Wood-Lawn Heights

Based on observation, interview, and facility policy review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one meal observed. The findings include: During an observation on 08/11/2025 at 5:55 PM, Certified Nursing Assistant (CNA) #5 used a #8 scoop, which was equal to 1/2 cup, to serve a single portion of regular shepherd's pie to the residents who received regular diets, and the residents who received mechanical soft diets, instead of 3/4 cup as per the menu. CNA #5 confirmed she should have used a 6-ounce scoop, which would have been equal to 3/4 cup, to serve the shepherd's pie to the residents on regular and mechanical diets. During a concurrent observation and interview on 08/11/2025 at 5:56 PM, CNA #5 used a #8 scoop, which was equal to 1/2 cup, to serve a single portion of pureed shepherd's pie to the residents who received pureed diets, instead of two #10 scoops, to equal to 2/3 cup as per the menu. CNA #5 stated that she should have served two #10 scoops of shepherd's pie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the refrigerator, freezer, and the dry food storage area were covered or sealed to prevent potential food born illnesses; expired food items were promptly removed and discarded on or before the expiration date; and dietary staff washed their hands, before handling clean equipment or food items for one of one meal observed. The findings include: During a concurrent observation and interview on 08/11/2025 at 10:12 AM, this surveyor observed the following in the walk-in refrigerator: a. An opened and unsealed bag of burritos was on a shelf, which exposed it to cross contamination. The Dietary Manager (DM) confirmed the bag was not sealed, so she would throw it away. b. A box that contained 10 packages of bologna was on a shelf, with an expiration date of 07/10/2025. The DM acknowledged the expired meat items, so she would throw them away. c. Two containers of tuna salad were on a shelf, with an expiration date of 08/09/2025. The DM acknowledged the expired tuna salads and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, it was determined the facility failed to notify the resident and the resident's representative in writing of a transfer to the hospital and failed to ensure the transfer notice had all required information regarding the transfer for 4 (Resident #31, Resident #26, Resident #85, and Resident #90) of 5 sampled resident reviewed for hospitalization. Findings include: A review of a facility policy titled, Transfer and Discharge (including AMA), implemented on01/2024, indicated, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer and discharge. b. The effective date of transfer or discharge. c. The specific location .to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State. e. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, for two (Resident #9 and #70) of three residents reviewed for psychotropic medications. Specifically, the facility failed to include a duration for an as-needed (PRN) psychotropic medication. These failures affected residents who received psychotropic medications and increased the risk of unnecessary medication administration, adverse reactions, and unwanted side effects of the medications. Findings included: 1. Review of an admission Record dated [DATE] for Resident #9 reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia, and anxiety disorder. Observation on [DATE] during initial rounds between 9:00 AM and 11:30 AM revealed Resident #9 in bed, sleeping. Observation on [DATE] at approximately 9:00 am, when interviewed, Resident #9 did not answer questions appropriate to the conversation. Review of an Annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (Resident #9) of four residents reviewed for assessment. Specifically, Resident #9's Quarterly MDS assessment indicated the resident had an ostomy. The resident did not have an ostomy. Findings included: Review of an admission Record dated 05/22/2024 for Resident #9 reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia, constipation, and essential hypertension. Review of an Annual MDS Assessment with an Assessment Reference Date (ARD) of 09/14/2023 for Resident #9, Section H indicated there was no ostomy. Review of a Quarterly MDS Assessment with an ARD of 03/12/2024 for Resident #9, Section H indicated there was an ostomy. Section C indicated Resident #9 had a BIMS of 3, indicating impaired cognitive function. Interview on 05/22/2024 at 8:10 AM with Licensed practical Nurse (LPN) #1, revealed Resident #9 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure each resident received treatment and care in accordance with the comprehensive person-centered care plan for one (Resident #6) of three residents reviewed. Specifically, the facility did not document blood pressures before administration of a blood pressure lowering medication with hold parameters. These failures had the potential to cause residents to experience unwanted side effects of medications such as lightheadedness, dizziness, and falls causing major injuries. Findings included: Review of Resident #6's admission Record dated 05/22/2024 reflected an admission date of 05/10/2023 with diagnoses including essential hypertension, history of transient ischemic attack (mini-stroke), muscle weakness and unsteadiness on feet. Observation on 05/21/2024 at 1:00 PM revealed Resident #6 was in bed, sleeping. Resident #6 did not speak to the Surveyor. Review of Resident #6's Significant Change Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to ensure food stored in the freezer was covered and/or sealed to prevent potential contamination or freezer burn and failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 100 residents who received meals from the kitchen (total census: 103), as documented on a list provided by the Dietary Supervisor on 04/04/23. The findings are: 1. On 4/03/23 at 12:50 PM the following food items were on a shelf in the walk-in freezer: a. One opened box of corn dogs was not covered or sealed. b. One opened box of polish sausage was not covered or sealed. c. One opened box of beef steak fingers was not covered or sealed. d. One opened box of sopapillas dough was not covered or sealed. 2. On 04/03/23 at 3:39 PM, Dietary Employee (DE) #1 turned on the 3 compartment sink and washed the blender bowl, the blade and the lid. He sanitized each and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the care and monitoring required related to respiratory therapy for 3 (Residents #1, #65 and #70) of 30 (Residents #1, #2, #3, #4, #10, #11, #16, #17, #22, #29, #31, #33, #37, #40, #44, #48, #52, #59, #63, #65, #70, #75, #78, #80, #82, #87, #90, #97, #252 and #302) sampled residents who received respiratory therapy. This failed practice had the potential to affect 102 residents with physician's orders for oxygen. The findings are: 1. Resident #1 had diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Acute and Chronic Respiratory Failure with Hypoxia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) and Nebulizer/Updraft supplies were properly stored to prevent contamination while not in use for 3 (Residents #65, #70 and #78) of 14 (Residents #1, #4, #10, #11, #17, #31, #33, #40, #48, #65, #70, #75, #78 and #82) sampled residents and failed to ensure oxygen usage was properly documented on the Medication Administration Record (MAR) for 1 (Resident #1) of 30 (Residents #1, #2, #3, #4, #10, #11, #16, #17, #22, #29, #31, #33, #37, #40, #44, #48, #52, #59, #63, #65, #70, #75, #78, #80, #82, #87, #90, #97, #252, and #302) sampled residents who had Physician Orders for oxygen therapy. The findings are: 1. Resident #1 had diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Acute and Chronic Respiratory Failure with Hypoxia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/23 documented the resident scored 14 (13-15 indicates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the pureed and regular diets were prepared and served as per the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 12 residents who received a pureed diet and 78 residents who received a regular diet according to the list provided by the Dietary Supervisor 04/04/23 at 7:55 AM. The findings are: 1. On 04/03/23, the lunch menu provided by the Dietary Supervisor documented residents on a regular diet were to receive 3 ounces of baked ham. 2. On 04/03/23 at 12:57 PM, 22 residents on Aspen Hall, 30 residents on Magnolia Hall and 26 residents on [NAME] Hall were served a small piece of sliced ham each. At 1:17 PM, the Surveyor asked the Dietary Supervisor to weigh the same amount of ham served to the residents who received regular diets on the Aspen Hall, Magnolia Hall, and [NAME] Hall. She did and it weighed 1.5 ounces, instead of 3 ounces. 3. On 04/03/23, the supper menu documented 2 enchiladas were to be served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 2 meals observed. This failed practice had the potential to affect 12 residents who received a pureed diet as documented on a list provided by the Dietary Supervisor on 04/04/23. The findings are: 1. On 04/03/23 at 12:14 PM, and at 12:20 PM, the following were on the steam table in the Magnolia Hall kitchen and in Aspen Hall kitchen: a. 3 pans of pureed ham, the meat was gritty with ground pieces of the burnt ham visible. b. A pan of pureed great northern beans, the consistency was lumpy and was not smooth. c. A pan of pureed spinach, the consistency of the pureed spinach was runny. d. A pan of pureed bread, the consistency of the pureed bread was lumpy and was not smooth, e. On 04/03/23 at 12:16 PM, the Surveyor asked Homemaker #1 to describe the consistency of the pureed food items on the steam table. She stated, Pureed ham was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.