Woodland Terrace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, review of facility cleaning calendar, and facility policy review, the facility failed to ensure staff cleaned the stove top. The facility reported a census of 81 residents. Findings include:On 6/22/26 at 11:20 AM an initial tour revealed the Vulcan stove had a build-up of a thick black tacky substance covering the entire stove top. On 6/24/26 at 9:50 AM an observation revealed the Vulcan stove still had a build-up of a thick black tacky substance covering the entire stove top. On 6/24/26 at 9:55 AM Staff B, Cook, indicated they only cleaned the grates but didn't clean the stove top. Staff B also stated, We don't clean it. It's over [AGE] years old. I wouldn't want to start a fire by using a degreaser (grease remover). On 6/24/26 at 9:59 AM the Dietary Manager (DM) indicated the cook's held the responsibility of cleaning the stove. She expected them to scrub it each shift. The DM added the stove's age exceeded 20 years. On 6/24/26 at 10:11 AM the Administrator indicated…

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 clinical record review, policy review, facility investigation review and staff interview the facility failed to complete a thorough investigation after a Certified Nursing Assistant (CNA) reported physical abuse which occurred on the dementia unit affecting 24 of 25 residents (Resident #2, #3,#4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26). The facility reported a census of 87 residents.Findings include:A Facility Investigation Note submitted to the Iowa Department of Inspection, Appeals and Licensing (DIAL) detailed on 7/02/25 Staff A, Registered Nurse (RN) called to inform Staff B, Director of Nursing (DON) of an allegation of abuse. At 4: 30 AM, Staff C, Certified Nursing Assistant (CNA) went in to assist Resident #1. Resident #1 became aggressive and started to hit and scratch Staff C. Staff C assisted the resident to sit down on her bed and stepped away to calm herself, then went to get Staff A. Staff A finished assisting Resident #1. Resident #1 was calm and compliant. At 5:45 AM, Staff C reported to Staff A…

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, clinical record review, document review, policy review and staff interview, the facility failed to ensure residents were free from physical abuse when a Certified Nursing Assistant (CNA) tapped a resident on the head during care provision for 1 of 3 residents sampled (Resident #1). The facility identified a census of 87 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00/15 indicating severe cognitive loss. Resident #1 exhibited inattention (being easily distractible/having difficulty keeping track of what is said) which was continuously present and disorganized thinking (rambling or irrelevant conversation, illogical flow of ideas, or unpredictable switching from subject to subject) continually present. Resident #1 required moderate/partial assistance (helper does less than half the effort. The helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with toileting…

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 observations, staff interviews, and policy review the facility failed to maintain a sanitary kitchen; failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. The facility reported a census of 86 residents. Findings include: During a continuous observation on 5/05/25 from 11:15 AM to 12:44 PM of meal service on second floor, Staff L, dietary, handling hamburger buns with her bare hands after touching her face and adjusting her shirt without performing hand hygiene for eight residents. At 11:43 AM after adjusting her glasses and not doing hand hygiene used her bare hands to slide food from one plate to another touching the food with her hands then serving it to a resident. At 11:57 AM Staff L rubbed her nose then went to the hand washing station, got soap on her hands and washed her hand for 5 seconds. She then got a tong and put it with the hamburger buns. Observation on 5/05/25 at 1:00 PM the kitchen floor on the second floor being very dirty with a bowl in the corner by 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, clinical record review, policy review, and staff interview, the facility failed to administer the correct dosage of medication as physician ordered resulting in a 7.69 percent (%) medication error rate affecting 2 of 8 residents sampled (Residents #2 and #29). The facility reported a census of 86 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 2 out 15 indicating a severe cognitive loss. The MDS documented Resident #2 with complaints of difficulty or pain when swallowing and a diagnosis of cancer of the oropharynx (middle part of the throat), unspecified. Resident #2's Physician Order electronically signed by the Provider on 4/11/25 directed to give Atropine Sulfate Ophthalmic Solution 0.01 % give 1 drop by mouth as needed for secretions four times a day as needed for secretions. On 5/06/25 at 7:49 AM Staff N, Certified Medication Aide (CMA) reported she planned to give Resident #2…

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, policy review and staff interviews, the facility failed to properly store medications and remove expired medications per the manufacturer's recommendations for use from 1 of 3 medication carts inspected. The facility identified a census of 86 residents. Findings include: Medication cart inspection of the Evergreen Arbor medication cart on 5/08/25 at approximately 8:47 AM revealed the following expired medications: a. One bottle stock Melatonin 1 Milligram (MG), 90 tablet count with 31 tablets left in the bottle, best by date 3/25. b. One bottle stock docusate sodium 100 MG, open date 12/21/24, bottle 2/3 full expired 4/25. c. Resident #16 one bottle Latanoprost 0.005% eye drop, instill one drop in each eye daily at bedtime, open date 3/4/25, expiration date 4/25, documented on the medication bag by Staff B, Registered Nurse (RN). d. Resident #58 one bottle Latanoprost 0.005% eye drops, instill one drop in each eye daily at bedtime, open date 3/4/25, expiration date 4/25, documented on the medication bag by Staff B. e. Resident #74 one Lantus Solostar KwikPen…

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, clinical record review, Center for Disease Control and Prevention (CDC), policy review, and staff interview, the facility staff failed to wear an isolation gown and gloves during high-risk care provision of 1 of 3 residents on CDC Enhanced Barrier Precautions (EBP) (Resident# 79) and failed to prevent cross contamination when a urinary drainage bag came into contact with the floor for 1 of 2 residents sampled (Resident #79). The facility identified a census of 86 residents. Findings include: Resident #79 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 6 out of 15 indicating a severe cognitive loss. Resident #79 required substantial to maximal assistance with toileting. The MDS documented Resident #79 utilized an indwelling urinary catheter for a diagnosis of obstructive uropathy and had a urinary tract infection (UTI) with in the last 30 days. A Hospital Progress Note, History of Current Hospitalization dated 4/15/25 at 8:01 AM…

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 observations, interviews, and record review, the facility failed to provide weekly assessment and intervention for 1 of 3 pressure ulcers (PU) reviewed (Resident #64). Review of this resident's record revealed that Resident #64 did not have consistent weekly measurements of an unstageable PU on her heel. The facility reported a census of 85 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or…

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, staff interview, and policy review the facility failed to perform proper hand hygiene and to follow proper personal protective equipment guidelines to prevent the spread of potential infection and germs during medication administration for 2 of 6 resident reviewed (Residents # 12 and #14). The facility reported a census of 85 residents. Findings include: During an observation on 5/28/23 at 11:05 AM, Staff A, Registered Nurse (RN) without doing hand hygiene gathered her supplies for insulin administration for Resident #12. Staff A wiped the insulin pen with alcohol and applied the needle cap and primed the pen. Staff A then turned the dial of insulin pen to the correct dosage and proceeded to the resident. Staff A then cleansed Resident #12's abdominal site with an alcohol wipe and administered the insulin. Staff A proceeded back to the cart and took the needle cap off and put it in the sharps container then put the insulin back in the cart. Staff A signed the insulin administration on the computer chart. Staff A did not do hand hygiene after administration of…

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.