Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
55 residents
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 55
Deficiencies: 9
Date: Nov 22, 2024
Visit Reason
Routine inspection of Woodside Healthcare Center to assess compliance with regulatory standards including resident care, medication management, safety, infection control, and food service.
Findings
The facility had multiple deficiencies including failure to assist a resident with nail care, unsafe electrical hazards, medication administration errors, expired medications given, improper psychotropic medication use, improper medication storage, food safety violations, infection control lapses, and inaccessible call light for a resident.
Deficiencies (9)
Failure to assist Resident 365 with nail care, resulting in long fingernails with blackish substance underneath.
Electrical extension cords observed on floors and unsecured power strips in resident rooms creating trip hazards for Residents 259, 261, and 414.
Medication administration errors including inaccurate documentation of controlled drug use for Residents 35 and 12, and expired eye medication administered to Resident 16 for 27 days.
Resident 259 received antidepressant medication without appropriate documented diagnosis.
Facility medication error rate exceeded 5%, with 4 errors out of 33 opportunities observed in Residents 261, 359, and 360.
Medications were improperly stored with loose pills found in medication carts and expired medication stored in medication cart.
Food safety violations including lack of air gap in produce wash sink and expired food stored in residents' refrigerator.
Infection control failures including improper cleaning of shared glucometer between residents and improper storage of Resident 41's nasal cannula.
Resident 24's call light was found under the bed and not within reach, posing a safety risk.
Report Facts
Resident census: 55
Medication error rate: 12.12
Days expired medication administered: 27
Number of residents sampled: 23
Number of residents affected by electrical hazard: 3
Number of residents affected by medication errors: 3
Number of residents affected by infection control lapses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 5 | CNA | Confirmed Resident 365 had long fingernails with blackish substance |
| Infection Preventionist/Director of Staff Development | IP/DSD | Confirmed no refusal of hygiene for Resident 365 and discussed controlled drug documentation and glucometer cleaning |
| Director of Nursing | DON | Provided statements on nail care, medication administration, infection control, and call light accessibility |
| Licensed Nurse 2 | LN | Observed medication administration errors and glucometer cleaning |
| Consultant Pharmacist | CP | Discussed medication administration errors, psychotropic medication use, and glucometer cleaning |
| Certified Nursing Assistant 1 | CNA | Confirmed electrical hazards and call light accessibility |
| Maintenance Director | DM | Confirmed electrical hazards and food service sink air gap issue |
| Licensed Nurse 3 | LN | Confirmed call light accessibility issue for Resident 24 |
Inspection Report
Routine
Census: 49
Deficiencies: 4
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, pharmaceutical services, food safety, and infection prevention at Woodside Healthcare Center.
Findings
The facility failed to administer Rybelsus medication according to manufacturer specifications, did not complete controlled medication sign-in/sign-out sheets for medication carts, had multiple food safety violations including improper food storage and equipment maintenance, and failed to properly clean, label, and store CPAP equipment for a resident.
Deficiencies (4)
Rybelsus medication was not administered on an empty stomach as required, potentially affecting diabetes management for Resident 40.
Controlled drug sign-in/sign-out sheets were not completed for two medication carts, risking medication abuse or misuse.
Food safety violations including bananas stored less than 6 inches off the floor, chest freezer with ice buildup and brown substance, improperly dried blender, chipped and dirty can opener, damaged cutting boards, lack of air gap in vegetable wash sink, and missing metal section on food prep surface.
CPAP device for Resident 17 was not cleaned, labeled, or stored properly, risking infection.
Report Facts
Residents affected: 49
Residents affected: 13
Residents affected: 5
Residents affected: 2
Measurement: 6
Measurement: 8
Measurement: 5
Measurement: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Administered Rybelsus medication and unaware of proper administration timing | |
| Director of Nursing | Confirmed medication administration expectations and CPAP cleaning/storage requirements | |
| Pharmacy Consultant | Provided information on proper Rybelsus administration | |
| Licensed Nurse 3 | Confirmed lack of controlled drug sign-in/sign-out sheets | |
| Dietary Services Supervisor | Acknowledged food safety violations including improper storage and equipment issues | |
| Maintenance Supervisor | Acknowledged ice buildup and poor seal in chest freezer and missing metal on food prep surface | |
| Licensed Nurse 5 | Observed unlabeled CPAP equipment | |
| Licensed Nurse 4 | Verified CPAP cleaning was not documented |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 8
Date: Dec 3, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident language needs, inadequate individualized activities, severe unplanned weight loss in a resident, improper disposal of controlled medications, duplicate psychotropic medication use without proper justification, unlabeled medications and supplies, improper food storage practices, and unsanitary garbage storage conditions.
Deficiencies (8)
Failure to provide reasonable accommodation of resident's language needs resulting in increased risk of unmet needs for Resident 37.
Failure to provide individualized activities of interest for Resident 37, placing her at risk of psychosocial harm.
Failure to maintain acceptable nutritional status for Resident 33, resulting in severe unplanned weight loss of 15 pounds (13.2%) in less than two months.
Failure to properly dispose of controlled medications, with crushed and uncrushed tablets stored in medication carts in a manner that did not render them unusable, risking diversion.
Failure to ensure drug regimen was free of unnecessary psychotropic medications for Resident 25, who received two antipsychotic medications from the same class without documented specific target behaviors or adequate non-pharmacological interventions.
Failure to label inhaler, insulin pen, and blood glucose test strips with open dates in medication carts, risking expired medication use or inaccurate test results.
Failure to ensure food removed from freezer and placed in refrigerator was dated and personal items were not stored in food storage areas.
Failure to maintain garbage storage area in a sanitary manner with garbage and refuse observed on the ground next to dumpsters.
Report Facts
Residents affected: 14
Residents affected: 52
Weight loss: 15
Weight loss percentage: 13.2
Medication carts inspected: 2
Residents affected: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged communication failures with Resident 37 and issues with psychotropic medication use for Resident 25. |
| Nurse Practitioner | Nurse Practitioner | Provided psychiatric services to Resident 25 and reported behaviors consistent with anxiety but no aggression or psychosis. |
| Pharmacy Consultant | Pharmacy Consultant | Acknowledged issues with controlled medication disposal and did not identify concerns with duplicate psychotropic medications. |
| Dietary Services Supervisor | Dietary Services Supervisor | Validated food storage and labeling deficiencies and personal items in food storage areas. |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Reported not using communication aides with Resident 37. |
| Licensed Nurse 6 | Licensed Nurse | Validated presence of controlled medications in medication carts not rendered unusable. |
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