Embassy of Woodview

In the surveyor’s words

From the most serious findings on record at Embassy of Woodview, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 1, 2024

  Based on observation, medical record review, review of hospital records, review of physician's notes and wound assessments, appointment reminder notice review, interviews with residents, family, outside entities, and staff, and policy review, the facility failed to provide adequate, timely and necessary care and services, including timely re-scheduling of vascular surgeon appointments for Resident #100, who had vascular wounds to meet the resident's total care needs. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm beginning on 07/16/24 when a vascular surgery follow-up appointment (with plans to discuss blood flow to the resident's lower extremities) was canceled with no evidence of attempts by facility staff to re-schedule or schedule a new vascular… […]

• Immediate jeopardy, isolatedF600Jun 1, 2022

  Based on review of a Self-Reported Incident (SRI), review of the facility's investigation of the SRI, review of the nursing schedule, review of employee time reports, record review, resident interview, staff interview, review of employee personnel files, and policy review, the facility failed to ensure a resident was free from neglect when State tested Nurse Aide (STNA) #200 failed to respond to the resident's calls for assistance to have her basic care needs met. This resulted in Immediate Jeopardy with the potential for serious physical, mental, and/or psychosocial harm and wellbeing, when Resident #11 had her call light on waiting for assistance and called out for help to STNA #200 who walked by her room. […]

• Immediate jeopardy, isolatedF684Feb 11, 2021

  Based on record review, review of facility medication error reports, review of the facility policy and procedure related to Medication Administration and Documentation, and interviews with facility staff including Corporate Registered Nurse (RN) #205, the Director of Nursing (DON), Nurse Practitioner (NP) #210 and Registered Nurse (RN) #121, the facility failed to provide quality care and treatment by ensuring an effective system was in place to properly identify residents on admission to ensure appropriate care and services were provided and all physician orders were delivered as prescribed to meet the total care needs of Resident #46 and Resident #04. […]

• Actual harm, isolatedF686May 13, 2025

  Based on interviews, record reviews, hospital documentation, observation and review of facility policy, the facility failed to initiate treatment and complete an accurate assessment for a suspected deep tissue injury (SDTI) [persistent non-blanchable deep red, maroon or purple discoloration of the skin] to the bilateral buttocks upon admission on 04/29/25 for Resident #174. Actual Harm occurred on 05/07/25 when Resident #174's SDTI to the bilateral buttocks worsened to four stage III pressure ulcers (full thickness skin loss in which the fat is visible in the ulcer and granulation tissue as well as rolled wound edges are often present) due to not following the Wound Certified Nurse Practitioner's recommendations. […]

• Actual harm, isolatedF600Mar 6, 2023

  Based on medical record review, observation, review of a facility self-reported incident (SRI), staff and Sexual Assault Nurse Examiner (SANE) #19 interviews, and review of the facility abuse and neglect policy, the facility failed to ensure a resident was free from resident-to-resident sexual abuse. This resulted in Actual Harm when Resident #01 was sexually abused by Resident #02 and subsequently required hospital evaluation/treatment for an abrasion to the fascia of her vagina. This affected one (#01) of three residents reviewed for abuse. Facility census was 70. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE]. […]