Woodlake Healthcare and Rehabilitation Center

Inspectors wroteBased on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 4 residents (R17) reviewed for hospitalizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure timely follow up for recommendations from in-house provider for 1 of 1 (R161) resident reviewed for eye drops.

Inspectors wroteBased on observation, and interview the facility failed to ensure all medications and biologicals were locked in compartments which only allowed authorized personnel to have access. This had the potential to affect all residents, staff, and visitors.

Inspectors wroteBased on observation, interview and document review the facility failed to maintain an environment that was clean and free from odors for 3 of 3 residents (R1, R2, R3) reviewed for environmental concerns.

Inspectors wroteBased on interview and document review the facility failed to ensure reasonable accommodation of resident needs and preferences upon admission to the facility for 2 of 3 residents (R1, R3) reviewed who reported concerns related to accommodation of needs upon admission to the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure assistance, to resident triggered call light needs, was provided timely to promote dignity and reduce the risk of potential complications (i.e., incontinence, skin impairments, falls, changes in condition, etc.) for 8 of 8 residents (R1, R2, R3, R4, R5, R6, R7, R8) who expressed concerns related to extended call light response times and associated potential risk factors to their health. R8:R8's quarterly Minimum Data Set (MDS), dated [DATE], identified R8 lacked communication impairments and required some form of physical assist with most of his ADLs and mobility. R8 was frequently incontinent of bowel and bladder, at risk for pressure ulcers, and was diagnosed with diabetes, Parkinson's disease, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately, but no later than two hours, report to the state agency an allegation of abuse for one of three residents (R1) reviewed for employee to resident sexual abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and maintain dignity for 1 of 1 residents (R106) reviewed for dignity. Findings Include: R106's quarterly minimum data set (MDS) dated [DATE], indicated a severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming and toileting. R106's care plan dated 7/21/24, indicated R106 required extensive assist of 1 staff for dressing and grooming. The care plan did not indicate if R106 preferred to wear her own clothes or a hospital type gown. On 10/22/24 at 3:26 p.m., R106 was in her room, sitting in her wheelchair wearing a white with blue flowers hospital type gown. R106 did not have on any type of footwear. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R423) reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assistance with dressing and grooming for 1 of 3 residents (R106) reviewed for activities of daily living (ADL) care provided for dependent residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure care plan interventions were being utilized for 1 of 2 residents (R106) reviewed for safety.

Inspectors wroteBased on interview and document review the facility failed to notify the physician of change in condition for 1 of 3 (R1) reviewed for change of condition.

Inspectors wroteBased on observation, interview, and document review the facility failed to follow the person-centered care plan for 1 of 1 residents (R1) reviewed for activities of daily living (ADL).

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and monitor after an acute change of condition related to increased weakness/fatigue was identified was identified for 1 of 3 residents (R1) reviewed for change of condition

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food temperatures were taken in the kitchenettes to prevent foodborne illness. This had the potential to affect all 161 residents currently residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure a written notification of transfer was provided for 3 of 6 residents (R119, R126, R128) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 5 of 6 residents (R119, R128, R45, R50, R59), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 3 of 6 medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect all residents that resided on the first and second floors in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement ongoing infection prevention and control program to prevent the spread of infection due to lack of appropriate use of personal protective equipment (PPE) for 1 of 1 resident (R6) on transmission-based precautions (TBP) for COVID-19. In addition, the facility failed to disinfect a multi-use mechanical lift used by COVID positive resident. This affected 2 of 2 residents (R2, R95), and had the potential to affect all 166 residents in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess the resident and determine safety for 1 of 1 resident (R103) reviewed for self-administration of medications (SAM) .

Inspectors wroteBased on interview and document review, the facility failed to provide a written notice of a bed hold upon transfer for hospitalization for 1 of 5 residents (R119) reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a urinary catheter drainage bag was kept below the level of the bladder to prevent infection for 1 of 1 residents (R121) reviewed for catheter care.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R121, R147) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to report to the State Agency (SA) immediately for an injury of unknown origin for 1 of 1 residents (R1) who was discovered to have a suspicious bruise (labia area).

Inspectors wroteBased on observations, interview and document review, the facility failed to notify a resident consulting urologist and medical provider group for 1 of 3 residents (R1) when he missed eight antibiotic doses while being treated for a urinary tract infection (UTI). R1's Minimum Data Set (MDS) dated [DATE], indicated he had moderate cognitive impairment, heart, and end stage kidney disease. He did not exhibit any behaviors, nor refuse care from staff, and needed extensive assistance from one nursing staff to get on and off the toilet. R1's care plan dated 11/3/23, indicated he needed extensive assistance from one nursing staff every two to three hours to get on and off the toilet. The care plan did not identify a risk for developing a UTI, bladder scan requirements, and when to drain his bladder with at catheter. [...]

Inspectors wroteBased on observations, interview and document review the facility failed to develop a comprehensive care plan for 1 of 3 residents R1 when his care plan did not identify risks, goals, and interventions to address his chronic kidney failure, chronic kidney infection, urinary retention, post void residual bladder scan (a scanning device to show how much urine was left in the bladder after he urinated), and intermittent catheterization (a catheter inserted into the bladder to drain a buildup of urine.) R1's Minimum Data Set (MDS) dated [DATE], indicated he had moderate cognitive impairment, heart, and end stage kidney disease. He did not exhibit any behaviors, nor refuse care from staff, and needed extensive assistance from one nursing staff to get on and off the toilet. [...]