Inspection Reports for
Woodland Manor

The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, improper medication administration, failure to hold quarterly care plan conferences, inadequate skin condition assessments, failure to obtain ordered laboratory tests timely, incomplete dental services, poor infection control practices related to urinary catheters, and unsafe environmental conditions such as dirty laundry floors, cracked flooring, and non-functioning electrical outlets.

The investigation was related to intakes 2614478 and 2567160. The resident was observed to unseal and empty the colostomy bag independently and inconsistently, sometimes causing unsanitary conditions. Staff failed to notify physicians of severe depression scores and did not document reminders or education regarding colostomy care behaviors. The resident had a history of behavioral incidents including reckless wheelchair use and alcohol consumption.

The facility failed to ensure that behaviors related to a resident's colostomy were care planned, monitored, and evaluated. Documentation and communication gaps were found regarding colostomy care, depression management, and behavioral interventions for the resident.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain battery-operated smoke alarms, improper placement of kitchen cooking appliances under fire suppression hood, incorrect fire alarm system time, lack of ground fault circuit interrupter (GFCI) protection on electrical receptacles, failure to conduct annual fire door inspections, failure to test non-hospital-grade electrical receptacles annually, and failure to maintain documentation and testing of Patient Care Related Electrical Equipment (PCREE).

This survey was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00453447 completed on February 28, 2025.

The facility was found deficient in multiple areas including failure to provide mail delivery on Saturdays, failure to provide proper notice prior to involuntary discharge, failure to provide showers per resident preference, failure to notify physician of abnormal blood sugars, improper storage of respiratory equipment, failure to attempt gradual dose reduction of psychotropic medications, and medication storage issues including unlabeled and loose medications.

The facility was found deficient in multiple areas including failure to provide mail delivery on Saturdays, lack of proper notice for involuntary discharge, inadequate assistance with activities of daily living, failure to notify physicians of abnormal blood sugars, improper storage of respiratory equipment, failure to attempt gradual dose reduction of antipsychotic medication, and improper medication labeling and storage.

Complaint IN00453447 was not corrected. Complaints IN00453989 and IN00452803 were corrected.

The facility failed to prevent the development of an unstageable pressure ulcer in one resident at mild risk for pressure ulcers and failed to follow infection control guidelines during incontinence care for another resident. The facility did not implement systemic plans of correction to prevent recurrence of these deficiencies. Some complaints were corrected while one remained uncorrected.

The investigation was complaint-driven, related to complaints IN00453989, IN00452803, and IN00453447, involving allegations of neglect, abuse, pressure ulcer mismanagement, staffing shortages, and infection control violations.

The facility failed to provide timely care and maintain dignity for residents, neglected incontinent care leading to actual harm, failed to prevent and identify pressure ulcers, had inadequate staffing levels resulting in delayed care, and did not follow infection control procedures for residents on Enhanced Barrier Precautions.

Complaints IN00453989, IN00452803, IN00453447 had substantiated federal deficiencies related to call light response, abuse and neglect, and pressure ulcer care. Complaint IN00448083 had no deficiencies related to the allegations.

The facility was found deficient in timely response to call lights affecting resident dignity, neglect and abuse including inadequate incontinent care and supervision, failure to prevent and identify pressure ulcers, insufficient staffing levels leading to delayed care, and failure to follow infection control procedures for residents on Enhanced Barrier Precautions.

This visit included a Post Survey Revisit to the Investigation of Complaints IN00442899, IN00446004 and IN00442666. Complaint IN00442666 was corrected, Complaint IN00446004 was not corrected, and Complaint IN00442899 was corrected.

The facility was found deficient in multiple areas including failure to timely notify physicians of changes in condition, failure to provide showers as scheduled, failure to follow dietary recommendations, failure to prevent accidents related to hot liquids, failure to ensure availability of physician-ordered medications, failure to follow infection control practices during catheter care, and failure to provide consented influenza and COVID-19 vaccinations.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards. Deficiencies included failure to annually review and update the Emergency Preparedness Plan and related policies, lack of tracking systems for staff and residents during emergencies, incomplete emergency communication plans, inadequate emergency preparedness training and testing, failure to conduct required fire drills on all shifts, and life safety issues such as malfunctioning self-closing doors, missing semiannual inspections of kitchen fire suppression and exhaust systems, and overdue maintenance of portable fire extinguishers.

This inspection relates to complaints IN00446004, IN00442666, and IN00442889 involving failure to notify physicians timely, inadequate ADL care, unsanitary conditions, maintenance issues, and pest control problems.

The facility failed to timely notify physicians of critical changes in residents' conditions, did not provide showers as scheduled for several residents, maintained unsanitary pantry conditions, had maintenance and cleanliness deficiencies in resident rooms and hallways, and had an ineffective pest control program with fruit fly infestations.

The investigation was complaint-driven, related to issues including failure to notify physicians timely, transfer documentation, care planning, medication administration, environmental hazards, infection control, vaccination, and pest control.

The facility was found deficient in multiple areas including failure to notify physicians timely of blood sugar changes and condition changes, failure to provide transfer and bed hold documentation for hospitalized residents, failure to develop comprehensive care plans for medication and activities, failure to provide timely pneumococcal vaccination, failure to maintain sanitary environment and pest control, medication administration errors including unavailable medications, failure to maintain safe environment including melted PTAC unit and unclean pantries, and failure to follow infection control practices during catheter care.

This survey included investigations of complaints IN00442666, IN00442686, IN00442899, IN00446004, IN00446365, and IN00446377. Several complaints were substantiated with federal deficiencies cited.

The facility was found deficient in multiple areas including failure to notify physicians timely of changes, incomplete transfer and discharge documentation, inadequate care plans, failure to provide showers as scheduled, medication administration errors, unsanitary pantry conditions, environmental maintenance issues, pest control deficiencies, infection control lapses, and incomplete employee training.

Complaint IN00442414 was substantiated with federal/state deficiencies cited at F698. Complaints IN00441939, IN00441580, and IN00441211 had no deficiencies related to the allegations.

The facility was found deficient related to Complaint IN00442414 for failing to ensure that a resident requiring dialysis received proper assessment and monitoring for complications before and after dialysis treatments. No deficiencies were found related to the other three complaints.

This citation relates to Complaint IN00442414.

The facility failed to ensure that a resident requiring dialysis received proper assessment and monitoring for complications before and after dialysis treatments, specifically lacking post-dialysis assessments and documentation of fistula site monitoring.

Complaint IN00436291 was substantiated with federal/state deficiencies cited. Complaint IN00436905 had no deficiencies related to the allegations.

The facility failed to ensure the Memory Care Unit was free from incontinence brief debris and failed to provide adequate supervision to a cognitively impaired resident, resulting in Resident C experiencing a blocked airway, a change in level of consciousness, and requiring emergent EMS treatment. Resident C subsequently became pulseless and non-responsive during EMT care.

This citation relates to Complaint IN00436291.

The facility failed to keep the Memory Care Unit free from incontinence brief debris and did not provide adequate supervision to a cognitively impaired resident, resulting in the resident experiencing a blocked airway, loss of consciousness, and requiring emergency medical intervention.

This citation relates to Complaint IN00436526. The complaint involved Resident B eloping from a physician's office during transport and being missing for several days before being found. The facility failed to provide adequate supervision and follow its elopement policy.

The facility failed to ensure adequate supervision of Resident B, who eloped from a physician's office during transport. The resident was missing for several days before being found, and the facility did not follow its elopement policy or provide timely supervision after the resident's return.

Complaint IN00436483 - No deficiencies related to the allegations were cited. Complaint IN00436526 - Federal/State deficiency related to the allegations cited at F689. Complaint IN00435617 - No deficiencies related to the allegations were cited.

The facility failed to ensure adequate supervision and adherence to elopement policy for a resident with traumatic brain injury who eloped from a physician's office appointment. The resident was missing for several days before being found. The facility implemented corrective actions including visual checks, wander guard placement, updated care plans, and staff training on elopement prevention.

The facility was found not in compliance with emergency preparedness requirements including lack of tracking system for staff and residents during emergencies, incomplete communication plans, failure to conduct required emergency preparedness exercises, and multiple life safety code deficiencies including egress door locking issues, obstructed exit discharge, incomplete fire watch and sprinkler system policies, missing fire door inspections, incomplete fire drills, and unsafe electrical and fire safety practices.

Complaints IN00434221 and IN00434242 were investigated. The visit resulted in an Immediate Jeopardy related to infection control practices, which was removed after corrective actions on 5/17/2024.

The facility was found deficient in multiple areas including resident dignity and respect, care planning, ADL care, catheter care, bedrail assessments, nurse staffing postings, pharmacy narcotic counts, food safety and sanitation, infection control including glucometer sanitation, and pest control. Immediate jeopardy related to infection control was removed after corrective actions.

This inspection relates to Complaints IN00434221 and IN00434242. The complaints involved concerns about food safety and pest control issues, both of which were substantiated by observations and interviews during the inspection.

The facility failed to ensure food was stored, prepared, served, and delivered in a sanitary manner, affecting 67 residents. Additionally, the facility failed to maintain an effective pest control program related to gnats in resident rooms and common areas.

Complaint IN00428613 was substantiated with federal/state deficiencies cited at F600 related to abuse. The facility failed to prevent sexual abuse by Resident B against Resident C. Resident B had a history of hypersexual behaviors documented prior to admission. The facility implemented 1:1 observation and discharged Resident B to a behavioral health facility. Resident C did not recall the incident and showed no negative psychological or physical effects.

The facility failed to ensure Resident C was free from sexual abuse by Resident B. Resident B was observed touching Resident C inappropriately while she was asleep. The facility responded immediately by placing Resident B on 1:1 observation and facilitating his discharge to a behavioral health facility. Resident C showed no negative psychological effects from the incident.

This citation relates to Complaint IN00428613. The complaint was substantiated based on observation, interviews, and record review confirming resident-to-resident sexual abuse.

The facility failed to ensure Resident C was free from sexual abuse by Resident B. Resident B was observed touching Resident C inappropriately while she was asleep, leading to actual harm and requiring intervention including 1:1 observation and transfer to a behavioral health facility.

This citation relates to Complaint IN00422875 regarding failure to notify the responsible party of a resident's transfer and incorrect clinical information sent to the hospital.

The facility failed to notify the responsible party of a transfer to the emergency room for one resident and sent incorrect clinical information to the receiving hospital, mixing data from two residents with the same name.

Complaint IN00422734 had no deficiencies related to the allegations. Complaint IN00422875 had federal/state deficiencies cited at F580 and F622 related to failure to notify responsible party of hospital transfer and failure to provide correct clinical information to receiving hospital. Complaint IN00424443 had no deficiencies related to the allegations.

The investigation found no deficiencies related to complaints IN00422734 and IN00424443. However, federal and state deficiencies were cited related to complaint IN00422875, specifically regarding failure to notify responsible parties of resident transfers and failure to provide correct clinical information to receiving hospitals.

The investigation was triggered by complaints IN00408204 and IN00414158 regarding narcotic misappropriation and documentation errors.

The facility failed to prevent misappropriation of narcotics and maintain accurate controlled drug records for three residents. Multiple medication errors, missing controlled drug records, and improper destruction of medications were documented.

Complaints IN00414158 and IN00408204 had Federal/State deficiencies related to allegations cited at F602. Other complaints had no deficiencies related to allegations.

The facility failed to prevent misappropriation of narcotics for 3 of 4 residents reviewed, with incomplete and inaccurate documentation of narcotic medications. Several medication errors and missing Controlled Drug Records (CDRs) were identified. Corrective actions including audits, education, and policy reviews were implemented.

The facility was found in substantial compliance with Emergency Preparedness requirements but had multiple deficiencies related to Life Safety Code including emergency power system testing, means of egress obstructions, fire door inspections, fire alarm system maintenance, sprinkler system accessibility and maintenance, fire extinguisher storage, water heater inspections, electrical junction safety, fire drills, smoking area maintenance, oxygen cylinder storage, and staff training on oxygen transfilling.

This Federal tag relates to Complaints IN00394202 (skin care), IN00394560 (falls), IN00388683, IN00394334, and IN00404072 (environmental safety).

The facility failed to provide appropriate timely skin treatment for a resident with a stage 2 pressure ulcer, failed to identify fall risk for a resident resulting in injury, and failed to maintain a safe, clean, and comfortable environment due to multiple maintenance and housekeeping deficiencies.

This visit included the Investigation of Complaints IN00388683, IN00394202, IN00394334, IN00394560 and IN00404072. Deficiencies related to these complaints were cited at various tags including F921, F686, F689.

The facility had multiple deficiencies including issues with resident funds management, baseline and comprehensive care plans, ADL care, activities programming, quality of care including medication administration and catheter care, nutrition, pharmacy services, medication storage, food safety, and environmental conditions.