Woodside Rehab & Nursing

Inspectors wroteBased on observations, record review and interviews it was determined that the facility failed to ensure: 1) appropriate resident information was sent to the receiving facility and 2) a resident's bed hold policy was maintained and care planned in accordance with facility policy and resident rights requirements, placing the resident at risk for misunderstanding bed hold procedures and return to facility expectations following hospitalization. This was evident for 3 (Resident #17, #6 and #77) out of 3 residents reviewed for hospitalizations.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility to code the residents' status accurately on the Minimum Data Set (MDS) assessment. This was evident for 3 (Resident #10, #72 and #8) out of 4 reviewed for accuracy of assessment during the recertification survey.

Inspectors wroteBased on observation, record review it was determined that the facility failed to ensure that comprehensive care plans were developed and implemented. This was found to be evident for one (Resident #9) out of eighteen residents reviewed during an annual survey.

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to maintain professional standards of practice related to oxygen orders. This was evident for 1 (Resident #82) out of 4 residents reviewed for respiratory orders.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to provide dependent residents with showers. This was evident for 1 (Resident #31) out of 8 reviewed for activities of daily living during the recertification survey.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to have evidence in Resident #8's care plan regarding Resident #8's limited mobility and the usage, monitoring and supervision of the bedrails. This was evident for one out of one resident (Resident # 8) reviewed for bedrails during an annual survey.

Inspectors wroteBased on review of employee personnel files and staff interview, the facility failed to complete annual performance evaluations for Geriatric Nursing Assistants (GNAs). This deficient practice was identified for 3 (GNA #23, #24, and #25) of 3 GNAs reviewed during the annual survey.

Inspectors wroteBased on employee file reviews and interviews with staff, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant maintained a current and active certification required for employment. This was evident for 1 (GNA #23) of 5 health care professionals reviewed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility's failed to ensure Resident #2's hospice documents including the coordinated plan of care were available to facility staff. This was evident for one out of two residents reviewed for hospice services.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain infection prevention and control practices related to sanitary ice handling by storing a cup directly inside a communal ice cooler instead of utilizing a sanitary ice scoop, creating the potential for cross contamination for residents receiving ice from the cooler. This was evident for 1 (Jamestown) out of 4 units

Inspectors wroteBased on the complaint, medical record review, reviews of all pertinent records from a local hospital and emergency services provider, interviews with current staff, and an interview with the resident's attending physician, it was determined that the facility failed to 1) honor a resident's end of life wishes. This caused harm to Resident #2. The facility also failed to follow the physician's specific pulse and blood pressure parameters before administering a cardiac medications. This was evident for 2 (Resident #2, Resident #4) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of medical records and all pertinent documents, and staff interview, it was determined that the facility failed to immediately notify a resident's physician with the results of a swallowing evaluation. This was evident for 1 (Resident #1) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of facility reported incident and staff interview, it was determined the facility staff failed to immediately report an allegation of suspected resident abuse to the local police. This was evident for 1 (Resident #4) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of all pertinent documents and a closed medical record and facility staff interview, it was determined that the facility failed to revise care plans to meet a resident's needs. This was evident for 1 (Resident #1) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to ensure medications were kept in locked compartments. This was evident in 1 (100 hall) of 4 nursing units observed.

Inspectors wroteBased on reviews of a medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #4) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to ensure a resident received mail. This was evident for 1 (#5) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interviews with facility staff, it was determined the facility failed to: 1) Remove outdated nourishment from the refrigerator, 2) ensure a sanitary environment in cleaning food items, and 3) ensure the labeling, dating, and expiration of food items. This was found to be evident during the facility's recertification/complaint Medicare/Medicaid survey and has the potential to affect all residents who consume food prepared in the facility's kitchen.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that advance directives were discussed with and/or information regarding advance directives was provided to residents and/or their responsible representatives (RP). This was evident for 2 (Resident #8 and #41) of 4 selected residents reviewed for advance directives during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with complainant and facility staff, it was determined that the facility failed to notify the Medical Director, the physician, or the resident's responsible party in a timely manner 1) when medication was not available from the pharmacy, and 2) when the resident had an inability to provide a urine sample for testing. This was evident during the review of 2 (Resident #76 and #78) of 3 complaints reviewed during this recertfication/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined the facility failed to ensure timely reporting of abuse allegations. This was evident for 2 (Resident #18 and #58) out of 6 residents reviewed for allegations of abuse during the complaint/recertification survey. Findings Included: 1) On 4/10/2025 at approximately 11:15 AM the surveyor notified Unit Manager Staff #16 that Resident #58 stated that a Geriatric Nursing Assistant (GNA), white lady with yellow big hair was very rough with him/her during care. The Resident added that when the GNA asked him/her to turn over, the GNA does not give him/her time to turn, and the GNA turns him/her very roughly. By 4/15/2025 at 2:00 PM the surveyor did not get any notification that this alleged incident was reported to the DON, the Administrator, or Office of Healthcare Quality (OHCQ). [...]

Inspectors wroteBased on medical record review and staff interviews it was determined that the facility failed to provide the bed hold policy on transfer out of the facility and/or mail it to the resident's responsible representative. This was found to be evident for 1(Resident #58) out of 2 residents selected for the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #53) of 5 residents reviewed for antibiotic use during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure that a PASARR screening (Preadmission Screening for Individuals with a Mental disorder and Individuals with Intellectual Disability) was re-evaluated as required. This was evident for 3 (Resident #9, #19, and #41) of 9 residents reviewed for PASARR screening during a recertification/complaint survey.

Inspectors wroteBased on observation, record review and interviews with facility staff, it was determined that the facility failed to 1) Initiate a wound care plan for a resident with wounds, 2) initiate a care plan for a resident who was receiving hospice care, and 3) failed to develop a comprehensive care plan that included psychotropic and antidepressant medications. This was evident for 3 (Resident #6, #11 and #65) out of 19 residents reviewed for care plans during the Medicare/Medicaid recertification and complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to: 1) conduct an interdisciplinary care plan meeting as required, 2) revise or update the care plan to reflect the needs of the resident, and 3) failed to review and revise the interdisciplinary care plan for discontinuation of Physical Therapy (PT) and Occupational Therapy (OT). This was evident for 2 ( Resident #18 and #60) of 19 resident care plans reviewed during the recertification/complaint survey.

Inspectors wroteBased on review of a complaint, medical record review, and interview with staff it was determined that the facility failed to ensure that a resident who required assistance with activities of daily living (ADL) received showers twice per week. This was evident for 1 resident (Resident #74) out of 19 residents reviewed for complaints during the Medicare/Medicaid recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to 1) properly date label oxygen tubing when changed, 2) follow physician's orders for the administration of oxygen, and 3) develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 1 (#15) of 3 residents reviewed for respiratory care during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to document the use of nonpharmacological methods for pain management. This was evident in the review of 2 (Resident #58 and #65) of 5 reviewed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility attending failed to follow up with the hospital discharge recommendations and her own physician notes related to a cardiac consult for a resident with a diagnosed cardiac condition. This was evident during the review of 1 (Resident #52) of 3 residents regarding coordination of care during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to provide and show documentation that the attending physician reviewed any irregularities identified by the pharmacist. This was evident for 2 (Resident #52 and #19 ) of 5 residents that were reviewed for drug regimen reviews during the recertification/complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to implement behavior monitoring for residents receiving antipsychotic medications. This was evident for 1 (Resident #65) out of 5 residents reviewed for unnecessary medications during the recertification survey.

Inspectors wroteBased on employee file reviews and interviews with staff, it was determined that the facility failed to ensure that nursing staff had an active license. This was evident for 1 (LPN #24) of 5 licensed health care professionals reviewed during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews with the staff, it was determined that the facility failed to provide outside services to a resident in a timely manner. This was evident for 1 (Resident # 52) out of 3 residents that were reviewed for coordination of care during the recertification/complaint survey. The Findings Include: Left ventricular (LV) thrombus is a blood clot (thrombus) in the left ventricle of the heart Resident #52's medical records were reviewed on 4/10/25 at 09:14 AM. There was a physicians note from 2/29/24 stating that the Resident was a new admission after being hospitalized for Cerebral Vascular Accident (CVA) caused by an LV thrombus, a blood clot that forms inside the left ventricle of the heart. [...]

Inspectors wroteBased on review of the medical record and staff interviews, it was determined that the facility failed to 1) ensure accurate documentation of a resident's personal hygiene preference and 2) ensure that the staff who performed activities of daily living (ADL) care documented in the resident's electronic record. This was evident for 1 resident (Resident #74) out of 19 residents reviewed for complaints during the Medicare/Medicaid recertification/complaint survey.

Inspectors wroteBased on record review and interviews with facility staff, it was determined that the facility failed to obtain a hospice plan of care for resident receiving hospice services to ensure that the needs of the resident were addressed and met. This was evident for 1 resident (Resident #11) out of 1 resident reviewed for hospice plan of care notes during the Medicare/Medicaid recertification/complaint survey.

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to have a Quality Assurance and Performance Improvement (QAPI) committee meeting at least quarterly and with enough frequency to conduct the required (QAPI) activities. This was evident during the recertification/complaint survey.

Inspectors wroteBased on Observation and interviews with the staff, it was determined that the facility failed to post all of the required staffing information on a daily basis. This was evident in the facilities main entrance and common areas observed during the recertification/complaint survey.

Inspectors wroteBased on the review of the clinical records, observations made during the medication pass process, and interviews with facility staff, it was determined that the facility's pharmacist failed to identify drug irregularities for 1 of 2 residents that require tube feedings (Resident #25).

Inspectors wroteBased on a review of the facility's observations, interviews with staff, and the review of administrative policies, it was determined that the facility staff failed to ensure staff adhered to wearing and removing personal protective equipment (PPE) on the Yorktown (observation) unit as required to comply with infection control measures.