Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodland Post-acute during CMS and state inspections, most recent first.
A resident with full cognitive understanding and a diagnosis of encephalopathy died, and the facility failed to return a $187.97 share of cost overpayment to the family within the 60-day period required by facility policy. The business office and administration confirmed the delay, and records showed the refund remained outstanding beyond the policy deadline.
A resident with a history of stimulant abuse and a recent positive drug screen for methamphetamine and fentanyl did not have a comprehensive, person-centered care plan developed or implemented. Despite staff awareness of the resident's substance use and unsupervised time outside with a significant other, no monitoring or interventions were put in place, and the facility's policy requiring individualized care planning for substance use disorder was not followed.
A facility failed to report an abuse allegation within the required timeframe. An allegation of verbal and physical abuse by a staff member towards a resident was reported to a licensed nurse but not communicated to the Administrator or the Department until several days later. Interviews confirmed the delay, and the Director of Nursing acknowledged the breach of the facility's policy, which requires reporting within two hours.
A resident with severe memory impairment was involved in an abuse allegation that was not documented by the nursing and social services departments. Despite a report of verbal and physical abuse, no nursing assessment, body check, or physician notification was completed. The facility's policies on abuse prevention and reporting were not followed, resulting in a failure to meet professional standards of care.
The facility failed to protect resident privacy by improperly disposing of tray tickets containing personal and health information in unsecured trash. A diet aide was observed discarding these tickets, which should have been shredded according to HIPAA regulations. This oversight potentially exposed the information of 87 residents.
A resident with gangrene in the left toe was readmitted to the facility without any wound care orders, monitoring, or care plans. Despite the resident's deteriorating toe condition, observations and interviews confirmed the absence of necessary treatment orders. Facility policies on wound care were not followed, leading to a lack of appropriate care for the resident's condition.
The facility failed to maintain proper pharmacy services by having an unsealed emergency kit and not replenishing medications in another kit after use. An unlocked e-kit was found with medications at risk for diversion, and another kit was accessed multiple times without notifying the pharmacy for replenishment, contrary to facility policy.
The facility failed to ensure residents were free from unnecessary antipsychotic medications. A resident was prescribed medications not FDA-approved for their condition, another was given antipsychotics without a documented mental health diagnosis, and a third received an antianxiety medication without a 14-day stop date. These actions were contrary to facility policy and placed residents at risk for adverse effects.
A LTC facility experienced a 17.2% medication error rate involving three residents. Errors included incorrect dosage of calcium and vitamin D, unavailability of hydroxyzine and buspirone, improper timing of sucralfate administration, and failure to administer famotidine as recorded. These issues were observed during medication administration and confirmed through interviews and record reviews.
The facility failed to properly store and label medications, including insulin pens and inhalers, leading to potential efficacy issues. Unopened insulin pens were stored at room temperature instead of being refrigerated, and opened inhalers lacked open dates. Personal items were improperly stored with medications, posing infection control and safety risks. Staff interviews confirmed these deficiencies, which violated the facility's policies on medication storage and labeling.
The facility failed to meet food safety standards, with wet-stored kitchen containers, improperly sealed food items, and unclean equipment. Observations included a steam table pan with food residue, a cutting board with deep grooves, a rusted shelf, and a discolored floor drain. These issues were acknowledged by the Dietary and Maintenance Supervisors as potential risks for bacterial growth and cross-contamination.
The facility failed to provide adequate storage and heating facilities for food brought in by family and visitors for residents. Staff confirmed that while residents could receive outside food, there was no refrigerator or microwave available for storing or reheating it. Leftover food was either discarded or taken home by family members. The facility's policy required food to be stored in resealable containers in a refrigerator, which was not being followed.
A facility failed to maintain an effective infection prevention and control program, as evidenced by uncovered and unlabeled nebulizers and oxygen equipment for three residents, and a urinary catheter touching the floor for another resident. Staff confirmed the equipment should have been covered and dated, and the catheter bag kept off the floor, but these protocols were not followed, increasing the potential for infection.
A resident with uncontrolled blood sugars did not receive prescribed Humalog insulin on three occasions when blood sugar levels exceeded 301, and the physician was not notified as required. The facility's policies for medication administration were not followed, as confirmed by staff interviews and record reviews.
A resident with diabetes and heel wounds was not provided with foam heel protectors as ordered, potentially worsening their condition. Observations showed the resident without the protectors, and staff did not offer assistance. The wound nurse confirmed the oversight, noting the importance of applying the protectors and floating the heels.
A resident experienced a significant weight loss of 14.5% over six months due to inadequate energy intake and a dislike of facility foods. Despite being on a regular diet with supplements, the resident's caloric intake was below the estimated needs. The interdisciplinary team failed to identify a definitive cause for the weight loss, and the facility did not implement effective interventions as per their weight monitoring policy.
The facility failed to maintain accurate medical records for two residents. One resident's MAR showed multiple instances of medications not being administered without explanation, while another resident's insulin administration was inconsistent with the prescribed sliding scale orders. The ADON confirmed these discrepancies, highlighting the importance of accurate documentation for patient safety.
The facility failed to report an alleged sexual abuse incident within the required timeframe involving two residents. A nurse witnessed one resident, diagnosed with dementia, unclothed and aggressive on top of another resident with schizophrenia. The incident was reported internally but not to the Department or law enforcement as required by policy, potentially compromising resident safety.
A resident with a history of aggressive behavior struck another resident in the head and chest during an altercation in the smoking area. The incident was witnessed by staff, and both the Social Services Director and the DON confirmed it as abuse. The facility's policy on protecting residents from abuse was not followed.
The facility did not report an abuse allegation within the required timeframe after a resident-to-resident altercation. The incident was documented but not reported to the Department until the following day, contrary to the facility's policy of reporting within two hours. The DON confirmed the delay, which had the potential to compromise resident health and safety.
Failure to Timely Refund Resident Share of Cost After Death
Penalty
Summary
The facility failed to follow its own policy and procedures regarding the timely refund of a resident's share of cost overpayment after the resident's death. Specifically, business office records showed that $187.97 was owed to the deceased resident's family, but this amount was not returned within the 60-day timeframe required by the facility's policy. The Business Office Manager (BOM) acknowledged being unaware of why the refund had not been processed, and both the BOM and the Administrator confirmed during interviews and record reviews that the refund remained outstanding beyond the policy's deadline. The resident involved had been admitted in 2020 with a diagnosis including encephalopathy and was documented as having full cognitive understanding at the time of assessment. The facility's own records indicated the overpayment and the requirement for a refund, and the issue was first raised by a complainant inquiring about the refund. The facility's policy, consistent with CMS regulations, required overpayments to be refunded within 60 days of identification, but this was not adhered to in this case.
Failure to Develop and Implement Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a known history of stimulant abuse, despite the resident's recent positive urine drug screening for methamphetamine and fentanyl. Upon admission, the resident was diagnosed with a deep skin infection and stimulant abuse, and was found to be cognitively intact and capable of making decisions. Multiple nursing notes documented the resident spending unsupervised time outside with a significant other, and subsequent hospital records confirmed intoxication and positive toxicology results for methamphetamine and fentanyl. After returning from the hospital, there was no documentation of a care plan addressing the resident's substance use, nor evidence of staff monitoring or intervention related to the ongoing risk. Interviews with facility staff, including a licensed nurse, physical therapist, activities director, social service director, and the DON, revealed that the resident and her significant other were frequently unsupervised outside, and that staff were aware of the resident's substance use history and recent positive drug screening. Staff confirmed that no care plan had been developed or implemented to address the resident's substance use, and that there was no communication or coordinated approach among the interdisciplinary team regarding the situation. The resident herself confirmed recent drug use on facility premises, specifically in unsupervised outdoor areas. A review of the facility's policy and procedure for care of residents with substance use disorder indicated that an individualized care plan should be developed for residents with a history of substance abuse, including monitoring and risk management interventions. Despite this policy, the facility did not initiate a care plan or implement monitoring for the resident, resulting in a lack of coordinated care and oversight for a resident at risk for ongoing substance use and related complications.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe, as per their policy, for one of the sampled residents. The incident involved an allegation of verbal and physical abuse by a registry staff member towards a resident. The allegation was initially reported to a licensed nurse on January 9, 2025, but was not communicated to the Administrator, who is the Abuse Prevention Coordinator, nor was it reported to the Department until January 15, 2025. This delay in reporting was confirmed through interviews with the licensed nurse and two certified nursing assistants who were aware of the allegation but did not report it. The Director of Nursing confirmed that the facility's policy mandates reporting allegations of abuse to the Department within two hours. A review of the facility's policy titled 'Abuse Reporting and Investigation' corroborated this requirement, emphasizing the need for prompt reporting of all allegations of abuse, neglect, and mistreatment. The failure to adhere to this policy resulted in a delayed response by enforcement agencies, potentially compromising resident safety.
Failure to Document and Address Abuse Allegation
Penalty
Summary
The facility failed to ensure that a resident received care meeting professional standards following an allegation of employee-to-resident abuse. The resident, who was admitted with diagnoses including encephalopathy and dementia, was involved in an abuse allegation that was not documented by the nursing and social services departments. The Minimum Data Set indicated severe memory impairment, and there was no documented evidence of the abuse allegation in the Skilled Services Documentation. Additionally, there was no body check, physician notification, or nursing progress note on the resident's psychosocial well-being. Interviews with facility staff revealed that a report of verbal and physical abuse was made to a licensed nurse, but no nursing assessment or documentation was completed. The Social Services Director confirmed the lack of follow-up interviews, psychosocial support, and interventions. The Director of Nursing stated that such an allegation should be considered a change of condition, requiring an assessment and monitoring, which were not performed. The facility's policies on abuse prevention, reporting, and change of condition were not followed, as there was no examination for physical signs of injury, no notification to the attending physician, and no documentation of the resident's progress.
Improper Disposal of Tray Tickets Violates Resident Privacy
Penalty
Summary
The facility failed to protect the privacy of residents' personal and medical records when tray tickets containing sensitive information were improperly disposed of in the trash. During an initial kitchen tour, it was observed that the path taken by kitchen trash led to outside dumpsters in an unsecured parking lot, accessible to the public. On a subsequent visit, a diet aide was seen discarding tray tickets into the garbage can along with leftover food and paper products. These tray tickets contained personal and health information such as names, ID numbers, dining locations, diet orders, and other dietary needs. The Dietary Supervisor confirmed that the tray tickets should have been placed in a designated bin for shredding to comply with HIPAA regulations. The facility's policy on Protected Health Information (PHI) mandates that such information must be managed and protected to prevent unauthorized disclosure. The failure to follow this policy resulted in the potential exposure of 87 residents' personal and health information, as the tray tickets were not properly secured and disposed of according to the facility's procedures.
Failure to Provide Wound Care for Resident with Gangrene
Penalty
Summary
The facility failed to provide appropriate wound care for a resident who was readmitted with a diagnosis of gangrene in the left toe, among other conditions such as diabetes and vascular disease. Upon review of the resident's records, it was found that there were no wound care orders, monitoring, or care plans created for the resident's left great toe wound. This oversight was evident in the skilled nursing facility admission orders, admission nursing assessment, order summary report, skin integrity care plans, and wound physician consultation notes, none of which included any mention of treatment or monitoring for the toe wound. Observations and interviews conducted on January 9th revealed that the resident's left great toe was in a deteriorated state, with dry, shriveled, and discolored skin, yet no treatment orders were in place. Licensed nurses and a nurse consultant confirmed the absence of necessary treatment orders and care plans, emphasizing the importance of monitoring wounds to prevent infection and promote healing. The facility's policies on pressure ulcers and wound care were not adhered to, as they require examination, treatment orders, and documentation for wound care, which were not provided in this case.
Failure to Maintain Sealed and Replenished Emergency Kits
Penalty
Summary
The facility failed to maintain proper pharmacy services for its residents, as evidenced by two significant issues with the emergency supply kits (e-kits). Firstly, an unsealed e-kit was found in the medication storage room, which posed a risk for medication diversion and unauthorized use. During an observation, it was noted that the e-kit was unlocked, and a bag of yellow zip-ties was placed on top of prescription medications and medical supplies. Interviews with the Licensed Nurse (LN) and the Consultant Pharmacist (CP) confirmed that e-kits should be sealed with red zip ties and resealed with yellow ones after use. The Interim Director of Nursing (DON) also stated that e-kits should not be accessed without pharmacy approval and must be sealed after use. Secondly, another e-kit was accessed multiple times without the medications being replaced by the pharmacy, which could lead to a shortage of emergency medications for residents. The e-kit was accessed on four separate occasions for different medications, including antibiotics and blood pressure medication, without the pharmacy being notified to replace the used medications. Interviews revealed that the nurses did not fax for an e-kit refill, and the pharmacy was not automatically alerted to replace the e-kit upon providing an access code. The facility's policy required that the pharmacy be notified for replacement within 72 hours of opening an e-kit, but this procedure was not followed, as confirmed by the CP and DON.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary antipsychotic medications. Resident 10 was prescribed antipsychotic medications for schizoaffective disorder, but the dosages and medications used were not FDA-approved for this condition. Quetiapine was prescribed at a dosage not approved for treating schizoaffective disorder, and divalproex sodium was used off-label without supporting literature. The Consultant Pharmacist and Director of Nursing acknowledged the inappropriate use of these medications, and there was no evidence of aggressive behavior from Resident 10 that would justify such prescriptions. Resident 30 was admitted with a new diagnosis of schizophrenia and was prescribed olanzapine and divalproex sodium without a documented history of serious mental illness. The facility records did not contain psychiatric evaluations to support the new diagnosis, and the Consultant Pharmacist recommended reevaluation of the medication use. Despite these recommendations, no action was taken to clarify the diagnosis or document the risk versus benefits of the medications. Observations and interviews indicated that Resident 30 did not exhibit behaviors that would necessitate the use of these medications. Resident 25 received an as-needed antianxiety medication, lorazepam, without a 14-day stop date, contrary to the facility's policy. The medication was administered beyond the 14-day period without a physician's review or documented rationale for continued use. The Assistant Director of Nursing confirmed the oversight and emphasized the importance of a stop date to reassess the resident's condition and medication needs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 17.2% error rate for three residents. For Resident 16, a Licensed Nurse administered an incorrect dosage of calcium and vitamin D, providing only one tablet instead of the prescribed two. This discrepancy was discovered during a medication reconciliation, and it was noted that the resident had a low calcium level, which necessitated the correct dosage to stabilize their condition. Resident 486 did not receive hydroxyzine as prescribed due to the medication not being available on the medication cart. The nurse attempted to administer the medication but found it missing and later borrowed it from another cart, which is against facility policy. This oversight was confirmed during interviews and record reviews, highlighting a failure to ensure medications were readily available and properly stocked. For Resident 55, multiple errors occurred. Buspirone was not administered due to unavailability, sucralfate was given after breakfast instead of on an empty stomach as recommended, and famotidine was marked as given in the electronic record but was not actually administered. These errors were observed during medication administration and confirmed through interviews and record reviews, indicating a lack of adherence to prescribed medication orders and facility policies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Unopened insulin pens were found stored at room temperature instead of being refrigerated, as required by their labels. This improper storage was confirmed by interviews with staff, who were unsure of the open dates and the efficacy of the insulin pens. The facility's policy mandates that medications requiring refrigeration must be stored in a refrigerator, which was not adhered to in this case. Additionally, opened multidose inhalers lacked open dates, making it impossible to determine their expiration dates. This was observed during a medication cart check, where inhalers were found without open dates, contrary to the manufacturer's instructions. Interviews with staff confirmed the lack of open dates, which could lead to the use of expired medications. The facility's policy requires that all medications be properly labeled, including expiration dates, which was not followed. The facility also stored personal and non-pharmaceutical items in medication carts and rooms, posing infection control and safety risks. Items such as CDs, money, a lighter, and a knife were found in medication storage areas. Interviews with staff confirmed that these items should not have been stored with medications, as they could lead to contamination and safety hazards. The facility's policy requires that drugs and biologicals be stored in a safe and secure manner, which was not the case here.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Kitchen containers, carafes, and steam table pans were found stored wet, which the Dietary Supervisor acknowledged could lead to bacterial growth. The facility's policy requires dishes to be air-dried before storage, aligning with the US FDA Food Code that mandates equipment and utensils to be air-dried after cleaning and sanitizing. Additionally, several food items in the freezer and refrigerator were not securely closed, exposing them to potential freezer burn and cross-contamination. The Dietary Supervisor confirmed that frozen food items should be tightly sealed to prevent these issues. The facility's policy supports this by stating that frozen foods should be stored in airtight, moisture-resistant wrappers. Other deficiencies included a steam table pan with food residue, a red cutting board with deep grooves, a rusted and discolored storage shelf, and a floor drain with green build-up and worn flooring. These conditions were acknowledged by the Dietary Supervisor and Maintenance Supervisor as concerns for bacterial growth and cross-contamination. The US FDA Food Code specifies that food-contact surfaces should be smooth and free of imperfections, and nonfood-contact surfaces should be easy to clean and maintain.
Inadequate Food Storage Facilities for Resident Meals
Penalty
Summary
The facility failed to provide adequate storage and heating facilities for food brought in by family and visitors for residents. During a kitchen tour, the Dietary Supervisor confirmed that resident food was not stored in the kitchen, and there was no designated place for residents to store their food within the facility. Interviews with various staff members, including Licensed Nurses and Certified Nursing Assistants, revealed that while residents were allowed to receive food from outside, there was no refrigerator or microwave available for storing or reheating this food. Staff members indicated that leftover food was either discarded or taken home by family members, as there were no facilities to store it safely. The Director of Staff Development mentioned that perishable foods should be date-checked and could only be left out for one hour before needing to be discarded. The Activity Assistant confirmed that the refrigerator in the social dining/activities room was used solely for storing items related to activities, such as sodas. The facility's policy on foods brought by family or visitors stated that such food should be stored in resealable containers with tightly fitting lids in a refrigerator, which was not being adhered to. This lack of proper storage facilities had the potential to lead to poor food intake, weight loss, and foodborne illness among the 87 residents consuming meals.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations involving four residents. Resident 32's nebulizer was found uncovered and unlabeled, despite the resident's occasional use of the device for breathing treatments. Both a Certified Nurses Assistant (CNA) and a Licensed Nurse (LN) confirmed the nebulizer should have been covered and clean when not in use, but there was no clear protocol communicated to staff regarding labeling. Similarly, Resident 53 and Resident 61's oxygen equipment was observed uncovered and undated, with staff acknowledging the equipment should have been stored in a bag and dated when not in use. Resident 57's urinary catheter was observed touching the floor on multiple occasions, despite the facility's policy to keep catheter tubing and drainage bags off the floor to prevent infections. The resident, who had moderate memory impairment, was noted to lower his bed, causing the catheter bag to touch the floor. Staff confirmed the catheter bag should not be on the ground, but the resident's control over the bed height and resistance to staff instructions contributed to the issue. The facility's policies and procedures for infection control, specifically regarding the covering and dating of respiratory equipment and the proper handling of urinary catheters, were not effectively implemented or communicated to staff. The Interim Director of Nurses acknowledged the expectations for equipment handling, but the lack of adherence to these protocols increased the potential for infection among the residents involved.
Failure to Administer Insulin and Notify Physician
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was readmitted with a diagnosis of uncontrolled blood sugars. The physician's orders specified the administration of Humalog, a fast-acting insulin, based on a sliding scale for blood sugar levels. The orders also required notifying the medical doctor if the blood sugar was less than 70 or greater than 301. However, on three separate occasions, the resident's blood sugar levels exceeded 301, yet the insulin was not administered, and the physician was not notified. Interviews and record reviews revealed that the Licensed Nurse and the Assistant Director of Nursing confirmed the failure to administer the insulin and notify the physician as per the orders. The facility's policies and procedures for administering medications and insulin were not followed, as they require medications to be administered safely, timely, and as prescribed, with any discrepancies reported to the Director of Nursing Services and the attending physician before administering insulin.
Failure to Implement Wound Prevention Measures
Penalty
Summary
The facility failed to implement wound prevention measures for a resident, identified as Resident 65, who was admitted with diagnoses including diabetes and non-pressure open wounds on the heels. The resident had a stage three pressure ulcer on the left heel and a stage two pressure ulcer on the right heel. According to the Wound Physician Consultation Note, there was no change in the wound status since the last visit. The resident's treatment orders required the application of foam booties to prevent wound progression, to be worn as tolerated when in bed, three times a day. However, observations revealed that the resident was not wearing the foam heel protectors as ordered. During an observation, the resident was found lying in bed without the foam heel protectors, and the protectors were placed in the corner of the room. The resident stated that they had not worn the protectors in a while and that staff did not offer to put them on. The wound nurse confirmed the absence of the protectors and acknowledged that staff should have been applying them and floating the resident's heels. Further observation showed that the resident's heels were in contact with the bed surface, and a CNA did not encourage or offer to put on the heel protectors during their visit to the resident's room.
Failure to Maintain Resident's Weight
Penalty
Summary
The facility failed to maintain the weight of a resident, who experienced a significant weight loss of 14.5% over a six-month period. Observations revealed that the resident, who had a history of reflux, depression, dysphagia, failure to thrive, anxiety disorder, and dementia, was easily distracted during meals and consumed only partial portions of his meals. Despite being on a regular diet with high-calorie nutritional supplements, the resident's intake was consistently below the estimated caloric needs, averaging between 1000-1499 calories per day against a requirement of 1730-1900 calories per day. The interdisciplinary team noted the resident's dislike of facility foods and inadequate energy intake as potential factors for the weight loss, but no definitive cause was identified. The Registered Dietitian, who had recently joined the facility, confirmed the resident's variable intake and the lack of a clear reason for the weight loss. The facility's policy on weight monitoring required timely interventions for significant weight changes, but the report indicates that the necessary assessments and interventions were not effectively implemented to address the resident's nutritional needs.
Inconsistent Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for two residents, leading to deficiencies in their care. For one resident, the Medication Administration Record (MAR) indicated that medications such as Metoprolol, Isosorbide, and Furosemide were not administered multiple times throughout December 2024. However, there were no corresponding progress notes explaining why these medications were withheld, as required by the facility's policy. This lack of documentation was confirmed by the Assistant Director of Nursing (ADON), who noted the importance of these medications in managing the resident's conditions, which included heart failure and high blood pressure. For another resident, inconsistencies were found in the documentation of insulin administration. The MAR showed that Humalog insulin was administered on three occasions when the resident's blood sugar levels were below 200, contrary to the sliding scale orders that required no insulin at those levels. Despite this, the MAR indicated the insulin was administered, and there were no progress notes to explain the discrepancy. The ADON confirmed the inconsistency and emphasized the need for accurate documentation to ensure patient safety. The facility's policy mandates that the method of administration and reasons for withholding or not administering medication must be documented, which was not adhered to in these cases.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required timeframe for two residents. Resident 4, diagnosed with paranoid schizophrenia, difficulty walking, spinal stenosis, and cognitive communication deficit, and Resident 6, diagnosed with unspecified dementia without behavioral disturbance, were involved in the incident. On the morning of September 2, 2024, a Licensed Nurse (LN 2) witnessed Resident 6, unclothed and aggressive, on top of Resident 4 in Resident 4's bed. The incident was reported to the Director of Nursing (DON) but not to the Department or local law enforcement as required by the facility's policy. During interviews, both the Administrator (ADM) and DON acknowledged the failure to report the incident within the mandated two-hour timeframe. The facility's policy, revised in December 2022, clearly states that any allegations of abuse must be reported to the Department, Local Ombudsman, and/or local law enforcement within two hours. This oversight had the potential to compromise the health and safety of vulnerable residents, as timely reporting is crucial in preventing further harm.
Resident-to-Resident Altercation Leads to Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when he was struck in the head and chest several times by another resident. Resident 1, who was admitted with diagnoses including Degeneration of the Nervous System Due to Alcohol and anxiety, was involved in an altercation with Resident 2. The incident occurred in the smoking area when Resident 2 attempted to obtain cigarettes and a lighter from other residents. Resident 1 told Resident 2 to stop, which led to Resident 2 hitting Resident 1 in the head. Resident 1 denied hitting Resident 2. Resident 2, who was admitted with diagnoses including Antiphospholipid Syndrome and stroke, confirmed hitting Resident 1 but claimed Resident 1 hit him first. Licensed Nurse 1 witnessed the altercation and noted Resident 2's history of aggressive behavior. The Social Services Director and the Director of Nursing both confirmed the altercation and agreed it constituted abuse. The facility's policy on Elder/Dependent Adult Abuse, revised in July 2017, states that the facility will protect residents from all forms of abuse, which was not adhered to in this incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for two residents involved in a resident-to-resident altercation. The incident was documented on a facility report dated 6/8/24, but the report was not received by the Department until 6/9/24. During an interview, the Director of Nursing (DON) confirmed that the facility's policy mandates reporting such allegations within two hours, but this was not adhered to in this case. The facility's policy, revised in 7/17, clearly states that reports of physical abuse should be made within two hours to the Department. This delay in reporting had the potential to compromise resident health and safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Woodland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grove Post-acute | 0.8 mi | — | 2 | 0 |
| Cottonwood Healthcare Center | 1.1 mi | — | 0 | 0 |
| University Retirement Community At Davis | 7.7 mi | — | 23 | 0 |
| Courtyard Health Care Center | 8.5 mi | — | 6 | 0 |
| River Bend Nursing Center | 14.1 mi | — | 2 | 0 |
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