Woodland Grove Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Woodland Grove Healthcare & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF842Sep 22, 2022

  Based on observations, interviews and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three (Residents #1, #2 and #3) of six residents sampled for elopement, from a total sample of 8 residents in the facility identified as an elopement risk. The findings include: 1. During a tour of the facility on 09/22/22 at 10:43 am, green Elopement binders were observed at the east wing nurses' station, west wing nurses' station and front lobby. The binders contained demographic information and photographs of 8 residents identified at risk for elopement. Residents #1, #2 and #3 were included in the binders. […]

• No harm, potential for more than minimal, patternF755Jul 22, 2021

  Based on observation, resident and staff interviews, and clinical record review, the facility failed to ensure that the pharmacy and nursing services accurately documented and administered controlled medication for one (Resident #45) of three sampled residents reviewed for pain management out of a sample of 34 residents. The findings include: On 07/22/21 at 8:00 AM, during an observation of a controlled medication reconciliation between Employee B, Licensed Practical Nurse (LPN), (outgoing night nurse) and Employee C, LPN, (oncoming day shift nurse), the narcotic count for resident #45 was found to be incorrect. […]

• No harm, potential for more than minimal, isolatedF607Mar 16, 2023

  Based on resident and staff interviews, clinical record review, and facility policy and procedure review, the facility failed to implement their abuse prohibition policy for reporting allegations of abuse for one (Resident #300) of one resident reviewed for abuse, from a total of 28 sampled residents. Failure to report abuse allegations may place the resident at risk of harm. The findings include: During an interview with Resident #300 on 03/13/2023 at 1:58 PM, she stated the staff rip my clothes off and handle me roughly. She stated the staff were mean to me. When asked to identify the staff that were doing this to her she stated, Honey, I don't know their names. […]

• No harm, potential for more than minimal, isolatedF657Mar 16, 2023

  Based on staff interviews and medical record review, the facility failed to develop and implement a care plan for one (Resident #59) of twelve residents on oxygen therapy, from a total sample of 28 residents, to ensure that the resident's oxygen flow rate was administered as per the physician's order. The findings include: During a tour of the facility on 03/13/2023 at 12:29 p.m., Resident #59 was observed lying in bed with her eyes closed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed to be set at 1.5 Liters per minute (L/min). (Photographic evidence obtained) On 03/14/2023 at 4:18 p.m., another observation of Resident #59 revealed she was lying in bed wearing a nasal cannula. […]

• No harm, potential for more than minimal, isolatedF695Mar 16, 2023

  Based on observations, interviews, and record review, the facility failed to ensure that a resident requiring respiratory care, received such care consistent with professional standards of practice, by failing to ensure that one (Resident #59) of 12 residents on oxygen therapy, from a total sample of 28 residents, received the oxygen flow rate ordered by the physician. The findings include: During a tour of the facility on 03/13/2023 at 12:29 p.m., Resident #59 was observed lying in bed with her eyes closed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed to be set at 1.5 Liters per minute (L/min). (Photographic evidence obtained) On 03/14/2023 at 4:18 p.m., another observation of Resident #59 revealed she was lying in bed wearing a nasal cannula. […]