Woodlawn Rehabilitation & Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, the facility failed to report an injury of unknown origin for a fracture identified on 5/15/26 to Licensing and Certification or Adult Protective for 1 of 1 resident reviewed for fractures. (Resident #1 [R1]).

Inspectors wroteBased on record review, facility Abuse Policy review, and interview, the facility failed to ensure that an investigation was completed for an undetermined injury of unknown origin (fracture of left arm) identified on 5/15/26 for 1 of 1 resident reviewed for fractures (Resident #1 [R1]).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the confidentiality of protected resident health information when a resident's electronic medication profile and residents' written medication information was left unattended on a medication (med) cart and a nursing assignment sheet containing resident health information was left unattended on the nurses' station countertop, leaving the residents' health information visible and accessible to residents and visitors on 1 of 2 units (West Unit).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the resident's environment remains free of accident hazards by failing to clean up spilled liquids on an ambulatory resident's floor on 1 of 2 units observed during a complaint investigation (West Unit). Additionally, the facility failed to ensure that a metal threshold plate at an entrance used by residents was properly secured, creating a tripping hazard with the potential to affect multiple residents.

Inspectors wroteBased on observation, interviews, and facility policy, the facility failed to ensure medications were stored properly on 1 of 2 units (West unit).

Inspectors wroteBased on interviews, and record review, the facility failed to follow their standing orders for bowel management for 1 of 3 residents reviewed for bowel management resulting in the resident having to be transferred to the hospital. (Resident #1)

Inspectors wroteBased on record review and interviews, the facility failed to obtain lab services in a timely manner for 1 of 1 resident reviewed for lab orders. In turn, this led to the resident needing to obtain treatment and receive care in the emergency room (ER). (Resident #1).

Inspectors wroteBased on observation and interview, the facility failed to ensure that emergency cart equipment and supplies were maintained in a clean, safe and ready-to-use condition for 1 of 1 emergency cart reviewed.

Inspectors wroteBased 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. Failure to install, maintain, and or operate this washer according to the manufacturer's instructions may result in conditions which can produce bodily injury and or property damage. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations and interview, the facility failed to provide a safe and comfortable environment for 1 of 6 residents reviewed for accidents (Resident #24 [R24]). In addition, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a safe, sanitary, orderly, and comfortable environment on 2 of 2 units (East and West) and the main lobby for 1 of 1 facility tour (7/31/25). 1. On 7/28/25 at 2:30 p.m., during an interview with two surveyors and the Maintenance Director, R24's bed chord was observed crossing the floor from the foot of the bed to the opposite wall and confirmed to be a trip hazard. On 7/29/25 at 3:30 p.m., during an observation with two surveyors, the Licensed Practical Nurse (LPN1) and the Maintenance Director, the following was observed and confirmed in room [ROOM NUMBER]: [...]

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to update/implement interventions on the current comprehensive care plan for the areas of smoking for 1 of 2 residents reviewed for smoking (Resident [R]43), hearing aids and dental for 1 of 1 resident (R17) reviewed, nutrition for 1 of 2 (R1) residents reviewed, and mobility for 1 of 2 (R19) residents reviewed. 1. Review of R1's care plan updated 7/10/25 states Monitor and document intake and output as per facility policy. Review of R1's Nutrition: amount eaten lacked documented intakes during: Breakfast on 7/1/25, 7/6/25, 7/19/25, 7/20/25, 7/22/25, 7/23/25, 7/24/25, 7/30/25 Lunch on 7/1/25, 7/3/25, 7/6/25, 7/9/25, 7/14/25, 7/17/25, 7/23/25 Dinner on 7/11/25, 7/13/25, 7/27/25, 7/30/25 During an interview on 7/30/25 at 4:15 p.m., the above was discussed with Director of Nursing (DON). 2. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were stored in a locked compartment for 1 of 3 medication areas (East Medication Storage Room), opened insulin was labeled with an open date, and expired medications were removed from the available for use supply in 2 of 3 medication storage rooms (West Medication Storage Room and East Medication Storage Room). [...]

Inspectors wroteBased on observations, interviews, and review of the facility's Food Storage policy/procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the three-bay pot sink and the walk-in freezer. Additionally, the facility failed to ensure foods were dated and/or discarded after best used by date in the walk-in refrigerator and on a beverage cart on a unit for 2 of 2 tours (7/28/25, and 7/29/25). The facility's Food Storage policy/procedure, dated 3/4/25, noted under Procedure: …All containers or storage bags must be legible and accurately labeled and dated. Refrigerated Food Storage: All foods must be covered, labeled, dated and routinely monitored to assure foods are used by their use by dates or discarded. 1. On 07/28/25 from 11:10 a.m. to 11:55 a.m., two surveyors completed an initial kitchen tour in which the following

Inspectors wroteBased on observations and interviews, the facility's laundry room and equipment presented safety hazards to the employees by having a frayed/ripped power supply wire for the washing machines for 3 of 4 days of survey (7/28/25, 7/29/25, and 7/30/25) by not having safe and properly functioning washing machines for 2 of 2 washing machines and for having broken floor tiles for 4 of 4 days of the survey (7/28/25, 7/29/25, 7/30/25, and 7/31/25). On 7/30/25 at 9:05 a.m., a surveyor observed the following in the laundry room:- The entire laundry room tiled floor was heavily soiled with dirt. - There were approximately 16 cracked/broken and loose floor tiles, creating a trip hazard for staff. - There was exposed/untreated cement flooring in front of, to the sides of, and behind the two washing machines.- The control panel on the left washing machine was missing 4 buttons. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide education and/or obtain informed consent from a resident's representative regarding the use of bed rails for 1 of 6 residents reviewed for accidents (Resident #7 [R7]). On 7/30/25, R7's clinical record was reviewed and indicated the following:On 4/30/24, R7 completed an advanced directive identifying a representative to make medical decisions on his/her behalf. On 6/20/25, R7 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. On 6/30/25, Informed Consent Regarding Side Rail Usage was provided to R7 to sign, indicating having considered all of the above (Risks in the use of side rails), I hereby consent to rails. The clinical record lacked evidence that education was provided for the resident representative to give informed consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) which included the participation of the resident and resident's representative after a Minimum Data Set (MDS) Quarterly Assessment, for 1 of 17 residents whose care plans were reviewed (Resident #2 [R2]). A clinical record review indicated R2 was admitted in 2021. The latest MDS Quarterly assessment was completed on 5/16/25. A review of R2 clinical record lacked evidence that a care plan meeting was held at any point as of 7/31/25 by the IDT that included, to the extent possible participation of R2 and/or his/her representative to review the Care Plan. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's right to formulate an advanced directive regarding code status (indicates the type of medical interventions to receive, such as cardiopulmonary resuscitation [CPR] in the event of a medical emergency) was accurate in the resident electronic clinical record for 1 of 7 residents reviewed for advanced directives (Resident #24 [R24]). On [DATE], Resident #24 medical record was reviewed. The electronic record indicated a code status of DNR/DNI (Do Not Resuscitate / Do Not Intubate). The electronic record and the paper chart also contained a Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicates a code status of Attempt Resuscitation/CPR. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an Interdisciplinary Care Plan Meeting (IDT) was held within 7 days after a Minimum Data Set (MDS) for 1 of 17 residents reviewed (Resident [R]17). Review of Resident [R]17 clinical record revealed Minimum Data Set (MDS) dated [DATE]. Further review of R17 clinical record revealed an Interdisciplinary Meeting (IDT) meeting was held 7/28/25 (17 days late). During an interview on 7/29/25 at 3:00 p.m., the Social Services Director (SSD) stated she is supposed to schedule IDT meetings within 7 days of the MDS completion. At this time SSD confirmed R17's IDT meeting was held yesterday (7/28/25). SSD stated she originally scheduled the meeting for 7/24/25 (6 days late) but thinks the family couldn't make it on the 24'th so it was rescheduled to 7/29/25. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure hearing aids were in use for 1 of 1 resident reviewed for communication (Resident #[R] 17). Observations of R17 on 7/28/25, 7/29/25 and 7/30/25 lacked evidence of hearing aid use. Review of R17 care plan updated 7/17/25 states Communication: ensure hearing aids are place appropriately .Review of R17 New admission Personal Item Inventory dated 10/13/24 states [he/she] was admitted with both left and right hearing aids. Interview on 7/30/25 at 1:10 p.m., Licensed Practical Nurse #2 (LPN2) stated [he/she] was not aware that R17 had hearing aids. During an interview on 7/30/25 at 1:05 p.m., R17 stated [he/she] does have hearing aids, and they are in a box in [his/her] room, [his/her] sister mailed batteries, but [he/she] can't get them in and is waiting for someone to help [him/her]. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection on 2 of 4 days of survey (7/28/25 and 7/29/25). On 7/28/25 at 11:45 a.m., a surveyor observed Resident #24 (R24)'s oxygen tubing labeled 7/28/25, connected to an oxygen concentrator. The filter on the concentrator was observed to be heavily soiled with dust/debris. On 7/29/25 at 3:30 p.m., during an interview with two surveyors and the Licensed Practical Nurse (LPN1), R24's oxygen concentrator was observed to have new tubing related to the addition of humidification dated 7/29/25. The nasal cannula tubing was observed to be dated 7/28/25. The concentrator filter was observed to be heavily soiled with dust/debris. LPN1 stated the filter should be washed with tubing changes. [...]

Inspectors wroteBased on observations and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for two trash receptacles for an area outside by a dumpster for 1 of 4 days of survey (7/28/25). On 07/28/2025 from 11:10 a.m. to 11:55 a.m., two surveyors completed an initial kitchen tour in which the following finding was observed: - There were two of three, approximately 30 to 40 gallon trash receptacles, that had the swing lids open and exposed trash hanging out. On 7/28/25 at 11:55 a.m., in an interview with a surveyor, the Food Service Director confirmed the findings.

Inspectors wroteBased on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 records reviewed (Resident #1 [R1]). R1 is has diagnoses to include paraplegia, Chronic kidney Disease (CKD) and Diabetes Mellitus (DM). Review of R1's care plan updated 7/10/25 states Monitor and document intake and output as per facility policy. Review of R1's Nutrition: amount eaten lacked evidence of documented intakes during:-Breakfast on 7/1/25, 7/6/25, 7/19/25,7/20/25, 7/22/25, 7/23/25, 7/24/25, 7/30/25-Lunch 7/1/25, 7/3/25, 7/6/25, 7/9/25,7/14/25, 7/17/25, 7/23/25-Dinner 7/11/25, 7/13/25, 7/27/25, 7/30/25. During an interview on 7/30/25 at 4:15 p.m., the above was discussed with Director of Nursing.

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).

Inspectors wroteBased on record review and interviews, the facility failed to monitor and document targeted behaviors to support the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #37 [R37]).

Inspectors wroteBased on record review, interviews and observations the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide enhanced barrier precautions (EBP's) pertaining to Resident's with urinary Foley catheters, and multi drug resistant organisms [MDRO] for 2 of 3 days of survey (8/26/24, and 8/27/24).

Inspectors wroteBased on interviews, and record review the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic.

Inspectors wroteBased on interview, the facility failed to ensure that the facility's Infection Preventionist (IP) had completed specialized training prior to starting the IP position.

Inspectors wroteBased on record reviews and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 3 residents reviewed for advanced directives (Resident #20 [R20] and R31).

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure an injury of unknown origin was investigated and reported to appropriate state agencies timely for 1 of 3 facility reported incidents reviewed (Resident #12 [R12]).

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to update/implement care plans for a resident diagnosed with Coronavirus (COVID-19) (Resident #191 [R191]).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to update/implement care plans for isolation precautions for 1 of 1 care plans reviewed for isolation precautions (Resident #26 [R26]). In addition, the facility failed to update/implement goals and interventions for 1 of 1 resident reviewed for a cardiac pacemaker (R37).

Inspectors wroteBased on record review, and interview, the facility failed to ensure that physician's orders were followed for 1 of 3 sampled residents receiving insulin coverage (Resident #19 [R19]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that tube feedings were administered according to provider orders for 1 of 1 resident observed for tube feeding (Resident #9 [R9]).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1 of 1 resident reviewed for respiratory care (Resident #38 [R38]).

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing information in a prominent place, readily accessible and visible to all residents, for 1 of 3 days of survey (8/26/24).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and records review, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 46 of 46 beds.

Inspectors wroteBased on interviews and observations, the facility failed to ensure that accommodations were made for residents that included call bells being within reach for 1 of 4 resident's (Resident #14), failed to ensure a bed was maintained and in working condition for 1 of 1 resident (Resident #15), and failed to ensure that accommodations were made to include the use of grab bars/side rails for a residents capable of using them for bed mobility and transfer assistance for 2 of 2 sampled residents accommodation of needs (Resident #16 and #25).

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 2 of 2 units (100's and 200's) for 2 of 2 environmental tours (3/15/23 and 3/16/23).

Inspectors wroteBased on record reviews and interviews, the facility failed to provide interventions outlined in the resident's care plan in the area of weights (Resident #12), in the areas of nutrition and safety (Resident #14), and in the area of respiratory for (Resident #15)

Inspectors wroteBased on observations, interviews, and Payroll-Based Journal (PBJ) review, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL)'s.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a ceiling vent and the ceiling. Additionally, the facility failed to ensure products in the walk-in refrigerator and walk-in freezer were labeled and dated, and failed to label whipped topping with a thaw date.

Inspectors wroteBased on facility policy, observations, and interviews, the facility failed to follow their own policy and failed to provide an environment to help prevent the development and transmission of disease and infection related to wound care (Resident #6). In addition, the facility failed to implement Infection Control Contact Precautions for a resident (Resident #6) diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) for 1 of 3 days of survey. (3/16/23). This has the potential to affect all 18 residents on the 100 unit.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the dignity of 1 of 2 resident's during a dressing change observation (Resident #6).

Inspectors wroteBased on record review and interview, the facility was unable to provide evidence that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055, which included appeal rights and liability of payment was provided at least 2 days prior to the resident's last covered day for 1 of 2 residents whose Medicare Part A services were discontinued, and the resident remained in the facility (#39).

Inspectors wroteBased on interviews, record review, and facility policy, the facility failed to ensure an injury of unknown origin was investigated timely for 1 of 2 facility reported incidents reviewed. (#193).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level 1 was accurately completed for 1 of 1 sampled resident reviewed for PASRR (#5).

Inspectors wroteBased on clinical record reviews (electronic and paper) and interviews, the facility failed to ensure Physician orders were followed and clarified for 1 of 1 sampled resident receiving antibiotics (Resident # 5). In addition, the facility failed to ensure a Physician order for weights were followed for 1 of 1 resident reviewed for Nutrition (Resident #12).

Inspectors wroteBased on observation and interview, the facility failed to maintain respiratory equipment consistent with the facilities Respiratory Therapy - Infection Control policy and procedure for 1 of 2 residents reviewed for respiratory care. (#8)

Inspectors wroteBased on observations and interviews, the facility failed to label both an Insulin pen and a Insulin vial that was available for use, with an open date, in 1 of 2 medication storage refrigerators. (Unit 200's)

Inspectors wroteBased on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 1 of 3 days of survey. (3/13/23)

Inspectors wroteBased on interviews and record review the facility failed to assist residents to organize and hold monthly Resident Council meetings for 17 of 17 residents reviewed for Resident Council.

Inspectors wroteBased on observation, interview, and record review the facility failed to post nurse staffing information on a daily basis including: the current date, resident census, and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 3 of 3 survey days.