Inspection Reports for Woodland Springs Nursing Center

The complaint investigation focused on Resident #1 who did not receive prescribed antibiotics after hospital discharge on 12/23/2025. Interviews with staff revealed failures in entering medication orders into the electronic system and delays in medication administration. The facility acknowledged the medication error, notified the nurse practitioner, and initiated a medication error report. Resident #1 was restarted on antibiotics on 12/26/2025. The failure placed the resident at risk for infection exacerbation and potential septic shock.

The facility failed to ensure Resident #1 received prescribed antibiotics following hospital discharge, resulting in a medication error that placed the resident at risk for worsened health outcomes. The failure involved missed medication orders and delays in administration, violating residents' rights to timely and appropriate care.

The complaint investigation found that 60 tablets of Hydrocodone-Acetaminophen were missing from the medication cart on 08/18/2025. The facility conducted a formal investigation including staff interviews, medication cart audits, drug testing, and camera reviews. The medication was not found, and the responsible staff could not be identified. The incident was reported to the police. Resident #1 had enough medication to avoid missed doses, but the diversion posed a risk of medication error and delayed therapy.

The facility failed to prevent the diversion of 60 tablets of Hydrocodone-Acetaminophen from the medication cart, which could place residents at risk for medication errors and delayed therapy. An investigation was conducted including interviews, medication audits, drug testing of staff, and law enforcement notification, but the missing medication was not recovered and the responsible party was not identified.

The complaint investigation focused on Resident #1, who fell out of his wheelchair during transport on 06/25/2025. The facility did not report the incident to the State Survey Agency within 24 hours as required. Interviews with Resident #1, the Activity Director (AD), Nursing Coordinator (NC), and Administrator (ADM) confirmed the incident and the failure to report. Resident #1 was not injured and declined hospital treatment. The facility's policy requires immediate reporting within 24 hours for non-serious injury allegations, which was not followed.

The facility failed to report the incident to the State Survey Agency within the required 24-hour timeframe, placing residents at risk of delayed incident investigations. Additionally, the facility failed to ensure the activities program was directed by a qualified professional, as the current Activity Director had not completed certification and no policy was in place regarding activities direction.

The complaint investigation revealed that Resident #25, diagnosed with schizoaffective disorder, bipolar type, and anxiety, did not receive the required Level II PASRR evaluation. Interviews with the Director of Nursing and ADON confirmed the evaluation was not completed, and the resident was not receiving PASRR services despite the diagnosis.

The facility failed to identify a diagnosis of mental illness on the PASRR assessment for Resident #25 and did not complete the required Level II PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining necessary mental health services.

The complaint investigation revealed failures in care coordination for Resident #2's eye care appointments and surgical procedures, and inadequate supervision and safe transfer for Resident #1, who suffered a fall with head trauma leading to death. The Immediate Jeopardy was identified on 05/22/2025 and removed on 05/26/2025 after corrective actions were implemented.

The facility failed to ensure Resident #2 received appropriate preparation and medical clearance for eye procedures and appointments, resulting in missed and rescheduled surgeries. The facility also failed to provide adequate supervision and safe transfer for Resident #1, who suffered blunt head trauma during a transfer, leading to hospitalization and death. An Immediate Jeopardy was identified related to Resident #1's injury and the facility's failure to follow safe transfer protocols and timely medical evaluation.

The complaint involved an allegation by Resident #1 that Resident #2 assaulted him in the facility secured unit. The facility failed to report this alleged abuse immediately to the State Survey Agency. The allegation was discovered during a PASRR update meeting on 05/15/25 but was not reported until after the surveyor's investigation. Staff interviews confirmed the failure to report despite training and policies requiring immediate reporting.

The facility failed to report alleged abuse involving Resident #1 and Resident #2 to the State Survey Agency. Resident #1 reported being hit by Resident #2, but the facility did not report the incident until after the complaint investigation began. Interviews revealed staff were trained on abuse reporting but did not act on the allegation promptly. The facility conducted regular in-service training on abuse, neglect, and exploitation.

The complaint investigation was triggered by Resident #1's elopement from the facility on an unspecified date. The resident was missing from approximately 5:00 am to 8:00 am and was located by police. The facility was found to have failed in supervision and safety measures, leading to an immediate jeopardy citation that was later removed after corrective actions.

The facility failed to ensure adequate supervision of Resident #1, who eloped from the facility and was missing for approximately three hours. The resident was found by police and transferred to a hospital for evaluation. The facility was cited for immediate jeopardy related to resident safety and supervision, which was later removed after corrective actions were implemented.

The complaint involved resident-to-resident abuse by Resident #52, including verbal and physical aggression resulting in injury to Resident #62. The facility failed to protect residents, failed to timely report the abuse, and failed to implement effective interventions. An Immediate Jeopardy was identified on 08/30/2024 and removed on 08/31/2024 after corrective actions.

The facility failed to protect residents from an aggressive resident (#52) who caused injury to another resident (#62) and verbal harassment to others. The facility also failed to implement effective interventions and timely report the abuse. An Immediate Jeopardy was identified and later removed after corrective actions including staff re-education, resident discharge, and policy reviews.

The investigation was complaint-related, focusing on failure to notify and properly assess Resident #1 after a significant change in condition. The complaint was substantiated with findings of actual harm.

The facility failed to notify the physician and resident representative of Resident #1's significant change in condition, including inability to swallow and refusal to eat, which led to emergency room transfer and diagnosis of pneumonia and septic shock. The facility also failed to conduct a thorough assessment and provide appropriate treatment and care according to professional standards and the resident's care plan.

The investigation was complaint-related, focusing on failure to notify and assess Resident #1 after a significant change in condition. The complaint was substantiated with findings of actual harm.

The facility failed to notify the physician and resident representative of Resident #1's significant change in condition, including inability to swallow and refusal to eat, which led to emergency room transfer and diagnosis of pneumonia and septic shock. The facility also failed to conduct a thorough assessment and provide appropriate treatment and care according to professional standards and the resident's care plan.

The complaint investigation found that Resident #2 physically and verbally aggressed Resident #1, striking her face and pulling off her wig. Resident #1 was visibly upset and sent to the ER. Resident #2 had a history of aggressive behavior requiring 1:1 supervision. The facility attempted to transfer Resident #2 to a behavioral hospital but faced challenges due to cognitive impairment and lack of consent. Staff were trained and interventions were in place, but the incident occurred before these measures took effect.

The facility failed to ensure residents were free from abuse, specifically Resident #1 who was physically struck by Resident #2. Despite interventions including 1:1 supervision and staff training, the incident occurred. Resident #1 was sent to the ER for evaluation and the incident was reported to the police. The facility implemented corrective actions prior to the survey entry.

The complaint investigation found that Resident #2 physically abused Resident #1 by striking her face and pulling off her wig. The incident was reported to the police and Resident #1 was sent to the ER. Resident #2 had a history of aggressive behavior requiring constant supervision. The facility attempted to manage the behavior through interventions and sought a safe transfer for Resident #2.

The facility failed to ensure Resident #1 was free from abuse, resulting in physical harm and emotional distress. Resident #2 exhibited ongoing verbal and physical aggression requiring 1:1 supervision. The facility implemented corrective actions including staff training, separation of residents, and attempted safe transfer of Resident #2. Resident #1 was sent to the ER for evaluation and later discharged after passing away.

The facility failed to ensure that Resident #5's care plan was accurately revised to reflect her advance directive status. The facility also failed to act upon pharmacist recommendations regarding duplicate medications and gradual drug reduction for Residents #71 and #2. Additionally, the facility did not ensure that residents on a pureed diet received the pureed bread component as required by the menu and dietitian guidance.

The facility failed to ensure proper PASARR screening for residents with mental disorders, develop comprehensive care plans for residents, prevent accidents including a burn injury from heat therapy, provide therapeutic diets as ordered, maintain proper food storage and temperature controls, and implement effective infection prevention and control practices.