Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 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.
Failure to address repeated significant weight loss: A resident with dx including dysphagia, hypothyroidism, bipolar disorder, and poor PO intake had multiple significant wt losses over several months, but the RD’s appetite stimulant recommendations were not carried out or documented, the physician notes did not reference the losses, weekly wt monitoring was not done, and the physician and RP were not notified of the resident’s declining nutritional status.
Failure to follow IV medication and BG notification orders: A resident with a PICC line did not have the line flushed before, between, and after IV ABX administration as expected by nursing practice and later orders; another resident with diabetes had BG readings over 400 mg/dl without documented MD notification or a change-in-condition assessment; and a third resident’s ordered IV meropenem was delayed because IV access was unavailable and the physician was not documented as being notified.
Medication services were not carried out accurately for several residents. A resident with osteomyelitis and sepsis had a prescribed antiplatelet medication documented as unavailable for multiple doses, with no physician notification recorded. Controlled drug records did not match MAR entries for oxycodone and hydrocodone for multiple residents, and one resident’s oxycodone count was not fully accounted for. Another resident with kidney-related diagnoses missed multiple doses of ferrous gluconate and folic acid even though the medications were available, and there was no documentation that the MD was notified.
Medications were found unsecured and improperly stored at bedside for three residents. An eye drop bottle and ampoules were observed on a resident’s bedside table, an orange tablet was found in an unlabeled cup at another resident’s bedside, and an unlabeled cup containing white powder was found on a third resident’s dresser. The DON and LN confirmed the items were not supposed to be at bedside, and the records noted the residents had diagnoses including sciatica, GERD, schizophrenia, bipolar disorder, ADHD, and adjustment disorder, with intact cognition documented on MDS assessments.
Pureed spaghetti was prepared outside the approved recipe instructions when a DA/cook processed the food to a smooth consistency but reprocessed it for only about 5 seconds instead of the required 30 seconds. The DA acknowledged she did not follow the recipe exactly, and the DM observed and confirmed the recipe was not followed for the reprocessing time.
Unsafe food handling and storage practices were observed when a DA calibrated thermometers without using the required ice-water slush method, cutting boards with crevices were found in the kitchen, a DS with a beard was not wearing a beard restraint, and resident food in a refrigerator was labeled with a discard date that did not match the earlier use-by date on one item. The DM acknowledged the thermometer calibration error, the condition of the cutting boards, and the mismatched food dates.
The facility failed to ensure the QAPI Committee included the required MD participation during quarterly meetings. Sign-in sheets did not show the MD was present at two meetings, and the ADM confirmed the MD missed one meeting while out of the country without a designee and that there was no documentation of the MD’s telephone participation at the other meeting. The facility’s QAPI plan stated the committee includes the ADM, DON, MD, and at least 3 other members and meets at least quarterly.
Failure to obtain informed consent before giving a psychotropic medication. A resident with CVA, bipolar disorder, depression, and moderate cognitive impairment was started on Depakote for bipolar disorder after a suicidal ideation episode, but the psychotherapeutic drug consent was not signed until after the medication had already been administered. The SSD, NP, and DON all acknowledged the consent was obtained late, and the DON stated the resident was not fully informed.
A resident was prescribed PRN lorazepam for anxiety, but the record showed no monitoring orders were in place when the medication was ordered. The care plan also did not include interventions or monitoring for the psychotropic medication, and an LPN and the DON both stated the behavioral monitoring order should have been entered with the med order.
MDS Weight Loss Coding Error: A resident with dysphagia and other diagnoses had an MDS Section K error when the MDSN coded no significant wt loss despite records showing more than 5% loss in 1 month and more than 10% loss in 6 months. The MDSC confirmed the wt loss, and the MDSN acknowledged the MDS should have been coded yes.
Failure to provide nail care and ADL assistance for two residents with impaired self-care needs. One resident had hemiplegia and moderate cognitive impairment, and the other had DM with CKD and severe cognitive impairment; both were observed in bed with long fingernails and blackish substance underneath the nails. Staff acknowledged the nails needed trimming and cleaning, and one CNA noted that diabetic residents’ nails are trimmed by the licensed nurse.
Respiratory care was not provided according to standards for a resident with COPD and acute respiratory failure. The resident’s nebulizer tubing was dated beyond the 7-day replacement interval, the LPN did not know when the oxygen tubing had last been changed, and the DON stated oxygen use was not documented in the MAR even though the resident had been using oxygen at night and had an O2 sat recorded while on nasal cannula. The facility policy required nebulizer administration sets to be discarded every 7 days and respiratory therapy to be documented in the medical record.
Missing Annual CNA Performance Review: The facility failed to ensure one CNA had an annual performance review in the personnel file. During record review, the CNA’s file showed hire on 2/4/25 but no documented annual evaluation. The DSD stated he was not sure how annual reviews were tracked and confirmed there should have been a review in the file. The facility handbook and P&P both required annual documented performance evaluations.
Medication administration errors exceeded the allowed rate when 2 of 31 opportunities were not given per physician orders. One resident's antiplatelet medication was not available for administration, and another resident's PPI was given after breakfast even though the order said to give on an empty stomach for best absorption. The DON and RN acknowledged the medication issues, and the facility policy required meds to be given in accordance with written orders and meal timing instructions.
A resident receiving HD had a physician order for treatment at an outside dialysis company, but the facility did not have a written agreement with the dialysis clinic. The ADM confirmed no agreement existed and stated the agreement was important to ensure the resident received dialysis care. The facility policy called for ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.
Failure to Follow Infection Control Practices: Staff did not implement EBP for a resident with an indwelling Foley catheter, and the resident’s room had no isolation precaution signs while staff entered without PPE. Staff also left soiled linens, a soiled brief, and soiled gloves on another resident’s bed while going to get a trash and linen cart. The DON stated the soiled items should not have been left on the bed, and the IP stated residents with catheters should be on EBP.
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 address repeated significant weight loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for one resident who experienced repeated significant weight losses over several months. The resident was admitted with diagnoses including polyneuropathy, bipolar disorder, hypothyroidism, dysphagia, and adjustment disorder, and the MDS dated 12/17/25 indicated intact cognition. The care plan identified impaired nutritional and hydration status, meal intake less than 75%, refusal of meals, noncompliance with diet, outside food intake, and a recommendation for MD consult and appetite stimulant related to poor PO intake. The resident’s weight record showed multiple losses, including 9 lbs in one month from 6/5/25 to 7/1/25, 7 lbs in one month from 9/1/25 to 10/3/25, 6.8 lbs in one month from 11/2/25 to 12/2/25, 15.6 lbs in six months from 6/5/25 to 12/2/25, and 13.6 lbs in three months from 10/3/25 to 1/1/26. The RD documented the 7/2/25 weight loss and recommended an appetite stimulant, but there was no documented evidence that the physician ordered it or that the reason for not following the recommendation was documented. The physician progress note dated 7/6/25 did not reference the weight loss or the RD recommendation. The record also showed that the resident’s significant weight loss from September 2025 to October 2025 was not addressed through a significant change in condition, and there was no documented evidence that the physician or RP was notified. The Dietary Supervisor documented on 11/4/25 that the resident’s weight fluctuated but remained stable and that there were no dietary changes that quarter, despite the ongoing losses. The resident’s further weight loss from November 2025 to December 2025 and the cumulative six-month loss were not reviewed by the RD or IDT, and there was no documented evidence that interventions were evaluated or changed, that a significant change in condition was initiated, or that the physician and RP were notified. The RD later documented another significant loss on 1/7/26 and again recommended an appetite stimulant, but the physician note dated 1/11/26 still did not reference the weight loss or explain why the recommendation was not followed. Interviews with the RD, DON, ADON, and NP confirmed that weekly weight monitoring was not done during the periods of significant loss, that the RD recommendations were not communicated or carried out, and that the resident’s severe weight losses were not documented in the physician progress notes.
Failure to follow IV medication and blood glucose notification orders
Penalty
Summary
Resident 93, who was admitted with acute osteomyelitis of the left ankle and foot, sepsis, and diabetes, had a PICC line used for IV nafcillin. The record showed orders for IV nafcillin and later an order to flush the PICC with normal saline before and after IV medication administration. However, the MAR did not reflect PICC flushing before and after medication administration prior to the later flush order. Resident 93 stated that on one occasion the nurse did not flush the line before giving the antibiotic, between the two bags of IV antibiotics, or after the antibiotic was completed, and later stated the nurse apologized for not flushing the PICC line. Resident 8, who had diagnoses including Prader-Willi syndrome and diabetes and was moderately cognitively impaired, had an order for insulin lispro with instructions to notify the MD if blood glucose was less than 70 or greater than 400. The MAR documented blood glucose readings of 499 mg/dl, 528 mg/dl, and 410 mg/dl. The clinical record did not show that the MD was notified of the elevated readings of 528 mg/dl and 410 mg/dl, and it did not show that a Change of Condition Assessment was initiated for the elevated blood sugars. Nursing staff acknowledged that blood sugars greater than 400 mg/dl should have prompted MD notification and that no Change in Condition Assessments were completed for those episodes. Resident 9, who had diagnoses including BPH, acute kidney failure, anxiety, major depressive disorder, neurogenic bladder, and resistance to multiple antibiotics, had an order for meropenem 1 gram IV every eight hours for UTI. The record showed that the antibiotic was ordered after a physician note changed therapy to meropenem, but the MAR indicated doses were not signed as administered at scheduled times because IV access was not available. Nursing documentation stated the IV medication was not available in the E-kit until 4 a.m. and that the resident was sent to the ER for PICC insertion later that day. The DON and ADON confirmed the resident did not have IV access to receive the antibiotic and that there was no documented evidence the physician was notified of the lack of IV access, resulting in a delay in administration.
Medication Availability, Administration, and Controlled Drug Accountability Failures
Penalty
Summary
Pharmaceutical services were not provided in a manner that ensured accurate acquiring, receiving, dispensing, and administering of medications for four sampled residents. Resident 93 was admitted with diagnoses including acute osteomyelitis of the left ankle and foot and sepsis. The resident had an order for Prasugrel 10 mg daily for antiplatelet therapy, but the medication was documented as not available for 10 days across multiple entries on the MAR. The record did not show that the physician was notified during those missed administrations, and the facility later documented that the medication was not covered by insurance and pharmacy would not dispense it. Controlled medication accountability was not accurate for three residents. For Resident 93, the CDR showed oxycodone-acetaminophen was taken out on three occasions, but the MAR showed the medication was not given. For Resident 8, the CDR and MAR did not match on multiple occasions involving hydrocodone-acetaminophen, including instances where the CDR showed medication removed but the MAR showed it not given, and other instances where the MAR showed medication given but the CDR did not show it removed. For Resident 17, the CDR for oxycodone HCl did not account for one tablet that had been delivered, and the record did not show the date and time it was taken out from the bubble pack. Resident 9, who had intact cognition and diagnoses including acute kidney failure, hydronephrosis, and abnormal blood chemistry findings, did not receive medications as ordered. The MARs showed ferrous gluconate was not available and not administered on multiple non-consecutive days across January, February, and March 2026, and folic acid was not available and not administered on two days in March 2026. The progress notes did not document that the physician was notified of the missed doses. Staff interviews confirmed that ferrous gluconate was available in the medication room and that folic acid had been refilled and was available in the medication cart, yet the doses were still not given.
Medications Left Unsecured and Unlabeled at Bedside
Penalty
Summary
The facility failed to ensure medications were appropriately stored and not available at bedside for three sampled residents. During observation, an eye drop bottle and four plastic ampoules of eye drops were found on top of Resident 68’s bedside table, an orange tablet was found in an unlabeled medication cup on Resident 5’s bedside table, and an unlabeled medication cup containing white powder was found on top of Resident 50’s dresser at bedside. The report states these medications and biologicals were not stored in accordance with accepted principles and were accessible in resident rooms. Resident 68 was admitted with diagnoses including sciatica and muscle weakness, and the MDS indicated intact cognition. When surveyed in the room, Resident 68 was lying in bed with eyes closed and did not respond to questions. The DON confirmed the eye drops and ampoules were in the room and stated they were not supposed to be at bedside. LN 7 also confirmed the eye drops were present and stated she was not aware of them being there, adding that medications should not be kept at bedside and that the eye drops could cause blindness if not used properly. Resident 5 was admitted with diagnoses including GERD, anxiety disorder, depression, and paranoid schizophrenia, and the MDS indicated intact cognition. Resident 5 was not present when the orange tablet was first observed in an unlabeled medication cup at bedside. When Resident 5 and LN 7 were later present, LN 7 confirmed the tablet and stated it looked like Tums; Resident 5 said it was Tums given by the nurse from the previous night for acid reflux. LN 7 stated the medication was not supposed to be at bedside and that staff needed to make sure the resident took the medication. Resident 50 was admitted with diagnoses including bipolar disorder, ADHD, and adjustment disorder, and the MDS indicated intact cognition. Resident 50 was observed in bed, awake but refusing to answer questions, while an unlabeled medication cup containing white powder was seen on the dresser at bedside; LN 7 confirmed the cup and stated she did not know what the powder was. The DON later stated staff are not supposed to keep medication at bedside because they do not know when the resident is going to take it and must observe residents to ensure the medication is taken.
Pureed Spaghetti Prepared Outside Recipe Instructions
Penalty
Summary
The facility failed to ensure foods were prepared to meet residents’ needs when the Dietary Aide did not follow the recipe for preparing pureed spaghetti. The facility’s winter menu 2026 recipe directed staff to place the needed portions of regular cooked spaghetti into a food processor, process it to a fine texture, add hot water, margarine, and nonfat dry milk powder, and then reprocess for 30 seconds until a smooth, pudding consistency was achieved. During a concurrent observation and interview, the Dietary Aide, who stated she was also a cook, prepared the pureed spaghetti for the lunch meal with the Dietary Manager present. The Dietary Aide added the correct ingredients and processed the food to a smooth pudding consistency, but then turned the food processor on for approximately five seconds instead of reprocessing for 30 seconds. When asked how long she reprocessed the food, she stated she did not time it and only reprocessed long enough to make sure it did not have any lumps. The Dietary Aide acknowledged she did not follow the recipe instructions exactly, and the Dietary Manager acknowledged that the recipe was not followed for the reprocessing length of time.
Unsafe Food Handling and Storage Practices
Penalty
Summary
Food was not prepared and stored in a safe and sanitary manner when the Dietary Aide calibrated thermometers without making a slush of crushed ice and water. During observation, the Dietary Aide placed five thermometers in a glass container with ice only, pushed them into the ice, and waited three minutes before reading the temperatures. The Dietary Manager acknowledged that the thermometer was not calibrated using the method described in the facility policy, which required crushed ice and cold tap water to form a slush before checking accuracy. The facility also had cutting boards with crevices. During observation, two of four cutting boards were noted to have crevices, and the Dietary Manager stated the crevices were from cutting meat with sharp knives. The Dietary Manager acknowledged that bacteria could be present in the crevices. The facility policy and the Food Code cited that cutting boards subject to scratching and scoring must be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if resurfacing is not possible. A Dietary Supervisor with a closely trimmed beard was observed in the kitchen without a beard net or other beard covering, and he stated he did not need one unless the beard was really big. In addition, resident food stored in the resident refrigerator was labeled with a discard date that did not match the earlier expiration date on one of the items. A bag contained individually wrapped cheese and unopened salami with the same use-by date, even though the salami package had an earlier expiration date. Nursing staff stated items were kept for three days, and the Dietary Manager acknowledged both items were in the same bag with the same discard date.
QAPI Committee Missing Required MD Participation
Penalty
Summary
The facility failed to ensure the required members of the Quality Assurance Performance Improvement (QAPI) Committee were present during quarterly meetings for a census of 82. Review of the facility’s quarterly QAPI meeting sign-in sheets dated 7/29/25 and 1/26/26 showed signatures of committee members who attended, but the sheets did not indicate that the Medical Director (MD) was present at either meeting. During interview, the Administrator confirmed the MD did not attend the 7/29/25 QAPI meeting because he was out of the country and did not assign a designee to attend. The Administrator also stated the MD was present by telephone during the 1/26/26 meeting but forgot to sign the sign-in sheet, and there was no documentation showing the MD’s telephone participation. The facility’s Annual QAPI & Patient Safety Plan, dated 2/21/26, stated the QAPI Committee is composed of the Facility Administrator, Director of Nursing, Medical Director, and at least 3 other members, and that the committee meets at least quarterly.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering Depakote to one sampled resident with multiple diagnoses including CVA, a left olecranon fracture, bipolar disorder, and depression. The resident was his own responsible party, and the MDS indicated moderate cognitive impairment with a BIMS score of 10 out of 15. The resident also had a documented episode of suicidal ideation on 2/10/26, including wrapping a call light cord around his neck. The resident had an order for Depakote 250 mg twice daily for bipolar disorder dated 2/18/26, and the MAR showed the medication was started on 2/19/26. The Psychotherapeutic Drug Informed Consent for Depakote was not signed until 3/13/26. The MAR also reflected a later entry for Depakote beginning 3/10/26 with gloves to handle the medication. During interviews, the SSD acknowledged the consent was not signed until after the medication had been ordered and stated informed consent should be obtained prior to administering the medication. The NP stated the resident had previously been on Abilify and was changed to Depakote after the suicidal ideation episode, but was unsure when consent was obtained. The DON acknowledged the consent was signed after the order date and stated the resident should have had informed consent when the medication was started; the DON also stated the resident was not fully informed.
Unmonitored PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary psychotropic medication use when Resident 11 was prescribed lorazepam for anxiety without adequate monitoring. Resident 11 was admitted to the facility in February 2026. The Order Summary Report dated 3/19/26 showed active orders entered on 2/17/26 for lorazepam oral tablet 0.5 mg: 1 tablet every 2 hours as needed for mild anxiety, 2 tablets every 2 hours as needed for moderate anxiety, and 3 tablets every 2 hours as needed for severe anxiety. The record review showed no monitoring orders for lorazepam at the time the medication was ordered. The care plan dated 3/19/26 also did not list any interventions or monitoring for lorazepam when it was ordered on 2/17/26. During interview, LN 3 stated she did not see any monitoring orders for lorazepam and that the monitoring order should be entered at the same time as the medication order. The DON stated the nurses were supposed to add the order for behavioral monitoring when the medication was ordered, but they did not. The facility policy titled Psychotropic Medication Use stated that residents receiving medications used to treat behaviors should be monitored for efficacy, risks, benefits, and harm or adverse consequences.
MDS Weight Loss Coding Error
Penalty
Summary
The facility failed to ensure the MDS accurately reflected the health status of one sampled resident, Resident 50, when Section K Swallowing/Nutritional Status was documented incorrectly. Resident 50 was admitted in April 2024 with diagnoses including dysphagia, hypothyroidism, bipolar disorder, and adjustment disorder, and the MDS dated [DATE] indicated intact cognition. In Section K of the MDS dated 12/17/25, Resident 50 was coded as weighing 120 lbs and as not having lost 5% or more in the last month or 10% or more in the last 6 months. Record review showed Resident 50's weights were 136 lbs on 6/5/25, 127.2 lbs on 11/2/25, and 120.4 lbs on 12/2/25. During interview, the MDSN stated she completed Section K and answered No to the weight-loss questions, while the MDSC reviewed the weights and confirmed Resident 50 had lost 5.5% in the last month and 11.7% in the last 6 months. The MDSN stated she should have selected Yes for the weight-loss item. The facility policy and the CMS RAI Manual both state that significant weight loss should be assessed and coded accurately in Section K.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to ensure two sampled residents were assisted with ADLs when their fingernails were long and unclean. Resident 34 was admitted with diagnoses including hemiplegia affecting the right dominant side and cerebral infarction, and his BIMS indicated moderate cognitive impairment. His care plan identified a self-care deficit requiring assistance or dependence in personal hygiene, with interventions to provide verbal, visual, and physical cues as indicated. During observation, Resident 34 was lying in bed with long fingernails and blackish substance underneath the nails. When asked later, Resident 34 stated he wanted his fingernails trimmed. A CNA stated the resident’s fingernails needed trimming, filing, and cleaning and acknowledged the blackish substance under the nails. Resident 62 was admitted with diagnoses including type 2 DM with diabetic chronic kidney disease and cognitive communication deficit, and his BIMS indicated severe cognitive impairment. His care plan identified a self-care deficit in ADLs including personal hygiene, with an intervention to assist in personal hygiene as needed. During observation, Resident 62 was lying in bed with long fingernails and blackish substance underneath the nails. When asked later, Resident 62 stated, "I guess so" when asked if his fingernails were long and dirty. A CNA stated Resident 62’s fingernails were long and dirty and noted that for diabetic residents the licensed nurse trims the nails. The DON and RN stated staff need to trim and clean residents’ nails after a shower, and Medical Records stated there was no care plan for refusal of nail care for either resident.
Respiratory Equipment Not Replaced and Oxygen Use Not Documented
Penalty
Summary
Respiratory care and services were not provided according to professional standards for one resident with COPD and acute respiratory failure with hypercapnia. The resident had orders for ipratropium-albuterol nebulizer treatments as needed for shortness of breath or wheezing and oxygen at 2 L/min via nasal cannula as needed for O2 saturation less than 92% or shortness of breath. During observation, the resident’s nebulizer tubing was stored in a clear bag and dated 3/8/26, and the licensed nurse stated it should have been changed 2 days earlier. The nurse also stated there was no date on the oxygen tubing and did not know when it had been changed. The resident stated he used oxygen at night, and the activities director later interpreted that he had been using oxygen every night due to shortness of breath and using the nebulizer treatment in the morning. During record review, the DON stated the resident’s bedtime oxygen order had been discontinued and there was no routine oxygen order for March, yet the resident’s oxygen saturation on 3/19/26 was 94% with oxygen via nasal cannula and this was not documented in the MAR. The DON stated licensed nurses were expected to document oxygen use in the MAR because oxygen is a medication. The facility policy titled Respiratory Therapy - Prevention of Infection stated nebulizer administration sets should be discarded every 7 days and respiratory therapy information should be recorded in the medical record.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had an annual performance review for one of five sampled CNA staff, CNA 3. During a concurrent interview and record review, CNA 3’s personnel file was reviewed and showed he was hired on 2/4/25, but no annual performance review had been completed. The Director of Staff Development stated he was not sure how the facility tracked when annual performance reviews were due and acknowledged that he did not see a performance review in the file, although there should have been one. The facility’s Employee Handbook stated that annual, documented reviews were established to formalize an interactive conversation about performance, improvement, goals, and objectives, and the facility’s Performance Evaluations policy stated that each employee’s job performance shall be reviewed and evaluated at least annually and that the completed evaluation would be sent to HR for placement in the personnel file.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5% when 2 of 31 medication opportunities were not given according to physician orders, resulting in a 6.45% error rate. One resident had an order for Prasugrel HCL 10 mg daily for antiplatelet therapy, but during a medication pass the medication was not available for administration. The nurse stated the medication was not available and had been ordered on 3/6/26, and the DON later stated he was made aware that the medication was not available because of insurance coverage. A second resident had an order for Prevacid delayed release 30 mg every 12 hours for heartburn, with instructions to give on an empty stomach for best absorption. During the medication pass, the nurse prepared and administered the medication after the resident had already eaten breakfast, and the nurse stated the meal trays had been passed between 6:30 and 7:00 a.m. The nurse later acknowledged the order indicated to give before meals for best absorption, and the RN also acknowledged the order indicated to give before meals. The facility policy stated medications are to be administered in accordance with written physician orders and within 60 minutes of the scheduled time, except for before or after meal orders, which are to be administered based on mealtime.
Missing Written Agreement for Dialysis Services
Penalty
Summary
The facility failed to obtain a written agreement for services furnished by an outside dialysis resource for one of 24 sampled residents, Resident 10, who was receiving hemodialysis. Resident 10 was admitted in October 2025 with diagnoses including atherosclerotic heart disease and end stage renal disease. A physician order dated 3/6/26 directed hemodialysis at a named dialysis company and address on Monday, Wednesday, and Friday. During interviews on 3/19/26 and 3/20/26, the Administrator stated he would look for the agreement with the dialysis clinic, then stated the facility had no agreement with the dialysis clinic and that the importance of the agreement was to make sure Resident 10 receives dialysis care. The facility policy titled Hemodialysis Care and Coordination stated the facility would provide necessary care and treatment and maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to implement infection prevention and control practices for Resident 15 by not placing the resident on Enhanced Barrier Precautions despite the presence of an indwelling Foley catheter. Resident 15’s facesheet listed diagnoses including Chronic Kidney Disease and Benign Prostatic Hyperplasia with lower urinary tract symptoms, and the order summary showed a Foley catheter order with a start date of 1/22/26. The MDS dated 12/29/25 indicated the resident had an indwelling catheter, but the order summary dated 3/17/26 showed no order for Enhanced Barrier Precautions. During observations on 3/17/26 and 3/18/26, Resident 15’s room did not have any isolation precaution signs, and multiple care staff were observed entering and exiting the room without PPE. The Infection Preventionist stated she did not think Resident 15 had a catheter until reviewing the record and said residents with catheters should be placed on enhanced barrier precautions; she also stated the order for EBP was entered on 3/17/26 and there was no order before then. The facility also failed to maintain infection control practices for Resident 19 when soiled linens, a soiled brief, and soiled gloves were left on the resident’s bed during an observation on 3/17/26. No staff were in the room at the time. The DON observed the soiled items on the bed and stated from an infection prevention standpoint they should not have been left there and should have been thrown away right after. CNA 4 stated she left the soiled linens and trash on the bed because she did not have her trash cart before assisting Resident 19 and went to get the trash and linen cart while leaving the dirty brief and soiled linens on the bed.
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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Illustrative
What surveyors actually found near you
We read the 529 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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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 | ★★★★★ | 15 | 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 | ★★★★★ | 7 | 0 |
| River Bend Nursing Center | 14.1 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.