Big Bend Woods Healthcare Center

In the surveyor’s words

From the most serious findings on record at Big Bend Woods Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686May 24, 2021

  Based on observation, interview and record review, the facility failed to have a process to ensure Certified Nurse Aides (CNAs) reported new or worsening skin conditions and soiled or missing dressings to the nurse when identified. In addition the facility failed to ensure nurses applied treatments to wounds with soiled or missing dressings timely, completed weekly skin assessments and ensure treatments were applied as ordered. The facility identified 13 residents with pressure ulcers. Of those 13, six were included in the sample and problems were found with all six. In addition, the survey team identified three residents with new pressure ulcers, not identified by the facility. (Residents #19, #224, #46, #63, #51, #45, #3, #22 and #55). The census was 75. […]

• Immediate jeopardy, isolatedF684Jan 4, 2021

  Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for one of three sampled residents. The facility failed to monitor the resident after a choking incident. The facility also failed to properly administer abdominal thrusts (the [MEDICATION(S)] maneuver (a first aid procedure used to treat upper airway obstructions or choking by foreign objects)) or call 911 after the resident became unresponsive. The resident expired at the facility (Resident #1). The census was 69. The administrator was notified on [DATE] at 4:00 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. […]

• Actual harm, isolatedF688Feb 8, 2024

  Based on observation, interview and record review, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three residents (Resident #77, Resident #48, and Resident #17). Resident #77 and Resident #48 had a decline in ability to ambulate. Resident # 48 also had a hand contracture, with an order for a splint that was not applied in accordance with the Physician Order Sheet (POS) and care plan. Resident #17 had a hand contracture and no splint use was addressed on the POS and care plan. Additionally, the facility failed to develop resident care policies for restorative services, based on professional standards of practice, including designating who may provide specific treatments. […]

• Actual harm, isolatedF697Jul 21, 2023

  See Event ID# WEW412 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies, dated 5/25/23. Based on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the resident's comprehensive care plan, by failing to ensure one resident was provided with his/her scheduled pain medication as ordered. The resident was out of his/her scheduled pain medication on 6/28/23 and remained out of his/her medication through 7/10/23 (Resident #8). The sample was 17. The census was 86. […]

• Actual harm, isolatedF686May 25, 2023

  Based on observation, interview and record review, the facility failed to ensure three residents with a pressure ulcer (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing (Resident #5, Resident #8 and Resident #3). The sample size was 16. The census was 91. Review of the facility's Skin Program Policy and Procedure, dated 5/28/19, showed: -Purpose: The purpose of the skin program is to ensure that every resident's skin condition is assessed on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed upon admission and as needed (PRN) for actual… […]