Woodlyn Heights Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Mar 15, 2023

  Based on interview and document review the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) and did not initiate cardiopulmonary resuscitation (CPR) according to the resident's wishes identified on the POLST of record for 1 of 3 residents (R1) who wished to have CPR. This has the potential to effect all 43 residents who had (CPR status) in the facility. The facility immediately implemented corrective action, so the Immediate Jeopardy (IJ) was issued at past noncompliance. The immediate jeopardy began on [DATE], at approximately 11:15 p.m. when R1 had no respirations or pulse, and CPR was not initiated. […]

• Actual harm, isolatedF695Jul 17, 2024

  Based on interview and record review, the facility failed to provide the ordered respiratory care and obtain an order to administer oxygen for one of one resident (R1) reviewed for respiratory status. R1 was harmed when he was admitted to the facility with an order to provide respiratory chest physiotherapy three times a day, was not provided the ordered therapy, contributing to R1's death. In addition, R1 received oxygen therapy without a physician order. Findings include: R1's medical record indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. R1's additional diagnoses included bronchiectasis, dysphagia, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). R1 was discharged from the facility on [DATE]. […]

• Actual harm, isolatedF760Jul 13, 2022

  Based on interview and document review, the facility failed to develop and implement a system for accurate transcription of physician and medication orders for 1 of 1 residents (R4) with a history of [CONDITION(S)] (CHF) who had medication omitted for 26 days, was subsequently hospitalized , and had a decline in activities of daily living (ADLs) as a result of the missed administration of medication resulting in harm. The facility further failed to ensure an International Normalized Ratio (INR a standard lab test used when taking blood-thinning medications) result was sent to the provider and obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF725Dec 31, 2025

  Based on observation, interview and document review, the facility failed to provide adequate nursing staff to meet assessed resident needs for 1 of 1 residents (R29) reviewed for restorative nursing; 1 of 1 residents (R43) reviewed for activities of daily living (ADLs); and 12 residents (R3, R14, R18, R29, R82, R33, R39, R5, R44, R57, R67, R74) and 3 staff members (NA-F, NA-E, NA-H) who voiced concerns with a lack of staffing. The lack of sufficient nursing staffing had the potential to affect all 46 residents in the facility. Findings include:RESTORATIVE PROGRAM:R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no rejection of care behaviors during the look-back period (LBP). The MDS indicated R29 had impaired ROM on both lower extremities. […]

• No harm, potential for more than minimal, widespreadF812Dec 31, 2025

  Based on observation, interview, and document review, the facility failed to perform adequate testing, per the manufacturer's instructions, to ensure proper sanitization of dishware used for meal preparation and meal service when using a low-temperature dishwashing machine. This had the potential to affect all 65 residents residing in the facility. Findings include: The National Sanitation Foundation (NSF) Data Plate for dishwasher Model ADC-44 dated 12/1/11, indicated that if the dishwasher was utilizing chemical sanitizer, the sanitizer required was 50 parts per million (PPM) of available Chlorine.An undated Ecolab Chlorine Test Paper (ECTP) instruction card, indicated that to test for PPM of free available chlorine, the strip should be dipped into the solution and immediately compared… […]