Woodland Manor

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Observe for and document resident's feelings relative to isolation, unhappiness, anger, and loss. Provide opportunities for the resident and family to participate in care, assist, encourage, and support about identified problems that cannot be controlled. There were no interventions related Resident A's colostomy behaviors. A review of Resident A's current care plan, dated 8/11/25, failed to address Resident A's ADHD diagnosis and behaviors. There were no care plans to address Resident A's colostomy behaviors.A review of physician orders, dated 3/10/25 at 18:00, indicated colostomy care was to be completed by staff every shift and emptied as needed.A review of the Task Administration Record for August 2025 indicated the colostomy bag was emptied as needed on 8/3/25 at 11:05 PM. Routine colostomy care was documented as completed.A review of the Task Administration Record for September 2025 indicated routine colostomy care was not documented as completed on 9/2/25 during day shift.A review of the Bowel Elimination Task dated 9/2/25 to 9/15/25 indicated stool output was recorded only one time on 9/4/25 and 9/12/25.A review of psychiatry progress notes, dated 9/11/25, indicated the physician was not aware of Resident A's most recent depression scale score of 20, indicating severe depression, completed on 8/21/25. There was no mention in the notes of Resident A taking off his colostomy bag, or taking off the bag and flange. A review of progress notes from 8/19/25 to 8/25/25 indicated staff had not notified the physician of the depression scale score result of severe depression. There were no notes related to Resident A taking off his colostomy bag, with or without the flange intact and no notes to indicate Resident A had been educated regarding colostomy care or addressing colostomy behavior. A review of progress notes from 8/19/25 to 8/25/25 indicated staff had not documented when the resident was reminded not to unseal the colostomy (phalange) daily.In an interview, on 9/15/25 at 1:12 PM, LPN 2 indicated colostomy care included cleaning

the skin around the colostomy area and emptying the bag of air and or stool. She indicated Resident A would spontaneously take the colostomy bag off including the flange and not tell the staff. In an interview,

on 9/15/25 at 1:27 PM, the Assistant Director of Nursing indicated Resident A had taken the colostomy off

in the past. The resident wanted to be independent at times and had a plan to move to assisted living.

Resident A had the ability to empty the colostomy independently, but Resident A had not been consistent in completing his own care. Resident A had been offered support groups but the resident had refused.In an interview, on 9/15/25 at 1:57 PM, the Administrator indicated Resident A had unsealed his colostomy emptying stool on the floor around the front door of the facility.In an observation, on 9/15/25 at 1:58 PM, the front entrance of the facility was cleaned and rinsed of a large amount of stool. In an interview, on 9/15/25 at 3:33 PM, RN 2 indicated Resident A had not changed or burped their colostomy bag recently. Resident A had needed the colostomy bag emptied 2 or 3 times during most shifts. Regular education had been provided to Resident A about telling staff when the colostomy bag was full. Emptied colostomy tasks should have been documented on the TAR or in the Elimination Task flowsheet. Resident A would would carry the full bag detached from the flange to the nurse's station. In an interview, on 9/15/25 at 4:40 PM, the Social Services Director indicated Resident A had turned the call light on for staff and had been mentally and physically capable of leaving the facility. All facility physicians (providers) had access to all forms and assessments completed by staff. The providers talked with the Social Services Director weekly. On 7/2/25

the physician was notified of Resident A had been drinking alcohol and drove the wheelchair recklessly on 7/1/25, as reported by staff who witnessed the event. The SSD did not indicate the providers had been made aware of Resident A's behavior with his colostomy bag. The policy regarding behavior identification and tracking was requested. There was no further information or policies presented by time of exit. This citation is related to intakes 2614478 and 2567160. 3.1-43(a)(1)

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