Woodland Manor Nursing And Rehabilitation

jeopardy to resident health or safety

Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Falls will be reviewed/monitored during clinical meetings, daily x5 days weekly, to review the event report, attempt to root cause, and update the care plan with person centered interventions.

Administrator and/or designee will monitor for compliance.Person(s) Responsible: Clinical Administration, Assistant Director of Nursing, Clinical Case Manager, and/or Designee.Date of Completion: 8/23/2025 Action: Ad hoc QAPI to inform Medical Director of the IJ template for 689 and the facility's plan to remove the immediacy.

Person(s) Responsible: Regional [NAME] President, Clinical Case Manager, Wound Care Nurse, and/or DesigneeDate of Completion: 8/22/2025 Monitoring: Observation of Resident #1 on 8/22/2025 and 8/23/2025 at various times revealed her to have her neck brace and sling on her right arm.

Record review of Resident #1's care plan included the following interventions: Education of safety, continue to encourage ask for assist to go to the bathroom, monitor her orthostatic hypertension.

Frequent checks will be provided, and staff would inform the nurse if she removed her neck brace and sling per order.

Continue to follow with Orthopedic physician. Resident #1 would be evaluated for appropriate assistive devices and will use wheelchair. Resident #1 will be evaluated for PT. Resident #1's record also included a PT evaluation conducted on 8/22/2025.

She was placed on services for five days.

Record review of Resident #1's MAR was updated to reflect orthostatic blood pressure every shift.

Further review revealed MD discontinued Cyclobenzaprine.

Record review of Resident #1's progress note dated 8/23/2025 revealed she had been reporting that she was well without taking the muscle relaxer Cyclobenzaprine.

Record review of the list of 25 residents listed were changed from low to high risk for falls.

Record review of 5 out of 25 sampled residents from the list of 25 residents had updated care plans related to falls (Residents #1, 2, 3, 4 and 5).

Record review of Resident #1's and Resident #3's resident profile revealed that it alerted staff that they are a fall risk.

Record review of test given to the clinical staff asked questions concerning fall interventions, when and who should notify RP, Physician, DON, Administrator.

Interviews with CNA's A, B, C, and D were conducted between 8/22-8/25/2025 on the 6am-6pm shift were able to communicate the recent in-services in which they were told where they could find resident interventions in their EMAR, notifying on-call administration after an incident event, and notifying their nurse of any incidents.

Interviews with the night shift (6p-6a) staff were CNA's E, F, H, and J were conducted on 8/24/2025.

They were able to communicate their in-services on interventions, resident profiles, increased rounding and notifying the Charge Nurse when there are Resident incidents.

Interviews with LVN's A, B and G were conducted between 8/24 and 8/25/2025 of night shift staff revealed they had been in-serviced on completion of a fall risk assessment, adding additional or different interventions to the care plans, notifying the RP, Physician, DON and Administrator, checking Resident profile for their person-centered assessments, providing full body skin assessments.Interview with MDS Coordinator and Wound care nurse on 8/23/2025 revealed them to state they had been in-serviced on resident interventions, accurate and timely documentation, fall risk assessments, notifying Administration, RP, and Physicians.

They were given a test for understanding the updated protocols.

The VPO was informed the Immediate Jeopardy was removed on 8/25/2025 at 3:40pm.

The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Facility ID: