Woodland Village

Facility failed to maintain 18 inch clearance in activities storage room floor 2.

Facility failed to provide fire door inspection report.

Facility failed to provide monthly emergency light testing during May and September.

Excessive storage found in maintenance office/mechanical room.

Facility failed to provide fire damper inspection report.

Facility failed to provide fire drills for swing shift and night shift for the first quarter of 2025, and night shift third quarter of 2024.

Facility fails to maintain strain protection on kitchen appliances.

Facility failed to provide quarterly fire sprinkler inspection reports.

Facility fails to provide annual inspection of fire resistance rated construction.

Facility failed to provide semi annual fire alarm system inspection. Fire alarm found inoperable; facility started fire watch and is working on replacement with AHJ.

The facility failed to implement policies and procedures to monitor a resident and notify the family after a resident sustained an injury of unknown origin.

Non approved multi plug adapter found in room 237

Non approved auxiliary device found blocking door in room 227

Extension cord found being used as permanent wiring in the Archives room

Failed to provide 4 year fire damper inspection report

Facility failed to provide annual fire resistance-rated construction inspection report

Failed to provide 3 year dry system trip test and annual forward flow report

Failed to provide annual fire door inspection report; multiple doors out of compliance (excessive gaps in rooms 240, 233, laundry room; holes in door of room 143b)

Failed to provide semi annual hood system report

Facility failed to complete ongoing assessments for Resident 1 following multiple falls, leaving staff without updated care strategies or effective interventions for the resident's changing needs.

Facility failed to ensure all staff were fit-tested for N95 respirators and failed to follow proper PPE doffing procedures, putting residents and staff at risk of infection.

The facility failed to ensure employees (Staff E and Staff F) had proper medical clearances and respirator fit testing. Additionally, staff were observed doffing PPE inside COVID-19 positive resident rooms and potentially contaminating the area before disposing of items in resident room trash cans.

Facility failed to maintain a safe, sanitary environment in Resident 1's room, which was heavily cluttered with trash, household items, and bicycles, creating significant tripping hazards and unsafe living conditions.

Facility failed to document necessary health support services from outside providers in the Negotiated Service Agreements (NSA) for 6 of 9 sampled residents.

One of two facility pets had an expired rabies vaccination.

Failure to ensure the NSA was agreed to and signed at least annually for 2 of 9 sampled residents (R5 and R8).

The facility failed to ensure 1 of 3 sampled staff had a current first aid and cardiopulmonary resuscitation (CPR) card.

Dishwasher failed to sanitize/rinse dishes at the required 165 degrees F as evidenced by multiple log entries below threshold.

Failure to complete a full assessment within fourteen days of the resident's move-in date for 3 of 3 sampled residents.

Hot water temperatures at sinks in common areas measured above the 120 degrees F limit (126 and 122 degrees F).

Failure to complete the Negotiated Service Agreement (NSA) within 30 days of admission for 1 of 3 sampled residents.

Facility failed to provide fire damper testing

Facility failed to provide annual forward flow testing documentation

Facility failed to present fire rated inventory and annual inspection

Kitchen hood suppression system shall have a heat survey conducted and documented

Facility failed to provide annual fire door inspection report

Facility failed to provide annual emergency lighting of exit signs and emergency lighting