Woodlawn Healthcare Center LLC

In the surveyor’s words

From the most serious findings on record at Woodlawn Healthcare Center LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Feb 19, 2026

  Based on interview, observation, and record review, the facility's water management plan failed to have an assessment documenting where Legionella or other opportunistic waterborne pathogens could grow and spread or to include interventions for when control limits were not met. This deficiency has the potential to affect the facility's census of 51 residents. Findings include:Review on 2/18/26 of facility policy titled Woodlawn Care Center Legionella Management Plan Policy and Procedure, revealed that there was no assessment identifying areas within the facility where Legionella or other opportunistic waterborne pathogens could grow and spread. Further review revealed that there were no established interventions for situations in which control limits were not met. […]

• No harm, potential for more than minimal, isolatedF582Feb 19, 2026

  Based on interview and record review, the facility failed to provide notifications of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 2 of 3 residents reviewed for Beneficiary Notification (Resident identifiers are #4 and #14).Findings include: Resident #4Review on 2/18/26 of the SNF Beneficiary Notification for residents who received Medicare Part A services (Form CMS-20052) revealed that the facility/provider initiated a discharge from Medicare Part A services for Resident #4 before the resident's benefit days were exhausted. Further review revealed that Resident #4 remained in the facility and that the last covered skilled services was 10/10/25. Resident #4 or Resident #4's representative was not provided the SNF ABN. […]

• No harm, potential for more than minimal, isolatedF688Feb 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents have the appropriate equipment to prevent a decrease in Range of Motion (ROM) for 1 of 1 resident reviewed for limited range of motion in a final sample of 13 residents (Resident identifier is #21).Findings include:Review on 2/18/26 of Resident #21's physician's orders revealed an order for OT [Occupational Therapy] Recommendation: B palm protectors [orthotic device] should be worn daily as tolerated to reduce contractures and skin breakdown. B palms should be cleaned and thoroughly dried before donning. The order had a start date of 12/30/25, and an end date of 3/24/26. Observation on 2/17/26 at 2:06 p.m. of Resident #21 revealed Resident #21 was sleeping in bed, both hands clenched. […]

• No harm, potential for more than minimal, isolatedF582Jan 14, 2025

  Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 1 of 3 residents reviewed for beneficiary notices (Resident identifier is #148.) Findings include: Review on 1/14/25 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #148 was discharged from Medicare Services on 9/2/24 to home or lesser care. Review on 1/14/25 of Resident #148's SNF Beneficiary Notification Review form revealed that Resident #148 was not provided a Notice of Medicare Non - Coverage (NOMNC) Form CMS - 10123 notice prior to discharge from Medicare Part A services. […]

• No harm, potential for more than minimal, isolatedF680Jan 14, 2025

  Based on interview and record review, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional for a facility census of 44 residents. Findings include: Interview on 1/13/24 at approximately 8:30 a.m. with Staff C (Activities Director) revealed that he/she started working at the facility as the Activities Director in April 2024. Interview on 1/14/24 at approximately 2:40 p.m. with Staff B (Administrator) confirmed Staff C had not completed a certification as a therapeutic recreation specialist and did not have 2 years of experience in a social or recreational program.