Carol Woods

In the surveyor’s words

From the most serious findings on record at Carol Woods, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jun 6, 2024

  Based on staff interview and record review the facility failed to submit accurate payroll data, regarding 24-hour licenses nurse coverage, for 9 of 9 days reviewed (10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, 12/31/23) of the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 1st quarter in fiscal year 2024. Findings included: The CMS submission report, PBJ Final File Validation Report for Fiscal Year 2024 (October 1 to December 31) showed the facility failed to have Licensed Nursing Coverage, 24 hours out of 24 hours for the days of 10/14/23, 10/28/23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2024

  Based on observations and staff interviews, the facility failed to discard expired food items, and label and date food available for resident use in 1 of 1 walk-in cooler and 1 of 4 reach-in coolers in the main kitchen, in 1 of 1 walk-in cooler and in 2 of 3 reach-in coolers in building 4 kitchen, and in 2 of 4 nourishment room refrigerators ([NAME] and blue bird pods' refrigerators) in the 3rd floor of building 4 where the nursing home residents resided. These practices had the potential to affect food and beverages served to the residents. Findings included: a. An initial tour of the kitchen on [DATE] at 11:05 am was made with the Dining Services Director, Master Chef and building 4 Kitchen Manager. […]

• No harm, potential for more than minimal, patternF883Jun 6, 2024

  Based on record review and resident and staff interviews the facility failed to follow their policy on pneumococcal vaccine and offer up to date pneumonia vaccines to 5 of 5 residents reviewed for immunization status (Resident #3, Resident #8, Resident #9, Resident #12, and Resident #123). The findings included: The facility's policy on pneumococcal vaccine last reviewed in July 2023 stated, the administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendation at the time of the vaccination. a. Resident #3 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF812Oct 7, 2021

  Based on observations, staff interviews, and record review the facility failed to maintain clean kitchen equipment on 3 of 3 days observed and staff failed to cover all hair while working in the kitchen for 4 of 14 staff observed. Findings included: 1. During observation of the kitchen on 10/04/21 at 12:43 PM the following items were observed: a. The grill had hard black food debris on the top and in between the grates, food debris on sides and top of grill, the two drip pans located under the grill grates with food/grease debris, and a white rag with areas of dark brown substance in the right drip pan. b. The fryer was observed with debris on the outer surface, dark oil with sediment in the oil, and a dark liquid substance on the floor around the right front leg of the fryer. c. […]

• No harm, potential for more than minimal, isolatedF582Feb 9, 2023

  Based on record review and staff interviews, the facility failed to provide the Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage Letter (NOMNC, CMS-10123 form) for 1 of 3 sampled residents reviewed for beneficiary protection notification review (Resident # 73). Findings included: Resident # 73 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to thrombosis of left vertebral artery; Type 2 diabetes mellitus with hyperglycemia, and muscle weakness and abnormalities of gait. The resident was discharged on [DATE]. A review of the Skilled Nursing Beneficiary Protection Notification Review form revealed Resident #73's Medicare Part A services started on 8/10/22 and the last covered day was 10/31/22. […]