Inspection Reports for
The Woodlake Senior Living

Two Type B deficiencies were cited: staff documented completion of incontinent care tasks for R1 that were not actually completed, and staff failed to complete a property inventory list upon R1's admission, posing potential risks to health, safety, and personal rights.

The inspection found that a resident left the memory care unit unsupervised despite needing assistance with ambulation and fall prevention, posing an immediate health and safety risk. The facility's care plans for elopement prevention were in place but not effective.

The inspection found several deficiencies including expired first aid certifications in 3 out of 10 staff files, cleaning supplies accessible to residents in a housekeeping closet, and an inoperable emergency call button in a bathroom due to dead batteries.

The visit was a follow-up to a complaint investigation conducted on 2025-02-11 regarding the facility's refusal to accept a resident requiring injections, leading to an involuntary transfer.

The facility failed to protect a resident from involuntary transfer by refusing to accommodate the resident's health needs related to an injection prescription, resulting in the resident being relocated to another facility. The facility did not contact a home health agency to administer the injection as ordered by the physician.

The complaint was substantiated. The resident did not receive medications in a timely manner, leading to health complications and hospitalizations. Staff failed to communicate with the resident's authorized representative and pharmacy. The allegation that staff did not maintain resident records was unsubstantiated.

The investigation substantiated that the facility failed to administer medications as needed, resulting in a resident missing 21 doses of medication, causing health issues including tremors and falls. The facility was cited for violations and a civil penalty was imposed. Another allegation regarding failure to maintain resident records was unsubstantiated.

The complaint was substantiated based on interviews, observations, and record review. Residents reported being left in bathrooms for 20 to 45 minutes while calling for help multiple times. Staff admitted to issues with shower schedules and other care tasks. The facility was cited under 22 CCR Sections 87464(f)(4).

The investigation found substantiated evidence that showers were not conducted as scheduled, residents were left unattended in bathrooms for extended periods, and basic resident needs were not consistently met, posing potential health and safety risks.

The complaint investigation was triggered by allegations received on 10/01/2024 regarding medication errors, staff instructing residents to be mean to others, and illegal eviction of a resident. The medication error involved Resident 1 (R1) receiving incorrect dosages from 9/1/24 to 9/19/24. Staff interviews confirmed instructions to residents to be mean to R1. The eviction allegation was found unsubstantiated after review of eviction notices, incident reports, and financial records.

The investigation substantiated that the facility failed to administer medications as prescribed and that staff instructed residents to be mean to other residents, posing immediate health and safety risks. The allegation of illegal eviction was unsubstantiated, with evidence supporting lawful eviction procedures, though the facility accepted payment beyond the eviction notice date.

The facility was cited for failing to submit two incident reports within the required seven-day timeframe, posing potential health, safety, and personal rights risks. A plan of correction involving staff training was agreed upon.

The visit was triggered by incident reports involving two residents: R1 found with an empty medication bottle requiring hospital transport, and R2 who eloped from the memory care unit unsupervised. The facility was cited under HSC Section 1569.312(a) for failure to provide required care and supervision.

The investigation found that one resident was found with an empty bottle of liquid medication and required hospitalization, while another resident eloped from the memory care unit unsupervised despite needing assistance, posing an immediate health and safety risk. The facility was cited for failure to provide adequate care and supervision.

The facility was generally clean and well-maintained with adequate food supply and safety measures. However, four out of ten staff files lacked first aid certificates, posing a potential health and safety risk.

The complaint investigation was triggered by allegations received on 12/02/2021 regarding resident injuries from falls, unexplained injuries, residents left unattended, failure to safeguard personal property, and insufficient staffing. The findings were unsubstantiated for most allegations except for insufficient staffing, which was substantiated.

The complaint findings were mixed: several allegations such as injuries from falls and unattended residents were deemed unsubstantiated due to lack of preponderance of evidence, while the allegation of insufficient staffing was substantiated. The investigation found that staffing shortages led to delayed care including late meals, delayed medication, and inadequate assistance with transfers, posing potential health and safety risks.

The complaint investigation was substantiated for delayed staff response to call buttons, with documented instances of pendants pressed with response times over 30 minutes and bedside pull switches with response times over 45 minutes. Other complaints about hygiene assistance, room cleanliness, odor, and meal provision were unsubstantiated.

The complaint that staff took too long to respond to call buttons was substantiated with evidence of delayed response times. Other allegations regarding hygiene assistance, dirty rooms, odor, and meal provision were found to be unsubstantiated due to lack of preponderance of evidence.

The visit followed up on a deficiency found during a complaint investigation reference # 27-AS-20210810092050.

The facility was found to have medicines stored in an unlocked rolling cart taken into residents' apartments during medication passes, which is not in compliance with regulations requiring centrally stored medicines to be kept in a safe and locked place.

The complaint investigation was substantiated for the allegation of late medication administration, meaning the allegation was valid based on the preponderance of evidence. The allegation of insufficient staffing was unsubstantiated due to lack of evidence.

The investigation substantiated the allegation of late medication administration, finding 41 late medication passes with an average delay of two hours, posing a potential health and safety risk. The allegation of insufficient staffing was unsubstantiated as staff and residents reported adequate care and staffing coverage.