Woodlawn Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Woodlawn Rehabilitation & Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 22, 2026

  Based on clinical record review, and interviews, the facility failed to ensure a resident's safety during care resulting in the resident rolling out of bed to the floor and sustaining a fractured left humerus (long bone in upper arm) for 1 of 1 resident reviewed for fall and fracture.Finding: On 7/22/26, a review of R1's clinical record was completed. Documentation in a nursing note, dated 4/25/26, a statement made by Certified Nurse Assistant #1 (C.N.A.1), indicated that while C.N.A.1 was changing R1's bed sheets, R1 rolled out of bed onto the floor. On 4/25/26, documentation made at the Emergency Department (ED) indicated the resident was seen due to a fall out of bed. […]

• Actual harm, isolatedF689Apr 23, 2024

  Based on review of the Nursing Facility Reportable Incident Form, the facility's internal investigation, the facility transfers policy and procedure, and interviews, the facility failed to ensure a resident's safety during a Hoyer lift transfer which caused harm to the resident. The facility failed to follow their Hoyer lift policy and procedure which resulted in the resident falling to the floor from the Hoyer lift. From this fall, the resident sustained a closed head injury for 1 of 1 resident. Finding: On 4/12/24, The Division of Licensing and Certification received a facility Reportable Incident Form indicating that on 4/9/24 at 10:30 a.m. Certified Nursing Assistant #1 (CNA) transferred Resident #1 alone in the Hoyer lift. […]

• No harm, potential for more than minimal, widespreadF908Jul 31, 2025

  Based on observations, interviews, facility documentation and manufacturer's instructions, the facility failed to ensure that the laundry room equipment was maintained according to manufacturer's instructions and in a correct and safe operating condition for 4 of 4 days of survey (7/28/25, 7/29/25, 7/30/25 and 7/31/25). This has the potential to affect all residents.The manufacturer's instructions, dated 2007, noted in the Safety and Maintenance Instructions:10. Do not tamper with the controls.18. Keep the washer in good condition. 24. Never operate the washer with any guards and/or panels removed.25. DO NOT operate the washer with missing or broken parts. 26. DO NOT bypass any safety devices. 27. […]

• No harm, potential for more than minimal, widespreadF909Jul 31, 2025

  Based on observations and interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 37 of 37 beds. This has the potential to affect the safety of all residents.On 7/28/25 at 2:12 p.m., a surveyor observed in room [ROOM NUMBER], Resident #24 (R24)'s exposed bedframe at the head of the bed had a 4.83-inch wide by 4-inch long opening which created a risk for the entrapment of body parts. The foot of the bed had a 4-inch gap between the mattress and the footboard creating a risk for entrapment of body parts. The resident was not in bed at the time of the observation. […]

• No harm, potential for more than minimal, widespreadF801Mar 16, 2023

  Based on interviews, the facility failed to ensure the facility's Food Services Supervisor met the qualifications of a Certified Food Service Director(FSD). This has the potential to affect all the residents. Findings: On 3/13/23 at 9:00 a.m., in an interview, the Food Service Director (FSD) indicated that he has been the Food Service Director since December 2022. At this time, the FSD stated that he has no current qualifications for the job and that he is not currently enrolled in any qualifying course or a manager ServSafe course. On 3/13/23 at 9:50 a.m., in an interview, the surveyor discussed the finding with the Administrator. The surveyor asked for qualifications and dates of hire for the last two FSDs. None were provided as of the end of survey. […]