Woodland Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Woodland Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF686Nov 3, 2021

  Based on clinical record review, staff and resident interviews, interview with Wound Clinicians, and review of facility policy, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three of five residents reviewed with pressure injuries (Residents #2, #4, and #7). The facility failed to ensure transportation secured for all residents requiring wound clinic services. For Resident #4, review of the resident's Weekly Skin Sheets showed the resident's wound on 10/4/21 measured 4.3 centimeters (cm) x 2.4 cm, and no depth, with inflammation, redness, and possible infection. On 10/11/21, the wound measured 8.0 cm x 4.0 cm and a depth of 0.5 cm. […]

• Immediate jeopardy, patternF689Sep 13, 2021

  Based on observation, record review, and staff interview the facility failed to provide adequate supervision for 1 of 4 sampled (Resident #1) for elopement. On 8/7/21 at 2:00 p.m., Resident #1 who had cognitive impairment eloped from the facility without staff knowledge. The staff reported the alarms failed to sound. The facility failed to fully repair a door alarm known to not function prior to the elopement. The facility failed to thoroughly investigate the root cause of the elopement. The failures resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported 5 resident had cognitive impairments and independently mobile. The facility reported a census of 50 residents. […]

• Immediate jeopardy, isolatedF689Jul 3, 2024

  Based on observation, interview, facility investigation review, and facility policy review the facility failed to ensure a severely cognitively impaired resident identified at risk for elopement, with wandering behaviors free from elopement on 4/30/24. The resident went through a set of double doors into a common area by the beauty salon, went through a door into the unoccupied assisted living portion of the facility when the keypad was disengaged, and exited through a third door present on the unoccupied assisted living portion of the facility which lead directly to the outside of the facility. […]

• Immediate jeopardy, isolatedF684Sep 7, 2023

  Based on observation, interviews, clinical record review, and hospital record review the facility failed to ensure residents are provided assessments and care in accordance with professional standards of practice when they failed to consistently, properly assess, and document changes in condition for a resident who had required immediate transfer to a hospital for septic shock. Also, the facility failed to consistently follow the following physician's order for another resident with a known history of Congestive Heart Failure; weigh resident daily and notify the physician for a three-pound weight gain. The facility staff did not consistently assess this resident or document for this resident with the weight gains. The resident had frequent hospitalization s as a result of fluid overload. […]

• Immediate jeopardy, isolatedF689Sep 7, 2023

  Based on clinical record review, staff interview, facility investigation review, and facility policy review, the facility failed to ensure safe transfer of a resident via Hoyer (mechanical) lift and failed to ensure a resident remained free from a preventable accident for two of four residents reviewed for accidents (Resident #37, Resident #39). On 3/12/23 the strap to the Hoyer sling ripped and Resident #39 fell approximately 3 feet during a Hoyer lift transfer. Resident #39's fall on 3/12/23 required transfer to the hospital. On 6/22/23 Resident #39 was lowered to the floor due to the Hoyer lift hydraulic breaking and the lift tipped. On 7/18/23, Resident #39 fell from the Hoyer when the sling broke. […]