Gracy Woods Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF697May 16, 2024

  Based on observation, interview, and record review the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain, in that: The facility failed to: Provide pain medication ordered for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. […]

• Immediate jeopardy, patternF755May 16, 2024

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents reviewed (Resident #1) for pharmacy services. The facility failed to: Provide pain medication ordered, for three consecutive months for different time frames, for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. […]

• Immediate jeopardy, patternF600Jan 26, 2024

  39269 Based on observation, interview and record review the facility failed to ensure residents were free from neglect for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for neglect. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital on [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. […]

• Immediate jeopardy, patternF686Jan 26, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for pressure ulcer care. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. […]

• Immediate jeopardy, patternF692Jan 26, 2024

  Based on interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 8 residents (Resident #71) reviewed for nutrition. The facility failed to ensure dietitian interventions of increased tube feedings and speech therapy were implemented when Resident #71 had a 10% weight loss in [DATE], leading to an overall weight loss of 32% from [DATE] to [DATE]. Resident #71 also developed pressure wounds on her foot and hip that worsened, and she died on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. […]