Woodland Terrace

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 4, 2024

  Based on observation, staff interviews, record review, and policy review, the facility failed to follow safety interventions for 1 of 3 residents reviewed (Resident #2). On 11/11/24 facility staff failed to position Resident #2's bed in the low position before leaving the resident unattended and alone in the room. The resident had an unwitnessed fall from the bed to the floor which resulted in a fracture of the right femur. The facility identified a census of 86 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. […]

• No harm, potential for more than minimal, patternF812Jun 25, 2026

  Based on observations, staff interviews, review of facility cleaning calendar, and facility policy review, the facility failed to ensure staff cleaned the stove top. The facility reported a census of 81 residents. Findings include:On 6/22/26 at 11:20 AM an initial tour revealed the Vulcan stove had a build-up of a thick black tacky substance covering the entire stove top. On 6/24/26 at 9:50 AM an observation revealed the Vulcan stove still had a build-up of a thick black tacky substance covering the entire stove top. On 6/24/26 at 9:55 AM Staff B, Cook, indicated they only cleaned the grates but didn't clean the stove top. Staff B also stated, We don't clean it. It's over [AGE] years old. I wouldn't want to start a fire by using a degreaser (grease remover). […]

• No harm, potential for more than minimal, patternF610Aug 27, 2025

  Based on clinical record review, policy review, facility investigation review and staff interview the facility failed to complete a thorough investigation after a Certified Nursing Assistant (CNA) reported physical abuse which occurred on the dementia unit affecting 24 of 25 residents (Resident #2, #3,#4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26). The facility reported a census of 87 residents.Findings include:A Facility Investigation Note submitted to the Iowa Department of Inspection, Appeals and Licensing (DIAL) detailed on 7/02/25 Staff A, Registered Nurse (RN) called to inform Staff B, Director of Nursing (DON) of an allegation of abuse. At 4: 30 AM, Staff C, Certified Nursing Assistant (CNA) went in to assist Resident #1. […]

• No harm, potential for more than minimal, patternF812May 8, 2025

  Based on observations, staff interviews, and policy review the facility failed to maintain a sanitary kitchen; failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. The facility reported a census of 86 residents. Findings include: During a continuous observation on 5/05/25 from 11:15 AM to 12:44 PM of meal service on second floor, Staff L, dietary, handling hamburger buns with her bare hands after touching her face and adjusting her shirt without performing hand hygiene for eight residents. At 11:43 AM after adjusting her glasses and not doing hand hygiene used her bare hands to slide food from one plate to another touching the food with her hands then serving it to a resident. […]

• No harm, potential for more than minimal, patternF800Feb 17, 2022

  Based on observation, facility document review, policy review, and staff interviews, the facility failed to perform hand washing between changing tasks, wear hairnets appropriately, utilize a clean barrier to prevent cross contamination on food surfaces, and reheat food to 165 degrees Fareheit or higher to prevent potential for forborne illness. The facility identified a census of 83 residents. Findings include: The following observations were observed on 2/15/22 with meal service being served by Staff H, Dietary Aide, in the Evergreen Arbor neighborhood. At 11:21 a.m. […]