Wood Aven Health and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections staff did not complete hand hygiene per standards of practice during wound care for 2 of 3 residents (R2 and R3). Evidenced by: The facility policy titled Hand Hygiene, revised 3-2026, states in part: 2. Use an alcohol-based hand rub containing at least 62% alcohol. for the following situations. b. Before and after direct contact with residents. d. Before performing any non-surgical invasive procedures. g. Before handling clean or soiled dressings, gauze pads, etc. i. After contact with a resident's intact skin. Example 1R2 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free from unnecessary medications for 1 of 3 residents (R) reviewed for medication errors (R2). R2 received Metformin (a medication to treat diabetes) for 8 days. R2 does not have a diagnosis of diabetes.

Inspectors wroteBased on interview and record review, the facility did not ensure 4 of 5 residents (R1, R8, R19, and R67) or their representatives received the proper notice of transfer, reason for transfer, and ombudsman notification.-Facility did not have a specific reason for the transfer notice for R1, R8, R19, and R67.-Facility did not notify the ombudsman of R8, R19, and R67's transfers to the hospital.

Inspectors wroteBased on observation, interview and record review, the facility did not determine if self-administration of medications was clinically appropriate for 1 resident (R7) out of 3 residents reviewed for self-administration of medications in a sample of 17 residents. The facility did not ensure the interdisciplinary team (IDT) assessed and determined R7 was clinically appropriate to self-administer prescription topical creams and inhalers, located in R7's room and at bedside. This could result in an adverse event happening because of R7 incorrectly self-administering medications.

Inspectors wroteBased on interview and record review, the facility did not notify the provider of changes in condition for 1 of 17 residents (R19) reviewed. This is evidenced by:The facility's Standing Orders, most recently reviewed and approved by the Medical Director on 03/05/26, states, Please follow these standing orders unless otherwise indicated by healthcare provider. Provider Notification: Systolic Blood Pressure less than 90 or greater than 200. R19 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit, acquired absence of right leg above knee, chronic kidney disease stage 3. R19's most recent quarterly Minimum Data Set (MDS) assessment, dated 03/18/26, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Surveyor reviewed R19's vital signs:*10/24/25, R19's blood pressure (BP) was documented as 83/50. [...]

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 2 of 8 employees reviewed. -The facility did not ensure their abuse policy was implemented when two employees' Background Information Disclosures (BID) did not include results from the Department of Justice (DOJ) and Integrated Background Information System (IBIS) before Certified Nursing Assistant (CNA) P and Facility Driver O started working for the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible for 1 out of 4 residents (R44). Staff transferred R44 with the incorrect mechanical lift resulting in a fall after Occupational Therapy (OT)'s recommendations for transfer were ordered. R44's care plan was not updated with transfer changes in a timely fashion.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident who is continent of bladder on admission receives services and assistance to maintain bladder function as possible for 1 of 5 residents (R54). The facility did not ensure an accurate bowel and bladder assessment completed upon admission to determine an appropriate toileting program or plan in place to manage current urinary status or regain/maintain urinary continence status. The facility policy titled Bowel and Bladder Assessment last revised 03/26 states: It is the policy of this facility to provide the resident who is incontinent of bowel and/or bladder the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Under the section titled Purpose states: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 2 of 2 residents (R10 and R55). The facility's policy and procedure included a method that is no longer recognized as a nationally accepted standard of practice. Staff were unable to provide a reference to a nationally recognized standard of practice used to develop their policy and procedure. Facility staff were observed using auscultation as it may not provide accurate results. R55 and R10's tube placement was checked using auscultation. This is evidenced by: Facility's policy titled, Gastrostomy Tube Care and Management, with a reviewed date of 03/2026, states in part: Policy: It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. Procedure: 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents are free from significant medication errors for 1 of 17 residents (R55) R55 was not administered medication for bowel regimen based on physician orders. R55 was admitted to the facility on [DATE] with diagnoses of dysphagia, amyotrophic lateral sclerosis (ALS,) pneumonitis due to inhalation of food and vomit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R55's physician orders dated 03/24/2026 state: Metamucil Oral Powder 48.57 % (Psyllium) Give 1 Tbsp via PEG-Tube one time a day for loose stools mixed in 4-8 ounces free water. R55's record shows last bowel movement was documented on 3/28/26 at 19:45 7:45 PM of incontinent small formed soft/normal stool. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 3 of 17 sampled residents (R7, R43, and R31). Staff did not implement enhanced barrier precautions for R7 and R43. Staff did not perform hand hygiene during R31's medication administration. The facility policy, titled Enhanced Barrier Precautions, dated 03/24/2026, states, Initiation of Enhanced Barrier Precautions (EBP), the facility will have the discretion in using EBP for residents who do not have a chronic wound.an order for enhanced barrier precautions will be obtained for residents with any of the following: [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to administer medications as scheduled for one of two residents (Resident (R) 1) reviewed for pharmacy services out of a total sample of six residents. The failure to acquire and administer routine medications to R1 had the potential for unrelieved pain and adverse consequences.

Inspectors wroteBased on interview and policy review, the facility did not ensure allegations of mistreatment were thoroughly investigated for 1 of 1 (R3) resident reviewed. Certified Nursing Assistant (CNA) C made a comment about the way R3 smelled, allegedly stating R3 needed a bath because he smells like he came out of a barn. The facility investigation did not include all nursing staff working R3's rehabilitation unit during the time of the reported incident. This is evidenced by: The facility policy, Resident Rights-Abuse Prevention, which was not dated, included in part: Policy: It is the policy of this facility that each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone . Procedures: Investigation-All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. The investigation shall consist of: 5. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 18 residents sampled. (R321) R321 has a history of daily opiate use and constipation. The facility bowel protocol was not followed or a thorough GI assessment completed, causing actual harm to R321. R321 was hospitalized with severe pain and was admitted with a fecal impaction.

Inspectors wroteBased on observation, record review and interview, the facility did not allow clean dishes sufficient time to air dry or store the clean dishes in a manner to prevent potential contamination. The facility practice has the potential to affect all 76 residents. This is evidenced by: The facility policy tilted Dishwashing and Ware Washing which was not dated was requested and received by Surveyor. The policy in part read: Objective: To ensure cleaning, sanitization and infection control in the dishwashing area to promote food safety, prevent contamination and minimize the risk of spreading infections. Washing (Mechanical or Manual): Dish Drying: ~Dishes, utensils and cookware will be allowed to air dry completely on clean, sanitized racks or drying shelves. Inverting Dishes: Inversion: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not effectively monitor psychotropic medications to ensure residents are receiving the lowest possible effective dose. The facility practice had the potential to affect 1 of 5 residents reviewed for unnecessary medications (R19). This is evidenced by: Surveyor requested and reviewed the facility policy titled Psychoactive Medications dated as most recently reviewed on 12/2024. The policy in part read: Policy: It is the policy of this facility to maintain every resident's right to be free from the use of psychoactive medication. ~Psychoactive medications .are to be administered only when required to treat the residents' medical symptoms. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide measures to prevent and treat Pressure Injuries (PI) while completing wound care for a PI, ensure that pressure relieving air mattress was operational and in continuous working order, and did not document pressure injury assessment including wound staging at least weekly for R12, R31 was not provided off-loading of pressure or repositioned timely. The facility practices had the potential to affect 2 of 3 (R12 and R31) residents reviewed for pressure injuries. This is evidenced by: Example 1 Surveyor reviewed facility policy titled, Prevention and Treatment of Skin Breakdown, noting NPUAP as reference included, in part: Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. [...]

Inspectors wroteBased on observation, interview and policy review, the facility did not establish and maintain an infection prevention and control program when staff did not offer hand hygiene prior to meal service for 3 of 8 residents (R) R209, R210 and R214, or provide wound care in a manner to prevent infection for (R) 42.