Woodlawn Healthcare Center LLC

Inspectors wroteBased on interview, observation, and record review, the facility's water management plan failed to have an assessment documenting where Legionella or other opportunistic waterborne pathogens could grow and spread or to include interventions for when control limits were not met. This deficiency has the potential to affect the facility's census of 51 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide notifications of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 2 of 3 residents reviewed for Beneficiary Notification (Resident identifiers are #4 and #14).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents have the appropriate equipment to prevent a decrease in Range of Motion (ROM) for 1 of 1 resident reviewed for limited range of motion in a final sample of 13 residents (Resident identifier is #21).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 1 of 3 residents reviewed for beneficiary notices (Resident identifier is #148.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional for a facility census of 44 residents.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to properly sanitize dishes according to manufacturer's instructions for a facility census of 44 residents.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 4 of the 4 quarterly meetings reviewed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement a resident's care plan for 1 of 2 residents reviewed for indwelling catheter in a final sample of 21 residents (Resident Identifier #16).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to update resident care plans with new or revised interventions after a fall for 2 of 6 residents reviewed for falls in a final sample of 21 residents (Resident Identifiers #14 and #29).

Inspectors wroteBased on record review, interview, and facility assessment it was determined that the facility failed to provide sufficient nursing staff in accordance with their facility assessment. Findings Include: Review on 2/21/24 at 9:00 am of 30 days (1/20/24 to 2/19/24) of the nursing staffing schedule revealed that on the following weekend days the facility had one nurse working from the hours of 6:00 pm until 10:00 pm: 1/20/24 and 1/21/24 1/21/24 and 1/22/24 1/27/24 and 1/28/24 2/3/24 and 2/4/24 2/10/24 and 2/11/24 2/17/24 and 2/18/24 Review on 2/21/24 of the Facility Assessment with a revised date of 1/20/24 revealed: .page 3 Woodlawn has 3 shifts 6 am to 2 pm, 2 pm to 10 pm, and 10 pm to 6 am. Minimum staff is as follows: 1st. shift has two nurses and 5 aides [Licensed Nursing Assistant], 2nd shift has two nurses and four aides, and 3rd shift has one nurse and 2 aides. [...]

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to store food and prepare food in accordance with professional standards for food service safety to prevent food-borne illness for one main kitchen and one kitchenette observed. Findings Include: Observation on 2/20/24 at 6:30 pm of the main kitchen revealed a zip-lock bag containing cut-up celery, dated 2/19, the edges of the celery were brown and soft. A blue container, with no date, containing cut-up mushrooms, the mushrooms in the container had an odor and were dark brown, soft, and sitting in a small amount of liquid. Interview 2/20/24 during the above observation with Staff F (Cook) confirmed the above findings.

Inspectors wroteBased on review and interview it was determined that the facility failed to complete the facility assessment related to staff competencies necessary to provide the level and types of care needed for the resident population.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide notification of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) and timely Notice of Medicare Non-Coverage (NOMNC) for 2 out of 3 residents reviewed for beneficiary notifications (Resident Identifiers #7 and #12).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to put measures in place to ensure that further potential abuse did not occur while an investigation was in process for 1 out of 1 resident reviewed for abuse (Resident Identifier is #1).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow the Centers for Disease Control and Prevention (CDC) return to work guidelines for Health Care Personnel (HCP) who were positive for COVID-19 for 3 of 24 HCPs reviewed (Staff identifiers are C, D, and E). Findings Include: Review on 9/6/23 of the CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposure to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP with SARS-CoV-2 Infection. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to employ, at least on a part-time basis, an Infection Preventionist who had completed specialized training in infection prevention and control.