Woodland Care & Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete and accurate when staff failed to document medication administrations during a multi-day internet/phone outage for four residents (Resident #1, #2, #3, and #4). The census was 87. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all alleged violations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when the facility failed to report an allegation of resident-to-resident abuse involving two residents (Resident #1 and Resident #2). Four residents were sampled out of a facility census of 89. Review of the facility policy and procedure titled, Abuse and Neglect, revised 07/21/25, showed the following information:-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standard, physician's order, and resident's preference when the facility failed to order or provide a drop arm commode for one resident (Resident #3), which would increase his/her independence. The facility census was 89. Record review showed the facility did not provide a policy regarding the process of ordering durable medical equipment or the process of handwritten physician orders. 1. Review of Resident #3's face sheet (gives basic profile information) showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were kept as free from accident hazards as possible when staff failed to [NAME] steps to prevent future burns and failed to update the care plan regarding a burn for one resident (Resident #3) who suffered burns after spiling hot soup on him/herself. The facility census was 89. Review showed the facility did not provide a policy related to resident use of microwaves. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA) A) spoke disrespectfully and did not honor the resident's sleeping preferences for one resident (Resident #1) in a selected sample of four residents. The facility census was 89. Review of the facility's Dignity and Quality of Life Policy, updated 02/13/25, included the following information:-The facility will promote care for the residents in a manner and in an environment that maintains and enhances each resident's dignity, quality of life and respect in full recognition of his or her individuality. Facility staff will respect and promote the rights of the resident to exercise his or her autonomy regarding what the resident considers important facets of his or her life. [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure all food was protected from possible contamination when the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the inside of the ice machine clean. The facility census was 85. Review of the facility's policy titled Cleaning instructions, Ice Machine, and Equipment, dated 2021, showed the following: -Ice machine will be cleaned and sanitized on a regular basis; -Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. Pay close attention to the crevices. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the outside of the ice machine clean and when the fans located in the walk-in refrigerator has lint and a black substance. The facility census was 85. Review of the facility's policy titled Cleaning Instructions, Ice Machine,and Equipment, dated 2021, said the following: -Clean the exterior of the machine with detergent solution daily; -Rinse and allow to air dry. Review of the 2013 Missouri Food Code showed the following information: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' drug regimens were free from unnecessary drugs when staff failed to provide a stop date or rationale for extending the order for one as needed (PRN) medication for one resident (Resident #47). The facility census was 85. Review of the facility policy titled Medication Therapy, , dated April 2007, showed the following: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks; -All medication orders will be supported by appropriate care processes and practices; [...]

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to complete quarterly care plan meetings for four residents (Residents #8, #1, #44, and #58). The facility census was 85. Review of the facility's policy titled, Resident Participation-Assessment/Care Plans, revised February 2021, showed the following: -The resident and his or her legal representative were encouraged to attend and participate; -It is the resident/representative's right to participate in the development and implementation of his/her plan of care; -The care planning process included an assessment of the resident's strengths and his/her needs as well as incorporating the resident's personal and cultural preferences; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent possible urinary tract infection (UTI - infection in any part of the urinary system, the kidneys, bladder) when staff failed to ensure the catheter drainage tubing (tubing that drains urine from the bladder to a collection bag) of one residents (Resident #68) did not sit or drag on the floor; and when the facility failed to ensure the staff entered a catheter order that included the size of catheter to be used for three residents (Resident #68, #8, and #42). The facility had a census of 85. Review of the facility policy titled Urinary Catheter (flexible tube inserted through the urethra into the bladder to drain urine) Care, dated August 2022, showed the following: [...]

Inspectors wrote5. Review of Resident #58's face sheet showed the following: -admission date of 05/16/24; -Diagnoses included metabolic encephalopathy (brain dysfunction often caused by illness or organ dysfunction), weakness, swelling, restless leg syndrome, insomnia, and obstructive sleep apnea (breathing disorder while asleep). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Upper extremity impairment to one side; -Dependent on others for toileting hygiene, showers, dressing, and bed mobility. Review of the resident's care plan, last updated/reviewed 05/19/25, showed the following: -Used side rail to assist in repositioning, mobility device; -Ensure valid consent on chart prior to use of side rails; -Quarterly review of safety for the device. Observation on 06/10/25, at 10:27 A.M., showed the resident's right side rail in the raised position. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to have ordered medications available for staff administration resulting in five residents (Resident #8, #77, #18, #68, and #70) not receiving medications as ordered. The facility census was 85. Review of the facility's policy titled Administering Medications, revised April 2019, showed the following: -Medications are administered in a safe and timely manner and as prescribed; -Medications are administered in accordance with prescriber's orders, including any required time frames. 1. Review of Resident #8's face sheet (a general information sheet) showed the following: -admission date of 12/29/23; -Diagnoses included quadriplegia (loss of movement in all four limbs) and depression (persistent feelings of sadness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for two residents (Resident #8 and #49) . The facility census was 85. Review of the facility's policy titled Protocol for Bathing/Shower/Tub, revised September 2021, showed the following information: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Document the date and time of the shower, name and title of the individual assisting, and assessment of the individual. 1. Review of Resident #8's face sheet (a general information sheet) showed the following: -admission date of 12/29/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies to prevent possible abuse when staff failed to follow-up on results for a criminal background check (CBC) requested on one staff member (Maintenance Assistant E). The facility census was 85. Review of the facility's Abuse and Neglect Policy and Procedure, updated 03/22/25, showed the following: -It was the policy and the right of each resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; -All potential employees will have CBC prior to hiring. 1. Review of the personnel file for Maintenance Assistant E showed the following: -Hire date of 03/16/25; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff) assessment for one resident (Resident #14) was completed timely as required. The facility had a census of 85. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a baseline care plan with 48 hours of admission for two residents (Residents #132 and #281) of 26 sampled residents. The facility census was 85. Review showed the facility did not provide a policy specific to baseline care plans for residents upon admission. 1. Review of Resident #132's face sheet (gives basic profile information) showed the following: -admission date of 05/28/25; -On hospice services on admission to facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to have a consistent code status (a medical directive that specifies the type of resuscitation and medical interventions a patient wishes to receive in the event of a cardiac or respiratory arrest) in the resident's medical record for two sampled residents (Resident #48 and Resident #17) out of 26 sampled residents. The facility census was 85. Review of the facility's policy entitled Advance Directives, revised [DATE], showed the following: -Advance Directives will be respected in accordance with state law and facility policy; -Upon admission the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective pain management program was in place for all residents when staff failed to administer pain medication as ordered for one resident (Resident #12) resulting in increased pain for the resident. The facility census was 85. Review of the facility provided policy titled Administering Medications, dated April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions; -Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility policy titled Adverse Consequences and Medication Errors, dated April 2014, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all dialysis residents received services consistent with professional standards of practice when staff failed to obtain orders related to dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) services, failed to appropriately monitor the resident after dialysis appointments, failed to routinely communicate and collaborate with the dialysis center after appointments, and failed to care plan dialysis for one resident (Resident #281). The facility census was 85. Review showed the facility did not provide a policy related to dialysis. 1. Review of Resident #281's face sheet (a general information sheet) showed the following: -admission date of 05/28/25; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring for one resident (Resident #48) out of 17 sampled residents . The facility census was 85 residents. Review of the facility's policy entitled Trauma-Informed Care and Culturally Competent Care, dated 2022, showed the following: -Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime an insulin pen before use for one resident (Resident #37). The facility census was 85. Review of the provided policy, titled Administering Medications, dated April 2019, showed the following: -Medications are administered in accordance with the prescriber orders; -Insulin pens containing multiple doses of insulin are for single-resident use only; -Insulin pens are clearly labeled with the resident's name; -Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident; -Manufacturer's instruction or user's manuals related to medication administration devices are kept with the devices or at the nurses' station. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure new residents completed the first step tuberculosis testing when two residents (Resident #231 and # 281) did not have their first TB test completed or documented in a timely manner. The facility had a census of 85. Review of the facility policy titled Screening Residents for Tuberculosis, dated August 2019, showed the following: -The facility shall screen all residents for tuberculosis infection and disease (TB - contagious bacterial infection, primarily affecting the lungs); -The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB; -If a potential resident has been exposed to active TB or is at increased risk of TB infection he/she will be screened for latent tuberculosis infection using tuberculin skin test or interferon gamma release assay; [...]

Inspectors wroteBased on Interview and record review, the facility failed to ensure all residents with a history of prior trauma received appropriate treatment and services to attain the highest practical psychosocial well-being when staff failed to care plan triggers and failed to provide care in a manner that was responsive to triggers caused by a history of post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person has experienced or witnessed a traumatic event) for one resident (Resident #1). Facility census was 81. Review of the facility policy titled Dignity and Quality of Life, undated, showed the following: -The facility will promote care for the residents in a manner and an environment that maintains the resident's dignity, quality of life, and respect in full recognition of his/her individuality. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system in placed to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when five NA's failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test within four months of hire and continued to work providing direct care to residents. The facility's census was 87. Review showed the facility did not provide a policy regarding NA training classes. 1. Review of the facility's list of NA's currently employed at the facility, and working the floor as an NA, as of 02/24/25, showed the following: -NA B was hired as a NA on 07/22/24; -NA C was hired as a NA on 08/05/24; -NA D was hired as a NA on 10/29/24; -NA E was hired as a NA on 11/19/24; -NA F was hired as a NA on 01/21/25. During an interview on 02/21/25, at 2: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to address and notify the provider in a timely manner of a change in condition for one resident (Resident #1) when the resident showed decline in cognition and required increased assistance with cares. The facility census was 87. Review of the facility's current policy titled Change in a Resident's Condition or Status, showed the following: -The facility promptly notifies the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status; -The nurse will notify the resident's attending physician or physician on-call when there has been a significant change in the resident's physical/emotional/mental condition or the need to transfer the resident to the hospital; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when one staff member (Licensed Practical Nurse (LPN) A) made disrespectful comments and spoke in a harsh tone to three residents (Resident #1, Resident #2 and Resident #3). The facility census was 86. Review of the facility's policy titled Dignity and Quality of Life Policy, undated, showed the following: -The facility will promote care for residents in a manner and in an environment that maintains and enhances each resident's dignity, quality of life and respect in full recognition of his or her individuality; -Staff will provides services in a manner which enhances/maintains a dignified existence for the residents; -Staff will respect resident's social status, speaking respectfully, listen carefully, treating residents with respect at all times. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standard of practice for all residents with pressure ulcers when the facility staff failed to complete and document full wound assessments in a consistent and timely fashion to track if wounds improved or declined for four residents (Residents #1, #2, #3, and #4) who had identified pressure ulcers. The facility census was 88. Review of the facility's policy Wound Protocol/Procedure, undated, showed the following: -The charge nurse should document in the wound event or progress note about the wound's drainage, wound bed, peri-wound and edges. This is also charted in the weekly skin assessment while the the wound is present, until healed; -The wound nurse will follow the wounds weekly with measurements and assessment and staging of the wounds or other skin issues until the wound heals. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for all residents when staff failed to address the use of, care of, and monitoring of and related to an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #5). The facility census was 88. Review of the facility policy Urinary Catheter Care, revised August 2022, showed the following: -Purpose of procedure was to prevent urinary catheter-associated complications, including urinary tract infections; -Empty the collection bag at least every eight hours using a separate, clean collection container; -Be sure the catheter tubing and drainage bag are kept off the floor; -Observe the resident's urine level for noticeable increases or decreased. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standard of practice when facility staff failed to accurately and consistently track one resident's skin conditions, failed to document timely full assessments of skin conditions, and failed to document orders for completion of skin care for one resident's (Resident #1) who developed cellulitis (a potentially serious bacterial skin infection). The facility census was 88. Review of the facility's policy Change in a Resident's Condition or Status, revised February 2021, showed the following: -The nurse will notify the resident's attending physician or physician on-call when there has been a significant change in the resident's physical, emotional, or mental condition; a need to alter the resident's medical treatment significantly; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete infection prevention and control program when the facility failed to develop a policy regarding enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device), failed to train staff on EBP, failed to have personal protective equipment (PPE) and signage present for residents that met the guidelines for EBP, and failed to ensure staff wore PPE in accordance with the Centers for Disease Control (CDC) guidelines for three or three residents (Residents #1, #2 and #3) who met the guidelines for EBP. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely complete and submit Minimum Data Set (MDS - federally mandated assessment completed by facility staff) assessments for three residents (Resident #52, #53, and #63), out of 39 sample residents. The facility census was 73. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/19, showed the following: -The RAI helps nursing home staff look at residents holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary; -Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life; [...]

Inspectors wroteBased on record review and interview, the facility failed to timely complete and submit Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) assessments for four residents (Resident #13, #19, #21, and #22), out of 39 sample residents. The facility census was 732. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/19, showed the following: -The Quarterly assessment is an OBRA (Omnibus Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; -The ARD (Assessment Reference Date) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two residents (Resident #11 and #47), of 39 sampled residents, were treated with dignity and respect when one resident's (Resident #11)' urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was observed uncovered and visible from the hallway and when one resident (Resident #47) was not provided with appropriate grooming to ensure the removal of her facial hair. The facility census was 73. Review of the facility's policy titled, admission Contract, undated, showed the resident's rights will be respected by staff. 1. Review of the facility's policy titled, Policy and Procedure Foley Catheter, dated 10/09/23, showed the equipment and supplies necessary when performing this procedure included dignity bag (bag that covered catheter collection bag). [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement an effective grievance policy and procedure when staff failed to file a grievance and follow-up with the resident for one resident (Resident #31), of 39 sampled residents, who reported multiple personal items missing. The facility census was 73. Review of the facility policy titled Grievance Policy, undated, showed no reference to missing personal items, reimbursement, or restitution for missing items. 1. Review of Resident #31's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an Assessment Reference Date (ARD) of 05/14/23, located in the Electronic Medical Record (EMR) under the MDS tab, showed an admission date of 07/29/19 and moderately impaired cognitive. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received assistive devices to maintain their hearing abilities when staff failed to assist one resident (Resident #25), of 39 sampled residents, with ensuring his/her hearing aids were being worn and that hearing aid's batteries were functioning. The facility census was 73. Review showed the facility did not provide a policy related to hearing aids. 1. Review of Resident #25's Electronic Medical Record's (EMR) Face Sheet, undated, under the Profile tab, showed diagnoses included bilateral hearing loss. Review of the resident's Care Plan, dated 12/12/22, showed the resident was hard of hearing and wore hearing aids for communication. Nursing staff is responsible for ensuring that hearing aids are clean, functioning, and properly placed in both ears. [...]

Inspectors wroteBased on interview and record review, the facility failed to review or update their Infection Prevention Program (IPCP), policies and procedures yearly. The facility census was 73. 1. Review of the facility's Policy and Procedures related to the IPCP showed the Policies and Procedues had not been reviewed or updated since 2020. During an Interview on 10/20/23, at 9:07 A.M., with the Administrator and the Infection Preventionist trainee (IP) showed both were not sure why the IPCP had not been reviewed and revised since 2020.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, for five residents (Resident #6, #35, #57, # 89, and #138). The facility failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for three residents (Resident #57, #89, and #138) out of 18 sampled residents. The facility census was 90. Record review of the facility's policy titled, Transfer or Discharge Documentation, included the following information to be documented in the medical record when a resident is transferred or discharged from the facility: -That an appropriate notice was provided to the resident and/or legal representative; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the bed hold policy at the time of a transfer to the hospital for four residents (Resident #35, #57, # 89, and # 138) out of 18 sampled residents. The facility census was 90. Record review of the facility's policy titled, bed-holds and returns, showed the following information: -Prior to a transfer, written information will be given to the resident and the resident representative that explains in detail: -The rights and limitations of the resident regarding bed-holds; -The reserve bed payment policy as indicated by the state plan (Medicaid residents); -The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's choice on code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for four residents (Resident #37, #42, #43, and #66) out of a facility sample of 18 residents in a facility with a census of 90. Record review of the facility's policy, titled Advance Directives, last revised [DATE], showed the following information: [...]