Woodside Lutheran Home

In the surveyor’s words

From the most serious findings on record at Woodside Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jan 18, 2022

  Based on record review and staff interview, the facility did not promptly consult with a physician after 1 Resident (R) (R1) of 1 resident reviewed choked on medication and was administered the [MEDICATION(S)] Maneuver and after a chest x-ray revealed bilateral upper lobe infiltrates. On the 10/24/21 AM shift, RN (Registered Nurse)-C performed the [MEDICATION(S)] maneuver after R1 choked on medication. RN-C did not notify a physician, R1's POA (power of attorney) (FM (Family Member)-H) or on-coming staff that the [MEDICATION(S)] maneuver was performed. R1 complained of rib pain and developed a wet cough on the 10/24/21 PM shift. A chest X-ray showed infiltrates (white spots that indicate an infection) in R1's lungs. […]

• Immediate jeopardy, isolatedF684Jan 18, 2022

  Based on record review and staff interview, the facility did not provide the necessary care and services according to professional standards of practice to maintain the highest practicable physical well being when a change in condition occurred for 1 Resident (R) (R1) of 1 resident reviewed. On the 10/24/21 AM shift, RN (Registered Nurse)-C performed the [MEDICATION(S)] maneuver after R1 choked on medication. RN-C did not notify a physician, R1's POA (power of attorney) (FM (Family Member)-H) or on-coming staff that the [MEDICATION(S)] maneuver was performed. Therefore, assessment and monitoring procedures were not initiated to detect and monitor for signs and symptoms of aspiration pneumonia and internal injury to ensure timely treatment if needed. […]

• No harm, potential for more than minimal, patternF761Jul 31, 2024

  Based on observation, staff interview, and record review, the facility did not ensure medications for 11 Residents (R) (R33, R404, R28, R21, R6, R76, R47, R65, R44, R15 and 26) of 11 residents in 4 of 8 medication carts and 3 of 5 treatment carts were stored, labeled, and/or dated appropriately. In addition, the facility did not ensure alcohol wipes, sterile syringes, and other medical supplies that were stored in 3 of 5 medication rooms were discarded after they expired Medication carts, treatment carts, and medication rooms contained opened, undated, unlabeled, and/or expired stock medication, treatment supplies, and prescribed medication for R33, R404, R28, R21, R6, R76, R47, R65, R44, R15, and R26. […]

• No harm, potential for more than minimal, patternF689Aug 3, 2022

  Based on staff interviews and record review, the facility did not ensure a Resident (R) with an unwitnessed fall had neurological checks completed to screen for subdural hematoma (blood collection on surface of the brain) for 5 (R8, R56, R354, R36, and R6) of 6 residents reviewed for falls. The facility did not implement their policy to consistently complete neurological checks and/or vital signs after R8 had unwitnessed falls on 5/8/22, 6/20/22, 7/19/22, and 7/20/22. The facility did not implement their policy to consistently complete neurological checks after R56 had an unwitnessed fall on 6/2/22 that resulted in an ankle fracture. The facility did not implement their policy to consistently complete neurological checks after R354 had an unwitnessed fall on 12/29/21, 1/5/22, and 2/5/22. […]

• No harm, potential for more than minimal, isolatedF880Sep 24, 2025

  Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R61) of 1 sampled resident.R61 had an indwelling urinary catheter. Enhanced barrier precautions (EBP) were not implemented for R61. In addition, staff provided high-contact resident care without donning the appropriate personal protective equipment (PPE).Findings include:The facility's Enhanced Barrier Precautions policy, dated 2/3/25, indicates: This policy is implemented for the prevention of transmission of multidrug-resistant organisms (MDROs) .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to… […]