Woodland Manor

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to the SSD and Administrator;-The Administrator should notify DHSS within two hours.During an interview

on 12/30/25, at 4:00 P.M., the SSD said the following:-She became aware of the resident-resident incident

on 12/29/25, when Resident #1 came and requested to file a grievance regarding the situation;-Any allegations of abuse are typically reported to DHSS within two hours;-While the resident requested to file a grievance, the resident got upset with being educated to turn on his/her call light versus addressed the situation his/herself and left the office so the SSD did not fill it out.During an interview on 12/30/25, at 10:14 A.M., the Administrator said the following:-She was notified on Saturday (12/27/25) of the allegations;-LPN

A reported to her that Resident #2 was ambulating via wheelchair and came to Resident #1's doorway.

Resident #1 came to the doorway and asked Resident #2 to leave. After asking Resident #2 to leave, he/she grabbed Resident #1 on the forearm. Resident #1 asked Resident #2 to let go, to which he/she did.

LPN A re-directed Resident #2 away from Resident #1;-Resident #2 was placed on 15-minute checks and LPN A assessed Resident #1 for injury;-Resident #2 had never been an issue before, which is why she did not report the incident;-She also did not report the incident to DHSS because there was no injury seen;-The resident (Resident #1) did come to her office on 12/29/25 and reported the incident;-She assessed the resident for injuries, and there was nothing there at the time of the assessment;-She told the resident, from now on, if there is another resident at his/her door, that he/she should turn on his/her call light instead of addressing the concern his/herself. The resident was upset with this.#2702852

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Manor

1347 East Valley Watermill Road Springfield, MO 65803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to take 6 to 8 weeks to be delivered. He/She did not have a copy of the cancelled order receipt;-The DOR brought him/her a picture/paper of a commode to order the first of December 2025, but the commode was $600.00, and it would not arrive for 6 to 8 weeks;-He/She had not received the physician's order for the resident to have a commode and he/she did not know when that order would be obtained;-Within the past two to three days, the DOR and the resident told him/her that the resident needed a commode;-He/She found a cheaper commode that he/she ordered this morning, and it should be arrive the next day. During an

interview on 12/30/25, at 5:34 P.M., the Administrator said the following:-He/She was informed about a week ago that the DOR asked the social worker to order a commode for the resident;-He/She had not seen

a physician's order for the commode;-This would not be the first time the DOR asked staff to order something without an order;-There needed to be a physician's order for a commode or any equipment for a resident;-The SSD did the ordering for the facility;-After the physician writes an order, the nurses should put

it into the resident's electronic medical record and provide the order to medical records, who would then give it to the SSD to order;-A commode was ordered for the resident last night or this morning. The SSD said it would arrive tomorrow;-The resident did not ask him/her for a commode or mention it to her;-The DOR had not come to him/her and asked him/her to order it either;-The resident would benefit from a commode;-The commode will have an arm that lifts up and the resident can use it with his/her sliding board;-The resident was getting more independent, and the commode will help him/her with his/her independence more.# 2701833 and 2699831

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Manor

1347 East Valley Watermill Road Springfield, MO 65803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

microwave;-If residents have food, they want heated up they can take it to staff, and the staff will heat it up for them;-The staff do various assessments on residents each month, but he/she had never completed a hot food/hot liquid assessment on any resident. During an interview on 12/30/25, at 3:20 P.M., Certified Nurse Aide (CNA) C said the following:-He/She witnessed the resident spill the hot bowl of soup on himself/herself;-The resident hit the exit door with his/her motorized wheelchair and the hot soup went all over him/her. The resident did not run into the laundry cart as the resident had been telling everyone;-He/She was not sure where the resident got the soup from;-The resident went into the room on

the unit hall to use the microwave frequently and his/her wheelchair gets stuck on the little refrigerator when he/she turns around to exit the room. The resident takes the little refrigerator about 6 inches away from the wall when his/her wheelchair back gets caught on the refrigerator;-The resident usually used the microwave to heat up his/her little pizza's that he/she had in his/her room and food supply;-The room in the unit hall that has the microwave did not have a lock on the door;-He/She had not seen other residents besides the resident go into the room with the microwave and refrigerator;-Staff have been instructed to tell the resident that he/she cannot go into the room and use the microwave, but staff do not block or lock the door to prevent the resident from entering;-Any resident could open the door where the microwave is, but the door was hard to open. During an interview on 12/30/25, at 4:28 P.M., the Social Services Director said the following:-He/She was not sure if the facility completed a risk or safety assessment for residents regarding hot food or hot liquids. If so, the nursing staff would do that;-He/She was not aware of the facility staff completing a safety or risk assessment for residents to use a microwave in the facility;-Every unit/hall had a room with a microwave. The door to the room was shut, not locked;-Some residents ignore the employee only sign on the door and sneak in to use the microwave;-He/She reminded residents to let staff help them warm their food and drinks up;-Any resident including those who are confused or who have dementia could open the door and go into the room where the microwave was;-He/She did not know how staff monitor who goes into the rooms with the microwaves;-The facility does not care plan resident use of a microwave;-He/She was not sure where the resident heated his/her food up at prior to being burned;-The resident was not supposed to be in the room with the microwave or using the microwave;-He/She was not aware of any microwave use policies for residents. During an interview on 12/30/25, at 5:34 P.M., the Administrator said the following:-He/She had never seen a hot foods/hot liquids assessment completed at

the facility;-Technically, residents are not supposed to use the microwaves in the unit halls and there is a sign on the doors saying the area is for employees only;-For the most part, the resident ignores the signs

on the doors and enter the rooms to use the microwaves anyway;-There was one microwave on each unit/wing and staff used them to heat up resident meals;-He/She had told staff that residents are not allowed to go into the rooms and use the microwaves;-He/She was not aware of the resident's wheelchair getting caught on the small refrigerator located in the room with the microwave;-He/She is not aware of any confused residents going in the rooms with the microwaves, but none of the rooms are locked, so anyone could go in there;-The facility kept the doors to the rooms with the microwaves closed and all of the rooms have a sign on the door saying the rooms are for staff only;-The facility did not do a care plan assessment for resident microwave use;-He/She was not aware of a resident microwave use policy at the facility.

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