Inspection Reports for
Woodmont Health Campus

The facility was found deficient in multiple areas including failure to clarify residents' code status, incomplete and outdated care plans, inadequate wound care and pressure ulcer management, failure to monitor resident weights accurately, incomplete neurological checks after falls, inaccurate nurse staffing postings, medication administration errors including crushing contraindicated medications, failure to monitor food temperatures, and inadequate antibiotic stewardship.

Complaint IN00441635 was investigated, and federal/state deficiencies were cited at F880 related to infection prevention and control. Residents C and D were monitored with no adverse effects found.

The facility failed to maintain infection control practices to mitigate the spread of COVID-19, including improper hand hygiene, touching resident furnishings without hand hygiene, and improper disposal of dirty gloves during observed care. Residents C and D suffered no ill effects from these deficient practices. The facility was found to be in compliance regarding the Residential Complaint and Residential COVID-19 Focused Infection Control Survey.

This citation relates to complaint IN00441635.

The facility failed to maintain proper infection control practices, including inadequate hand hygiene by staff and improper handling of gloves and resident furnishings during care activities.

This citation relates to complaint IN00441635.

The facility failed to maintain proper infection control practices to mitigate the spread of COVID-19. Staff were observed not completing proper hand hygiene, touching resident furnishings without hand hygiene, and placing a dirty glove on a medication cart during care.

The facility was found in compliance with Emergency Preparedness Requirements. However, it was not in compliance with Life Safety Code requirements due to one resident room corridor door (room 210) failing to close completely and latch properly. The door was replaced, and corrective actions including monthly audits were planned to prevent recurrence.

The facility was found not in compliance with emergency preparedness requirements due to an incomplete hazard vulnerability assessment and failure to conduct required emergency plan exercises. Life safety deficiencies included sprinkler heads covered with corrosion and paint, a resident room door that would not latch properly, fire drills not held at varied times for all shifts, and improper use of power strips and extension cords in staff offices.

The facility was found deficient in multiple areas including failure to complete quarterly care plan conferences for residents, improper posting of nurse staffing information, unsafe food storage and sanitation practices in the kitchen, inadequate infection prevention practices during incontinence care, unsanitary environmental conditions in resident halls and shower rooms, and failure to involve the local fire department in fire drills. Corrective actions and education plans were implemented for each deficiency.

The facility was found deficient in completing quarterly care plan conferences for residents, posting accurate nurse staffing information daily, maintaining safe food storage and proper sanitation in the kitchen, providing proper infection prevention practices during incontinence care, and ensuring a clean, safe, and homelike environment in resident areas and equipment.

Complaint IN00430645 was substantiated with federal/state deficiencies cited at F689 related to inadequate supervision and failure of the wander guard alarm system leading to resident elopement.

The facility failed to provide adequate supervision and functioning exit alarms to prevent Resident C, who has a history of exit-seeking behavior and severe cognitive impairment, from exiting the facility unnoticed and being found outside for approximately 45 minutes. The wander guard alarm system was not functioning properly, and the main exit door did not lock as required.

This tag relates to complaint IN00430645. The complaint was substantiated as the facility failed to prevent elopement due to inadequate supervision and malfunctioning wander guard alarm system.

The facility failed to ensure adequate supervision and proper functioning of the wander guard alarm system, resulting in a resident with exit-seeking behavior leaving the facility unnoticed for approximately 45 minutes. The facility implemented corrective actions including staff training, system testing, and policy review.

This citation is related to complaints IN00418698 and IN00424901.

The facility failed to provide assistance with bathing for 4 of 5 residents reviewed, who did not receive bathing assistance according to their care plans and scheduled shower days. Documentation showed multiple missed bathing days and refusals, indicating noncompliance with the facility's bathing policies.

Complaint IN00418698 and IN00424901 were investigated. Federal/state deficiencies related to the allegations were cited at F677. Residential Complaint IN00424901 had no deficiencies cited and was found to be in compliance.

The facility failed to provide assistance with bathing for 4 of 5 residents reviewed for activities of daily living (ADLs), specifically Residents B, C, D, and F, who did not receive assistance according to their care plans and bathing schedules. No residential deficiencies were cited related to the residential complaint.

This Federal tag relates to Complaint IN00411865.

The facility failed to provide adequate supervision and fall prevention interventions for Resident B, who had multiple falls and inconsistent care plans and physician orders. Observations and interviews revealed missing non-skid strips and lack of proper assistance during transfers.

Complaint IN00411865 was substantiated with a Federal/State deficiency cited at F0689 related to failure to prevent accidents and provide adequate supervision/devices.

The facility failed to provide adequate supervision and fall prevention interventions for Resident B, who had multiple falls and inconsistent care plans and physician orders. Observations and interviews confirmed missing fall interventions such as non-skid strips and lack of gait belt use during ambulation.

The facility was found not in compliance with Life Safety Code requirements, including issues with fire door closures, egress door accessibility, smoke detector placement, sprinkler system inspection documentation, boiler inspection certificates, GFCI protection in wet locations, and incomplete fire drill documentation.

Complaint IN00404924 was investigated with federal/state deficiencies cited related to allegations at F740.

The facility was found deficient in multiple areas including resident dignity and respect, advance directives compliance, care plan implementation, respiratory care, nurse staffing posting accuracy, behavioral health services, psychotropic medication management, infection control practices, and QMA authorization for PRN medications.

This Federal tag relates to Complaint IN00404924.

The facility failed to ensure behavioral health services were provided to maintain the resident's highest practicable well-being. A resident requiring behavioral health monitoring was not evaluated or monitored for behaviors, and care plans and documentation were lacking.

The facility was found deficient in multiple areas including resident dignity, advance directives compliance, care plan implementation, respiratory care, nurse staffing posting, behavioral health care, medication management, and infection control practices.

Complaint IN00403391 was investigated with state deficiencies cited at R117 related to staff qualifications and insulin administration. The complaint was substantiated with findings that QMAs administered insulin without certification.

The facility was found to be in compliance overall, but failed to ensure that Qualified Medication Aides (QMAs) administering insulin were properly certified, affecting 3 diabetic residents. The facility submitted a plan of correction addressing staff training, certification, and ongoing compliance monitoring.

Complaint IN00374679 was substantiated with related deficiencies cited at F656. Complaints IN00378797, IN00376110, and IN00374838 were unsubstantiated due to lack of evidence.

The facility was found to have a substantiated deficiency related to failure to follow a physician's plan of care for treatment of skin tears for one resident (Resident B). Treatment and dressing changes were not completed as prescribed, with dressings not changed timely and drainage observed. Other complaints were unsubstantiated due to lack of evidence.