Wood-Lawn Heights

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one meal observed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items stored in the refrigerator, freezer, and the dry food storage area were covered or sealed to prevent potential food born illnesses; expired food items were promptly removed and discarded on or before the expiration date; and dietary staff washed their hands, before handling clean equipment or food items for one of one meal observed.

Inspectors wroteBased on observations, interviews, record review, and the facility failed to develop, implement, and update a comprehensive person-centered care plan for 4 (Resident #85, Resident #90, Resident #31, and Resident #81) of 10 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to ensure resident's falls were addressed appropriately in the care plan to prevent any further accidents and failed to follow the care plan related to falls.

Inspectors wrote3. A review of the admission Record, indicated Resident #81 had diagnoses of Alzheimer's disease, Parkinsonism, dementia with behavioral disturbance, repeated falls, anemia, and type 2 diabetes mellitus. The Signification Change MDS with an ARD of 04/02/2024, revealed Resident #81 had a BIMS score of 6 which indicated the resident had severe cognitive impairment. A review of Resident #81's Comprehensive Care Plan revealed the resident was at risk for bleeding date initiated 10/24/2024, interventions included to administer antiplatelet medication as ordered; at risk for easily bruising or skin tears. Nurse to notify doctor of any new skin issues. The care plan did not include any intervention to protect skin. During an observation on 05/22/2024 at 8:36 AM, Resident #81 was sitting in a common area in a wheelchair, wearing a short sleeve shirt. [...]

Inspectors wroteBased on interviews, record review, it was determined the facility failed to notify the resident and the resident's representative in writing of a transfer to the hospital and failed to ensure the transfer notice had all required information regarding the transfer for 4 (Resident #31, Resident #26, Resident #85, and Resident #90) of 5 sampled resident reviewed for hospitalization.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, for two (Resident #9 and #70) of three residents reviewed for psychotropic medications. Specifically, the facility failed to include a duration for an as-needed (PRN) psychotropic medication. These failures affected residents who received psychotropic medications and increased the risk of unnecessary medication administration, adverse reactions, and unwanted side effects of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (Resident #9) of four residents reviewed for assessment. Specifically, Resident #9's Quarterly MDS assessment indicated the resident had an ostomy. The resident did not have an ostomy.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure each resident received treatment and care in accordance with the comprehensive person-centered care plan for one (Resident #6) of three residents reviewed. Specifically, the facility did not document blood pressures before administration of a blood pressure lowering medication with hold parameters. These failures had the potential to cause residents to experience unwanted side effects of medications such as lightheadedness, dizziness, and falls causing major injuries.

Inspectors wroteBased on observation, and interview, the facility failed to ensure food stored in the freezer was covered and/or sealed to prevent potential contamination or freezer burn and failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 100 residents who received meals from the kitchen (total census: 103), as documented on a list provided by the Dietary Supervisor on 04/04/23.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the care and monitoring required related to respiratory therapy for 3 (Residents #1, #65 and #70) of 30 (Residents #1, #2, #3, #4, #10, #11, #16, #17, #22, #29, #31, #33, #37, #40, #44, #48, #52, #59, #63, #65, #70, #75, #78, #80, #82, #87, #90, #97, #252 and #302) sampled residents who received respiratory therapy. This failed practice had the potential to affect 102 residents with physician's orders for oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) and Nebulizer/Updraft supplies were properly stored to prevent contamination while not in use for 3 (Residents #65, #70 and #78) of 14 (Residents #1, #4, #10, #11, #17, #31, #33, #40, #48, #65, #70, #75, #78 and #82) sampled residents and failed to ensure oxygen usage was properly documented on the Medication Administration Record (MAR) for 1 (Resident #1) of 30 (Residents #1, #2, #3, #4, #10, #11, #16, #17, #22, #29, #31, #33, #37, #40, #44, #48, #52, #59, #63, #65, #70, #75, #78, #80, #82, #87, #90, #97, #252, and #302) sampled residents who had Physician Orders for oxygen therapy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the pureed and regular diets were prepared and served as per the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 12 residents who received a pureed diet and 78 residents who received a regular diet according to the list provided by the Dietary Supervisor 04/04/23 at 7:55 AM.

Inspectors wroteBased on observation, record review, 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 2 meals observed. This failed practice had the potential to affect 12 residents who received a pureed diet as documented on a list provided by the Dietary Supervisor on 04/04/23.