Woodlyn Heights Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteDuring observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on a mobile medication cart in the long-term care unit. This had the potential to affect 11 residents (R7, R10, R12, R14, R15, R20, R31, R43, R55, R56, R60) whose personal information was left unattended on a medication cart in the hallway corridor.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident rooms were maintained at a comfortable temperature between 71- and 81-degrees Fahrenheit for 7 of 7 residents (R64, R4, R7, R38, R27, R29, R29) reviewed who indicated their rooms were cold. In addition, the facility failed to provide a homelike dining experience by serving meals on hard plastic trays for 1 of 1 resident (R29) reviewed for dining, which had the potential to affect all residents who ate in the dining room.

Inspectors wroteBased on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 1 of 5 residents (R9) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed provide appropriate side effect monitoring (i.e., orthostatic hypotension) with antipsychotic medication consumption for 1 of 5 residents (R9) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care and shaving) was completed and provided for 2 of 2 residents (R44, R43) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to consistently implement a restorative nursing program (RNP) to prevent a possible decrease in range of motion (ROM) for 1 of 1 residents (R29) reviewed for ROM.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow developed interventions for eating assistance to reduce the risk of aspiration or choking for 1 of 2 residents (R6) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure ordered nutritional interventions were provided to promote weight gain for 1 of 2 residents (R6) reviewed for nutrition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure pharmacist recommendations were acted upon timely for 1 of 5 residents (R9) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R4) reviewed for immunizations. Also, the facility failed to document shared clinical decision making for 2 of 5 residents (R16, R27) identified as needing or being offered an updated pneumococcal immunization per CDC's Recommendation of Adult Immunizations Schedule for Ages 19 Years or Older, United States, 2025, Revised October 7, 2025.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff were offered, and or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for 3 of 3 staff (LPN-A, LPN-B, HSK-A) reviewed for COVID-19 vaccinations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess potential signs of constipation to determine what, if any, interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R15); failed to comprehensively assess and develop interventions to ensure a consistent nursing approach with a developed, non-pressure skin condition for 1 of 2 (R5); and failed to ensure orders for a peripherally inserted central catheter (i.e. PICC line) were clarified and the line was managed in accordance with professional standards of care for 1 of 1 residents (R28) reviewed who had a PICC.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 4 of 4 residents (R5, R15, R32, R112) reviewed for dining. This had the potential to affect 35 residents identified to reside on the units with cold food complaints.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators and freezers was completed to reduce the risk of foodborne illness. This had the potential to affect approximately 10 residents who regularly consumed deli sandwiches from the facility kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 3 of 4 residents (R4, R12 and R28) whom resided on different wings of the care center.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 2 residents (R112) reviewed for Physician Orders for Life Sustaining Treatment (POLST) had the correct code status (i.e., full code, DNR) information outlined within the medical record. This could cause R112 to receive resuscitation efforts (i.e., CPR) against his wishes.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure privacy was maintained during the provision of personal cares for 1 of 1 resident (R4) observed to be receiving peri-care with their window blinds open to the outside parking lot.

Inspectors wroteBased on observation, interview and document review, the facility failed to clean and maintain a resident's wheelchair for 1 of 1 residents (R39) reviewed for safe, clean and homelike environment.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure nails were trimmed and cleaned for 1 of 1 resident (R9) who was dependent upon staff for cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively reassess after repeated refusals of a range of motion (ROM) program and, if needed, develop interventions to reduce the risk of mobility loss for 2 of 3 resident (R9 and R39) reviewed for ROM.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and, if needed, develop interventions to promote safety and reduce the risk of injury or impairment for 1 of 1 resident (R16) reviewed who had been attempting to order alcohol from a mobile delivery service (i.e., DoorDash).

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess a resident who had significant weight gain at the care facility (37%) in less than 1 year, and failed to care plan appropriate interventions to assist with weight loss goals for 1 of 2 residents (R51) reviewed for nutrition status.

Inspectors wroteBased on interview and document review, the facility failed to attempt a gradual dose reduction (GDR) or document a clinical rationale for not attempting for 1 of 5 residents (R51) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident personal fund accounts were insured with adequate surety bond coverage (a contract or promise by a surety or guarantor to pay a certain amount if a second party fails to meet the obligation) to cover the total account balance. This had potential to affect 20 residents identified to have an account with a positive balance.

Inspectors wroteBased on interview and document review, the facility failed to have a therapeutic recreation director (i.e., activities director) whom was successfully qualified and/or credentialed, as required, to ensure competent assessment and implementation of activities programming within the care center. This had potential to affect all 66 residents at the time of survey.

Inspectors wroteBased on interview and document review, the facility failed to ensure the posted nurse staffing information accurately displayed the total number/actual hours worked by the licensed staff for each shift on a daily basis. This had the potential to affect all 66 residents or visitors who wished to review the information.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure narcotic and controlled substance reconciliation was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft on 2 of 3 medication carts reviewed. This had the potential to affect 6 residents identified to have controlled substances in these carts which were reviewed during a facility-reported incident investigation for possible drug diversion.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment to two out of two residents (R2, R3) reviewed for environment. R4 had been playing his music loudly and R2 and R3 had complaints of not being able to hear their music or their televisions. Findings Include: During an observation in the 600 hallway on 7/15/24 at 11:01 a.m., R4 had his door to his room open and loud explicit music playing. This explicit music could be heard from the front entrance of the facility as well as in the other hallways. During an observation in the 600 hallway on 7/15/24 at 12:28 p.m., R4 had his door to his room open and loud music playing. This music could be heard from the front entrance of the facility as well as in the other hallways. R2's medical records printed on 7/16/24 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of cerebral palsy. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan to meet the residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for one of one resident (R1) reviewed for care plans. R1 was on dialysis, used tube feeding to get his nutrients, and had respiratory concerns, and activities of daily living and those care areas were not addressed on his care plan.

Inspectors wroteBased on interview and record review the facility failed to monitor and assess the hydration status for one of one resident (R1) reviewed for hydration. R1 had an order for tube feedings with direction to adjust the free water flushes pending hydration status one time a day and facility staff were not monitoring or assessing R1's hydration status.

Inspectors wroteBased on interview and record review the facility failed assess a resident before and after dialysis for one of one resident (R1) reviewed for dialysis.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medical record was accurately document vital signs and assessments for one of one resident (R1) reviewed for medical records. R1's treatment administration record (TAR) indicated R1 was to have a pre-and-post dialysis assessment done three days a week and all but three of those assessments were not completed. R1's vital signs were documented while he was not in the facility.

Inspectors wroteBased on interview and document review, the facility failed to offer a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties for 11 of 17 residents (R1, R2, R4, R5, R15, R17, R22, R28, R42, R47, and R48) reviewed for binding arbitration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure community use glucometers were properly cleaned and disinfected between patient use for 4 of 4 residents (R10, R47, R42, R35) to have their blood glucose checked with the devices. This had the potential to affect 25 of 69 identified in the facility with orders to obtain blood glucose monitoring. In addition, the facility failed to ensure a wound vac machine was kept off the floor for 1 of 1 residents (R176) reviewed for wound care. Glucometer disinfecting between residents Per manufacturer's instruction for use of Even Care G3 Blood Glucose Monitoring System in the Cleaning and Disinfecting section highlighted the EVENCARE G3 Meter should be cleaned and disinfected between each patient and to avoid wetting the meter test strip port. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to assess 2 of 2 residents (R10, R27) reviewed for the ability to self-administer medications (SAM).

Inspectors wroteBased on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 2 of 2 residents (R4, R27) reviewed for PASARR.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate infection control techniques were implemented during wound care for 2 of 2 residents (R11, R49) who were reviewed for wound care. In addition, the facility failed to comprehensively assess, monitor, and provide necessary care for 1 of 1 residents (R2) with a intrathecal baclofen pump.

Inspectors wroteBased on observation, interview and document review the facility failed to provide assistance for hearing appliances for 1 of 1 (R17) residents reviewed who had bilateral hearing aides.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen therapy was appropriately administered as well as provide Continuous Positive Airway Pressure ([CPAP]- ventilation machine that administers air via an external device at a predetermined level of pressure) therapy for 1 of 1 residents (R47) reviewed for respiratory care.

Inspectors wroteBased on interview and document review, the facility failed provide appropriate side effect monitoring with psychotropic medication consumption for 1 of 5 residents (R24) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 residents (R27) reviewed for medication errors were free of significant medication errors whenwhen R27 didn't receive ordered metoprolol (medication to treat high blood pressure and control heart rate) for 30 days and in addition, R27 didn't receive ordered atorvastatin (medication to treat high blood cholesterol) between 2/13/24 and 3/13/24.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dental needs were appropriately acted upon for 1 of 1 residents (R47) reviewed for dental care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain accurate medical records to ensure accurate medication lists, nurse/licensed professional monitoring and interventions were implemented for 2 of 2 residents (R2 and R27) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure binding arbitration agreements were clearly communicated in a form and manner that they understood prior to signing the forms for of 2 of 2 residents (R2, R47) reviewed for binding arbitration agreements.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure nurse staffing information was posted on the weekend and in a timely manner at the start of the shift. This had potential to affect all 69 residents, staff, and visitors who could wish to review this information.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a system in place to record accurate narcotic reconciliation to be able to account for all controlled substances for a 1 of 3 residents (R1) reviewed. The facility failed to identify prompt identification of loss or potential diversion of a controlled medication or determine the extent of loss for thirty morphine tablets ordered for R1.

Inspectors wroteBased on interview and records review, the facility failed to thoroughly assess pain and implement orders for pain management for 1 of 1 resident (R2) reviewed who was suffering from headaches and prescribed tramadol.