Woodbridge Place.

“The home's weekly menus for the current week and following week were not posted in the Secured Dementia Care Unit. This is a repeated violation.”

“Protected health information regarding a resident's need for supervision with power wheelchair mobility was posted on signage outside the resident's apartment door, violating confidentiality requirements.”

“Staff person A was hired and did not have a criminal background check completed until after the hire date. Staff person B was hired and did not have a criminal background check completed until after the hire date.”

“Direct care staff person C received only 8 hours of annual training in training year 2024, falling short of the required 12 hours of annual training relating to job duties.”

“Direct care staff person C did not receive required training topics during training year 2024, specifically Safe Management Techniques and Care for residents with mental illness or an intellectual disability.”

“Staff person C did not receive required annual training topics in 2024: Fire Safety, Emergency Preparedness Procedures, Resident Rights, and Falls and Accident Prevention. Staff person D did not receive Emergency Preparedness Procedures and New population groups training.”

“The keypad used to operate the Stairwell 3, Door 1 exit in the Secured Dementia Care Unit was malfunctioning, creating a safety hazard.”

“An inoperable keypad blocked egress from the home's Secured Dementia Care Unit in Stairwell 3 at Door 1, obstructing an emergency exit route.”

“The fire extinguisher in the designated smoking area did not have an inspection tag with a date of inspection.”

“The home failed to immediately report three suspected abuse incidents involving a resident to the local area agency on aging as required. Incidents included staff making derogatory statements to the resident, unauthorized use of the resident's debit card, and a resident's purse found in a trash can.”

“The home failed to develop and implement a plan of supervision or suspend Staff Person C after an internal investigation determined this staff member made derogatory statements to a resident.”

“The home failed to report incidents (derogatory staff statements to resident and resident's purse found in trash) to the Department's personal care home regional office within 24 hours as required.”

“The home failed to inform other residents and their designated persons who could potentially be harmed after validating that a staff member committed theft and fraud involving a resident's debit card.”

“A resident was subjected to abuse, including theft of funds from the resident's debit card (approximately $[amount] in fraudulent purchases) by staff member, and derogatory verbal statements made by a staff member stating nobody cares for the resident, nobody wants to work with them, all staff hate them, and nobody wants to change them.”

“A resident was not treated with dignity and respect when a staff member made derogatory statements including that nobody cares for the resident, nobody wants to work with them, all staff hate them, and nobody wants to change them.”

“Staff person G did not receive required orientation on evacuation procedures during their first day of work.”

“A resident's preadmission screening form was completed outside the required 30-day window prior to admission.”

“The home's administrator has not successfully completed a Department-approved orientation program prior to initial employment.”

“The laundry room door in the Memory Care Unit was observed unlocked, unattended, and accessible to residents. Not all residents in the Memory Care Unit have been assessed as capable of recognizing and using poisonous materials safely.”

“A wood bed frame was observed at the Memory Care Unit's back door exit, obstructing the egress route from the facility.”

“A resident's medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency and health status as required.”

“A resident's medication administration records and medication pill pack do not indicate the diagnosis or purpose for the prescribed medication.”

“A resident's initial assessment was not completed within the required 15 days of admission. This is a repeat violation.”

“A staff member who participated in the development of a resident's support plan failed to sign and date the support plan as required.”

“A resident was admitted to the Secure Dementia Care Unit (SDCU), but the written cognitive preadmission screening was not completed within the required 72 hours prior to admission.”

“Staff person A woke up a resident and forced them into the shower without consent. The resident was uncomfortable with the interaction. This allegation of abuse was not reported to the Older Adult Protective Services as required.”

“Following an allegation of abuse involving staff person A who forced a resident into a shower, the home did not place the staff person on suspension and did not obtain a supervision plan approved by the Department.”

“The home did not report an incident involving staff person A forcing a resident into a shower to the Department within the required 24 hours.”

“A resident's home contract was not signed by the resident as required.”

“A resident was forced out of bed and into a shower by staff person A without consent, with staff citing family complaints about the resident's smell. The resident did not want to get up early for a shower and was forced to undress and shower against their will, violating the requirement to treat residents with dignity and respect.”

“Poisonous materials (Meyers Clean Day Body Wash and Medline roll-on antiperspirant) bearing manufacturer warnings were unlocked, unattended, and accessible to residents #1 and #2, who have not been assessed as capable of safely recognizing and using poisons.”

“The bathroom for residents #1, #2, and #3 does not have an operable window or ventilation fan.”

“Resident #4 does not have access to a source of light that can be turned on/off at bedside.”

“The home's menu for the week following 12/30/2024-1/4/2025 was not posted in the main kitchen dining area and Lilac Terrace.”

“Nystatin 100,000 unit/ML prescribed for resident #1 was in the medication cart but was discontinued on 12/25/2024. Glucagen 1MG Hypokit and Glucose 15 gel 40% prescribed for resident #5 were in the medication cart but were discontinued on 11/11/2024.”

“Glucometer readings for resident #5 were not accurately documented on the medication administration record: on 12/23/2024 at 5:02 pm the reading was 142 but recorded as 172; on 12/22/2024 at 7:22 pm a reading of 115 was not documented; on 12/17/2024 at 5:23 pm a reading of 81 was not documented.”

“Resident #6's controlled substance sheet does not include the signature of the staff person who administered Clonazepam 0.5 mg on 12/21/2024 at 9:00 pm.”

“Resident #5's prescribed Advair 250-50 Diskus inhaler was not available in the home on 12/30/2024 at 3:25 pm.”

“Resident #1's medical evaluation indicates a need for a mechanical soft diet, but the resident's support plan does not address how this dietary need will be met.”

“Emergency exit from stairwell #3 going out to front of home was blocked by residents sitting in chairs on front patio at approximately 10:40 am.”

“Staff member lifted resident's shirt in dining area in front of other residents to apply medication, exposing resident's back without privacy. Additionally, an Amazon Echo Dot was in use in memory care common room without signs indicating audio recording and no policy on audio monitoring devices.”

“The home does not have a staff training plan developed for 2024.”

“Resident in wheelchair in memory care unit could not easily open their bedroom door; door required forceful pushing. This prevents safe access to room when resident pleases.”

“Large stain on carpets outside common bathroom on first floor and strong odor of urine while walking up stairs to second floor.”

“Dumpster located in back of home was uncovered at approximately 10:30 am.”

“Resident's bathroom does not have an operable outside window or ventilation fan; the vent is inoperable and there is no window in the bathroom.”

“Approximately one-inch-thick accumulation of lint in lint trap on commercial dryer at 9:15 am with no clothes in dryer.”

“Home's written emergency procedures do not include contact information for each resident's designated person.”

“Care staff member was immediately suspended and returned to work with residents without an approved supervision plan submitted to the Department. The facility failed to submit a plan of supervision or notice of suspension to DHS before the staff person resumed duties.”

“Care staff member physically abused a resident by slapping the resident's hand during care. The resident yelled in response, appeared scared, and flinched when touched afterward. This was a repeat violation from 8/14/2023.”

“The home served 59 residents requiring 177 gallons of emergency drinking water but had only 25 gallons on hand. The home also does not maintain a three-day supply of nonperishable emergency food.”

“Resident #1 was discharged but did not receive the required refund within 30 days. An itemized statement was produced and submitted to corporate for check issuance, but no check was actually issued to the resident or resident's estate.”

“Colgate PreviDent 5000 toothpaste, labeled as potentially harmful if swallowed in large amounts, was unlocked, unattended, and accessible in resident #2's room. Not all residents have been assessed as capable of safely using or avoiding poisonous materials.”

“The door from the memory care patio leading back into the building would not open after entering the code because the latch was damaged, creating a safety hazard.”

“Colgate PreviDent 5000 prescribed to resident #2 was unlocked, unattended, and accessible in resident #2's bathroom, in violation of medication storage requirements.”

“Resident #7 is prescribed medication to be given every three hours as needed for pain, but multiple bags in the medication cart had conflicting directions (some labeled every two hours, some every three hours). The mislabeled bags lacked indication of the change in directions on the pharmacy label.”

“The home served 59 residents requiring 177 gallons of emergency drinking water but had only 25 gallons on hand. The home also did not maintain a three-day supply of nonperishable emergency food.”

“On 10/16/2023 at 10 am, Colgate PreviDent 5000 prescribed to resident #2 was unlocked, unattended, and accessible in resident #2's bathroom.”

“Resident #1 was discharged but did not receive the required refund within 30 days. An itemized statement was prepared and submitted to corporate for issuance but no check was issued to the resident or resident's estate.”

“Colgate PreviDent 5000 with poison control warning was unlocked, unattended, and accessible in resident #2's room. Not all residents of the home have been assessed capable of recognizing and using poisons safely.”

“On October 26, 2023, the latch on the memory care patio entrance door was damaged and would not open after entering the code.”

“A glucometer belonging to resident #1 was not calibrated to the correct date and displayed an incorrect date (0/2023).”

“Resident #1 requiring assistance with eating did not receive this assistance as required; resident was found slumped/sleeping over breakfast plate with staff unavailable to help with feeding. Resident #2 requiring assistance with bladder and bowel management did not receive this assistance as required; resident had strong urine odor and required changing.”

“An unattended utility cart was found in the memory care unit containing plates, knives, spoons, and forks, creating a safety hazard.”

“The support plan for resident #1 was not revised to address a change in dietary need when the resident's diet was changed from mechanical soft to pureed.”

“Staff member failed to provide total physical assistance with toileting to a resident requiring such care. The resident was left soiled with dried fecal matter, making it uncomfortable to sit, after staff was informed of the need and chose to take a break instead.”

“Staff member A yelled at a resident experiencing an anxiety attack, using abusive language ('sit the hell down,' 'get out of my face'), violating the resident's right to be treated with dignity and respect. Additionally, staff member A refused to provide required toileting assistance to another resident.”

“Staff member A locked resident bedroom doors in the memory care unit after residents exited, preventing residents from accessing their own bedrooms at all times. Staff stated this was done to prevent theft between rooms.”

“An opened medication was stored in the medication cart without an opened-on date. Per manufacturer's instructions, the medication must be discarded after 28 days, and dating is required to track proper disposal.”