Wood-Lawn Heights

In the surveyor’s words

From the most serious findings on record at Wood-Lawn Heights, in the surveyor’s own words.

• Actual harm, isolatedF656May 22, 2024

  Based on observations, interviews, record review, and the facility failed to develop, implement, and update a comprehensive person-centered care plan for 4 (Resident #85, Resident #90, Resident #31, and Resident #81) of 10 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to ensure resident's falls were addressed appropriately in the care plan to prevent any further accidents and failed to follow the care plan related to falls. Findings include: A review of a facility policy titled, Comprehensive Care Plans, implemented on 04/2023, indicated, The comprehensive care plan will describe, at a minimum, the following: a. […]

• Actual harm, isolatedF689May 22, 2024

  Based on observations, record review, interviews, and facility policy review, the facility failed to investigate to determine the causative factors of falls to facilitate development of effective interventions to prevent further falls and minimize the risk of fall-related injuries and failed to ensure current fall documentation and interventions were accessible to all direct care staff for 2 (Resident #85 and Resident #90) of 3 residents reviewed for falls. These failures led to falls resulting in a laceration to the head and bruising to the eyes for Resident #85 and a fractured back and a hematoma to the forehead for Resident #90. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2023

  Based on observation, and interview, the facility failed to ensure food stored in the freezer was covered and/or sealed to prevent potential contamination or freezer burn and failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 100 residents who received meals from the kitchen (total census: 103), as documented on a list provided by the Dietary Supervisor on 04/04/23. The findings are: 1. On 4/03/23 at 12:50 PM the following food items were on a shelf in the walk-in freezer: a. One opened box of corn dogs was not covered or sealed. b. […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2021

  Based on observation, record review and interview, the facility failed to ensure food items stored in the refrigerator, freezer and storage area were covered and sealed; dietary staff washed their hands before handling clean equipment or food items; and hot foods were maintained at or above 135 degrees Fahrenheit (F.) on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 main kitchen and 4 (Willow, Aspen, Magnolia and Orange Blossom kitchenettes) of 4 kitchenettes. […]

• No harm, potential for more than minimal, patternF803Aug 14, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one meal observed. The findings include: During an observation on 08/11/2025 at 5:55 PM, Certified Nursing Assistant (CNA) #5 used a #8 scoop, which was equal to 1/2 cup, to serve a single portion of regular shepherd's pie to the residents who received regular diets, and the residents who received mechanical soft diets, instead of 3/4 cup as per the menu. […]