Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The document reports on the facility's compliance status based on the implementation of an acceptable Plan of Correction (POC).
Findings
The facility was deemed to be in compliance as of 05/15/2025 following the implementation of the Plan of Correction.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to document and properly handle a resident's grievance about lost, missing, or stolen dentures.
Complaint Details
The complaint was substantiated. The facility failed to properly document and investigate the grievance regarding missing dentures for Resident 363 and did not replace the dentures in a timely manner, resulting in the family paying for replacement dentures.
Findings
The facility failed to document a resident's concern about missing dentures on the grievance log, did not conduct a proper investigation, and did not offer a replacement in a timely manner. Interviews revealed staff were unaware or inconsistent in grievance procedures, and the resident's family paid $800 for replacement dentures after lack of facility action.
Deficiencies (1)
F 0585: The facility failed to document a resident's grievance about lost, missing, or stolen dentures, did not conduct an investigation, and did not promptly replace the dentures as required by policy.
Report Facts
Replacement dentures cost: 800
Resident sample size: 21
Brief Interview for Mental Status (BIMS) score: 9
Resident admission date: Mar 8, 2024
Assessment Reference Date (ARD): Apr 9, 2024
Grievance log review date: 202404
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Named in grievance investigation and communication with resident's family regarding missing dentures. |
| Director of Nursing | Director of Nursing (DON) | Provided information on grievance procedures and staff education related to grievances. |
| Administrator | Administrator | Responsible for grievance oversight and communication with complainant about missing dentures. |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional nursing standards, medication labeling and storage, and infection prevention and control practices at Woodland Oaks nursing facility.
Findings
The facility failed to ensure nurses observed residents taking medications, failed to date multi-use medications after opening, and did not maintain proper infection prevention practices including hand hygiene, glove use, and cleaning of shared and personal equipment.
Deficiencies (3)
F 0658: The facility failed to ensure nursing staff observed residents take their medications, as Licensed Practical Nurse (LPN) 3 did not stay to watch Residents 6 and 19 take their medications.
F 0761: The facility failed to ensure all drugs were labeled with the date opened, as multiple treatment and medication carts contained multi-use medications not dated after opening.
F 0880: The facility failed to implement an effective infection prevention program, as LPN3 did not perform proper hand hygiene, glove use, or disinfect shared and personal equipment including glucometers and pulse oximeters.
Report Facts
Residents affected: 2
Treatment carts with unlabeled medications: 5
Medication carts with unlabeled medications: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Named in medication administration and infection prevention deficiencies |
| RN 2 | Registered Nurse / Unit Manager | Provided expectations on medication observation and infection control |
| ADON 1 | Assistant Director of Nursing | Provided infection prevention and medication administration expectations |
| ADON 2 | Assistant Director of Nursing / Infection Preventionist / Staff Educator | Provided infection prevention and medication administration expectations |
| DON | Director of Nursing | Provided infection prevention and medication administration expectations |
| Medical Director | Provided infection prevention and medication administration expectations | |
| Administrator | Provided infection prevention and medication administration expectations |
Inspection Report
Deficiencies: 1
Date: Nov 14, 2019
Visit Reason
The inspection was conducted to assess compliance with respiratory care standards and infection control related to oxygen and respiratory equipment use in the facility.
Findings
The facility failed to provide safe and appropriate respiratory care for five of twenty-eight sampled residents by not dating oxygen tubing and respiratory equipment to indicate when last changed, risking potential contamination and infection.
Deficiencies (1)
F 0695: The facility failed to date oxygen tubing and nasal cannulas for five residents, including Resident #54, #60, #88, #301, and #302, indicating when they were last changed. Respiratory equipment such as C-PAP tubing and masks were also not stored properly or dated, increasing infection risk.
Report Facts
Sampled residents: 28
Residents affected: 5
Oxygen flow rates: 4
Oxygen flow rates: 5
Oxygen flow rates: 2
Inspection Report
Routine
Deficiencies: 4
Date: Sep 27, 2018
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, medication storage and administration, care plan adherence, and medical record maintenance at Woodland Oaks nursing facility.
Findings
The facility failed to meet professional standards in medication administration and storage, care plan implementation for skin integrity and pressure ulcer prevention, and maintenance of accurate medical records. Specific issues included loose unlabeled medication in the medication cart, improper medication storage, inadequate skin assessments and repositioning for a resident at risk for pressure ulcers, and missing active physician orders for a suprapubic catheter upon resident re-admission.
Deficiencies (4)
F 0658: The facility failed to meet professional standards of quality by leaving a loose, unidentified pill in a medication cart without packaging or labeling, creating potential for medication error.
F 0659: The facility failed to provide care by qualified persons according to Resident #15's written plan of care, including inadequate weekly skin assessments, failure to turn and reposition every two hours, and lack of knowledge and monitoring of Low Air Loss mattress settings.
F 0761: The facility failed to ensure proper storage and labeling of drugs and biologicals, including undated opened vials of Tubersol, unlabeled Acetylcysteine solution, and loose pills in medication carts.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #41 by lacking active physician orders for a suprapubic catheter upon re-admission, likely due to transcription error.
Report Facts
Opened Tubersol vials: 2
LAL mattress weight setting: 450
Skin assessments performed: 2
Turning and repositioning frequency: 2
Medication dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Left loose Proscar pill in medication cart and acknowledged it was improper procedure. |
| DON | Director of Nursing | Investigated loose pill incident and stated expectations for medication disposal and reporting. |
| CMA #1 | Certified Medication Aide | Observed loose pill in medication cart and stated it should be disposed and reported. |
| LPN #3 | Licensed Practical Nurse | Explained medication labeling and dating requirements for multi-dose medications. |
| QA Nurse/Wound Nurse | Licensed Practical Nurse | Responsible for following pressure ulcers and noted failures in skin assessment and mattress monitoring. |
| SRNA #1 | State Registered Nursing Assistant | Reported turning and repositioning Resident #15 but lacked training on mattress settings. |
| SRNA #2 | State Registered Nursing Assistant | Reported turning and repositioning Resident #15 and reviewed care plan interventions. |
| Administrator | Facility Administrator | Stated expectations for medication administration and care plan implementation. |
| Senior Director of Clinical Services | Senior Director | Expected accurate skin assessments and care plan adherence. |
| LPN #1 | Licensed Practical Nurse | Explained procedure for placing physician orders on hold and reactivating upon resident re-admission. |
| LPN #2 | Licensed Practical Nurse | Described process for verifying physician orders upon resident re-admission. |
| SCSD | Senior Clinical Service Director | Noted transcription error likely caused missing active order for suprapubic catheter. |
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