Advena Living on Woodlawn

Inspectors wroteThe facility identified a census of 72 residents. The sample included eight residents with three reviewed for falls. Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for Resident (R) 1. On 12/15/25 at 03:15 PM, per camera footage, Certified Nurse Aide (CNA) M propelled R1 in a wheelchair without the use of foot pedals, down an incline when the resident's right foot dropped under the wheelchair, where it became entangled, causing R1 to fall to the floor. This resulted in a right femur (thigh bone) fracture.

Inspectors wroteThe facility had a census of 72 residents. The sample included eight residents, with three residents reviewed for involuntary discharge. Based on interview and record review, the facility failed to provide a complete recapitulation of Resident (R) 3's stays in the facility, including medication reconciliation, and further failed to ensure the involuntary discharge notice included the required information.

Inspectors wroteThe facility had a census of 72 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with interventions to address the care for Resident (R) 2.

Inspectors wroteThe facility had a census of 72 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Residents (R) 2 and R4, who did not receive medications as ordered.

Inspectors wroteThe facility reported a census of 70 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.

Inspectors wroteThe facility reported a census of 70 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment in two of the three shower rooms when the facility failed to ensure the walls remained free of any mildew, or unknown and unintended substances. Additionally, the facility failed to ensure the smoking courtyard and main entrance entry way area was maintained in a sanitary manner that included proper disposal of cigarette butts. This placed the affected residents at risk for decreased quality of life.

Inspectors wroteThe facility reported a census of 70 residents. The sample included 12 residents with six residents reviewed for abuse. Based on observation, interview and record review, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and mistreatment. This deficient practice placed the resident at risk for fear and decreased quality of life.

Inspectors wroteThe facility reported a census of 66 residents. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for five Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate care and services provided to the residents of the facility. The facility identified five CNAs employed for more than a 12-month period. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility reported a census of 66 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility reported a census of 66 residents. Five Certified Nurse Aide (CNA) staff, CNA S, CNA II, CNA LL, CNA MM, and CNA NN, who worked in the facility for over a year, were reviewed for the required annual in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 hours per year. Five CNAs lacked the required training topics, and five CNAs lacked the required 12 hours per year of in-service training.

Inspectors wroteThe facility reported a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with six residents observed for accidents and hazards. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards when multiple residents had lighters in their rooms. Additionally, R45 had unsecured medications and R52 had an unsecured 1.75-liter bottle of vodka along with firecrackers and a two-inch pocketknife. Additionally, the facility failed to store chemicals in a secure safe manner. These failures placed the affected residents at risk for preventable accidents and related injuries.

Inspectors wroteThe facility reported a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to ensure staff utilized acceptable infection control practices to mitigate the spread of infections when staff failed to cover clean clothes left in the folding area, and under areas with noted debris and insulation. The facility staff failed to utilize enhanced barrier precautions (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing a dressing change for Resident (R) 52 and additionally failed to use EBP for R39 when staff administered a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). [...]

Inspectors wroteThe facility reported a census of 66 residents which included a sample of three residents identified by the facility with Medicare Part A stay termination of benefits before exhaustion of Medicare Part A 100-day benefit period. Based on interviews and record review, the facility failed to provide two residents with the Centers for Medicare and Medicaid Services (CMS) form CMS- 10055 Skilled Nursing Facility Advanced Beneficiary Notice [ABN], which provides the recipient with the information related to the right to choose continued services and associated charges for continued skilled services after termination of Medicare Part A services for Resident (R) 13 and R121. This placed the residents at risk for uninformed decisions and unanticipated costs regarding skilled services.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to two residents, Resident (R) 28, and R69, and/or their representative at the time of the residents' transfers to the hospital. This placed the residents at risk for impaired ability to return to the facility in the same room.

Inspectors wroteThe facility reported a census of 66 with 18 in the sample, which included Resident (R)2 reviewed for Preadmission Screening and Resident Review (PASARR). Based on observation, interviews, and record review the facility failed to obtain a PASARR Level 2 for R2. This placed R2 at risk for unidentified care needs and impaired quality of care.

Inspectors wroteThe facility reported a census of 66 residents. The sample included 18 residents reviewed for comprehensive care plans. Based on observation, interview, and record review the facility failed to review and revise comprehensive care plans for Residents (R)43 related to bathing. This placed the resident at risk for poor hygiene due to uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility reported a census of 66 residents. The sample included 18 residents with seven dependent residents reviewed for activities of daily living (ADLs). Based on observation, interview, and record review the facility failed to provide necessary services in accordance with their preferences and in keeping with their plan of care for Resident (R)43, R51, and R28. This placed the affected residents at risk for decreased quality of care. Findings Included: [...]

Inspectors wroteThe facility reported a census of 66 residents which included 18 residents sampled, which included two residents reviewed for functional equipment. Based on interview, observation, and record review, the facility failed to ensure Resident (R)29 and R2's bed was in safe and operable condition. This deficient practice placed the residents at risk for discomfort and decreased safety.

Inspectors wroteThe facility reported a census of 66 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly, and in a sanitary condition, ensuring the lids were down to cover the disposed waste.

Inspectors wroteThe facility reported a census of 69 residents, with five residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired Resident (R) 1, identified at high risk for elopement. On 05/06/24 at 07:09 PM the charge nurse let R1 out the front doors of the building not realizing he was not allowed out the front doors to smoke. When R 1 went out the doors his WanderGuard (a bracelet that sets off an alarm when a resident wearing one attempts to exit the building without an escort) caused the alarm to activate, and the charge nurse located a CNA to turn off the alarm. The CNA did not check which resident cause the alarm to activate before or after turning off the alarm. [...]

Inspectors wroteThe facility reported a census of 66 residents with one resident sampled for sexual abuse. Based on observation, interview and record review, the facility failed to report an allegation of abuse by one Resident (R)1, when he made an allegation of sexual abuse.

Inspectors wroteThe facility reported a census of 60 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility.

Inspectors wroteThe facility reported a census of 60 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.

Inspectors wroteThe facility reported a census of 60 residents with 18 selected for review. Based on observations, interviews, and record review the facility failed to sanitize a multi-resident use glucometer (a device that measures the amount of sugar in the blood) in an appropriate manner, failed to provide sanitary catheter care of two Residents (R)28 and R15, failed to provide sanitary dressing changes for R53, R64, and R15, failed to maintain oxygen tubing in a sanitary manner for R21, and failed to store personal protective equipment in a sanitary manner.

Inspectors wroteThe facility reported a census of 60 residents. Based on observation, record review, and interview, the facility failed to provide necessary maintenance services for the kitchen floor and floors on the resident 400 halls and one resident room on 400 hall to provide a safe, functional, and sanitary environment.

Inspectors wroteThe facility reported a census of 60 residents. Based on interview and record review the facility failed to ensure residents had opportunities for COVID boosters.

Inspectors wroteThe facility reported a census of 60 residents with 18 selected for review, which included two residents reviewed for personal property. Based on observation, interview, and record review, the facility failed to ensure a completed inventory for one Resident (R)119.

Inspectors wroteThe facility reported a census of 60 residents with 18 residents sampled. Based on interview and record review, the facility failed to complete a comprehensive assessment for one Resident (R)50, by the failure to complete triggered Care Area Assessments (CAA).

Inspectors wroteThe facility census totaled 60 residents with 18 included in the sample. Based on interview and record review the facility failed to complete discharge tracking assessments when two residents were discharged from the facility. Resident (R) 17, R25.

Inspectors wroteThe facility census totaled 60 residents with 18 included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for two Residents (R)45 regarding pain and R65 for the lack of communication between the facility and the dialysis center.

Inspectors wrote- Resident (R) 21's signed Physician Orders dated 07/01/23 revealed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), morbid obesity (the state or condition of being very fat or overweight), and chronic resp failure (lungs are unable to provide the body with enough oxygen). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required total assistance of two to three staff for all daily cares. The resident had shortness of breath with all activities. [...]

Inspectors wroteThe facility reported a census of 60 residents with 18 residents sampled, including three residents reviewed for Activities of Daily Living (ADL's). Based on observation, interview, and record review, the facility failed to provide appropriate ADL assistance to one dependent Resident (R)28, regarding facial shaving and nail care.

Inspectors wroteThe facility reported a census of 60 residents with 18 selected for review, which included three residents reviewed for urinary tract infection/urinary catheter. Based on observation, interview, and record review, the facility failed to provide sanitary catheter care as ordered by the physician for one Resident (R)15.

Inspectors wroteThe facility census totaled 60 residents with 18 included in the sample, and one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure that Resident (R) 21's oxygen (O2) tubing was maintained and documented, and the resident received the ordered O2 therapy.

Inspectors wroteThe facility reported a census of 60 residents with 18 residents sampled, including one resident reviewed for dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney). Based on observation, record review, and interview the facility failed to ensure coordination of care between the dialysis center and the facility, for one Resident (R) 65, regarding a lack of regular dialysis communication sheets, with the facility.

Inspectors wroteThe facility reported a census of 60 residents with 18 selected for review and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed up on the pharmacy recommendation to complete the Abnormal Involuntary Movement Scale (AIMS) for three Residents (R) 15, R28 and R50 to ensure the residents did not experience adverse effects from psychoactive (medications used to treat severe mental disorders) medications.

Inspectors wroteThe facility reported a census of 60 residents with 18 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor three Residents (R)15, R 28 and R 50 for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms).

Inspectors wroteThe facility census totaled 65 residents. Based on observation, interview, and record review the facility failed to protect female resident in the facility when staff failed to adequately monitor Resident (R)30 after an allegation of resident to resident sexual abuse (reported to the facility involving R30 and R7) on the evening of 11/18/21. Less than eight hours later, and after the facility implemented 15-minute checks, leading to a subsequent allegation of resident to resident sexual abuse alleging R30 went into R69's room for 30 to 45 minutes (as reported by R30) in the early morning of 11/19/21. R69 reported feeling unsafe and stated a man came into her room and she fought him off and said no. This deficient practice placed R69, and the other female residents in the facility in immediate jeopardy.

Inspectors wroteThe facility reported a census of 65 residents who all received their meals from one main kitchen. Based on observation, interview and record review the facility failed to prepare and serve food in a sanitary manner by the observation of roaches in the food prep area, on steam table and on plates used for the noon meal. This had the potential to affect all residents in the facility.

Inspectors wroteThe facility reported a census of 65 residents. Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of live cockroaches.

Inspectors wroteThe facility census totaled 65 residents with 11 residents reviewed for Minimum Data Set assessments later than 120 days, with no assessment completed. Based on interview and record review the facility failed to complete Quarterly MDS assessments as required by State and Federal regulations not less frequently than once every three months for 10 residents who had quarterly assessments due and not completed. Resident (R) 7, R9, R8, R3, R6, R5, R2, R14 and R4.

Inspectors wroteThe facility reported a census of 65 residents with 16 included in the sample. Based on observation, interview, and record review the facility failed to include the resident in the development and planning of the resident's care plan and failed to have regular care plan meetings for Resident (R) 49.

Inspectors wroteThe facility census totaled 65 residents with 11 reviewed for Minimum Data Set assessments later than 120 days with no assessment completed. Based on interview and record review the facility failed to complete a comprehensive MDS assessment by the due date of 10/19/21 for Resident (R)10.

Inspectors wroteThe facility reported a census of 65 residents with 16 sampled which included two for respiratory care. Based on observation, interview, and record review the facility failed to provide safe and sanitary care for oxygen tubing to help prevent the development and transmission of diseases and infections for both Resident (R) 64, and R69. Findings Included: - R64's Electronic Health Record (EHR) documented the diagnosis of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 02/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental status (BIMS) of 15, indicating intact cognition. The 02/02/21 Care Plan documented R64 had COPD. Staff were to monitor R64 for signs or symptoms of acute respiratory insufficiency and respiratory infection. [...]

Inspectors wroteThe facility census totaled 65 residents, with 16 included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to provide pharmaceutical services by the failue of staff to administer insulin (a hormone which regulates blood sugar) according to the physician orders to Resident (R)51. Findings Included: - The Physician Orders in the Electronic Health Record (EHR) documented R51 with a diagnosis of type 2 diabetes (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R51 received insulin daily. [...]

Inspectors wroteThe facility reported a census of 65 residents, with 16 included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified and reported missing documentation concerning the lack of administration of Tresiba (very long acting insulin) insulin (a hormone which regulates blood sugar) for R51 and missing blood sugar documentation for R11.

Inspectors wroteThe facility census totaled 65 residents, with 16 included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the adequate monitoring of insulin, when staff did not obtain physician ordered blood glucose (blood sugar) levels for three diabetic residents: Resident (R)11, R29 and R49. The facility also failed to ensure adequate monitoring of antihypertensive medication when staff did not obtain pulses prior to administration of Carvedilol for R29.

Inspectors wroteThe facility reported a census of 65 residents. Based on observation, record review, and interview the facility failed to properly date an opened tuberculin vial (a purified protein derivative used in a skin test to help diagnose tuberculosis infection in persons at increased risk of developing active disease). The facility further failed to remove a package of two promethazine (used to treat allergy symptoms, nausea and vomiting, or used a sedative to help with sleep) suppositories (medication that is inserted into the rectum to be broken down and absorbed by the body) with an expiration date of [DATE].

Inspectors wroteThe facility reported a census of 65 residents. Based on observation, interview, and record review the facility failed to ensure nursing staff use Personal Protective Equipment (PPE) appropriately to reduce the risk of spread of infectious diseases. Findings Included: - On 11/18/21 at 08:11 AM, observation revealed Licensed Nurse (LN) E entered R64's room with just a mask on. R64 was on Transmission Based Precautions (TBP, the second tier of basic infection control and are to be used in addition to Standard Precautions) from her recent hospital stay. LN E entered the room and talked to the resident, put R64's O2 mask on and adjusted it. LN E then left the room and used hand sanitizer from the hall dispenser. There was a sign instructing the staff to don PPE and a PPE supply cart located outsideof R64's room. There were 2 bins in R64's room for trash and linens. [...]