Inspection Reports for
Woodland Hills Independent Living, Assisted Living & Memory Care

The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to failure to report major incidents to the regional licensing office within 24 hours. Additional violations not related to the self-report were also identified during the investigation.

The investigation did not substantiate the self-reported non-compliance, but violations unrelated to the self-report were identified, including failure to complete a uniform assessment instrument (UAI) as required, improper medication administration not following physician instructions, and incomplete documentation on medication administration records (MARs).

Complaint was substantiated with evidence supporting non-compliance in medication management and administration timing.

The investigation found violations related to the facility's failure to implement their medication management plan to ensure timely filling and refilling of medications, and failure to administer medications within the facility's standard dosing schedule timeframes.

Complaint was received on 2025-05-14 regarding resident care and related services. The evidence gathered did not support the allegation of non-compliance with standards or law.

The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to ensure that physician or prescriber orders, services provided, evaluations of progress, and other pertinent rehabilitative service information were recorded in the resident's record.

The investigation supported some, but not all, of the self-reported allegations and found areas of non-compliance related to resident care and related services. A violation notice was issued with opportunities for the licensee to submit a plan of correction.

The investigation supported some but not all of the self-reported incident; non-compliance was found in administration and administrative services. A violation notice was issued related to failure to report a major incident within 24 hours.

The inspection found non-compliance with applicable standards related to the physical plant, specifically that harmful materials or objects were accessible to residents without staff supervision.

The investigation supported some but not all of the self-report; areas of non-compliance were found related to resident care and related services. Violations were issued regarding incomplete uniform assessment instruments and unsigned individualized service plans.

The complaint was substantiated in part. Evidence showed that a resident-to-resident altercation occurred on 2025-05-23, resulting in a resident being sent to the hospital. The facility did not report this incident to the regional licensing office until 2025-05-27, four days later.

The investigation supported some, but not all, of the allegations. Non-compliance was found in administration and administrative services, specifically the failure to report a major incident within 24 hours to the regional licensing office.

The investigation supported some, but not all, of the self-reported incident; areas of non-compliance were found related to resident care and related services. Violations included failure to update individualized service plans for significant resident condition changes and failure to administer medications according to physician instructions.

The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to medication administration by unqualified staff. The facility failed to ensure medications were administered by licensed or registered staff as required.

The inspection identified multiple areas of non-compliance including deficiencies in resident assessments, staff training, medication management, safety protocols, record keeping, and individualized service plans. Violations were documented and a plan of correction was requested to address these issues by June 1, 2025.

The complaint was substantiated. Allegations included inaccurate staffing disclosure, medication administration timing violations, and failure to administer medications per physician orders. Evidence included review of staffing records, medication administration observations, resident record reviews, and staff interviews.

The investigation supported the allegations of non-compliance with applicable standards and laws, resulting in violations issued. Specific deficiencies included inaccurate staffing disclosure, medication administration timing issues, and failure to administer medications according to physician instructions.

The inspection found multiple violations related to resident record keeping, medication management, individualized service plans, emergency preparedness, and availability of records. The facility was cited for non-compliance in several areas and given the opportunity to submit plans of correction.

The inspection found non-compliance related to the facility's failure to ensure that Do Not Resuscitate Orders (DNR) were properly documented with valid written physician orders. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.

The visit was not complaint-related but was triggered by a self-reported incident involving alleged verbal abuse from a staff person to residents 1 through 5. The staff person was suspended pending investigation. Interviews revealed that a report of suspected abuse had not been completed or sent to Adult Protective Services (APS).

The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to ensure that all mandated reporters reported suspected abuse, neglect, or exploitation of residents as required by Virginia law.

The complaint was substantiated based on evidence including observations of low hot water temperatures in multiple resident rooms and the kitchen sink, and staff interviews confirming boiler issues.

The investigation supported the allegation of non-compliance with regulations, specifically the facility failed to maintain hot water temperatures between 105°F and 120°F at taps available to residents. Violations were issued and the facility was working on corrective actions including boiler repairs.

The inspection identified multiple areas of non-compliance including staff training deficiencies, medication management issues, incomplete resident records and individualized service plans, improper storage of hazardous materials, and failure to document required resident safety rounds. Violations were documented and a plan of correction was requested.

The complaint was substantiated in part, with violations related to Emergency Preparedness. Evidence included an incident report of a resident injury during transport, staff interviews, hospital discharge summary, and review of facility policies. The facility was cited for failure to implement emergency procedures and failure to conduct timely staff reviews of these procedures.

The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Emergency Preparedness, specifically related to failure to implement the written plan for resident emergencies and failure to review emergency procedures with all staff at least every six months.

The inspection found multiple violations related to medication management, individualized service plans, confidentiality of resident records, diet order compliance, medication storage and administration, and facility safety such as unlocked storage of cleaning supplies.

Complaint related: Yes. The complaint was substantiated in part, with non-compliance found in resident care and emergency preparedness.

The investigation supported some of the allegations, identifying non-compliance in resident care and emergency preparedness. Violations were issued related to failure to provide services listed on individualized service plans and failure to ensure semi-annual review of the emergency preparedness plan with residents.

The investigation did not substantiate the self-reported non-compliance, but violations unrelated to the self-report were identified, including incomplete uniform assessment instruments and unsigned individualized service plans.

The inspection found multiple areas of non-compliance including failure to address identified needs on individualized service plans, failure to serve prescribed diets according to physician orders, medication management plan deficiencies, improper medication storage, failure to administer medications as prescribed, lack of documentation for medical treatments, unavailability of medications ordered for PRN use, and improper storage of cleaning supplies.

The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards or law.

The investigation supported the allegation of non-compliance with standards or law related to medical procedures and treatments not being provided according to physician orders and not properly documented. Violations were issued based on review of resident records and staff interviews.

The inspection identified multiple non-compliances including deficiencies in staff training, resident record documentation, medication management, emergency preparedness, physical plant conditions, and staff background checks. Violations were documented and corrective plans were proposed.

The complaint investigation was substantiated with evidence supporting allegations of non-compliance with standards or law, resulting in violations issued.

The investigation found multiple violations including insufficient direct care staff on duty in the special care unit, inadequate staff knowledge and numbers to meet resident needs, failure to update fall risk ratings after falls, incomplete or unsigned resident assessments and individualized service plans, medication storage issues, missing oxygen safety signage, and improper storage of hazardous materials.

The investigation supported the self-report of non-compliance with standards or law, specifically that individualized service plans (ISPs) were not updated to address all identified needs, including monitoring for signs of increased symptoms or suicidal ideations related to depression.

The investigation supported the self-report of non-compliance with standards or law related to resident rights violations involving inappropriate videos taken of a resident and uploaded to social media. Staff person 1 was suspended and subsequently terminated.

The investigation found non-compliance with training requirements, specifically that direct care staff did not complete the required 10 hours of training in cognitive impairments within the first four months of employment, resulting in violations issued.

The inspection identified multiple non-compliances including failure to ensure written justification for special care unit placement, insufficient staff training in cognitive impairments and aggressive behavior management, inadequate staffing levels, incomplete fall risk assessments, incomplete individualized service plans, medication management plan violations, and missing documentation on medication administration records.

The complaint inspection was initiated on 3/5/2021 and concluded on 3/16/2021. The evidence supported the allegation of non-compliance with standards or law.

The investigation found non-compliance with relevant state law and facility policies related to emergency temporary standard infectious prevention training for staff, resulting in violations.