Wood Aven Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Wood Aven Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 8, 2025

  Based on interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 18 residents sampled. (R321) R321 has a history of daily opiate use and constipation. The facility bowel protocol was not followed or a thorough GI assessment completed, causing actual harm to R321. R321 was hospitalized with severe pain and was admitted with a fecal impaction. Findings include: The facility's bowel protocol, reviewed on 11/18/24, includes, in part: Bowel and Bladder Management . […]

• No harm, potential for more than minimal, widespreadF812Jan 8, 2025

  Based on observation, record review and interview, the facility did not allow clean dishes sufficient time to air dry or store the clean dishes in a manner to prevent potential contamination. The facility practice has the potential to affect all 76 residents. This is evidenced by: The facility policy tilted Dishwashing and Ware Washing which was not dated was requested and received by Surveyor. The policy in part read: Objective: To ensure cleaning, sanitization and infection control in the dishwashing area to promote food safety, prevent contamination and minimize the risk of spreading infections. Washing (Mechanical or Manual): Dish Drying: ~Dishes, utensils and cookware will be allowed to air dry completely on clean, sanitized racks or drying shelves. […]

• No harm, potential for more than minimal, patternF628Apr 1, 2026

  Based on interview and record review, the facility did not ensure 4 of 5 residents (R1, R8, R19, and R67) or their representatives received the proper notice of transfer, reason for transfer, and ombudsman notification.-Facility did not have a specific reason for the transfer notice for R1, R8, R19, and R67.-Facility did not notify the ombudsman of R8, R19, and R67's transfers to the hospital.Findings include: Surveyor reviewed policy titled, Criteria for Transfer and Discharge, dated 12/25 last reviewed, .Procedure: 5. If the transfer or discharge is necessary for the resident's welfare and the residents' needs cannot be met in the Facility, the resident's physician shall document in the resident's medical record: a. […]

• No harm, potential for more than minimal, isolatedF880Jul 22, 2026

  Based on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections staff did not complete hand hygiene per standards of practice during wound care for 2 of 3 residents (R2 and R3). Evidenced by: The facility policy titled Hand Hygiene, revised 3-2026, states in part: 2. Use an alcohol-based hand rub containing at least 62% alcohol. for the following situations. b. Before and after direct contact with residents. d. Before performing any non-surgical invasive procedures. g. Before handling clean or soiled dressings, gauze pads, etc. i. […]

• No harm, potential for more than minimal, isolatedF757May 27, 2026

  Based on interview and record review, the facility did not ensure residents were free from unnecessary medications for 1 of 3 residents (R) reviewed for medication errors (R2). R2 received Metformin (a medication to treat diabetes) for 8 days. R2 does not have a diagnosis of diabetes.Findings: R2 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia and chronic kidney disease. R2 has a Brief Interview for Mental Status (BIMS) score of 7/15 which means severe cognitive impairment. R2 has a legal representative for health care decision making. R2's care plan, last revised 01/26/2025, with a target date of 01/27/2026, states: At risk for impaired cognitive function/dementia or impaired thought process. […]