Woodland Park Nursing & Rehab

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for three residents identified as being at risk for falls. One resident, with a history of traumatic brain injury, paraplegia, and severely impaired cognition, was assessed as high risk for falls but did not have a care plan addressing this risk. After being placed on a low air loss mattress, the resident experienced an unwitnessed fall resulting in a cervical vertebra fracture, with documentation showing no interventions were implemented to prevent falls following the mattress change. Another resident, diagnosed with cerebral palsy and severely impaired cognition, experienced two unwitnessed falls. After the first fall, the only intervention documented was sending the resident to the ER for evaluation, with no additional fall prevention measures developed. Following the second fall, interventions were limited to medication review and behavioral assessment notifications, again without specific fall prevention strategies being added to the care plan. A third resident, with end stage renal disease and multiple comorbidities, fell from her wheelchair while attempting to reach a wall and was subsequently assessed as high risk for falls. However, the care plan was not updated to address the fall, and no new interventions were implemented. Observations revealed that residents at high risk for falls did not have fall mats in place, and beds were not maintained in the lowest position, further indicating a lack of effective fall prevention measures.

Removal Plan

• Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.
• The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention.
• Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides.
• The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall.
• MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions.
• Administrator and DON were in-serviced by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions.
• If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.
• The Medical Director was made aware of the Immediate Jeopardy and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process.
• A QAPI meeting was held with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer.
• This plan was initially implemented and will be monitored through completion by corporate and regional staff.
• Plan of Removal completion with continuation of oncoming staff and follow-up.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate assessments and implement recommendations from the Pre-Admission Screening and Resident Review (PASRR) program for a resident with multiple complex diagnoses, including cerebral palsy, schizoaffective disorder, chronic osteomyelitis, and lymphedema. The resident was identified as PASRR positive and required specialized services, including a customized manual wheelchair (CMWC), as recommended and agreed upon by the interdisciplinary team (IDT). Despite these recommendations, the facility did not provide or arrange for the CMWC within the required timeframe set by PASRR. Record reviews showed that the IDT meetings identified the need for several specialized assessments and services, including occupational therapy (OT), physical therapy (PT), speech therapy (ST), habilitation coordination, and independent living skills training. Documentation indicated that the facility was aware of the PASRR requirements and the need to submit the necessary forms and obtain physician signatures. However, delays occurred due to changes in the resident's payor source, frequent hospitalizations, and the unavailability of the medical director to sign required forms. As a result, the necessary PASRR forms and service arrangements were not completed in a timely manner. Observations confirmed that the resident continued to use a standard wheelchair rather than the recommended CMWC. Interviews with facility staff, including the MDS Nurse, Business Office Manager, and Administrator, revealed awareness of the outstanding PASRR requirements and the reasons for the delays, such as administrative transitions and lack of physician availability. Facility policy required timely notification and implementation of PASRR recommendations, but these procedures were not followed, resulting in the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents identified as high risk for falls. For three residents reviewed, the care plans did not address their assessed fall risks or include specific interventions to prevent falls or injuries. In one case, a male resident with a history of traumatic brain injury, paraplegia, and impaired cognition was assessed as high risk for falls, but his care plan did not include fall prevention interventions. After being placed on a low air loss mattress, there was no documentation of additional fall prevention measures, and the resident subsequently experienced an unwitnessed fall resulting in a cervical vertebra fracture and required hospitalization. Another resident, a female with cerebral palsy, schizoaffective disorder, and severely impaired cognition, experienced two unwitnessed falls. Despite being identified as high risk for falls after the first incident, her care plan only included sending her to the ER for evaluation and did not add further fall prevention interventions. After the second fall, the care plan was updated to include medication review and behavioral assessment, but again lacked specific interventions to prevent future falls. A third resident, a female with end stage renal disease, diabetes, and bipolar disorder, was not initially identified as high risk for falls but experienced a fall while in her wheelchair. Following the incident, her fall risk assessment was updated to high risk, but her care plan was only revised to include bed rails for safety, without addressing the fall event or implementing additional fall prevention strategies. Interviews with facility staff confirmed that care plans were not consistently updated to reflect residents' fall risks or incidents, and that interventions were not always implemented as required by facility policy.

Removal Plan

• Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved.
• The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention.
• Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides.
• The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall.
• MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions.
• Administrator and DON were in-serviced by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions.
• If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift.
• The Medical Director was made aware of the Immediate Jeopardy and has been involved in developing the Plan of Removal.
• A QAPI meeting was held with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer.
• This plan will be monitored through completion by corporate and regional staff.
• Plan of Removal completion with continuation of oncoming staff and follow-up.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate communication of discharge information for a resident, leading to a delay in receiving necessary home health services. The resident, who was discharged to her home, did not receive home health services until three days after discharge due to a miscommunication. The facility had intended to send the discharge summary to the home health agency (HHA) on July 3, 2024, but an incorrect fax number was used, resulting in the HHA not receiving the information until July 9, 2024. The resident in question had multiple complex medical conditions, including sepsis, stroke, cancer, diabetes, acute kidney failure, and pressure ulcers. She required extensive assistance for daily activities and had severe cognitive impairment. The discharge plan included home health services to manage her medical needs, including wound care and medication management. However, due to the incorrect fax number, the HHA was not informed of the resident's discharge and could not provide the necessary services immediately. Interviews with facility staff and the HHA confirmed the communication breakdown. The staff member responsible for the discharge process was unaware of the error until notified by the HHA on July 9, 2024. The Director of Nursing also acknowledged the importance of ensuring that discharge information is correctly communicated to ensure continuity of care. The facility's policy required specific information to be communicated to the receiving provider, but this was not effectively executed in this case.

Penalty

Inspection fine: $12,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safe transfer of a resident, leading to an accident involving a fall from a transport van. The incident occurred when the van driver did not properly raise the mechanical wheelchair lift before attempting to transfer the resident out of the van. As a result, the resident fell backward out of the van, hitting her head on the pavement and sustaining a hematoma. The resident involved was an elderly female with a history of acute pyelonephritis, cirrhosis of the liver, muscle weakness, and difficulty walking. She used a wheelchair for mobility and required assistance with transfers. At the time of the incident, the resident was being transported back to the facility after a medical appointment. The van driver, who had been driving the van for about six months, left the resident alone in the van while taking another resident inside. Upon returning, the driver unfastened the resident's wheelchair and attempted to roll her backward onto the lift without ensuring it was raised, leading to the fall. The incident was attributed to driver error, as the van driver forgot to raise the lift and did not keep it in view while transferring the resident. The resident remained conscious after the fall and was quickly assessed by staff before being transported to the hospital. CT scans revealed no acute posttraumatic abnormalities, and the resident was discharged back to the facility with some pain managed by medication.

Penalty

Inspection fine: $12,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during two quarters of 2023. Specifically, there was no RN coverage on July 8, 2023, October 7, 2023, and October 8, 2023. This deficiency was identified through a review of the CMS Payroll-Based Journal (PBJ) reports, which documented the absence of RN hours on these dates. The Director of Nursing (DON) acknowledged that on July 8, 2023, an agency RN was scheduled but did not show up for the shift without notifying the facility. The DON could not recall the reasons for the lack of RN coverage on the other two dates. During interviews, both the DON and the Administrator expressed challenges in hiring RNs, which contributed to the lapses in coverage. The Administrator noted that a new RN was hired in October, which improved the situation, but acknowledged the absence of RN coverage on the specified dates. The facility's policy, revised in August 2022, mandates that an RN provides services for at least eight consecutive hours every day, highlighting the importance of having a supervisor present to oversee resident care.

Penalty

Inspection fine: $12,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate resident assessments for three residents, leading to incorrect documentation of medication types. Specifically, the assessments inaccurately indicated that the residents were receiving anticoagulant medications when, in fact, they were prescribed antiplatelet medications such as aspirin and clopidogrel. This discrepancy was identified during a review of the Minimum Data Set (MDS) assessments and physician orders, which showed no orders for anticoagulants for these residents. The MDS assessments incorrectly coded the medications, which could potentially impact the care plans and resident care. The MDS Nurse acknowledged the error, stating that the medications should have been coded as antiplatelets according to the Resident Assessment Instrument (RAI) manual, which serves as the facility's policy. The Director of Nursing (DON) and the Administrator both expressed that their expectation was for the MDS assessments to be accurate, as inaccuracies could affect resident care. The report highlights the importance of correct coding in assessments to ensure that care plans are appropriate and reflective of the residents' actual medication regimens.

Penalty

Inspection fine: $12,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary services for activities of daily living, specifically in maintaining grooming and personal hygiene for a resident. The resident, who was cognitively intact and required partial assistance for showering, did not receive scheduled showers on three occasions within a week. The resident's care plan indicated the need for assistance with showering, and the facility's shower schedule required showers three times a week. However, records showed that the resident did not receive showers on the specified days, and there was no documentation of the resident refusing care. Observations and interviews confirmed the deficiency, with the resident reporting not receiving showers and exhibiting signs of poor hygiene, such as unkempt and greasy hair. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issue, with the ADON noting a problem with showers not being given and conducting an in-service training. Despite these efforts, the resident continued to miss scheduled showers, indicating a lapse in the facility's adherence to its own procedures for maintaining resident hygiene.