Kirtland Woods of Journey

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Sep 9, 2021

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 tracking log, review of facility policies, observations, interviews with the local health department (LHD), staff and residents and record review the facility failed to conduct consistent and appropriate screening for visitors upon entering the facility and failed to implement appropriate infection control practices including quarantine of exposed residents and appropriate use of personal protective equipment (PPE). […]

• Actual harm, patternF880Aug 28, 2023

  Based on observation, interview, and record review, the facility failed to treat potentially contagious/communicable rashes per physician orders, failed to timely implement transmission-based precautions to prevent spreading the rash to other residents, failed to implement exposure control measures, failed to educate and in service staff on infection control relative to preventing the spread of potentially contagious/communicable rashes, failed to report the outbreak to the local health department, and failed to prohibit State tested Nursing Assistant (STNA) #373, who exhibited signs of a potentially communicable/contagious rash, from direct resident contact. […]

• Actual harm, isolatedF684May 2, 2024

  Based on observation, record review, and interview, the facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104. This affected one resident (#104) of three residents reviewed for activities of daily living. The facility census was 120. Actual Harm occurred on 04/22/24 when Resident #104, who was admitted on [DATE] with severe cognitive impairment and was known to use contact lenses, developed right eye redness and pain and was diagnosed with conjunctivitis (pink eye) which required antibiotic treatment due to a lack of routine eye care for the resident. […]

• Actual harm, isolatedF689May 2, 2024

  Based on observation, record review, policy review and interview the facility failed to provide adequate assistance, supervision and/or assistive devices to prevent falls and consistently implement fall interventions for Resident #57 and Resident #101. Actual harm occurred on 04/14/24 when Resident #57, who was moderately cognitively impaired and required two staff assist with bed mobility, sustained a fall out of bed when being provided hands on care by only one staff member. The resident sustained a right shoulder fracture as a result of the fall. This affected two residents (#57 and #101) of three residents reviewed for falls. The facility census was 120. Findings Include: 1. […]

• Actual harm, isolatedF689Oct 20, 2023

  Based on observation, record review, interview, facility policy and procedure review, Self-Reported Incident (SRI) review and facility investigation review, the facility failed to ensure residents were properly transferred, as per their plan of care and/or physician's order to prevent actual injury and/or potential injury. Actual Harm occurred on [DATE] when Resident #125 who was dependent on staff for activities of daily living (ADL) and required a mechanical lift (device used to transfer a person from one place to another) of two staff assist for transfers was transferred by only one staff, State tested Nursing Assistant (STNA) #614 without a mechanical lift from his bed to his wheelchair. […]