The Woods, A Nightingale Community

In the surveyor’s words

From the most serious findings on record at The Woods, A Nightingale Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 3, 2025

  Based on observations, interviews, record review, and facility policy review, it was determined the facility did not ensure residents were not provided the code to entrance/exit doors to safeguard residents and prevent residents from eloping from the facility for one (Resident #20) sampled resident. The IJ began on 04/01/2025 at approximately 4:30 PM, when Resident #20 used a code for the exit doors provided by facility staff to exit the building without staff knowledge. Resident #20 verified knowledge of codes to the entrance/exit doors of the facility. These findings have been determined to have resulted in Immediate Jeopardy as defined at 42 CFR §483.25. The Administrator was informed of the Immediate Jeopardy on 07/02/25 at 5:34 PM, and a Plan of Removal was requested. […]

• Immediate jeopardy, isolatedF689Jul 14, 2021

  Based on record review and interview, the facility failed to ensure High risk elopement assessments were appropriately care planned and failed to ensure appropriate elopement interventions were implemented to prevent potential elopements for 1 (Resident #1) of 3 (Residents #1, #3 and #6) sampled residents who were at high risk for elopement. This failed practice resulted in past noncompliance at the level of immediate jeopardy which caused or could have caused serious injury, harm or death for Resident #1 who exited the building through a window on the east hall. This failed practice had the potential to cause more than minimal harm to 3 residents at high risk for elopement. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2024

  Based on observation and interview, the facility failed to ensure expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods stored in the refrigerator and dry storage area were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated when opened to assure first in, first out usage to prevent potential for food bone illness, cooking equipment, ceiling tiles and air vents were free of greasy food crumbs, stains and rust and were maintained in clean sanitary conditions to prevent potential for cross contamination; dietary staff. washed their hands before handling clean. […]

• No harm, potential for more than minimal, widespreadF812Mar 30, 2023

  Based on observation, and interview, the facility failed to ensure the oven was maintained in good working condition; employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, ensure refrigerator temperatures were maintained at 41 degrees Fahrenheit or below to prevent the potential for food spoilage and/or bacteria growth for residents who received food from 1 of 1 kitchen. The failed practices had the potential to affect 63 residents who received meal trays from the kitchen (total census: 67) as identified on the list provided by the Dietary Supervisor on 03/28/23 at 2:50 PM. The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF885Mar 30, 2023

  Based on record review, and interview, the facility failed to inform residents, their representatives, and families, of suspected or confirmed COVID-19 cases in the facility by 5:00 PM the next day. This failed practice had the potential to affect all 68 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Clinical Consultant on 03/27/23 at 1:48 PM. The findings are: 1. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (QSO-20-29-NH) Memorandum for Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated 05/06/20 documented, .The facility must: Inform residents, their representatives, and families of those residing in facilities by 5 p.m. […]