Woodhaven Nursing Center

Inspectors wroteBased on observation, staff, resident and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when the resident fell from the bed during incontinence care, reported knee and hip pain at a level of 9 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. The resident required evaluation at the emergency department where she was diagnosed with a non-displaced medial femoral condylar fracture (a fracture at the end of the thigh bone near the knee joint where the bones rub together causing pain and requiring strict immobilization for healing). This deficient practice affected 1 of 3 residents (Resident #1) reviewed for accidents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that a circular bed rail was maintained in safe working condition. As a result, the rail did not remain secure, and the resident fell from the bed during care sustaining a fractured femur (the long thigh bone). This deficient practice affected 1 of 1 resident (Resident #1) reviewed for bed rails.

Inspectors wroteBased on record review, and interviews with staff, and the Consultant Pharmacist, the facility failed to maintain a system of records of receipt and disposition of a controlled medication (Alprazolam - an antianxiety medication) sufficient to enable accurate reconciliation. The Director of Nursing (DON) rewrote a controlled medication count sheet for a residents Alprazolam after administration times had been altered by nursing staff, replacing the original sheet instead of retaining it. The DON also signed the rewritten sheet as a witness to a controlled dose being wasted, although staff confirmed no waste ever occurred. The facility was unable to produce the original controlled medication count sheet for review. This occurred for 1 of 2 residents reviewed for medication administration (Resident #2).

Inspectors wroteBased on record review and staff, and Nurse Practitioner interviews, the facility failed to administer an as needed antianxiety medication (Alprazolam) according to the physician's order. This occurred for 1 of 2 residents reviewed for administration of controlled medications (Resident #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain complete and accurate medical records for 1 of 2 residents reviewed for administration of controlled medications (Resident #2).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of wrong route and medications to be taken with food (5 medication errors out of 31 opportunities), resulting in a medication error rate of 16.13% for 2 of 5 residents observed during medication pass (Resident #24 and Resident #47).

Inspectors wroteBased on record review, observations, and staff, Resident Council and Resident Representative interviews, and test tray, the facility failed to provide palatable foods for 7 of 7 residents reviewed for food palatability (Residents #14, #41, #50, #63, #96, #107 and #109).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure dishware was clean, in good condition and not stacked wet, failed to maintain food preparation areas clean and free from dried debris, failed to label and date leftover food stored for use in 1 of 1 walk-in cooler and 1 of 2 walk-in freezers, failed to monitor and record the internal temperatures of food for 2 of 2 tray line observations and failed to ensure hot food was served at or above 135 degrees Fahrenheit (F). These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and resident, staff and Medical Director interviews, the facility failed to assess whether the self-administration of medication was clinically appropriate before leaving medications at the bedside. This was for 2 of 2 residents reviewed for medication administration (Resident #3 and Resident #35).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure a cup of medications stored in 1 of 5 medication carts reviewed for medication storage (medication cart for Hall 1600).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement their infection control policies when Nurse #2 did not don (put on) a gown while administering medications via a gastrointestinal tube (a tube inserted through the abdomen to the stomach) to Resident #37 who required enhanced barrier precautions (EBP) due to the presence of a gastrointestinal tube (G-tube). This practice occurred for 1 of 3 staff members observed for infection control.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the daily posting of health care staff form had the correct resident census for 15 of 29 days.

Inspectors wroteBased on observations, record reviews, and resident, staff, Physician, and Vascular Clinic Nurse interviews, the facility failed to provide Thromboembolic Deterrent (TED) compression stockings and elevation of the lower extremities when up in her wheelchair which were ordered by the Vascular Nurse Practitioner (NP) on 6/5/2024 for 3 months, for a resident with bilateral lower extremity edema (swelling and puffiness of the lower legs and feet as a result of weakness or damage to veins in the legs), (Resident #27), for 1 of 2 residents reviewed for compression stockings.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to discard expired opened multidose medications, date an opened multidose medication and dispose of loose unidentifiable pills in the drawer of the medication cart (1100 Long Hall) and failed to discard an opened multidose medication per manufacturer's instructions stored for use in the medication cart (Memory Care Unit) for 2 of 6 medication carts reviewed. And the facility failed to remove expired medications available for use in the automated medications dispensing machine in 1 of 4 medication rooms (the Rehab Unit) reviewed for medication storage.

Inspectors wroteBased on record review, pharmacist interview, and staff interviews, the facility failed to act on a pharmacy recommendation to complete an Abnormal Involuntary Movement Scale (AIMS/discus) assessment for a resident who received an antipsychotic medication for 1 of 5 residents reviewed for psychotropic medications, Resident #57.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow their abuse policy when Confidential Staff #1 allowed Nurse #3 to continue providing care to residents after witnessing Nurse #3 slap Resident #3. Confidential Staff #1 did not report the abuse to the administration resulting in no protection of residents from further abuse, no investigation, and no notification to the state, adult protective services or law enforcement. A second incident of abuse occurred when Nurse Aide #2 and Nurse Aide #3 did not identify abuse when they witnessed Nurse #3 rip a dressing off Resident #3's forearm resulting in the resident experiencing pain and her skin tear reopening and bleeding. Nurse #3 then raised her hand to Resident #3 like she was going to slap her. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to protect Resident #3's right to be free from abuse. In March of 2024 Confidential Staff #1 witnessed Nurse #3 slap Resident #3 across the face during care after Resident #3 spit on Nurse #3 twice. In July of 2024 during a weekly skin check Nurse Aide #2 and Nurse Aide #3 witnessed Nurse #3 rip a dressing off Resident #3's forearm resulting in a skin tear reopening and bleeding. Resident #3 repeatedly yelled you're hurting me. Resident #3 then spit on Nurse #3 twice and in response, Nurse #3 raised her hand like she was going to slap Resident #3 when Nurse Aide #2 intervened and Nurse #3 lowered her hand and proceeded to change the dressing. Resident #3 did not have the cognitive capacity to express a psychosocial outcome. A reasonable person expects to be free from abuse in their home. [...]

Inspectors wroteBased on record reviews and interviews with staff, Emergency Medical Services personnel, and the Medical Director, the facility failed to immediately initiate emergency medical services (EMS) on a pulseless, nonbreathing resident who was a full code. On [DATE] at approximately 12:03 AM Resident #1 was found to be unresponsive, pulseless, and not breathing. Nurse #1 began cardiopulmonary resuscitation (CPR) (a way to try to restart the heart and lungs if they stop) and yelled out Code Blue. After approximately 2 minutes of (CPR) no other staff had come to assist Nurse #1 so she went to the door, saw a nurse assistant and yelled Code Blue she then resumed CPR on Resident #1. Nurse #2 arrived with the crash cart, applied the automatic external defibrillator (AED) pads and 2-person CPR was started. Staff failed to meet EMS at the door that was locked and with non-working doorbell. [...]

Inspectors wroteBased on observations, record review, staff and Wound Care Nurse Practitioner interviews the facility failed to perform daily wound care treatments on a stage IV sacral wound and a deep tissue injury to left heel (Resident #4) and a stage IV pressure wound of the right posterior medial heel (Resident #5) according to the physician's order for 2 of 3 residents reviewed for wound care.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement the Enhanced Barrier Precautions (EBP) policy regarding applying Personal Protective Equipment (PPE) to include applying gloves and gown during high contact resident care activities. Two nursing staff were observed providing care to a resident with a stage IV pressure ulcer who was receiving wound care to the sacrum and were not wearing a gown during care. This occurred for 1 of 2 residents (Resident #1) observed for Infection Control. Review of the facility's policy for Enhanced Barrier Precautions (undated) revealed It is the policy of this facility to use enhanced barrier precautions (EBP) based on guidance from the Center for Disease Control (CDC). EBP expands use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. [...]

Inspectors wroteBased on observations, record review, staff and physician interviews the facility failed to ensure a resident had transportation for a neurology appointment that was scheduled on 10/03/2023. The appointment on 10/03/23 was canceled due to the transportation provider being unavailable and was not rescheduled until 03/19/24 for 1 of 1 residents reviewed (Resident #2).

Inspectors wroteBased on observations, record review and staff and physician interviews, the facility ' s Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a complaint investigation on 12/15/23. This was for 1 deficiency that was originally cited in the area of medically related social services and was subsequently recited on the current complaint investigation on 04/24/24. The continued failure during 2 surveys of record shows a pattern of the facility ' s inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, staff, and Orthopedic Surgeon interviews the facility failed to perform comprehensive skin assessments, to conduct skin monitoring to the area under an immobilizer and to coordinate care with the resident's orthopedic surgeon to ensure care needs were met when the resident missed her 10/4/23 surgical follow up orthopedic appointment and was not seen by the orthopedist until 11/17/23. At the 11/17/23 orthopedic surgeon visit Resident #1 was identified with a wound on her right knee that appeared necrotic (dead tissue), black in color, and the skin around it appeared darker like a bruise. This was for 1 of 1 resident reviewed for wound care.

Inspectors wroteBased on record review, family, staff, non-emergency transportation services Manager, Orthopedic Surgeon, and orthopedic surgeon's Office Manager interviews, the facility failed to ensure a resident had transportation arrangements for initial post-operative appointment with the Orthopedic Surgeon on 10/4/2023, resulting in the resident not being seen by the Orthopedic Surgeon until 11/17/2023. At the 11/17/23 orthopedic surgeon visit Resident #1 was identified with a wound on her right knee that appeared necrotic (dead tissue), black in color, and the skin around it appeared darker like a bruise. This occurred for 1 of 1 resident reviewed for medically related social services (Resident #1).

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to provide the resident or resident's representative with the bed hold policy upon transfer to the hospital 4 of 4 residents (Resident #15, Resident #48, Resident #69, and Resident #7) reviewed for hospitalizations.

Inspectors wroteBased on medical record review and staff interviews the facility failed to complete a significant change assessment on 1 of 1 residents (Resident #18) reviewed for significant change.

Inspectors wroteBased on record review and staff interviews, the facility failed to invite a cognitively intact resident (Resident #2) to an interdisciplinary care plan meeting for 1 of 18 residents reviewed. Resident # 2 was admitted to the facility on [DATE] with medical diagnoses of debility, heart failure, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. A review of Resident #2's quarterly MDS dated [DATE] indicated the resident was cognitively intact and had no signs of delirium or behaviors. Resident #2's care plan was last reviewed on 4/4/23 by MDS Nurse #1. Resident #2's care plan meeting minutes last reviewed on 4/4/23 did not include if Resident #2 was invited to attend. An interview conducted with Resident #2 on 5/15/23 at 4:01 PM revealed that Resident #2 had not been invited or attended any care plan meetings since Resident #2's admission. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following a recertification and complaint investigation on 01/24/22. This was for one deficiency that was originally cited in the area of comprehensive assessments after significant change and was subsequently recited on the current recertification and complaint survey on 05/19/23. The continued failure during 2 survey of records shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Assessment (MDS) for 1 of 1 residents (Resident #28) who received dialysis treatments.