Woodlands Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure free from unnecessary psychotropic medication (medications capable of affecting the minds, emotions, and behaviors) for one of three sampled resident (Resident 1) when: 1. There was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before administered psychotropic medication lorazepam (used to treat for anxiety [persistent worry and fear about everyday situations]) to Resident 1;2. There was no documented evidence of side effects monitored for use of lorazepam (an unintended consequence of a medication, may be harmful) for Resident 1;3. There was no documented evidence of episodes of adequate behavior monitored for use of lorazepam for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to notify primary care physician (PCP) for refusal of blood tests (a laboratory analysis of a blood sample used to assess various aspects of resident's health) as ordered by the physician for one of three sampled resident (Resident 1) to meet professional standards. This failure had the potential to affect Resident 1's medical condition and well-being.

Inspectors wroteBased on interview, record review, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #51) of 2 sampled residents reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to follow it's Policy and Procedure titled Isolation-Categories of Transmission- Based Precautions, when the facility failed to provide evidence of implementing isolation precautions (process of creating barriers between people and germs to help prevent the spread of infectious microbes) during an outbreak of infectious gastrointestinal related illnesses for four of six sampled residents (Resident 1, Resident 2, Resident 3 & Resident 4). This failure had the potential to spread infectious disease to other residents and staff at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four of thirty-one residents investigated, (Residents 14, 41, 160 and 18) when: 1. Residents 14 and 41, the activity care plans did not specify the activities provided, there were no frequency of visits for the activities, and no measurable outcomes of the visits; 2. Resident 160, there were no interventions that were developed in the activity care plan, and 3. Resident 18, there was no care plan to address her excessive sleepiness issue. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 15 sampled residents (Residents 16, 18, and 21) when: 1. Resident 16, there were two duplicated insulin orders without parameters; 2. Resident 18, the treatment nurse did not label the dressing with the date, time, and initial and; 3. Resident 21, the licensed nurse did not refill her eye drop medicine on time and caused six missed treatments. These failures had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received the necessary care and services for five of 15 residents (2, 8, 20, 22, and 37) when: 1. Licensed nurses did not follow the physician's order for pain medication based on the resident's pain level for Resident 2; 2. A bottle of gel hand sanitizer was on Resident 8's night stand in her room; 3. Licensed nurse did not follow the physician's order for oxygen supplement for Resident 20; 4. Licensed vocational nurse G (LVN G) did not know how to monitor Resident 22's AV fistula (a special connection that is made by joining a vein onto an artery, usually in the arm) and what to do if it was bleeding; and 5. LVN G did not know how to monitor the signs and symptoms if the pacemaker would malfunction for Resident 37. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. unlabeled, discontinued, and expired medications were not removed from the medication carts to prevent medication errors; 2. medications were not labeled with full names or open date; 3. an insulin glargine injection pen (medication to lower blood sugar) did not have a patient-specific label; 4. two bottles of normal saline, and a cup with itching medication were left inside the resident's room. These deficient practices had the potential for residents, to receive medications with unsafe and reduced potency, from using them past their discard date and medication errors due to medications not being labeled or removed from active stock.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food palatability was maintained, when three of nine residents investigated, (Residents 3, 155 and 161), complained about the taste of the food being served. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. one 8-ounce water bottle brought by employee, was in Freezer #1; 2. one plastic bag with 7 frozen beef strips inside, had no used by date; and 3. the temperature of Refrigerator #2 was 50 degrees Fahrenheit (F, temperature scale). These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness for the 56 residents eating at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for five of fifteen sampled residents (Residents 16,18, 161, 20, and 26) when: 1. Resident 16 and 18, the licensed nurses did not perform hand hygiene between glove changes during medication administration, 2. Resident 161, the licensed nurse did not disinfect the medication tray after touching potentially contaminated surfaces, 3. Resident 20, the filter of the oxygen concentrator was dusty and 4. for Resident 26, Certified Nursing Assistant C (CNA C) walked out of Resident 26's room with gloves on her hands. These failures could result in the spread of infection and cross-contamination that could affect the 61 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to meet the needs of two residents (13 and 20) when they were simultaneously administered two medications with drug-to-drug interaction (situation in which a drug affects the activity of another drug when both are administered together). This interaction may decrease the therapeutic effect of the medications for the residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to follow its policy and procedure on foods brought by resident's family for two of fifteen residents (11 and 21), when an expired 8-ounce bottle of Glucerna (a nutritional supplement) and an expired box of sesame cookie rolls were on Resident 11's and Resident 21's night stands. These failures had the potential to result, for Resident 11 and Resident 21, to develop foodborne illness.

Inspectors wroteBased on observation, interview and document review, the facility failed to store and prepare food under sanitary conditions when: 1. There was outdated food in the kitchen refrigerator; 2. There was water leaking from a ceiling vent onto the kitchen freezer; 3. There was a brown substance inside the ice machine; and 4. Dietary staff used expired test strips and improper technique when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to result in foodborne illness (illness resulting from contaminated food) throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for five of 15 sampled residents (Residents 55, 35, 58, 6 and 12) when: 1. Nursing staff provided ice chips to Resident 55, who had a strict nothing by mouth (NPO, no food or drinks) doctor's order; 2. Nursing staff did not provide Resident 35's right hand carrot orthosis (device used to prevent further stiffening of the hand) as ordered; 3. Nursing staff did not provide a left fifth finger splint to Resident 58 as ordered; 4. For Resident 6, the charge nurse signed for a treatment that was provided by the treatment nurse; and 5. The physical therapist did not use a gait belt (device attached to the resident to assist with transferring and walking) while walking Resident 12 when indicated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant L (CNA L) did not perform the COVID-19 (infectious disease caused by SARS-Cov-2 virus) healthcare professional screening prior to entering the facility; 2. The housekeeper (HK) and CNA J did not perform hand hygiene in between tasks; 3. The treatment nurse (TN) did not perform hand hygiene in between tasks and practiced double gloving (wearing of inner and outer gloves) during wound care; and 4. The business office manager (BOM) did not perform the COVID-19 screening assessment prior to entering the facility. These failures had the potential to compromise resident's health and safety in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess if the resident was safe to self-administer medications for one of 15 sampled residents (Resident 6). A resident may only self-administer medications after the IDT (Inter Disciplinary Team) has determined which medications may be self-administered. This failure had the potential to result in unsafe medication administration, and could have allowed other residents to access unlocked medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's code status (instructions on what to do if the resident has no pulse and stops breathing) was clearly indicated in the medical record for one of 15 sampled residents (Resident 24). This failure had the potential to result in the facility not acting in accordance with Resident 24's wishes in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 15 sampled residents (Resident 11) when: 1. The facility did not obtain treatment orders for the resident's multiple pressure ulcers in a timely manner; 2. There was no documentation indicating the facility provided treatments for the resident's multiple pressure ulcers; and 3. The facility did not develop care plans to address the resident's multiple pressure ulcers. These failures had the potential to result in worsening pressure ulcers and the development of new pressure ulcers for Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement appropriate new interventions after a fall for one of 15 sampled residents (Resident 9). This failure had the potential to result in Resident 9 experiencing further falls and injury.

Inspectors wrote2. A review of Resident 12's clinical record indicated the resident was admitted with a diagnosis of acute respiratory failure with hypoxia. A review of Resident 12's physician order, dated 10/28/21, indicated Change humidifier bottle every week, every Sunday and as needed (PRN) when empty. During observations on 12/13/21 at 9:17 a.m. and on 9/14/21 at 1:10 p.m., Resident 12 was in bed, with oxygen at six LPM and no humidifier bottle connected to the oxygen concentrator. During a concurrent interview and record review on 12/15/21 at 10:40 a.m., the nurse supervisor (NS) reviewed Resident 12's physician order and confirmed the resident had an order for humidifier. During an interview on 12/16/21 at 12:50 p.m., the DON confirmed Resident 12 did not have an oxygen humidifier when she did her rounds on 12/15/21. [...]

Inspectors wroteBased on interview and record review, the facility failed to document administration of controlled medications (medications controlled by the government because they may be abused or cause addiction) on the controlled medication accountability sheet (count sheet) for three residents (Residents 6, 11 and 16). This failure compromised the facility's ability to ensure accurate administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 50) had the appropriate indication for the use of Nuedexta (medication for pseudobulbar affect). This failure put the resident at risk for receiving unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 50) was free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when there was no documentation of monitoring for the specific target behavior of paranoid ideation. This failure resulted in lack of adequate behavior monitoring and had the potential for the resident to receive unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Five expired medications were properly discarded and not stored in the medication cart and/or the medication refrigerator and, 2. Safe storage of medications for two of two treatment carts. These deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date and risk the misuse of medications because they were unlabeled or improperly labeled.