Woodland Estates Senior Living

A revisit survey was completed on 4/23/26 for previous deficiencies cited on 2/11/26. The agency is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint, prompted by #CO41604, was completed on 2/11/26.Deficiencies were cited. 9999 INFORMATIONAL ADVISMENTTHIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. 13.3 The assisted living residence shall establish written house rules and place them in a publicly visible location so that they are always available to residents and visitors. Based on Record review and interview, the residence failed to ensure each staff member received initial orientation prior to providing any care or services to a resident. Affecting seven of seven current staff (#1-#7). (Cross-reference U662)Findings include:1. Record ReviewResidence personnel records for staff #1 through #7 failed to contain documented proof of an orientation that included the following:Care and services provided by the assisted living residenceAssignment of duties and responsibilities specific to the staff member or volunteerHand hygiene and infection control, or portable trainingEmergency response policies and procedures, includingRecognizing emergenciesRelevant emergency contact numbersFire response, including facility evacuation proceduresBasic first aid, or accept proof of portable training in accordance with Part 7.9(D)Automated external defibrillator (AED) use, if applicablePractitioner assessment, andSerious illness, injury, and/or death of a resident.Reporting requirements, inc.. Based on record review and interview, the residence failed to have personnel files onsite and readily available for the Department to review, affecting three of seven staff files (#1-3). (Cross-reference U640)Findings Include: 1. Record Review Personnel records for Former Staff #5-7 could not be provided by the residence. The residence schedule read, in part: Former Staff #5 and #7 had worked at the residence on 2/5/26 from 11:00 a.m. - 7:00 p.m. 2. Interviews On 2/11/ 26 at 9:15 a.m., Former Staff #7 stated he had only worked at the residence twice in February 2026. On 2/11/26 at 9:41 a.m., the dining director stated that they use an external contractual staff to assist when they are understaffed. He stated that Staff #5-#7 were contractual staff who had worked at the residence in February 2026. On 2/11/26 at approximately 10:00 a.m., the administrator stated that the former contractual staff #5-7 had worked at the residence. He stated that he was unaware that, even though the staff members were temporary, the r..

A licensure complaint, prompted by #CO41187 and #CO41481, was completed on 1/29/26. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence, affecting two sample residents (#2, #3).Findings include:1. Residence Policiesa. The residence agreement, undated, read in part: "You will be provided with the following residential services at the community (residence), subject to the terms of this agreement. These services are included in your monthly Fee unless otherwise indicated. Your Apartment will be equipped with an emergency call system ... The call system is monitored 24 hours per day to alert staff to emergencies and illn.. Based on observations, record review and interviews, the residence failed to provide a physically safe and sanitary environment, affecting 17 residents residing in a secure environment (SE).Findings include:1. ObservationsAn environmental tour on 1/27/26 at 10:30 a.m., revealed Resident #5' s bathroom toilet had feces and urine in an unflushed toilet, a trash can without a trash bag with soiled paper products, and multiple dried, brown mounds varying in size from a dime to a quarter on the bathroom and bedroom floors. The counter of Resident #5' s bathroom sink had a white film covering the entire surface of the counter and white streaks running down the cupboard doors. There w.. Based on record review and interview the residence failed to develop care plans that reflected the most current assessment information; Promote resident choice, mobility, independence and safety; Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; Identify all external service providers for two of seven sample residents whose records were reviewed (#2 and #4), and one Former resident (#9).Findings include:1. Record reviewFormer Resident #9 was admitted to the secure environment (SE) of residence on 6/26/25 with a diagnosis of dementia. A care plan, dated 6/26/25, read in part: Former Resident #9 was independent with tr.. Based on record review and interview, the residence failed to comply with practitioner orders associated with medication administration except for those medications which a resident self-administered, affecting three sample residents whose medications were reviewed (#1, #2, and #4). Findings include:1. Record reviewResident #4 was admitted to the residence on 7/1/25, diagnoses that included gastroesophageal reflux disease (GERD), chronic pain syndrome, and muscle spasms. A written practitioner' s order for Resident #4, dated 10/15/25, directed the residence to administer famotidine 40 mg tablets daily. However, the December 2025 medication administration record (MAR) r.. Based on record review and interview, the residence failed to evaluate a resident prior to re-admission to the residence after transfer to another health care entity, affecting one of seven sample residents whose records were reviewed (#3), and Former Resident #11.Findings include:1. Record reviewFormer Resident #11 admitted to the residence on 7/7/25, diagnoses including A-fib, osteoporosis and frequent urinary tract infections. A progress note, dated 10/24/25 read in part: residence received information from the hospital that Former Resident #11 was receiving in-patient hospital services. A progress note, dated 10/28/25 read in part: Former Resident #11 was returning to the ..

A revisit survey was completed on 11/6/25 for previous deficiencies cited on 9/9/25. The agency is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint, prompted by #CO40905, was completed on 9/9/25. Deficiencies were cited. Based on interview and record review, the residence failed to reflect detailed personal service needs and the stafftasks necessary to meet those needs and identify all external service providers along with the care coordinationarrangements in the care plan affecting one of four sample residents (#3) and two former residents (#1, #9) who resided in the secure environment. (Cross reference U1146, U2230 and U3060)Findings include: 1. Residence.. Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them, affecting two former residents (#1, #9). (Cross-reference U1150)Findings include:1. Record ReviewFormer Resident #1 was admitted to the residence on 5/28/25.A progress note dated 8/4/25, read in part, Former Resident .. Based on record review and interview the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting one former resident (#1).Findings include:1. Residence PolicyThe residence' s medication services policy, dated 9/19/24, read in part: "all medications that staff members handle, store, and assist with will b.. Based on record review and interview, the residence failed to comply with the authorized practitioner' s orders associated with medication administration, affecting two of five sample residents (#6, #8) and one former resident (#9). (Cross-reference U1602)Resident #6 was admitted to the residence on 8/8/25 with a diagnosis of bipolar disorder.A written practitioner' s order, dated 8/27/25, directed the residence to administer the following medicatio.. Based on record review and interview, the residence failed to maintain a record that documented the date and time controlled medications were administered and the quantity of the controlled substance remaining, affecting two of four sample residents (#5, #8) who were administered controlled medications. (Cross-reference U1568)Findings include: Resident #5 was admitted to the on 12/13/22 with a diagnosis of dementia. A written practitioner' s order, d.. Based on record review and interview, the residence failed to provide an enhanced care plan for two of four sample residents (#5 and #6) who lived in a secured environment. (Cross reference U1146 and U1150) Resident #6 was admitted to the residence on 8/8/25 with a diagnosis of bipolar disorder. A care plan dated 8/11/25 read in part that Resident #6 had a history of wandering, but no interventions were listed on the care plan. A progress not.. Based on record review and interview, the residence failed to update each resident' s comprehensive assessment at least annually and whenever the resident' s condition changes from baseline status, affecting one of four sample residents (#3) and two former residents (#1) who resided in the secure environment. (Cross reference U1150)Findings Include:1. ReferenceChapter VII regulations governing assisted living residences, part 12.7, requires:"The comprehen.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1 Chapter 7.18.9 The face sheet shall be updated at least annually and contain the following information: (K) Resident ' s current diagnoses

A complaint revisit was completed on 9/9/25 for the previous deficiency cited on 7/23/25. A deficiency was cited. Based on record review and interview, the residence failed to provide an enhanced care plan for two of four sample residents (#5 and #6) who lived in a secured environment. (Cross reference U1146 and U1150) Resident #6 was admitted to the residence on 8/8/25 with a diagnosis of bipolar disorder. A care plan dated 8/11/25 read in part that Resident #6 had a history of wandering, but no interventions were listed on the care plan. A progress note, dated 8/18/25, read that Resident #6 " was wandering all throughout the night, he was also going in and out of the other resident' s room. A progress note, dated 8/20/25, read in part that Resident #6 did not sleep at all the night before. He wandered around and was going into other residents rooms. When the caregiver would go to redirect him out of the room, he would run into other residents bathrooms and try to hide in there. He went into his room and came out completely naked, and went back into the residents' rooms. He kept knocking on another resident' s doors. He was also chasing after the caregiver, telling her, " I want you baby". A progress note, dated 8/26/25, read in part: Resident #6 walked in the courtyard during the night and did not sleep all night. His behavior had been worse each night. The resident was scary at night and acted like he wanted to fight. 2. Interviews On 9/8/25 at approximately 11:00 a.m., Staff #5 stated that Resident #6 was often found in other residents' rooms taking items that did not belong to him. On 9/8/25 at approximately 4:00 p.m., the health and wellness director stated she was aware of Resident #6 wandering into other residents' rooms. She stated she would expect wandering patterns and interventions to be listed on the enhanced care plan. She acknowledged the care plan did not have specific interventions to assist resident #6 with his wondering. She added she is responsible for updating care plans. On 9/9/25 at 11:32 a.m., the administrator acknowledged that the enhanced care plan did not ..

A complaint survey, prompted by #CO38867, was completed on 7/23/25. One deficiency was cited.A change of ownership occurred on 9/30/24. Based on record review and interview, the residence failed to provide an enhanced care plan for three of three sample residents (#1-#3) who lived in a secured environment.Findings include:1. Record ReviewResident #1 was admitted to the residence on 5/28/25 with undocumented diagnoses.An undated care plan read in part that Resident #1 did not have wandering or elopement tendencies and did not have any special care needs. A progress note, dated 6/7/25, read that Resident #1 "wanders a lot."A progress note, dated 6/9/25, read in part that Resident #1 was found in a bush and was trying to climb a tree to leave the secured environment. A progress note, dated 6/10/25, read in part: Resident #1 did not sleep for most of the night and was observed wandering into other residents' rooms. Resident #1 also triggered the fire exit alarms and attempted to elope.A progress note, dated 6/17/25, read in part that Resident #1 was found in another resident' s room without any clothes on.2. InterviewsOn 7/23/25 at 9:35 a.m., Staff #2 stated that Resident #1 was often found in other residents' rooms. She also reported that Residents #2 and #3 frequently entered rooms that were not their own.On 7/23/25 at 8:15 a.m., Staff #3 stated that redirection often failed and that it typically required more than one staff member to assist the residents in leaving other residents' rooms.On 7/23/25 at 1:56 a.m., the administrator acknowledged that the enhanced care plans did not address how staff would prevent unwanted visitors from entering bedrooms that were not theirs. He further stated that the residence should have addressed individualized interventions for residents who wandered.Evidence revealed similar deficient practice for Residents #2 and #3.