Woodside Village

F-F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by:

* Completed an investigation on 09/13/24, including an interview with the CNA #8 who transferred Resident #87 via wheelchair.

* Determined the CNA #8 provided wheelchair transport to Resident #87 without the foot pedals in the proper position.

* Placed CNA #8 on administrative leave on 09/10/24 until further investigation and education was provided.

* Email education to all staff, dated 09/10/24, stated, Foot pedals or leg rests always need to be used when pushing a resident in a wheelchair. It is never acceptable to allow a resident's feet to dangle when pushing them, not even for a short distance.

* Memo dated 09/13/24 addressed to all staff, stated, ANYTIME a resident is being pushed in their wheelchair the foot pedals MUST BE ON.

* CNA #8 and all other nursing staff signed rosters indicating review and understanding of the 09/13/24 memo.

* The charge nurses were responsible for reviewing education provided in the 09/13/24 memo after the 09/07/24 fall.

* Continue weekly quality assurance audits to ensure resident safety during wheelchair transport.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 355112 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355112 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodside Village 4000 24th Ave S Grand Forks, ND 58201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 40488 potential for actual harm 45873 Residents Affected - Few Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #126) observed during tracheostomy cares and 1 of 1 supplemental resident (Resident #283) observed during insulin administration. Failure to practice infection control standards related to glove use/hand hygiene has the potential to spread infection throughout the facility.

Findings include:

Review of the facility policy titled Handwashing/Hand Hygiene occurred on 01/08/25. This policy, dated October 2024, stated, . Hand hygiene is indicated . After contact with blood, body fluids or contaminated surfaces; After touching a resident; After touching the resident's environment . The use of gloves does not replace hand washing/hygiene.

Review of the facility policy titled Insulin Pen Injections occurred on 01/08/25. This policy, dated January 2023, stated, . Technique . Gather equipment . Perform hand hygiene . Preparing insulin pen . Apply clean gloves . Select appropriate site . Administer injection.

- Review of Resident #126's medical record occurred on all days of survey. The record identified a tracheostomy, enhanced barrier precautions, and a recent Influenza A infection.

Observation on 01/09/25 at 11:38 a.m. showed a staff nurse (#5) applied a gown and gloves, prepared for

the sterile portion of Resident #126's tracheostomy cares, and handed the resident a paper napkin to cough into during care. The nurse (#5) completed the sterile portion of the care, removed the sterile gloves, performed hand hygiene, and applied clean gloves to complete the non-sterile portion of the care. The nurse removed the used paper napkin from Resident #126's hands, cleansed the ostomy site with cotton swabs and a solution of peroxide and saline, and threw the cotton swabs into the garbage. The nurse (#5) handed

the same used paper napkin to the resident, and with the same gloves, touched many items in the resident's room, then removed the gown and gloves, performed hand hygiene, and exited the room.

The nurse (#5) failed to remove the soiled gloves, perform hand hygiene, and apply new gloves before moving on to other tasks.

During an interview on 01/08/25 at 2:35 p.m., two administrative nurses (#6 and #7) stated they expected staff to remove their contaminated gloves and perform hand hygiene before moving on to other tasks.

- Review of Resident #283's medical record occurred on 01/08/25. Physician's orders showed Insulin Glargine 12 units and Novolog 3 units sub-cutaneous injections daily.

Observation on 01/08/25 at 8:41 a.m. showed a nurse (#4) performed hand hygiene and without applying gloves, administered Resident #283's insulin injections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 355112 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355112 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodside Village 4000 24th Ave S Grand Forks, ND 58201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 01/08/25 at 4:53 p.m., an administrative staff member (#2) confirmed she expected nurses to wear gloves while administering an injection. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 355112