Woodruff Manor

In the surveyor’s words

From the most serious findings on record at Woodruff Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 29, 2024

  Based on review of facility policy, record review, and interviews, the facility failed to properly supervise Resident (R)1, resulting in R1's successful elopement from the facility. Specifically, on 05/24/24 at approximately 9:00 PM, R1 crawled through the window in his room to elope from the facility. R1 was found by local law enforcement on a highway and sent to the local hospital. R1 suffered a skin tear to the right forearm, while crawling out of the window. On 05/29/24 at 1:07 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. […]

• Immediate jeopardy, isolatedF600Feb 1, 2024

  Based on observations, interviews, record review, and facility policy review, the facility failed ensure residents remained free of neglect, for 1 of 3 residents. Specifically, a nurse administered medications to Resident (R)1 that belonged to another resident, resulting in R1 being sent to the emergency room (ER) via Emergency Medical System (EMS). On [DATE] at 9:52 AM, the Administrator was notified that the failure to administer the correct medications to a resident, based on physician orders, constituted Immediate Jeopardy (IJ) at F600. On [DATE] at 9:52 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. […]

• Immediate jeopardy, isolatedF760Feb 1, 2024

  Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure that 1 of 3 sampled residents, Resident (R)1, was free from significant medication error. Specifically, the nurse administered medications to R1 that were ordered for R1's roommate, resulting in R1 being transported to the emergency room (ER) via Emergency Medical System (EMS). Findings include: On [DATE] at 9:52 AM, the Administrator was notified that the failure to administer the correct medications to a resident, based on physician orders, constituted Immediate Jeopardy (IJ) at F760. On [DATE] at 9:52 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. […]

• Actual harm, isolatedF689Jul 19, 2023

  Based on record reviews, facility policy review, and interviews, the facility failed to ensure 1 of 1 resident's assistive device, wheelchair, was properly secured for transportation. Specifically, Resident (R)4's wheelchair was not properly secured for transportation, resulting in R4 experiencing medical injuries. Findings Include: Review of the policy titled, Fall Assessment and Fall Response, with an effective date of 07/2022 states, Procedure: Each resident shall have standard fall precautions in place Investigation: 1. Determine what may have caused or contributed to the fall, including ascertaining what the resident was trying to do before he/she fell . 2. […]

• Actual harm, isolatedF689May 23, 2023

  Based on review of facility policy, interview, and record review, the facility failed to prevent accidents/accident hazards for 1 of 5 residents reviewed for accidents. Specifically, Certified Nursing Assitant (CNA)1 removed fall safety precautions from Resident (R)1 prior to providing care. R1 was left unattended and fell from the bed resulting in a head injury. Findings Include: Review of the facility policy titled Fall Assessment and Fall Response with policy effective date of 07/2022 revealed, Each resident shall have standard fall precautions in place. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to; diffuse traumatic brain injury (TBI), malnutrition, prior vertebral fracture, and muscle spasms. […]