Woodland Convalescent Center

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered for 1 of 4 residents (Resident 1) reviewed for medication errors. This failure placed residents at risk for complications and decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe transfer during the use of a mechanical (hoyer) lift for 1 of 4 residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm when the hoyer lift sling detached during a mechanical lift transfer resulting in a fall; the resident sustained injuries to the head, rib fractures, and fractures of the lumbar vertebra (spine) that required hospital evaluation and treatment.

Inspectors wroteBased on interview and record review the facility failed to report falls with significant injury, misappropriation, and an allegation of abuse/neglect for 5 of 5 residents (11, 21, 35, 41, and 252) reviewed for reporting. The facility's failure to report delayed appropriate oversight and investigation, placing residents at risk for harm and unidentified abuse and/or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to timely administer 13 of 27 medications for 4 of 9 residents (35, 24, 201, and 25) observed during medication pass audit resulted in a medication error rate of 48.15%. The failure to administer medications on time placed residents at risk for side effects and/or altered medication effectiveness.

Inspectors wroteBased on observation and interview, the facility failed to store and label medications appropriately and failed to discard expired medications and expired medical supplies for 1 of 1 medication rooms, 1 of 1 emergency carts, 1 of 1 treatment carts, and 1 of 1 medication carts reviewed. These failures placed residents at risk of receiving expired or less effective medications, receiving treatment with outdated equipment, and residents having inappropriate access to medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were conveyed to the resident or resident's representative within 30 days of discharge for 1 of 1 discharged residents (300) reviewed for Trust Funds. This failure placed residents and/or their representatives at risk for delayed reconciliation of resident trust funds.

Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled residents (21) reviewed for grievances. This failure placed the residents at risk for emotional distress, a denial of personal rights, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) assessment (a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) accurately reflected mental health diagnoses for 2 of 5 sampled residents (6 & 27) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 1 of 7 sampled residents (37) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure submission of the Payroll Based Journal (PBJ) per the Centers of Medicare and Medicaid (CMS) requirement for 1 of 1 Fiscal Year (FY) Quarter (Q3 2024 [July 1 through August 31, 2024]), reviewed for PBJ submission. This failed practice resulted in CMS having inaccurate data related to nursing home staffing levels which had the potential to impact on the care and services provided to all the residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 2 kitchen freezers, and in 1 of 1 nourishment refrigerator/freezer (Unit 100) reviewed for food storage in a sanitary manner. This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate Enhanced Barrier Precautions (EBP) for 8 of 51 sampled residents (16, 31, 33, 35, 36, 40, 48, 252), properly implement standard precautions during dressing changes for wound care for 2 of 2 sampled residents (40 & 41), implement proper aseptic techniques for urinary catheter maintenance for 1 of 4 sampled resident (31), and ensure staff preformed hand hygiene for 1 of 3 sampled staff (G) reviewed for infection prevention and control. These failures placed residents, staff, and visitors at risk for development and transmission of communicable diseases, contracting infectious diseases and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promoted dignity while assisting with meals for 1 of 11 sampled residents (Resident 47) observed during dining services in their rooms. This failure placed residents at risk for being treated with a lack of dignity, lack of respect, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain comfortable sound levels for 2 of 6 sampled residents (21 & 34) reviewed for homelike environment. This failure placed residents at risk of loss of control over unwanted noise and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of inappropriate resident-to-resident touching for 1 of 6 sampled residents (2) reviewed for investigating alleged abuse and neglect. This failure placed residents at risk for not identifying corrective actions to prevent further abuse and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 2 of 4 sampled residents (44 & 39) reviewed for quality of care related to constipation. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer and/or administer the influenza and pneumococcal vaccine to 2 of 5 sampled residents (46 & 39) reviewed for immunizations. This failure placed residents at risk for developing influenza and/or pneumonia with potential negative outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot beverages were served at a safe temperature at or below 150 degrees Fahrenheit for 1 of 6 sampled residents (1) reviewed for accident hazards related to hot beverage service. This failure caused harm to Resident 1 who sustained three first degree burns and one second degree burn after a cup of hot cocoa spilled in their lap. This failure placed residents at risk for serious or life threatening injury from burns and a diminished quality of life. An Immediate Jeopardy was called on 10/25/2023 at 4:15 PM after observation, interview, and record review identified beverages were being served and were available at an average temperature ranging from 170 to 180 degrees Fahrenheit with no controls in place to prevent injuries to residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a manner that promoted the resident's dignity and quality of life when private information about residents was discussed in common areas for 2 of 2 sampled residents (16 & 8), when staff failed to knock or introduce themselves prior to entering resident rooms for 1 of 1 sampled residents (39), and when personal grooming was not provided for 3 of 4 sampled residents (15, 34 & 38) reviewed for dignity. These failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff handwashing was completed while delivering meal trays around 5 of 5 resident rooms (124, 128, 129, 130 & 137) reviewed for infection control and prevent regarding dining services. This failure placed residents at risk of infectious disease exposure and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the Office of the State Long-Term Care Ombudsman describing the reason for transfer/discharge for 1 of 1 sampled residents (41) reviewed for hospitalization. This failure placed residents at risk for lack of access to an advocate who can inform them of their options and rights, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and report changes in daily weights, per physician's order, for 1 of 5 sampled residents (29) reviewed for quality of care related to unnecessary medication. This failure placed residents at risk of worsening conditions, health complications and a diminished quality of life.