Woodstock Center for Nursing and Healing LLC

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure one Resident (R) (R8) of seven residents reviewed for abuse was free from verbal abuse. The deficient practice had the potential to affect resident safety.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure residents were free from misappropriation of medications, specifically controlled substances for three Residents (R) (R9, R10, and R11) of 19 sampled residents reviewed for medication misappropriation. The deficient practice resulted in delayed administration of prescribed medication and placed residents at risk for unrelieved or worsening pain, anxiety, agitation and psychological distress, compromising resident safety and well-being.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure areas around the garbage dumpsters were kept free from debris and failed to ensure the sliding doors of two of two garbage dumpsters were kept closed when not in use to prevent pests and rodents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Resident Personal Funds, the facility failed to purchase a sufficient Surety Bond to assure the security of all funds. The deficient practice had the potential to affect 56 total accounts of 125 residents managed by facility.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to maintain a safe, clean, comfortable, and homelike environment by failing to repair roof leaking in a timely manner, failing to repair a hole in the wall in Resident (R) (R2)s room in a timely manner, and failing to eliminate offensive odors in the 100, 200 and 300 hallways.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy title, Activities of Daily Living (ADLs), the facility failed to ensure staff provided ADLs for three of 19 Residents (R) (R115, R107, and R82) who required assistance from staff with ADLs. The deficient practice had the potential to cause R115, R107, and R82 a decline in ADL abilities and not to achieve and maintain their highest practicable outcomes.

Inspectors wroteBased on observations, staff interviews, record review and the review of the facility's policies titled, Charting and Documentation and Medication Administration, the facility failed to follow physician's order for one resident (R) (R89) of 33 sampled residents. Specifically, TED Hose (compression stocking for swelling) were documented as applied to R89 but were observed not to have been applied.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Administering Medications Through a Small Volume (Handheld) Nebulizer, the facility failed to ensure that the medication administration error rate was less than 5 percent (%) as evidence by an error rate of 6.45 % from two of three nurses observed during medication administration.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Prevention of Components of Facility Abuse Prevention Program, the facility failed to protect the resident's right to be free from sexual abuse by another resident for four of 50 sampled residents (R52, R51, R8, and R270). Specifically, R52 was groped by R51 and R270 placed their hand down R8's shirt.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to provide activities of daily living (ADL) for one of 50 sampled residents (R) (R35) related to showers/baths. Review of the EMR revealed that R35 was admitted with diagnoses that included, but were not limited to spina bifida (a birth defect that occurs when the spine and the spinal cord do not develop completely), neurogenic bowel (the loss of normal bowel function due to a nerve problem), neuromuscular dysfunction of bladder, and Fournier gangrene (a rare, life-threatening bacterial infection of the scrotum, penis or perineum). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R35 had a Basic Interview of Mental Status (BIMS) score of 15, indicating little or no cognitive impairment. Section E-Behavior revealed that he had no behaviors. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to follow physician orders related to O2 liter flow for one of four sampled residents (R) (R61) with physician orders for O2 as needed (PRN).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Storge of Medications, the facility failed to safely secure resident medications as evidenced by the observation of two of six medication carts left unlocked when left unattended. The deficient practice had the potential for residents, staff, and visitors to have unauthorized access to resident's medications.

Inspectors wroteBased on observations and staff interviews, the facility failed to properly perform infection control practices to prevent the possible spread of infections during medication administration for one of three nurses observed. Specifically, the facility failed to properly disinfect an electonic blood pressure cuff in between uses and by handling medication with ungloved hands.

Inspectors wroteBased on observation, record review, staff and resident interviews and review of the facility policies titled Abuse Prevention Program, Preventing Resident Abuse, Investigating Allegations of Neglect, Investigating Allegations of Resident to Staff Abuse, Protection of Residents During Abuse Investigations, and Investigating Allegations of Resident-to-Resident Abuse, the facility failed to ensure that one of 37 sampled residents (R) (R#209) was free from physical abuse by R#68. In addition, the facility failed to ensure that all residents were safe from potential abuse by not pursuing placement for R#68 with documented behaviors of verbal and physical aggression toward other residents and staff. [...]

Inspectors wroteBased on interview, record review, and review of facility policy titled Abuse Investigation and Reporting, the facility failed to ensure that alleged physical abuse was reported to the State Survey Agency (SSA) within a two-hour timeframe for one of 37 sampled residents (R)(R#209). On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: [...]

Inspectors wroteThe facility failed to revise the care plan for one of 37 sampled residents (R) (R#68) after multiple incidents of attempted physical aggression against other residents which occurred from [DATE] through [DATE]. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility's Administrator, Regional Consultant Nurse, and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 5:35 p.m. The immediate jeopardy is outlined as follows: [...]

Inspectors wroteBased on record review, review of the Rules and Regulations of the State of Georgia Department 393 Rules of Georgia State Board of Long-Term Care Facility Administrators dated [DATE], and the Georgia Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, and staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality for two of 37 sampled residents (R) (R#68 and R#209) related to the failure of the Administration and clinical staff to conduct an Interdisciplinary Team (IDT) Meeting to include the Psychiatrist, Medical Director, and other direct care staff related to ensuring that all residents were safe from potential abuse by R#68 and failed to initiate neurological checks related to an unwitnessed fall for R#209. [...]

Inspectors wroteBased on record review, interviews and Administrator Job description titled, Administrator issued: [DATE]. Previous Administrator BB failed to ensure that one of 37 sampled residents (R) (R#209) was free from physical abuse by R#68. In addition, previous Administrator BB failed to ensure that all residents were safe from potential abuse by not pursuing placement for R#68 with documented behaviors of verbal and physical aggression toward residents and staff. Previous Administrator BB failed to implement an effective process to protect residents and staff from abuse. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The sample size was 37.

Inspectors wroteBased on staff interviews, facility documentation, record review, and facility policy titled, Facility COVID-19 Vaccination Plan, the facility failed to ensure 100 percent (%) of all current staff were fully vaccinated against COVID-19. The facility's census was 116 residents.