Inspection Reports for
The Woodlands of DeWitt

The complaint alleged Resident B did not receive personal care as per service plan, ran out of Lumigen eye drops, had dirty sheets, and did not receive water as preferred. Some allegations were substantiated (care not provided per plan, medication issues), while others (dirty sheets, water provision) were not substantiated.

The investigation found violations related to Resident B not receiving care according to the service plan, including failure to document refusals of showers and missed medication doses. The facility did not ensure prescribed eye drops were administered as ordered and failed to contact the physician regarding missed doses. No violations were found regarding dirty sheets or water provision.

The complaint alleged that Resident B was not involved in the development of the service plan. The investigation substantiated this allegation and established a violation.

The investigation found that Resident B did not participate in the development of their service plan as there was no documentation or signature evidencing participation, establishing a violation of the admission and retention of residents rule.

Complaint received on 01/04/2024 alleged the facility denied visitation to Relative B1 on 01/01/2024 due to no management on site. Investigation confirmed denial of visitation consistent with physician order and facility policy. Violation established.

The investigation found that Relative B1 was denied visitation on 01/01/2024 because there was no management present, and the caregivers refused entry. A physician's order limited Relative B1's visitation to weekdays from 9:00 to 17:00 in a public area, excluding mealtimes. The denial of visitation was consistent with the physician's order and facility policy. The complaint was substantiated as a violation.

The complaint alleged that Resident A was issued an improper discharge and that the discharge letter did not provide correct appeal information. Both violations were substantiated.

The investigation found that Resident A was improperly discharged due to the guardian's statements towards staff, which did not meet licensing criteria. Additionally, the discharge letter failed to provide correct information on how to file a complaint with the Licensing Department. Both violations were established.

The complaint alleged that Resident A was given morphine without a prescription. The allegation was substantiated with violation established.

The investigation found that Resident A had a physician-ordered prescription for morphine; however, medication administration records showed varying doses and administration outside of physician orders, including a documented instance where morphine was given based on the resident's wife's request despite no pain. The facility was found to be in violation due to inconsistent documentation and administration practices.

The complaint alleged that Resident C was not provided medical attention for a urinary tract infection for one week, residents were not treated respectfully, Staff Person 5 was not trained in medication administration, and medications were not administered properly. The investigation substantiated the allegations regarding Resident C's medical attention, Staff Person 5's training, and medication administration, but did not substantiate disrespectful treatment of residents.

The investigation established violations related to Resident C not receiving timely medical attention for a UTI, Staff Person 5 not being properly evaluated for medication administration competencies, and staff failing to initial medication administration on multiple occasions. The allegation that residents were not treated respectfully was not substantiated.

The complaint alleged insufficient staffing causing residents to wait a long time for assistance. The complaint was substantiated with a violation established.

The investigation found that the facility did not have adequate staffing to meet the care needs of residents, particularly in the memory care unit where staffing ratios left some hallways unattended. The facility was found to be in violation of staffing requirements.

Complaint alleged the facility did not allow Relative B1 to visit Resident B. The complaint was substantiated as a violation was established.

The investigation found that the facility limited visitation between Resident B and Relative B1 without a physician's documented medical contraindication. Additionally, the admission agreement was signed by a relative rather than Resident B, rendering it invalid.

Complaint alleged insufficient staff to meet resident care needs, staff not trained to administer medications, residents not being bathed, and Resident C's bed being too small. Violations were not established for staffing, training, or bathing. Violation established for inadequate service plan regarding Resident C's bed.

The investigation found no violations regarding staffing levels, medication administration training, or bathing practices. However, a violation was established related to Resident C's service plan lacking instructions for the hospital bed and bed rails, which posed a protection concern.