Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodmont Health Campus during CMS and state inspections, most recent first.
A CNA took an unauthorized short video of a resident with severe cognitive impairment using a personal cell phone while the resident was in the hallway. The resident had diagnoses including cognitive communication deficit, abnormal gait and mobility, lack of coordination, and major depression. Facility leadership stated that only certain authorized staff may photograph or video residents with consent, and CNAs and nurses are not authorized to do so while providing care.
Surveyors found that pharmaceutical services were not sufficient to ensure physician-ordered routine medications were available and administered as prescribed for two residents. One resident with multiple conditions, including HF, CKD, type II DM, anemia, SIRS, and an acute URI, had several missed doses of artificial tears, ferrous sulfate, sliding-scale insulin, ipratropium-albuterol nebs, and methylprednisolone documented on the MAR as unavailable. Another resident with type II DM, HF, and CKD missed a dose of cyanocobalamin and an evening dose of Novolog insulin because the medications were not available. These missed doses occurred despite a facility policy stating that medications would be administered in accordance with prescriber orders and supported by a sufficient medication distribution system.
A resident with multiple chronic conditions, including type II DM, heart failure, and kidney failure, experienced significant medication errors when two nurses administered Novolog 10 units twice due to failure to document on the MAR, and on another occasion an LPN gave the resident a full set of medications intended for the roommate, resulting in wrong-resident and wrong-medication administration. Staff interviews confirmed the errors, and facility policy and a QMA’s statements indicated that proper resident identification and adherence to the five rights of medication administration were required but not followed.
Food temperatures were not obtained before residents were served during a plating observation. An employee plated food while the computerized temperature log was blank, and another employee would not confirm whether temperatures had been taken. The Dietary Manager later entered the kitchen, stopped plating, and began checking temperatures of multiple food items.
Unclear Code Status and Conflicting Advance Directive Orders: A resident with metastatic stage 4 cancer had conflicting code status documents, with a physician order allowing intubation and a signed POST form stating do not intubate. Staff gave inconsistent statements about the resident’s wishes, the record lacked a code-status care plan, and the resident’s daughter said the resident did not want to be intubated.
Care plans were not reviewed and revised to match resident condition changes. Two residents still had antianxiety medication care plans even though current orders showed no antianxiety meds, one resident’s UTI care plan was not discontinued after the infection resolved and was not revised when a new UTI occurred, and a resident with pressure ulcers did not have wound-specific care plans after one wound healed and the areas were combined on one plan.
The facility failed to meet professional standards for weight monitoring, infection control, and wound documentation. One resident with multiple chronic conditions had highly inconsistent weights and unclear follow-up on abnormal changes, another resident with MRSA in urine remained on contact precautions after a follow-up culture no longer showed MRSA, and a third resident with heart failure, renal failure, and pressure ulcers had missed daily weights, an undated and uninitialed sacral dressing, and inaccurate wound treatment documentation by nursing staff.
Failure to follow ordered wound care and EBP during pressure ulcer treatment. A resident with severe dementia and multiple pressure ulcers had incomplete wound-specific care planning, inaccurate and incomplete wound assessments, and treatment orders that were not followed. During observed wound care, a PT did not wear a gown for EBP, used wound cleanser instead of ordered NS, did not apply an ordered foam dressing to one wound, and used the same gloves while moving between wound care tasks.
A resident with a history of falls, a prior fracture, and significant assistance needs had repeated falls while fall precautions were not consistently in place. The resident was seen barefoot or in regular socks instead of non-skid footwear, a call don't fall sign could not be located in the bathroom, and ordered post-fall neuro checks were not fully completed after unwitnessed falls.
Medication error rate exceeded 5 percent during a med pass. An LPN crushed and mixed Tradjenta, levothyroxine, and metoprolol succinate ER with pudding before giving them to a resident with DM2, hypothyroidism, constipation, and HTN. The pharmacist stated those meds should not be crushed, and levothyroxine should not be given with food or other meds. Surveyors found 3 errors in 25 opportunities, for a 12 percent error rate.
Failure to follow antibiotic stewardship for UTI treatment. Two residents with indwelling urinary catheters received antibiotics for suspected UTI without appropriate culture support: one was started on Macrobid while the urine culture was still pending and later had a culture showing pseudomonas aeruginosa with Cipro resistant, and another received Macrobid even though the urine culture showed no uropathogens and the UTI criteria form indicated the criteria were not met. The IP stated waiting for culture results before starting antibiotics was inconsistent.
Inaccurate Posted Nurse Staffing Forms: The facility failed to keep the posted nurse staffing form accurate on multiple observed days. Surveyors found the census listed as 46 at the nurses station while the Administrator stated the actual census was 54, 55, 55, and 56 on different observations. The Administrator said the scheduler posted the form and floor nurses were responsible for verifying it daily, and a requested staffing policy was not provided.
The facility failed to adhere to proper hand hygiene practices during care activities for two residents. A CNA performed insufficient handwashing during urostomy and incontinence care, while an RN improperly handled gloves and a glucometer during glucose monitoring. These actions did not comply with the facility's hand hygiene policy.
The facility failed to store food safely and maintain proper sanitation in the kitchen. Observations revealed unlabeled and open food items in the freezer, and the dishwasher did not reach the required rinse temperature. Temperature logs were incomplete, and staff failed to report or address the dishwasher's malfunction. Facility policies on temperature checks and documentation were not followed.
The facility failed to conduct quarterly care plan conferences for four residents, as required by their policy. A resident with dementia and hypertension, another with anxiety and depression, a third with hypertension and anxiety, and a fourth with fibromyalgia and depression all missed scheduled care conferences. The Social Service Director acknowledged the oversight, and the facility's policy mandates quarterly meetings to ensure communication and participation in the residents' care plans.
The facility failed to ensure a sanitary and homelike environment, with observations of soiled toilets, uncovered bedpans, and dirty equipment across resident halls and a shower room. Staff interviews revealed unclear cleaning protocols and responsibilities, contributing to the deficiencies.
The facility failed to ensure proper hand hygiene during incontinence care for two residents. CNAs did not change gloves or perform adequate handwashing between tasks, and a clean incontinence pad was placed on the bathroom floor before use. The DON confirmed that staff should lather hands for 20-30 seconds and change gloves when touching different items.
The facility did not ensure daily posting of accurate nurse staffing information, as observed on one occasion when the staffing sheet was outdated. The ADON indicated that the Scheduler and weekend nurse were responsible for posting the information, according to the facility's policy.
Unauthorized Video of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a resident’s right to privacy and confidentiality for 1 of 3 residents reviewed for resident rights when an employee took an unauthorized video of a cognitively impaired resident with a personal cell phone. The incident report indicated that CNA 4 was taking a video in the hallway of Resident C, and the video was approximately five seconds long and recorded on the employee’s personal cell phone. Resident C’s clinical record showed diagnoses including cognitive communication deficit, abnormal posture, abnormalities of gait and mobility, lack of coordination, and major depression. The most recent annual MDS indicated the resident had severe cognitive impairment. During interview, the Activity Director stated that only Activity Staff and certain facility leaders were authorized to photograph or video residents with consent, and that CNAs and nurses were not authorized to take photographs or videos of residents while providing care.
Failure to Provide Prescribed Medications Due to Unavailable Pharmacy Stock
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services were available so that physician-prescribed routine medications were administered as ordered for two residents. For one resident with diagnoses including heart failure, kidney failure, type II diabetes, anemia, SIRS, and acute upper respiratory infection, the MAR for February 2026 showed multiple missed doses of ordered medications because they were unavailable at the facility. These included artificial tears not given for an evening and night time period, ferrous sulfate not given on one day, sliding-scale insulin lispro not given before breakfast on one day, ipratropium-albuterol nebulizer solution not given for a scheduled morning dose, and methylprednisolone not given for a morning time block. The resident reported that staff had informed her on more than one occasion that they were out of her routine medications. A second resident, with diagnoses including type II diabetes, heart failure, and kidney failure, also did not receive prescribed medications due to unavailability. Record review showed that this resident’s daily cyanocobalamin (vitamin B-12) was not administered on one day in January 2026 because it was unavailable, and a scheduled evening dose of Novolog insulin was not given on another day for the same reason. The facility’s written policy stated that the facility would have sufficient personnel and a medication distribution system to ensure safe administration of medications and that medications are administered in accordance with written prescriber orders, but the documented missed doses due to unavailability demonstrate that this did not occur for these two residents.
Failure to Prevent Significant Medication Errors and Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, including a double insulin dose and administration of another resident’s medications. Record review showed that the resident had diagnoses including type II diabetes, heart failure, kidney failure, anxiety, and depression, and was receiving insulin, antidepressant, diuretic, anticoagulant, hypoglycemic, and anticonvulsant medications. Nursing progress notes documented that on one occasion the resident was given Novolog 10 units twice by two different nurses because the first administration was not documented as given on the MAR, leading the second nurse to be unaware that the insulin had already been administered. On another occasion, an event report documented that the resident received a full set of medications intended for the roommate, including Xanax 0.5 mg, atorvastatin 40 mg, Aricept 10 mg, metoprolol 25 mg, Remeron 7.5 mg, Singulair 10 mg, ranolazine 500 mg, and ropinirole 1 mg. The error was described as involving the wrong resident and wrong medications, with the reason identified as wrong resident. During interview, an LPN stated she mistakenly administered the roommate’s medications to the resident. Another staff member (a QMA) indicated that nursing staff are expected to use the five rights of medication administration, and the facility’s policy required resident identification before medication administration by checking a photograph, calling the resident by name, having the resident verify their last name, or verifying identification with other personnel.
Food Temperatures Not Obtained Before Serving
Penalty
Summary
Food was not temperature-checked prior to serving residents during a plating observation on 8/28/25 at 6:02 A.M. [NAME] 17 used tongs and scoops to plate food items for residents, while [NAME] 19 later stated that a computerized system was used to log food temperatures and showed that the temperature log was blank. [NAME] 17 indicated temperatures should have been obtained by [NAME] 21, who refused to answer whether the food temperatures had been taken. At 6:09 A.M., the Dietary Manager entered the kitchen, reviewed the computerized system, and then directed [NAME] 17 to stop plating food while he began taking temperatures of the food items, including oatmeal, gravy, scrambled eggs, sausage links, puree eggs, and mechanical meat. A current Food Safety and Handling policy reviewed 6/2016 stated that reaching proper temperatures within an appropriate time period can help ensure food is safest to eat and that cooks must know the proper temperatures.
Unclear Code Status and Conflicting Advance Directive Orders
Penalty
Summary
The facility failed to clarify a resident’s code status for 1 of 1 residents reviewed for advance directives. Resident 56 had diagnoses including metastatic stage 4 cancer, and the admission MDS assessment was still in progress. The resident’s Physician Orders listed, “CODE STATUS: No chest compressions. May intubate,” dated 8/22/25, while a current POST form signed the same day indicated “Limited Additional Interventions” and “Do not intubate.” The resident’s clinical record also lacked a care plan related to code status. During observation and interviews, the resident’s daughter stated the resident did not want to be intubated. RN 23 stated that if the resident coded, he wished to be intubated. Clinical Support 1 stated the resident’s code status was DNR, which indicated he should not be intubated. The facility’s Guidelines for Advanced Directives policy stated that nursing staff would confirm the desired code status and obtain a physician order, and that verbal wishes witnessed by 2 people would be honored until an order was officially obtained.
Care plans were not updated for medication changes, UTI status, and pressure ulcers
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised for residents with changes in condition and treatment status. Resident 6 and Resident 18 each had a current care plan for risk for adverse consequences related to antianxiety medication, but current physician orders did not include an antianxiety medication for either resident. Clinical Support 2 stated both residents were no longer on antianxiety medications and the care plans should have been removed. Resident 6 had diagnoses including severe dementia with psychotic disturbance and adjustment disorder, and Resident 18 had dementia with behaviors and depression. The facility also failed to update a urinary tract infection care plan for Resident 45 and failed to develop wound-specific care plans for Resident 1's pressure ulcers. Resident 45 had an indwelling urinary catheter, received antibiotic treatment for a UTI beginning after a urinalysis identified infection, and later had another urinalysis showing a UTI with a second antibiotic course ordered; the existing UTI care plan was not discontinued after the first UTI and was not revised for the second UTI. Resident 1 had two unstageable pressure ulcers on admission, and the current pressure ulcer care plan combined the sacral and left hip areas on one plan even though the Assistant Director of Nursing stated the left hip pressure ulcer had healed. The facility policy stated the comprehensive care plan should be reviewed no less than quarterly and revised to reflect changes in the resident's condition as they occur.
Failure to Monitor Weights, Isolation Status, and Wound Care Documentation
Penalty
Summary
The facility failed to ensure services met professional standards of quality for residents reviewed for nutrition, UTI, and pressure ulcer care. One resident with diabetes, CKD, hypertension, lymphedema, edema, morbid obesity, and dementia had monthly weight monitoring ordered, but the order was discontinued while care plans still referenced weight monitoring. The resident’s recorded weights varied significantly, including a documented gain of 34.2 lbs on one date and a re-weigh showing a 14.2 lb gain in 11 days, yet the record lacked documentation of what was done in response. Staff later observed the resident being weighed with a Hoyer lift, and staff interviews showed uncertainty about the weight fluctuations and the scale’s accuracy. A second resident with stroke, neurogenic bladder, and an indwelling catheter had MRSA in the urine and was on contact precautions. The physician order stated contact precautions could be discontinued when MRSA had cleared, and a follow-up urine culture later did not indicate MRSA in the urine. However, the record did not show that contact precautions were discontinued after the follow-up culture, despite the infection preventionist stating they should have been stopped once MRSA cleared. A third resident with heart failure, renal failure, significant weight loss, and unstageable pressure ulcers had daily weights ordered, but several weights were not completed or had no reason documented. The resident’s wound vac orders were in place for sacral and left hip wounds, but the sacral dressing observed by surveyors was not initialed or dated. Staff also documented wound vac treatment as completed on a date when one nurse stated she did not actually perform the treatment and only signed off after confirming with another staff member that it had been done. The record also showed the left hip wound had healed and the wound vac had been discontinued, while staff documentation still reflected treatment activity on the wound-related record.
Failure to Follow Ordered Wound Care and EBP During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure a resident with severe dementia and a pressure ulcer received ordered treatment and services to promote healing and prevent new ulcers from developing. The resident’s record showed a quarterly MDS indicating severe cognitive impairment, dependence for toileting, substantial to maximum assistance for bed mobility and transfers, and one facility-acquired unstageable pressure ulcer. Current physician orders included Enhanced Barrier Precautions during wound care and specific wound treatment orders for the right lateral foot, left heel, and left lateral first metatarsal, but the record lacked a wound-specific care plan for the left heel and left first metatarsal wounds, and the current orders lacked Santyl dosage and application instructions. Weekly skin assessments and wound care notes showed the right lateral foot wound changed in size over time and was repeatedly documented with incomplete wound observations and inconsistent staging. The left heel wound and the left lateral first metatarsal wound were also documented, but the wound observations were not completed, and the clinical record lacked documentation of a new event or skin occurrence for those wounds. The facility’s wound guidelines required detailed wound documentation, including measurements, exudate, color, odor, margins, surrounding tissue, and tunneling or undermining when applicable. During observation of wound care, the PT performed treatment without wearing a gown, despite the EBP care plan requiring gown and gloves during wound care. The PT used wound cleanser instead of normal saline as ordered, did not apply the ordered Allevyn LIFE dressing to the left first metatarsal wound, and used the same gloves while moving between wound care tasks. The PT also applied Santyl and dressings in a manner that did not match the ordered treatment sequence, and debridement was stopped when the resident pulled away and said it hurt. The ADON/WCC stated the treatments should be done as ordered and that normal saline was not the same as wound cleanser, and also stated EBP should be used when performing wound care.
Failure to maintain fall precautions and complete post-fall neuro checks
Penalty
Summary
The facility failed to provide adequate supervision and prevent falls for a resident who was cognitively intact, required substantial to maximal staff assistance for transfers and toileting, and had diagnoses including a right pubis fracture, hypertension, anxiety disorder, and depression. The resident’s care plan identified fall risk interventions including non-skid strips in the bathroom, a call don't fall sign in the bathroom, and non-skid footwear, and the physician’s orders also included a call don't fall sign and non-skid strips in the bathroom. During observation, the resident was seen in a recliner wearing regular white socks, and later was assisted to the bathroom barefoot. A CNA stated the resident had not been wearing non-skid socks throughout the day, and an LPN was unable to locate the call don't fall sign in the bathroom. The resident had multiple falls in the prior 3 months, including an unwitnessed fall in the bathroom where the resident was found on the floor incontinent of urine and barefoot, a fall found on the floor between the bed and roommate’s bed with shortening of the right lower extremity and no range of motion to the right lower extremity, and another fall found sitting on the bathroom floor in front of the toilet. The facility did not complete the ordered neurological checks after the unwitnessed falls, including the required hourly and every-4-hour checks after one fall and the required every-30-minute and every-1-hour checks after another fall. Staff interviews indicated neuro checks should be completed after unwitnessed falls and that care plan interventions should be implemented at all times, while the facility policy stated physician orders should be carried out and the care plan updated to reflect new or changed interventions.
Medication error rate exceeded 5 percent during medication pass
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 5 residents observed during the medication pass. During observation of medication administration to Resident 31, the LPN used ABHR, prepared multiple medications, crushed Tradjenta, levothyroxine, and metoprolol succinate ER, and mixed the crushed medications with pudding before administering them to the resident. The observation identified 3 medication errors out of 25 opportunities, resulting in a 12 percent medication error rate. Resident 31 had diagnoses including diabetes mellitus type II, hypothyroidism, constipation, and hypertension. The physician’s orders included docusate sodium 10 mL daily, Tradjenta 5 mg daily, metoprolol succinate ER 25 mg daily with instructions to hold if systolic blood pressure was less than 110, and levothyroxine 50 mcg daily to be given 30 to 60 minutes before food or other medications. The pharmacist stated Tradjenta, levothyroxine, and metoprolol should not be crushed, and levothyroxine should not be given with food or other medications. Facility staff later stated there was no Do Not Crush list available on the medication carts, and the DON acknowledged there was no such list and that the facility did not have documentation from the physician allowing levothyroxine to be given with food and other medications.
Failure to Follow Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to ensure antibiotic use protocols were followed for two residents with urinary tract infections. One resident with stroke, neurogenic bladder, moderate cognitive impairment, and an indwelling urinary catheter was ordered Macrobid for UTI while the urine culture was still pending, and later received a different antibiotic after the physician was updated that Macrobid had already been ordered. The record showed the urine culture later identified pseudomonas aeruginosa, with Cipro listed as resistant, and another course of Macrobid was again ordered for UTI with culture pending before the culture was completed. The Infection Preventionist stated that waiting for urine culture results before starting an antibiotic was hit or miss with physicians. A second resident with heart failure, renal failure, moderate cognitive impairment, and an indwelling urinary catheter was ordered Macrobid for UTI after a urinalysis and urine culture were obtained. The urine culture showed no uropathogens isolated, and the symptom/urinalysis review form listed only increased lethargy related to a yeast infection; it also indicated UTI criteria was not met. Despite this, the resident received Macrobid. The facility’s Antibiotic Stewardship policy stated that treatment of infections should be optimized by ensuring residents who require an antibiotic are prescribed the appropriate antibiotic and by reducing unnecessary or inappropriate antibiotic use.
Inaccurate Posted Nurse Staffing Forms
Penalty
Summary
The facility failed to ensure posted nurse staffing forms were accurate for 4 of 6 days during the survey. On 8/27/25, 8/28/25, 8/29/25, and 9/2/25, surveyors observed a posted nurse staffing form at the nurses station listing the facility census as 46, while the Administrator stated the current census was 54, 55, 55, and 56, respectively. On 9/2/25, the Administrator stated the scheduler was responsible for posting the staffing form and the nurses on the floor were responsible for verifying its accuracy daily. A posted nurse staffing policy was requested on 9/2/25 and was not provided.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically in hand hygiene, during care activities for two residents. In the first observation, a CNA provided urostomy and incontinence care for a resident requiring Enhanced Barrier Precautions. The CNA performed handwashing for only 10 to 12 seconds, which is below the facility's policy requirement of at least 20 seconds. After removing gloves, the CNA touched the resident's privacy curtain with bare hands before completing hand hygiene in the bathroom. In the second observation, an RN conducted glucose monitoring for another resident. After pricking the resident's finger and checking the blood sugar level, the RN removed one glove and carried the glucometer out of the room. The RN placed a used glove on a medication cart in the hallway, removed the other glove, and disposed of both gloves in the trash on the cart before completing hand hygiene. These actions were contrary to the facility's hand hygiene policy, which requires handwashing after removing gloves and before having direct physical contact with residents.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food and proper sanitation procedures in the kitchen. During observations, food items such as beef patties and chicken breasts were found open to air and unlabeled in the walk-in freezer. Additionally, the high-temperature dishwasher did not reach the required rinse temperature of 180 degrees Fahrenheit, with recorded temperatures of 168, 170, and 172 degrees during various observations. Temperature logs for food, dish machine, refrigerator, and freezer were incomplete or missing for several days, indicating a lack of proper documentation and monitoring. Interviews with staff revealed that there was a lack of communication and action when the dishwasher failed to reach the required temperature. A staff member admitted to not notifying the Dietary Manager or Maintenance Director when the rinse temperature was below the required level, as they were not present. The Administrator was only informed of the issue after the surveyor's observation, and it was noted that the facility had not used disposable dishes despite the dishwasher's malfunction. The facility's policies required specific temperature checks and documentation, which were not adhered to, contributing to the deficiency.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly for four out of five residents reviewed for unnecessary medications. Resident 28, diagnosed with dementia with behaviors and hypertension, did not have a care conference between January 2, 2024, and June 3, 2024. Resident 8, with anxiety disorder and depression, lacked a care conference between December 12, 2023, and May 8, 2024. Resident 19, diagnosed with hypertension and anxiety disorder, missed care conferences between August 27, 2023, and January 3, 2024, as well as on May 30, 2024. Resident 29, with fibromyalgia and depression, did not have care conferences between August 27, 2023, and December 12, 2023, and on June 11, 2024. During an interview, the Social Service Director confirmed that these residents should have had care plan conferences every three months. The facility's policy, as provided by Regional Support 2, indicated that subsequent meetings for residents should be conducted at a minimum of quarterly, emphasizing communication and participation regarding the resident's plan of care, medical condition, and care needs.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment across multiple areas, including resident halls and a shower room. Observations revealed that resident toilets were visibly soiled, and fracture pans and urine hats were left uncovered and improperly stored. Equipment such as vitals machines and lift equipment were also found to be visibly soiled. Additionally, the carpet in the 200 Hall was stained, and the shower room had soiled grout, chipped tiles, and a broken tile by the bathroom wall. Specific observations included a brown substance on the back of a toilet, uncovered bedpans on handrails, and dusty vent fans and handrails in resident bathrooms. Rooms were found with dusty surfaces, unpainted plaster, and scuff marks on walls. In one instance, a sit-to-stand lift was observed with food and debris on the footplate. The shower room had multiple cleanliness issues, including a strong urine smell, stained upholstery, and a black substance smeared on the floor. Interviews with staff revealed a lack of clarity and adherence to cleaning protocols. The Environmental Services Director indicated that daily cleaning tasks should be completed and signed off by staff, but there was no checklist for cleaning the shower room. The Maintenance Director relied on staff notifications for maintenance needs, but staff were not adequately trained to enter work orders. Additionally, there was no clear policy for cleaning resident equipment, and confusion existed among staff regarding responsibilities for maintaining cleanliness.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections during incontinence care for two residents. In the first instance, two CNAs were observed providing care to a resident without adhering to proper hand hygiene protocols. CNA 48 washed her hands with a 5-second lather and CNA 56 with a 10-second lather before donning gloves. During the care process, CNA 48 laid a clean incontinence pad on the bathroom floor, which was then placed on the resident. Additionally, CNA 48 did not perform hand hygiene after removing gloves and before handling the resident's wheelchair and other items. When questioned, CNA 48 acknowledged the lapse in hand hygiene and washed her hands with a 6-second lather. In the second instance, CNA 23 and a CNA in training provided incontinence care to another resident. CNA 23 used the same pair of gloves to handle various items, including the bedside table, trash bag, and bed remote, without changing gloves or performing hand hygiene. CNA in training 21 also failed to change gloves and perform hand hygiene before placing a clean brief on the resident. After completing the care, CNA 23 did not perform hand hygiene before handling the resident's blankets and other items. The Director of Nursing indicated that staff should lather their hands for 20-30 seconds and change gloves when touching different items during care.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing sheets were posted and contained the correct information daily, as required. On July 21, the Posted Nurse Staffing form was observed at the nurse's station with a date of July 19, indicating that the staffing information was not updated for that day. During an interview, the Assistant Director of Nursing (ADON) stated that the Scheduler was responsible for posting the staffing form daily in the morning at the beginning of the shift, and on weekends, the 300 Hall nurse was responsible for posting it at the change of shift. The facility's policy, revised on May 11, 2016, requires that the number and hours of licensed nurses and unlicensed nursing personnel providing direct care to residents be posted at the beginning of each day.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transcendent Healthcare Of Boonville | 3.1 mi | ★★★★★ | 12 | 0 |
| Transcendent Healthcare Of Boonville - North | 3.6 mi | ★★★★★ | 20 | 2 |
| Cypress Grove Rehabilitation Center | 9.2 mi | ★★★★★ | 7 | 0 |
| Brickyard Healthcare - Woodlands Care Center | 10.1 mi | ★★★★★ | 0 | 0 |
| Hamilton Pointe Health And Rehab | 11.8 mi | ★★★★★ | 3 | 0 |
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