Advena Living on Woodlawn

In the surveyor’s words

From the most serious findings on record at Advena Living on Woodlawn, in the surveyor’s own words.

• Immediate jeopardy, patternF610Nov 30, 2021

  The facility census totaled 65 residents. Based on observation, interview, and record review the facility failed to protect female resident in the facility when staff failed to adequately monitor Resident (R)30 after an allegation of resident to resident sexual abuse (reported to the facility involving R30 and R7) on the evening of 11/18/21. Less than eight hours later, and after the facility implemented 15-minute checks, leading to a subsequent allegation of resident to resident sexual abuse alleging R30 went into R69's room for 30 to 45 minutes (as reported by R30) in the early morning of 11/19/21. R69 reported feeling unsafe and stated a man came into her room and she fought him off and said no. […]

• Immediate jeopardy, isolatedF689May 9, 2024

  The facility reported a census of 69 residents, with five residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired Resident (R) 1, identified at high risk for elopement. On 05/06/24 at 07:09 PM the charge nurse let R1 out the front doors of the building not realizing he was not allowed out the front doors to smoke. When R 1 went out the doors his WanderGuard (a bracelet that sets off an alarm when a resident wearing one attempts to exit the building without an escort) caused the alarm to activate, and the charge nurse located a CNA to turn off the alarm. […]

• Immediate jeopardy, isolatedF689May 9, 2023

  The facility reported a census of # residents with 3 residents sampled for elopement. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent the elopement of newly admitted (05/05/23), cognitively impaired Resident (1), a resident with history of elopement and assessed by the facility as high risk for elopement. On 05/06/23, R1 pushed on the north facility exit door until it opened and R1 walked out the door at around 06:30 AM. CMA R heard the alarm, looked out the window, shut off the alarm, but did not locate the resident or go out the door at that time. The resident walked about three miles to a family member's house, along a busy 4-lane road with speed limits of 40 miles per hour. […]

• Immediate jeopardy, isolatedF689Dec 29, 2021

  The facility reported a census of 68 residents, with three sampled for wandering behaviors. Based on observation, interview, and record review the facility failed to provide a safe/secure environment for cognitively impaired Resident (R) 1, identified by the facility as at risk for wandering and exhibited exit seeking behaviors. R1 eloped on 12/24/21 through the front door of the facility. R1 was out of the facility between the hours of 12:45 PM and 01:14 PM and was within walking distance (1/4 mile) of a busy intersection (four-lane with 40 mph speeds). These failures placed R1 in immediate jeopardy. […]

• Actual harm, isolatedF689Jan 21, 2026

  The facility identified a census of 72 residents. The sample included eight residents with three reviewed for falls. Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for Resident (R) 1. On 12/15/25 at 03:15 PM, per camera footage, Certified Nurse Aide (CNA) M propelled R1 in a wheelchair without the use of foot pedals, down an incline when the resident's right foot dropped under the wheelchair, where it became entangled, causing R1 to fall to the floor. […]