Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woodside Healthcare Center during CMS and state inspections, most recent first.
Three residents were at risk due to electrical hazards in their rooms, including unsecured extension cords and power strips on the floor. Staff confirmed these as trip hazards, acknowledging the need for cords to be mounted on walls for safety. The facility's policy requires immediate reporting of such hazards.
The facility failed to ensure safe pharmaceutical services, with discrepancies in controlled drug documentation for two residents and the administration of expired eye medication to another. These errors were confirmed by staff, highlighting risks of drug diversion and reduced treatment efficacy.
A facility's medication error rate exceeded the acceptable threshold, with errors observed in three residents. An LPN administered Famotidine without food and Pantoprazole too early, contrary to physician orders. Another LPN failed to repeat the inhalation process for Spiriva, potentially reducing its effectiveness. Both the Consultant Pharmacist and DON emphasized the importance of following physician orders.
The facility failed to properly label and store medications, with loose pills found in medication carts and an expired bottle of Latanoprost for a resident. Licensed Nurses, the Consultant Pharmacist, and the DON confirmed these issues, highlighting the risks of unidentified and expired medications. The facility's policy requires medications to be stored in original packaging and outdated drugs to be returned or destroyed.
The facility failed to maintain food safety standards, affecting all 54 residents. The fruit and vegetable wash sink lacked an air gap, risking contamination from backflow, as confirmed by the Dietary Supervisor and Director of Maintenance. Additionally, expired food was found in the residents' refrigerator, including a seafood salad and lettuce, which should have been discarded according to facility policy. The Director of Nursing outlined the procedure for handling food from home, emphasizing the need to discard expired items after 72 hours.
The facility failed to maintain effective infection control practices, as a shared glucometer was not properly disinfected between uses for three residents, and a nasal cannula for a resident with respiratory conditions was improperly stored when not in use. The glucometer was wiped for less than the required one minute, and the nasal cannula was left uncovered, contrary to facility policies and manufacturer instructions, increasing the risk of cross-contamination.
A resident with muscle weakness and diabetes was found with long fingernails and a blackish substance underneath, indicating a lack of proper nail care. Despite requiring substantial assistance with personal hygiene, there was no documentation of refusal for nail care. The DON and IP/DSD confirmed the importance of clean nails for infection control, but the facility failed to adhere to its policy on providing appropriate ADL support.
A resident was prescribed Sertraline for depression without a documented diagnosis of depression. The resident was admitted with anxiety and restless legs syndrome, and staff interviews indicated no signs of depression. The Director of Nursing confirmed the medication was initially for anxiety, but the facility documented it incorrectly. The facility's policy requires medications to be clinically indicated for specific conditions.
A resident's call light was found under the bed and not within reach, potentially affecting their ability to request assistance. The resident, who was cognitively intact and required substantial assistance, had a care plan indicating the need for the call light to be accessible. Staff interviews confirmed the expectation for call lights to be within reach, and the facility's policy supported this requirement.
Electrical Hazards Pose Safety Risks for Residents
Penalty
Summary
The facility failed to maintain an environment free from potential accident hazards for three residents, as observed during a survey. Resident 259, who was admitted with anxiety, restless legs syndrome, and muscle weakness, had an electrical extension cord with wires on the floor beside her bed. This was noted during an observation and interview, where the resident acknowledged the danger. Her care plan indicated a risk for falls due to impaired balance, and she had an unwitnessed fall prior to the observation. Resident 261, admitted with a fracture, muscle weakness, and a history of falling, was found to have an extension cord with multiple wires on the floor beside the bed. Observations and interviews with staff, including a CNA and a licensed nurse, confirmed the presence of the cord and recognized it as a trip hazard. The Maintenance Director and the Director of Nursing also acknowledged the safety issue, noting that power strips should be mounted on the wall to prevent tripping. Resident 414's room contained a metal power strip that was not properly anchored, posing a fall hazard. This was confirmed during observations and interviews with a CNA and the Maintenance Director, who stated that the power strip should be attached to the wall. The Director of Nursing also confirmed the risk associated with the unsecured power strip. The facility's policy on electrical safety, dated 2011, requires reporting any unsafe electrical hazards immediately.
Documentation Errors and Expired Medication Use in LTC Facility
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for its residents, as evidenced by discrepancies in the documentation of controlled drug administration and the use of expired medication. For Resident 35, the administration of oxycodone was not accurately documented in the Medication Administration Record (MAR) after being signed out from the Controlled Drug Record (CDR). Similarly, for Resident 12, the administration of Norco was documented in the MAR but not signed out in the CDR. These documentation errors were confirmed by the Infection Preventionist/Director of Staff Development (IP/DSD) and the Consultant Pharmacist (CP), who highlighted the risk of controlled drug diversion due to these discrepancies. Additionally, Resident 16 received expired Latanoprost Ophthalmic Solution for 27 days. The medication, used to treat glaucoma, was found in the medication cart with an expiration date of 10/22/24, yet it continued to be administered until 11/18/24. The Licensed Nurse (LN) confirmed the use of the expired medication, and the Nurse Consultant (NC) and Director of Nursing (DON) acknowledged the lack of a pharmacy receipt for a new supply of the medication, indicating that the expired solution was indeed used. The facility's policies and procedures require accurate documentation of controlled substances and checking expiration dates before administering medications. However, these protocols were not followed, leading to potential risks for the residents involved. The DON confirmed that expired medications should not be administered as they affect the efficacy of treatment, and the CP emphasized the importance of signing both the CDR and MAR to prevent medication discrepancies and potential diversion.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 12.12%, which is above the acceptable threshold of 5%. This was observed in a resident census of 55, with errors occurring in three out of 11 residents observed for medication administration. The errors were identified during medication administration observations conducted over multiple days and at varied times throughout the facility. One of the errors involved a Licensed Nurse (LN) administering Famotidine to a resident without following the physician's order to take the medication with food. Another error occurred when the same LN administered Pantoprazole to two residents earlier than the scheduled time, which was supposed to be 30 minutes before a meal. The LN acknowledged that the medications were administered too early, which could lead to the medications being ineffective when the residents eat. Additionally, another LN failed to follow the physician's order for administering Spiriva to a resident. The LN did not repeat the inhalation process a second time, as required, to ensure the entire contents of the capsule were inhaled. This oversight could result in the resident not receiving the full dose of the medication. Both the Consultant Pharmacist and the Director of Nursing confirmed that the physician's orders should be followed to ensure residents receive the full benefits of their medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored according to their policies and procedures, as well as accepted professional principles. During an observation and interview, two loose pills were found in the medication cart at the north station, and one loose pill was found in the medication cart at the south station. Licensed Nurses confirmed these observations, acknowledging that loose pills in medication carts pose a risk because staff would not be able to identify the medication or its intended recipient. Additionally, an expired bottle of Latanoprost, a prescription eye drop medication, was found in the south station's medication cart, which was intended for a resident identified as Resident 16. The Consultant Pharmacist and the Director of Nursing both confirmed that loose pills and expired medications should not be present in medication carts. The Consultant Pharmacist emphasized that loose pills are considered lost doses and that expired medications could have health consequences if administered. The Director of Nursing highlighted the risk of loose pills potentially being picked up by residents and the inability of staff to identify them. The facility's policy on medication storage, revised in April 2007, specifies that drugs and biologicals should be stored in their original packaging and that discontinued, outdated, or deteriorated drugs should be returned to the pharmacy or destroyed.
Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, impacting all 54 residents who consumed facility-prepared meals. The first deficiency involved the absence of an air gap in the fruit and vegetable wash sink, which was confirmed by both the Dietary Supervisor and the Director of Maintenance. This lack of an air gap could potentially allow contaminated water to backflow into the sink, posing a risk of food-borne illnesses. The Registered Dietician acknowledged the issue, noting the potential for contamination if the sink did not have an air gap, as outlined in the 2022 FDA Food Code. The second deficiency was observed in the residents' refrigerator, where expired food items were found. A Licensed Nurse discovered a seafood salad and crackers, along with a bag of lettuce labeled for a resident, both of which were expired. The lettuce appeared brownish with discolored water, and the Dietary Supervisor confirmed that these items should have been discarded. The Director of Nursing explained the process for handling food brought from home, stating that expired food should be thrown out after 72 hours. The facility's policy indicated that any suspicious or contaminated food should be discarded immediately, highlighting a lapse in following this procedure.
Infection Control Deficiencies in Glucometer Use and Nasal Cannula Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper cleaning and sanitization of a shared glucometer used for three residents. During medication administration observations, a licensed nurse used the glucometer to measure blood sugar levels for three residents without adequately disinfecting it between uses. The nurse wiped the glucometer with a germicidal alcohol wipe for less than five seconds, contrary to the manufacturer's instructions and facility policy, which required the device to remain visibly wet for one minute to ensure proper disinfection. Additionally, the facility did not properly store a nasal cannula for a resident with respiratory conditions, including obstructive sleep apnea and COPD, when it was not in use. Observations revealed that the nasal cannula was left uncovered and hanging on the bed's side rail or placed on the bed, exposing it to potential contamination. Staff interviews confirmed that the nasal cannula should have been stored in a designated antimicrobial bag to prevent contamination when not in use. The facility's policies and procedures, as well as the manufacturer's instructions for the glucometer and nasal cannula storage, were not followed, leading to an increased risk of cross-contamination and potential exposure to germs for the residents involved. The Director of Nursing and Infection Preventionist acknowledged the lapses in protocol and the associated risks of spreading infection due to these deficiencies.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for one resident, identified as Resident 365, who was unable to perform activities of daily living independently. Resident 365, who had diagnoses including muscle weakness, diabetes mellitus, and hearing loss, was observed with long fingernails and a blackish substance underneath them. Despite having an intact cognition and requiring substantial assistance with personal hygiene, there was no documentation indicating that Resident 365 refused nail care. The resident expressed a desire for her nails to be cleaned and trimmed, and a Certified Nurse Assistant (CNA) confirmed the condition of the nails, acknowledging the risk of infection and potential for skin injury. The Director of Nursing (DON) and the Infection Preventionist/Director of Staff Development (IP/DSD) both confirmed that residents should have clean and well-trimmed fingernails as part of personal hygiene and infection control. The facility's policy on Activities of Daily Living (ADLs) supports the provision of appropriate care and services for residents unable to carry out ADLs independently, including hygiene and grooming. However, the facility did not adhere to this policy for Resident 365, as evidenced by the lack of nail care provided, despite the resident's care plan indicating a need for extensive assistance with all ADLs.
Resident Prescribed Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who was admitted with diagnoses including anxiety and restless legs syndrome, was prescribed Sertraline for depression, despite having no documented diagnosis of depression. The Minimum Data Set indicated the resident had intact cognition, and the physician's order and informed consent documentation incorrectly listed depression as the reason for the medication. Interviews with staff, including a CNA, licensed nurses, the Director of Social Services, and the Director of Nursing, revealed that the resident did not exhibit behaviors indicative of depression. The Director of Nursing confirmed that the medication was initially prescribed for anxiety at the hospital, but the facility incorrectly documented it for depression. The Consultant Pharmacist emphasized the importance of having a correct diagnosis to ensure the medication's necessity and benefit. The facility's policy stated that residents should not receive medications that are not clinically indicated for a specific condition.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light system was accessible for a resident, identified as Resident 24, which could potentially impact the resident's safety by hindering their ability to request assistance. Resident 24 was admitted with diagnoses including a fracture of the left tibia and fibula, muscle weakness, and a history of falling. The Minimum Data Set (MDS) indicated that Resident 24 was cognitively intact and required substantial assistance with various activities of daily living. The care plan for Resident 24, revised in September 2024, highlighted the risk of falls and specified that the call light should be within reach when the resident is in their room. During observations on November 19, 2024, the call light for Resident 24 was found under the bed and not within reach, both in the morning and later at noon. Licensed Nurse 3 confirmed the call light's inaccessibility and acknowledged that the resident uses it to request assistance. Interviews with staff, including a Certified Nursing Assistant and a Licensed Nurse, revealed that the call light should be placed within the resident's reach and that regular checks should be conducted to ensure accessibility. The Director of Nursing also emphasized the importance of the call light being reachable at all times. The facility's policy, dated September 2022, stated that residents should have a means to call staff for assistance through a communication system.
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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 Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Park Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 20 | 0 |
| Sherwood Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Gramercy Court | 1.7 mi | ★★★★★ | 16 | 0 |
| Arden Park Post Acute | 2 mi | ★★★★★ | 15 | 0 |
| Mckinley Park Care Center | 2.8 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.