04/01/2025 at approximately 4:30 PM, when Resident #20 used a code for the exit doors provided by facility staff to exit the building without staff knowledge. Resident #20 verified knowledge of codes to the entrance/exit doors of the facility. These findings have been determined to have resulted in Immediate Jeopardy as defined at 42 CFR §483.25. The Administrator was informed of the Immediate Jeopardy on 07/02/25 at 5:34 PM, and a Plan of Removal was requested. [...]

Inspectors wroteBased on record review and interview, it was determined the facility did not ensure the quarterly Minimum Data Set Assessment reflected a behavior that the resident exhibited for one (Resident #20) of one resident reviewed for assessment accuracy.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure all areas of the skin were cleansed during incontinent care for 1 (Resident #5) of 1 resident reviewed for incontinence care.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure staff performed hand hygiene, changed gloves and did not touch items in the room with gloves used during incontinent care for 1 (Resident #5) of 1 resident reviewed for incontinent care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure staff provided proper incontinence care to 1 (Resident #6) sampled resident.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure staff used proper hand hygiene while providing care to 1 (Resident #6) sampled resident.

Inspectors wroteBased on interviews and record review, it was determined the facility failed to notify the State of Long Term-Care Ombudsman in writing of a transfer to the hospital for 1 resident (Resident #1) reviewed for hospitalization.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an assistive communication device was utilized to facilitate communication between a resident and staff for 1 (Resident #3) sampled resident who required an assistive communication device.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the enteral feed and flush was administered at the physician's ordered rate for 1 (Resident #3) sampled resident who received enteral nutrition and water through a Percutaneous Endoscopic Gastrostomy (PEG) tube.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods stored in the refrigerator and dry storage area were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated when opened to assure first in, first out usage to prevent potential for food bone illness, cooking equipment, ceiling tiles and air vents were free of greasy food crumbs, stains and rust and were maintained in clean sanitary conditions to prevent potential for cross contamination; dietary staff. washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during meals observed. This failed practice had the potential to affect 6 residents who receive meal trays in their rooms on the East Hall, 6 residents who receive meal trays on the North Hall, and 12 residents who receive meal trays in their room on the South hall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fingernails were clean, smooth, and trimmed to promote good personal hygiene and grooming for 1 (Resident #49) sampled resident who required staff assistance for nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a raised toilet seat and outer toilet bowl was cleansed of a dark brown substance to promote a clean and sanitary environment for 1 (Resident #173) of 1 sampled resident who used the bathroom in their room.

Inspectors wroteBased on interview and record review, the facility failed to act as a responsible fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The facility failed to separate accounting for each resident's funds and to ensure each resident received interest payments each month on the funds in their accounts.

Inspectors wroteBased on interview, record review, facility document review and facility policy review, it was determined that the facility failed to maintain separate accounting for each resident's funds.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the oven was maintained in good working condition; employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, ensure refrigerator temperatures were maintained at 41 degrees Fahrenheit or below to prevent the potential for food spoilage and/or bacteria growth for residents who received food from 1 of 1 kitchen. The failed practices had the potential to affect 63 residents who received meal trays from the kitchen (total census: 67) as identified on the list provided by the Dietary Supervisor on 03/28/23 at 2:50 PM.

Inspectors wroteBased on record review, and interview, the facility failed to inform residents, their representatives, and families, of suspected or confirmed COVID-19 cases in the facility by 5:00 PM the next day. This failed practice had the potential to affect all 68 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Clinical Consultant on 03/27/23 at 1:48 PM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents or resident representatives were supplied the information, and provided the opportunity, to file an appeal for skilled therapy services when Medicare Part A services ended for 2 (Residents #66 and #67) of 3 (Residents #66, #67 and #68) sampled residents. The failed practice had the potential to affect 68 residents whose Medicare Part A services ended since the facility's last recertification as documented on a list provided by the Administrator on 03/29/23 at 1:46 PM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 1 (Resident #43) of 2 (Residents #6 and #43) sampled residents who received tube feedings and 1 (Resident #70) of 1 closed record sampled resident who was discharged home.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure facial hair was removed to promote dignity and good grooming for 2 (Residents #6 and #47) and failed to ensure fingernails were clean, filed, and trimmed for 2 (Residents #2 and #19) of 24 (Residents #1, #2, #6, #9, #19, #22, #24, #28, #31 ,#38, #40, #41, #43, #45, #47, #48, #49, #50, #51, #54, #55, #61, #218 and #266) sampled residents who required assistance with shaving and nail care as documented on a list provided by the Administrator on 03/29/23 at 1:46 PM.

Inspectors wroteSurveyor: [NAME] Based on observation, record review, and interview, the facility failed to obtain Physician Orders for oxygen therapy for 1 (Resident #28) and failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent potential hypoxia or other respiratory complications for 1 (Resident #31) of 7 (Residents #1, #6, #13, #19, #28, #31 and #39) sampled residents who received oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 03/29/23 at 10:00 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the appropriate use of Personal Protective Equipment (PPE) and Isolation Protocols for Transmission Based Precautions for COVID-19 to prevent the spread of infection. This failed practice had the potential to affect all 67 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Clinical Consultant on 03/27/23 at 10:46 AM.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the Infection Preventionist had adequate time to perform the duties of the position and to adequately monitor and manage the Infection Prevention and Control Program, as evidenced by multiple Infection Control findings during the Annual Recertification Survey. This failed practice had the potential to affect all 67 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the Clinical Consultant on 03/27/23 at 1:48 PM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Pneumococcal immunizations were administered to eligible residents and immunization records were accurately documented for 4 (Residents #19, #41, #55, and #61) of 5 (Residents #19, #41, #48, #55 and #61) sampled residents whose charts were reviewed for the completion of the Pneumococcal vaccines. This failed practice had the potential to affect 63 residents who resided in the facility as documented on a list of residents not receiving Hospice services provided by the Director of Nursing (DON) on 03/29/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of the identification of a decline and/or improvement in two or more activities of daily living (ADLs) for 1 (Resident #47) of 15 (Residents #1, #9, #13, #22, #39, #40, #41, #45 #48, #49, #50, #51, #54, #55 and #61) sampled residents whose MDSs were reviewed. This failed practice had the potential to affect all 67 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Nurse Consultant on 03/27/23 at 1:15 PM.

Inspectors wroteBased on record review, and interview, the facility failed to refer 1 (Resident #39) of 6 (Residents #13, #22, #24, #28, #39 and #54) sampled residents who was identified with possibly serious mental illnesses or intellectual disabilities to the appropriate state-designated authority for a Level II Preadmission Screening and Annual Resident Review (PASARR) evaluation and determination. This failed practice had the potential to affect 12 residents in the facility who had a diagnosis of serious mental illness or intellectual disability as documented on a list provided by the Administrator on 03/30/23 at 12:48 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were care planned for required assistance with Activities of Daily Living (ADL) for 1 (Resident #19) of 22 (Resident #1, #2, #6, #13, #19, #24, #28, #31, #39, #40, #41, #43, #47, #48, #49, #50, #54, #61, #63, #64, #218, and #266) sampled residents residing in facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for storage of residents' lighters, matches, electronic cigarettes as well as other smoking related items to prevent the potential for accidents for 1 (Resident #54) of 2 (Residents #22 and #54) sampled residents who smoke as documented on a list provided by the Administrator on 03/27/23 at 10:44 AM.

Inspectors wroteBased on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/28/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the physician's plan of care for thickened liquids was followed for 1 (Resident #266) of 2 (Residents #266 and #218) sampled residents who had Physician Orders for thickened liquids according to a list provided the Dietary Supervisor on 03/28/23 at 2:50 PM.