Woodland Country Manor Inc

In the surveyor’s words

From the most serious findings on record at Woodland Country Manor Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Dec 2, 2025

  Based on record review and staff interviews, the facility failed to ensure services were provided by a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents residing in the facility. The facility census was 52.Findings include:Review of the schedules and timecard punches from 10/21/25 to 12/01/25 revealed there was only documentation of hours for one RN (#378). RN #378 worked less than eight hours on 10/22/25, 10/26/25, 10/27/25, 10/29/25, 11/02/25, 11/03/25, 11/05/25, 11/06/25, 11/10/25, 11/13/25, 11/15/25, 11/16/25, 11/18/25, 11/20/25, 11/24/25, and 11/25/25.Interview on 12/01/25 at 3:39 P.M., the Administrator verified the facility had been unable to meet the requirements for RN coverage. […]

• No harm, potential for more than minimal, widespreadF880Dec 2, 2025

  Based on record review, staff interview and review of online resources from Centers for Disease Control (CDC), the facility failed to have a comprehensive Water Management Plan to assess, measure, monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. This had the potential to affect all 52 residents in the facility.Findings include: Review of the Water Flushing & Temperature Monitoring forms revealed in January 2025 one resident room (312) had the shower water ran for five minutes with a temperature of 101 degrees Fahrenheit (F) on 01/09/25, one resident room (104) had the sink water ran for six minutes with a temperature of 102 degrees F on 01/24/25, and one resident room (205) had the toileting flushed. […]

• No harm, potential for more than minimal, isolatedF689Dec 2, 2025

  Based on record review, staff interview, physician services interview, and policy review, the facility failed to complete thorough investigations following a resident's falls and do neurological (neuro) checks following a resident's fall. This affected one (Resident #57) of seven residents reviewed for accidents. The facility census was 52. Findings include: Review of the medical record for Resident #57 revealed an admission date of 12/27/22. Diagnosis included multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. There was no documented history of seizures. […]

• No harm, potential for more than minimal, isolatedF689May 29, 2025

  Based on record review, review of a Self-Reported Incident (SRI) and investigation, policy review, resident and staff interviews, and observations, the facility failed to ensure staff provided adequate supervision to prevent a resident from leaving the facility unsupervised and failed to conduct a thorough investigation into the resident's elopement. This affected one (Resident #27) of three residents reviewed for elopement. The facility identified 11 residents at risk for elopement. The facility census was 51. Findings include: Record review for Resident #27 revealed the resident was admitted to facility on 03/13/25. Diagnoses included dementia, delirium, insomnia, depression, and auditory hallucinations. […]