Woodlake, The

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: ) Insufficient staff to meet reisdents needs 2) Facility staff refuse resident showers. 3) Facility staff refuse resident transportation. 4) Facility staff did not provide medication in a timely manner.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the The Woodlake RCFE on 10/31/25 at 9:10am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with staff, Corinna Goode and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. The department conducted interviews with four (4) staff members and one resident. All staff members interviewed denied they are unable to meet resident needs due to staffing shortages. LPA conducted interview with R1 who could not identify any unmet needs at the time of interview. LPA reviewed call button response times for R1 and LPA observed an average response time of under 10 minutes with no excessive wait times documented. Report Continued on LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 31, 2025 · control 27-AS-20250221105702

Allegation investigated: ) Questionable death 2) Staff mismanaged resident's medication 3) Signal system did not operate in resident's room. 4) There is insufficient staff at the facility to meet the needs of residents in care

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the The Woodlake RCFE on 10/31/25 at 12:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with staff, Latrice Ross and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. The department conducted interviews with six (6) staff members, four (4) residents and reporting party. LPA conducted file review for four residents and reviewed facility response time records for all residents. The department obtained and reviewed death certificates for two residents and observed no documentation that would be considered questionable or suspicious causes of death for the residents identified in this complaint. Per witnesses interviewed and documentation reviewed it was determined that no call for assisthe state’s words, verbatim · CDSS document, Oct 31, 2025 · control 27-AS-20250530151441

Allegation investigated: Facility did not meet resident's nutritional needs resulting in ketosis Facility did not ensure resident's hygiene care needs were met Facility did not provide adequate care and supervision to meet residents needs

Unannounced complaint visit made out to this facility on 08/25/2025 by Licensing Program Analyst (LPA) Charlie Yang. LPA was met by the facility designated Administrator, Latrice Ross, who was briefly interviewed at this time. Current census was 125 residents. The purpose of this visit was to inform this facility, and it's representative, about the findings from this complaint investigation at this time. Based on interviews conducted during the course of this investigation, it was learned that R1 resided in the Assisted Living portion of this facility since initial admission in 2023. It was learned that R1 was primarily deemed to be independent and did not require facility staff assistance with Activities of Daily Living (ADLs). It was learned that R1 was on a strict diet which limited R1's salt intake and a restriction on consuming concentrated sweets. It was also learned that R1's diet did not contain any carbohydrates which could have attributed to the ketosis for R1. It was learnedthe state’s words, verbatim · CDSS document, Aug 25, 2025 · control 27-AS-20250610144352

Allegation investigated: Staff do not provide adequate food service Staff do not provide adequate beverage service Staff do not ensure residents are provided with utensils Staff do not ensure the facility is clean and sanitary

Unannounced complaint visit made out to this facility on 08/25/2025 by Licensing Program Analyst (LPA) Charlie Yang. LPA was met by the facility designated Administrator, Latrice Ross, who was briefly interviewed at this time. Current census was 125 residents. The purpose of this visit was to inform this facility, and it's representative, about the findings from this complaint investigation at this time. Based on interviews conducted during the course of this investigation, it was learned that R1 resided in the memory care unit of this facility since initial admission earlier this year in 2025. It was learned that the physical plant layout for the memory care unit composed of private rooms, as well as, jack and jill setups where two individual rooms shared a common restroom between them. It was learned that R1 resided in the jack and jill floor plan at this time. Based on a review of the forms and documents retrieved during the course of this investigation, it was learned that this facthe state’s words, verbatim · CDSS document, Aug 25, 2025 · control 27-AS-20250624134252

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not keep resident medical information confidential Staff did not treat resident with respect

On 04/18/2025, Licensing Program Analysts (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPA Williams met with facility Health and Wellness Director Corrina Goode and together discussed the investigation details. It was alleged that staff did not keep resident medical record information private. During the course of this investigation, this LPA conducted interviews with residents and staff members. Based on interviews conducted it was learned that the reporting party (RP) said that R1 talked to the RP about another resident’s health history. The RP said that a staff member informed R1 about R2’s health history. In an interview, R1 said that they know this information because R2 told R1 not a staff member. R2 stated that they did tell R1 about their medical information. 6 out of 6 staff members stated they have not heard staff talk about any resident’s medical history to other residents. 5 out of 5 residthe state’s words, verbatim · CDSS document, Apr 18, 2025 · control 27-AS-20250107154441

Allegation investigated: Staff did not refill residents medication prescription in a timely manner.

On 04/18/2025, Licensing Program Analyst (LPA) Holly Williams arrived unannounced to conduct a complaint visit. LPA Williams met with Health and Wellness Director Corrina Goode and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. Current census was 114. A brief interview with Corrina Goode was conducted. It was alleged that staff did not refill residents’ medication prescription in a timely manner. During the course of this investigation LPA reviewed facility documents and conducted interviews. Based on interviews conducted and residents notes it was learned that a refill was ordered on 12/11/2024 but was not filled. According to Communication and Care forms a Registered Nurse (RN) on 12/31/2024 and 1/30/25 called and requested a refill for the resident. In an interview, RN stated that they called several times to the Physician, and the front desk said they would pass it on to the Physician, but nothing was ever rthe state’s words, verbatim · CDSS document, Apr 18, 2025 · control 27-AS-20250206094857

Allegation investigated: Facility not issuing a refund to the responsible party. Unlawful Eviction.

On 04/18/2025 Licensing Program Analysts (LPA) Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Williams met with the Health and Wellness Director Corrina Goode who was briefly interviewed at this time. The purpose of this visit was to deliver the findings of this investigation to this facility, and it's representative, at this time. It was alleged facility is not issuing a refund to the responsible party. According to interviews with the business office and the responsible party, the responsible party was refunded their money. In reviewing financial records and receipts the refund was processed on 3/12/2025. Based on the evidence, the facility did issue a refund to the responsible party. [Continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 18, 2025 · control 27-AS-20250211103604

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure that the resident’s medications was refilled in a timely manner. Facility staff does not communicate with authorized representative.

Licensing Program Analyst (LPA) Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Williams met with Martin Nichols and explained the purpose of the visit. This investigation consisted of record review and interviews with staff, family,and resident. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed Nichols. 2 staff members (S1-S2), 1 resident (R1), and R1’s responsible parties (RP1). In an interview, Martin Nichols the administrator said that R1 did not receive their medication on time and they have corrected it with training. In an interview, Nichols said, "there was an oversight for sure." Nichols said, "the medication technician opens up a temporary service plan and it notifies managers. The managers could see that the medications needed to be refilled but if no one does that then no one would know the medications needed to be refilled." Nichols stated that R1 went to the hospital for a fallthe state’s words, verbatim · CDSS document, Mar 3, 2025 · control 27-AS-20241003162551

Allegation investigated: Staff do not ensure that resident's needs are being met

Licensing Program Analyst (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPA Williams met with facility administrator Martin Nichols and together discussed the investigation details. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed Nichols, seven staff members (S1-S10) and 2 residents (R1-R2). In an interview, S8 said that S1 went into the break room and told everyone that the showers cannot be missed. In an interview S8 said showers are not being conducted on the scheduled days, staff members are putting the showers off on other staff members, and the showers never get done. In an interview, S8 said residents are complaining. In an interview, S8 said that S10 skipped resident R1 shower on 9/10/24, [Continued on 809-C] Substantiatedthe state’s words, verbatim · CDSS document, Jan 17, 2025 · control 27-AS-20240909113241

Allegation investigated: Cleaning solutions are accessible to residents.

Licensing Program Analysts (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPA Williams met with facility administrator Martin Nichols and together discussed the investigation details. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed three staff members (S1-S3) and inspected 11 rooms. On 12/16/24 LPA Williams checked the 11 residents’ rooms and checked the cabinets where the facility keeps cleaning supplies or hygiene products that could be dangerous from the resident to see if it was locked. All cabinets were locked except for two. One resident R11 was in the hospital and not coming back. One resident R5 was allowed to have these hygiene products as stated in the LIC602. Overall LPA Williams did not find any cleaning solutions. In an interview, S1 said that the cabinets in memory care are not for storing cleaning supplies and they do [Continued on 909the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 27-AS-20241108123056

Allegation investigated: Administrator is not permitting resident's authorized representative to participate in decisions regarding resident's care

Licensing Program Analysts (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPA Williams met with facility administrator Martin Nichols and together discussed the investigation details. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed two staff members (S1-S2), Caregiver, and one resident (R1). R1 was given pain medication on 10/16/24 and 10/17/24 according to what was found in the investigation the pain medication made R1 decompensate, and the pain medication was discontinued. According to the Medication Administration Report (MAR) the medication was given on 10/16/24 and 10/17/24 and then ordered to stop and not to be given without consent. During the investigation the medical power of attorney is found to be valid. Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation mathe state’s words, verbatim · CDSS document, Jan 17, 2025 · control 27-AS-20241021094841

Allegation investigated: Facility is not administering medications as prescribed. Facility staff are instructing residents to be mean to other residents.

Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Williams and Moleski spoke with facility administrator Martin Nichols over the phone and together discussed the investigation details. Nichols said business office manager Sandra Chizek could sign this report in his absence. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed Nichols. 11 staff members (S1-S11), 2 residents (R1-R2), and R1’s responsible party (R1’s RP). According to an incident report dated 10/07/2024, R1 was not getting the correct dosage of medication from 9/5/24 through 9/19/24. According to the incident report, R1 was receiving 125 milligram doses of the medication but should have been receiving 500 milligram doses. According to the incident report, R1 was exhibiting aggressive behaviors during that time. In an interview, Nichols said tthe state’s words, verbatim · CDSS document, Nov 25, 2024 · control 27-AS-20241001170841

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: . Staff do not ensure food that is served to residents is of good quality 2. Staff spoke inappropriately while in front of resident 3. Staff yell at residents in care 4. Staff do not ensure medications are dispensed as prescribed 5. Staff do not ensure diapering needs of residents are being met 6. Staff do not ensure resident call system is responded to in a timely manner 7. Staff do not ensure facility is free of mal odors

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude a complaint investigation of the above mentioned allegations on 7/18/24 at 8:45a. LPA met with Martin Nichols, General Manager (GM), and stated the purpose of the visit. On 5/2/24, LPA attempted to interview resident #1 (R1-R2) and interviewed Martin Nichols, General Manager and Angel Salcedo,Chef. LPA requested and received a copy of the following: Advertising brochures, Food Menu for April 2024, Staff roster with contact information and work schedules, Incident reports regarding any medication errors for April 2024, Diet restrictions for R1-R2, Visitors log for April 2024, last service for Call system, Facility notes regarding R1-R2 for April 2024, incontinence care schedule, medication list for R1, Weight record for R2, and Resident roster. During today’s visit, LPA continued conducting interviews of staff and residents and reviewing facility documents. Unfoundedthe state’s words, verbatim · CDSS document, Jul 18, 2024 · control 27-AS-20240423154715

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.