Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Census: 44
Deficiencies: 4
Date: Jan 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including beneficiary notices, activities program qualifications, food sanitation, and quality assurance committee attendance.
Findings
The facility was found deficient in multiple areas including failure to provide Medicare non-coverage notices to residents, activities program not directed by a qualified professional, improper sanitization of dishes, and failure to ensure required Quality Assurance committee members attended quarterly meetings.
Deficiencies (4)
Failed to ensure that the resident and/or resident representative was informed of the Skilled Nursing Facility Advance Beneficiary Notice for 1 of 3 residents reviewed.
Failed to ensure that the activities program was directed by a qualified professional for a facility census of 44 residents.
Failed to properly sanitize dishes according to manufacturer's instructions for a facility census of 44 residents.
Failed to ensure that the required Quality Assessment and Assurance committee members attended meetings at least quarterly for 4 of the 4 quarterly meetings reviewed.
Report Facts
Facility census: 44
Residents reviewed for beneficiary notices: 3
Residents affected: 1
Quarterly meetings reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed failure to provide Medicare non-coverage notice | |
| Activities Director | Not qualified as therapeutic recreation specialist | |
| Administrator | Confirmed Activities Director qualifications and Quality Assurance committee attendance | |
| Dietary Manager | Observed improper dish sanitization | |
| Dietary Aide | Confirmed dish sanitization testing process |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notifications, care planning, staffing, food safety, and facility-wide assessments at Woodlawn Healthcare Center LLC.
Findings
The facility was found deficient in providing timely Medicare beneficiary notifications, implementing and updating resident care plans, maintaining adequate nursing staff per facility assessment, ensuring food safety standards in kitchen storage and preparation, and completing a comprehensive facility-wide staff competency assessment.
Deficiencies (6)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (ABN) and timely Notice of Medicare Non-Coverage (NOMNC) for 2 of 3 residents reviewed.
Failed to implement a resident's care plan for indwelling catheter for 1 of 2 residents reviewed.
Failed to update resident care plans with new or revised interventions after falls for 2 of 6 residents reviewed.
Failed to provide sufficient nursing staff in accordance with facility assessment.
Failed to store and prepare food in accordance with professional standards to prevent food-borne illness.
Failed to complete facility-wide assessment related to staff competencies necessary to provide care.
Report Facts
Residents reviewed for beneficiary notifications: 3
Residents reviewed for indwelling catheter care plan: 2
Residents reviewed for falls: 6
Nursing staffing schedule days reviewed: 30
Weekend days with only one nurse on 6pm-10pm shift: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Business Office Manager | Confirmed failure to provide SNF ABNs and NOMNCs timely |
| Staff B | Director of Nursing | Confirmed failures related to care plan implementation, fall care plan updates, and nursing staffing |
| Staff F | Cook | Confirmed food storage and preparation deficiencies |
| Staff E | Administrator | Confirmed failure to complete facility-wide staff competency assessment |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 19, 2023
Visit Reason
The inspection was conducted to investigate alleged violations including potential abuse of a resident and compliance with infection prevention and control guidelines, specifically related to COVID-19 return-to-work protocols for healthcare personnel.
Complaint Details
The complaint investigation found substantiated issues including failure to prevent potential abuse of a resident during an ongoing investigation and failure to follow CDC COVID-19 return-to-work guidelines for healthcare personnel.
Findings
The facility failed to prevent potential abuse during an ongoing investigation of a resident abuse allegation and did not follow CDC return-to-work guidelines for COVID-19 positive healthcare personnel. Additionally, the facility lacked a qualified infection preventionist with specialized training.
Deficiencies (3)
Failed to put measures in place to ensure that further potential abuse did not occur while an investigation was in process for 1 resident.
Failed to follow CDC return to work guidelines for Health Care Personnel who were positive for COVID-19 for 3 of 24 HCPs reviewed.
Failed to employ, at least on a part-time basis, an Infection Preventionist who had completed specialized training in infection prevention and control.
Report Facts
Healthcare Personnel reviewed: 24
Healthcare Personnel non-compliant: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrator | Interviewed regarding abuse allegation and facility policies |
| Staff F | Licensed Nursing Assistant | Alleged to have provided rough care to Resident #1 |
| Staff G | Charge Nurse | Reported concerns about rough care of Resident #1 |
| Staff A | Director of Nursing and Infection Preventionist | Interviewed regarding infection prevention and COVID-19 policies |
| Staff C | Licensed Practical Nurse | Tested positive for COVID-19 and returned to work early |
| Staff D | Licensed Nursing Assistant | Tested positive for COVID-19 and returned to work early |
| Staff E | Housekeeper | Tested positive for COVID-19 and returned to work early |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Dec 30, 2022
Visit Reason
The inspection was conducted to investigate complaints related to failure in documenting advanced directives, failure to notify physicians of resident condition changes, failure to follow medication parameters, failure to ensure monthly drug regimen reviews, failure to maintain infection control practices, and failure to perform timely COVID-19 testing.
Complaint Details
The visit was complaint-related, investigating multiple issues including advanced directive documentation, physician notification failures, medication administration parameters, drug regimen reviews, infection control practices, and COVID-19 testing. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including inaccurate documentation of advanced directives, failure to notify physicians of resident condition changes, lack of medication administration parameters, missing monthly pharmacist drug regimen reviews, improper infection control during wound dressing changes, and failure to test a symptomatic resident promptly for COVID-19.
Deficiencies (6)
Failed to document advanced directives accurately for 1 out of 25 residents reviewed.
Failed to consult with residents' physician when there was a need to alter treatment for 1 out of 1 resident reviewed.
Failed to ensure medication parameters were followed according to physician orders for 2 out of 5 residents reviewed for unnecessary medications.
Failed to ensure drug regimen reviews were reviewed and addressed by the provider for 2 of 5 residents reviewed for unnecessary medications.
Failed to maintain infection control practices in regards to wound dressing changes and hand hygiene and glove use for 1 out of 1 resident observed.
Failed to test a resident with symptoms consistent of COVID-19 for 1 out of 1 COVID-19 positive residents reviewed for COVID-19 testing.
Report Facts
Residents reviewed for advanced directives: 25
Residents reviewed for notification of changes: 18
Residents reviewed for unnecessary medications: 18
Residents reviewed for drug regimen reviews: 5
Residents observed for infection control: 1
COVID-19 positive residents reviewed for testing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Staff F identified in advanced directive and medication parameter findings. | |
| Minimum Data Set (MDS) Coordinator | Staff D involved in advanced directive and medication record review findings. | |
| Licensed Practical Nurse | Staff B involved in notification of physician failure and COVID-19 symptom documentation. | |
| Registered Nurse | Staff A involved in notification of physician failure. | |
| Registered Nurse | Staff E involved in medication parameter findings and infection control observation. | |
| Director of Nurses | Staff C involved in infection control and COVID-19 testing findings. |
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