Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Convalescent Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility did not report multiple incidents of suspected abuse, neglect, misappropriation, and falls with significant injury involving several residents with cognitive impairment and complex medical conditions. Grievances and incident logs showed that allegations and injuries, including head trauma and deep lacerations, were not reported to authorities or fully investigated as required.
Surveyors found that the facility did not maintain a medication error rate below 5%, with nearly half of observed medications administered outside the required time window. Multiple residents received medications for conditions such as end-of-life care, hypertension, Parkinson's disease, and infection later than scheduled, as confirmed by MAR review and staff interviews. Facility expectations for timely administration were not met, resulting in a regulatory deficiency.
Surveyors found that medications and medical supplies were not properly stored, labeled, or secured. Expired OTC medications and supplies were present in storage areas and on emergency carts. Opened medications on a medication cart lacked required labeling, and both medication and treatment carts were left unlocked and unattended. Staff interviews confirmed that carts should be locked when not in use, but this was not consistently followed.
A resident's trust fund balance was not disbursed to the resident or their representative within the required timeframe after discharge, with funds remaining undispersed for several months. The business office manager confirmed the delay, which did not comply with regulatory expectations.
A resident with PTSD and hypertension reported $80.00 missing after a canceled store trip and filed a grievance. The facility did not investigate, follow up, or resolve the grievance, and staff confirmed the lack of action, citing a staffing gap in Social Services.
The facility did not accurately complete PASRR assessments for two residents with serious mental illnesses, resulting in missing or incomplete documentation of required mental health evaluations. The Social Services Director confirmed that the PASRR Level I screenings were done incorrectly at both admission and upon repeat, leading to failures in identifying and addressing the residents' mental health needs.
A resident who was moderately cognitively impaired experienced over five days without a bowel movement, during which the facility failed to initiate the required bowel management protocol. Staff interviews and record reviews confirmed that no interventions were administered or documented as per policy, resulting in a deficiency in providing appropriate care.
The facility did not submit the required Payroll Based Journal (PBJ) staffing data to CMS for a fiscal quarter, as confirmed by record review and administrator interview, resulting in no staffing data being available for that period.
The facility failed to label and date opened food items in both the kitchen freezer and the Unit 100 nourishment refrigerator/freezer. Undated and unlabeled items included meatballs, potato wedges, Chicken Cordon Blue, French fries, vegetables, Jello, and ice cream. Staff acknowledged the oversight.
The facility failed to initiate Enhanced Barrier Precautions for eight residents, properly implement standard precautions during dressing changes for two residents, and ensure proper aseptic techniques for urinary catheter maintenance for one resident. Additionally, a staff member did not perform hand hygiene before and after assisting a resident with meals.
A facility failed to promote dignity while assisting a resident with meals. The CNA did not communicate properly, placed a clothing protector without permission, and stood over the resident during meal assistance. This did not align with the care plan or facility expectations for promoting resident dignity.
The facility failed to maintain comfortable sound levels, leading to complaints from two residents about excessive noise from TVs and staff conversations, particularly at night and early in the morning. Despite staff awareness, the issue persisted, affecting the residents' quality of life.
The facility failed to investigate an allegation of inappropriate resident-to-resident touching involving a severely cognitively impaired resident. The incident was not documented in the incident report log or the resident's progress notes, and proper procedures such as alert charting were not followed.
The facility failed to initiate bowel interventions for two residents as per the established bowel management policy, resulting in prolonged periods without bowel movements and lack of documented actions. Interviews with staff confirmed the protocol was not followed, placing residents at risk for discomfort and health complications.
The facility failed to offer and/or administer the influenza and pneumococcal vaccines to two residents, both severely cognitively impaired, despite signed consents. The medical records lacked documentation of vaccine administration, and staff confirmed the vaccines were not given.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Report Abuse, Neglect, Misappropriation, and Significant Injuries
Penalty
Summary
The facility failed to timely report incidents of suspected abuse, neglect, misappropriation, and falls with significant injury for five residents, as required. For one resident with moderate cognitive impairment and hemiplegia, a grievance was filed by a friend alleging staff yelled at and were rude to the resident, but there was no evidence that this allegation of abuse or neglect was reported to the appropriate authorities. Another resident, who was cognitively intact and had hypertension and PTSD, reported missing money, but the grievance was not completed or investigated, and there was no report of misappropriation made. A third resident with moderate cognitive impairment and supranuclear ophthalmoplegia experienced multiple falls, including two with head injuries, but these incidents were not reported to Residential Care Services (RCS) as required. Documentation showed injuries such as bumps, abrasions, and facial bruising, with neuro checks initiated, but no external reporting occurred. Similarly, another resident with moderate cognitive impairment and acute kidney failure sustained a fall resulting in a hematoma near the eyebrow, but this was not reported to RCS. Documentation included witness and nursing notes describing the incident and injury. A fifth resident with moderate cognitive impairment and lung cancer suffered a fall resulting in a deep laceration to the left lower extremity, requiring hospital transport. Despite the severity of the injury, there was no evidence that this incident was reported to RCS. Across all cases, review of facility logs and reported incidents confirmed that required reports for significant injuries, misappropriation, and abuse/neglect allegations were not made, and in some cases, investigations were incomplete or not conducted.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a medication error rate of 48.15% during a medication pass audit. Surveyors observed that 13 out of 27 medications for four residents were not administered within the required time frame. Specifically, medications scheduled for administration at 9:00 AM, 8:00 AM, and 6:00 AM were instead given significantly later, with some being administered more than an hour past the scheduled time. The medications involved included treatments for end-of-life comfort, dry eyes, dysphagia, hypertension, Parkinson's disease, chronic pain, and antibiotic therapy for infection. Staff interviews and record reviews confirmed that the facility's expectation was for medications to be administered within one hour before or after the scheduled time as listed on the Medication Administration Record (MAR). However, observations showed that this standard was not met for multiple residents, as medications were prepared and administered outside of the required time window. This failure to adhere to scheduled medication administration times constituted a deficiency under the cited regulation.
Failure to Properly Store, Label, and Secure Medications and Supplies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices, including improper storage, labeling, and disposal of medications and medical supplies. In the medication storage room, numerous unopened bottles of over-the-counter medications and supplements were found to be expired, such as B Complex, B-12, Folic Acid, Vitamin C, Fish Oil, and liquid Iron. The emergency cart contained six expired Suction, Catheter, and Glove Kits. On the Flagship medication cart, several opened bottles of medication lacked documentation of the date opened and the date for disposal. Additionally, both the Flagship medication cart and a treatment cart were left unlocked and unattended for approximately half an hour, allowing potential unauthorized access to medications and supplies. Further observations revealed that medication carts were not consistently secured when not in use. On one occasion, a bottle of probiotics requiring refrigeration was left on an ice pack on the medication cart, which was then locked and left unattended by an LPN. The medication remained unsecured on the cart until the nurse returned. Staff interviews confirmed that the expectation was to keep medication and treatment carts locked when not in direct use, but this was not consistently practiced. These actions and inactions resulted in medications and medical supplies being improperly stored, labeled, and secured, contrary to facility policy and accepted professional standards.
Delayed Disbursement of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that resident funds were conveyed to the resident or their representative within 30 days of discharge, as required. Specifically, one discharged resident had a trust account balance of $100.05 that remained undispersed 147 days after discharge. Review of records confirmed the resident was discharged with no return anticipated, and the business office manager acknowledged that the funds were not distributed as expected. This deficiency was identified through interview and record review, and it was noted that the delay in dispersing the funds did not meet regulatory requirements.
Failure to Investigate and Resolve Resident Grievance Regarding Missing Money
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance submitted by a cognitively intact resident who was admitted with diagnoses including post-traumatic stress disorder and hypertension. The resident reported missing $80.00 from their funds after a canceled store trip, and a grievance was filed regarding the missing money. The grievance form documented the resident's account of the incident but contained no evidence of investigation, follow-up, or resolution. Interviews with the resident confirmed that the money remained missing and that there was no follow-up from the facility. Staff interviews revealed that grievances related to misappropriation were managed by Social Services, but the grievance in question had no documented follow-up or resolution. The facility administrator acknowledged that the grievance was not completed, attributing the lapse to a period when there was no social worker on staff, resulting in the grievance being overlooked.
Failure to Accurately Complete PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected mental health diagnoses for two residents. For one resident admitted with a diagnosis of depressive disorder and documented as severely cognitively impaired, the admission PASRR Level I did not indicate the presence of major depressive disorder. A repeat PASRR Level I later documented depressive disorder but did not clarify whether a PASRR Level II evaluation was indicated. For another resident admitted with diagnoses including post-traumatic stress disorder, anxiety disorder, and major depressive disorder, the admission PASRR Level I noted serious mental indicators but did not require a Level II evaluation due to an exempted hospital discharge. A subsequent PASRR Level I again documented serious mental illness but lacked documentation regarding the need for a Level II evaluation. During interviews, the Social Services Director acknowledged that both residents had serious mental illnesses prior to admission and that the PASRR Level I screenings were completed incorrectly at admission and upon repeat. The lack of accurate and complete PASRR documentation resulted in the failure to properly identify and address the residents' mental health needs as required.
Failure to Initiate Bowel Protocol for Resident with Extended Constipation
Penalty
Summary
The facility failed to implement its bowel management protocol for a resident who was moderately cognitively impaired. According to the facility's policy, specific interventions such as administering Polyethylene Glycol, Docusate Sodium, Milk of Magnesia, Sodium Phosphate enema, or Bisacodyl Suppository were to be initiated if a resident had not had a bowel movement for three days. Documentation showed that the resident went over five days without a bowel movement, yet the bowel protocol was not initiated during this period, and there was no documentation of interventions or refusals. Interviews with staff confirmed that an alert should have triggered after three days without a bowel movement and that interventions should have been administered and documented per policy. The Medication Administration Report for the relevant period did not show any bowel interventions provided, and the Director of Nursing was unable to provide further documentation of successful interventions. This lapse resulted in a failure to provide appropriate treatment and care according to physician orders and facility policy.
Failure to Submit Required Payroll Based Journal Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Fiscal Year Quarter 3, 2024, as required. Review of the Q3 2024 HPRD Reporting Results showed that the facility had zero data available for this period. During an interview, the Administrator confirmed that the Payroll Based Journal (PBJ) data had not been submitted to CMS for the specified quarter. This deficiency was identified through record review and staff interview, with no PBJ data available for the required reporting period.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure food items were labeled and dated when opened in both the kitchen freezer and the Unit 100 nourishment refrigerator/freezer. During an observation of the kitchen freezer, several undated and unlabeled opened items were found, including plastic bags of meatballs, potato wedges, Chicken Cordon Blue, French fries, and vegetables. Staff L, a cook, acknowledged that the items should have been dated but were not. Similarly, an inspection of the Unit 100 nourishment refrigerator/freezer revealed undated and unlabeled opened items such as Jello in a red plastic cup, a 14 oz container of vanilla bean ice cream, and Talenti ice cream. Staff M, the Dietary Manager, and Staff B, the Director of Nursing Services and Registered Nurse, confirmed that all items should be dated when opened and acknowledged the failure to do so.
Infection Control Deficiencies
Penalty
Summary
The facility failed to initiate Enhanced Barrier Precautions (EBP) for eight residents who had pressure ulcers or indwelling catheters. Despite having a policy in place, the facility did not implement EBP for these residents, which was confirmed by the Infection Preventionist and other staff members. The staff acknowledged that they were still working on a plan to implement EBP effectively, but it had not been put into practice during the survey period. The facility also failed to properly implement standard precautions during dressing changes for two residents with wounds. In one instance, a nurse did not change gloves or perform hand hygiene after cleaning a resident's bowel movement and proceeded with the dressing change. In another instance, a nurse did not perform hand hygiene between removing dirty dressings and applying new ones. Both instances were acknowledged by the staff as not meeting the facility's expectations for aseptic techniques. Additionally, the facility did not ensure proper aseptic techniques for urinary catheter maintenance for one resident. The resident's Foley catheter drainage bag was observed lying on the floor multiple times, which is against the facility's policy. Staff members admitted that the drainage bag should not be on the floor and acknowledged the need to find a solution to prevent this from happening. Furthermore, a staff member failed to perform hand hygiene before and after assisting a resident with meals, which was also against the facility's policy and CDC guidelines.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity while assisting with meals for one resident. Resident 47, who had severely impaired cognition but could adequately hear and communicate, was observed being assisted with meals by a Certified Nursing Assistant (CNA) without proper communication or respect for the resident's dignity. The CNA placed a clothing protector on the resident without warning or permission and stood over the resident while assisting with eating, engaging in minimal conversation. This was observed on two separate occasions, with the CNA failing to sit at the resident's level or engage in meaningful conversation as expected by the facility's standards. Interviews with Registered Nurses (RNs) confirmed that the expectation was for staff to sit next to residents and communicate with them while assisting with meals. The care plan for Resident 47 included interventions to ensure staff conversed with the resident, allowed time for the resident to answer questions, and encouraged the resident to express their feelings. The observed actions of the CNA did not align with these care plan interventions, leading to a failure in promoting the resident's dignity and respect during meal assistance.
Failure to Maintain Comfortable Sound Levels
Penalty
Summary
The facility failed to maintain comfortable sound levels for two residents, leading to complaints about excessive noise. Resident 34, who was cognitively intact, reported that the TV in the hallway was too noisy at night, waking him up early in the morning. He had to use headphones to sleep and expressed a desire to see the facility's TV/noise policy. Resident 21, who was moderately cognitively impaired, also complained about noise, specifically her roommate's loud TV. Despite being moved to the main lounge to escape the noise, the issue persisted, and she reported no improvement in the noise levels in her room. Staff members corroborated the residents' complaints, noting that noise issues, particularly loud TVs and staff conversations, were common around 10:00 PM and early in the morning. The Social Services Director and an LPN acknowledged the frequent noise complaints, and the Admissions Director confirmed that managers would ask residents to lower their TV volumes. However, the Administrator seemed unaware of the extent of the noise concerns, stating that such issues would go through the grievance process and that the facility had a noise policy in place.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of inappropriate resident-to-resident touching involving a severely cognitively impaired resident. The incident was reported in the facility's grievance log, but there was no documentation in the April 2024 Incident Report Log or the resident's progress notes about the incident. Additionally, there was no alert charting or interventions documented to ensure the safety of the residents involved. Staff interviews revealed that proper procedures were not followed. According to the facility's policy, an incident investigation should have taken place, and the residents involved should have been put on alert charting for at least 72 hours. However, this did not occur, indicating a failure to adhere to the facility's abuse prevention program and investigative protocols.
Failure to Initiate Bowel Interventions
Penalty
Summary
The facility failed to ensure bowel interventions were initiated for two residents reviewed for quality of care related to constipation. Resident 44, who was cognitively intact, did not have a bowel movement for nine days, from 04/05/2024 to 04/14/2024. Despite the facility's bowel management policy, which mandates specific interventions after three days without a bowel movement, no actions were documented or taken for Resident 44 during this period. Similarly, Resident 39, who was severely cognitively impaired and unable to express care needs, did not have a bowel movement for four days, from 04/20/2024 to 04/24/2024. Again, the bowel management protocol was not initiated as required by the facility's policy. The April 2024 Medication Administration Record (MAR) confirmed that the bowel protocol was not followed for either resident. Interviews with staff members, including a Registered Nurse, the MDS Coordinator, and the Director of Nursing Services, revealed that the bowel protocol should have been triggered after three days without a bowel movement. However, none of the staff could provide documentation that the protocol was initiated for either resident. This failure to follow the established bowel management policy placed the residents at risk for discomfort, health complications, and a diminished quality of life.
Failure to Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and/or administer the influenza and pneumococcal vaccines to two residents, placing them at risk for developing influenza and/or pneumonia. Resident 46, who was severely cognitively impaired, was admitted to the facility and had consents for both vaccines signed by the guardian. However, the medical record did not show documentation of the administration of either vaccine. Staff C, the Infection Preventionist and RN, confirmed that the vaccines were not given despite the signed consent and the expectation from the Director of Nursing Services that they should have been administered. Similarly, Resident 39, also severely cognitively impaired, was admitted to the facility and had consents for influenza, pneumococcal, and COVID vaccinations signed by the Power of Attorney. However, there was no documentation in the medical record showing the administration of the pneumococcal vaccine. Staff C was unable to provide additional documentation to confirm the vaccine was given. These failures were in violation of the facility's policies and procedures for offering and administering vaccines within specified timeframes.
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Illustrative
What surveyors actually found near you
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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.
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) |
|---|---|---|---|---|
| Saint Helens Post Acute | 4.3 mi | ★★★★★ | 36 | 0 |
| Avalon Care Center - Scappoose | 11.4 mi | ★★★★★ | 17 | 0 |
| Brookfield Health And Rehab Of Cascadia | 12.8 mi | ★★★★★ | 0 | 0 |
| Salmon Creek Post Acute & Rehabilitation | 13.4 mi | ★★★★★ | 27 | 0 |
| Bridge Crest Post Acute | 17 mi | ★★★★★ | 29 | 0 |
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