Woodland Care Center

In the surveyor’s words

From the most serious findings on record at Woodland Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF806Apr 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 71) with known food allergies (a substance that causes an allergic reaction [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances]), was not served food containing allergens, by: 1. Serving for breakfast, on 4/8/2025, cream of wheat (a type of hot cereal that contains gluten [a protein found in the wheat plant and some other grains]; wheat is commonly used in breads, baked goods, and pastas) to Resident 71, who was known to be allergic to gluten as indicated in Resident 71's Physician's Order, Care Plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments),… […]

• Immediate jeopardy, isolatedF806May 3, 2024

  Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 147) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when: 1. Certified Nursing Assistant 2 (CNA 2) did not inform a licensed nurse (a Licensed Vocational Nurse [LVN] or Registered Nurse [RN]) of Resident 147's request for a snack on 4/14/2024 which would then require a licensed nurse to complete a Diet Order and Communication Form (DOCF- a form designed to ensure clear communication between residents, nurses and dietary staff that indicates dietary preferences and restrictions to promote safe food distribution) prior to providing… […]

• No harm, potential for more than minimal, widespreadF814Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster's (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) surrounding floors had trash and litter. This failure had potential to attract birds, flies, insects, pests (animal or microorganism that has a negative effect on humans) and possibly spread infection to 138 of 138 facility residents. Findings: During a concurrent observation and interview on 6/3/2026 at 11:25 a.m., of the dumpster area with the Dietary Supervisor (DS), observed soiled gloves, napkins, and disposable spoons on the dumpster floor surroundings. […]

• No harm, potential for more than minimal, widespreadF880Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to implement the facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) by failing to ensure the hot water tank was flushed monthly. This failure placed the residents, staff and visitors at risk for exposure to unsafe water conditions. Findings: During a concurrent interview and record review on 6/4/2026 at 9:25 a.m. with the Maintenance Supervisor (MS), the facility's Water Management Program (WMP) was reviewed. The MS stated that he and the Infection Preventionist Nurse (IPN) was responsible for the implementation of the facility's WMP. […]

• No harm, potential for more than minimal, patternF684Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of continuous glucose (sugar) monitoring (CGM-glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) for one of one sampled residents (Resident 145). This deficient practice had the potential to result in inaccurate blood sugar readings due to the lack of training provided to the licensed nurses on the functionality of the CGM device which could negatively affect management of Resident 145's diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar… […]