Woodland Park Nursing & Rehab

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 5 residents (Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) reviewed for pharmacy services. The facility did not ensure accurate acquiring of Mounjaro (medication used to lower blood sugar-not insulin) for Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8. This failure could place residents at risk for drug diversion and being charged for medications not ordered by their physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 14 resident reviewed for infection control. (Resident # 3, #29, #37 and #54) The ADON failed to follow infection control procedures on 07/22/25 while providing wound care for Resident #3 who was on EBP. The ADON failed to follow infection control procedures on 07/22/25 after Resident #3's indwelling urethra catheter tubing disconnected from the urinary catheter bag tubing during wound care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 14 (Resident #41) reviewed for quality of care. The facility failed to ensure NP and MD was notified of UA/C&S results for Resident #41 on 01/11/25. The facility failed to ensure a urologist appointment was made for Resident #41 when he was seen at ER on [DATE]. The facility failed to ensure follow-up with the hospital's UA/C&S results on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/23/2025 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:17 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 14 residents reviewed for pressure sore management. (Resident #54)The nursing staff failed to document an accurate skin assessment and treat Resident #54's wounds from admission [DATE] through 07/23/2025. This failure could place residents at risk of not receiving appropriate care leading to worsening skin condition. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours 7 days a week for 1 of 4 quarters of 2024 and 2025 (Quarter 2 - January 01, 2025, through March 31, 2025) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 01/16/2025. This failure could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 2 meals (lunch) reviewed for palatability and temperature. The facility failed to provide food that was palatable and an appetizing temperature for 1 observed on 07/22/25 (lunch) meal. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician regarding a change in condition for 3 of 14 residents reviewed for physician notification. (Residents #3, #6, and #40)The facility failed to consult physician for Resident #3, #6, and #40 when their BP medications were held for patterns of vital signs being outside the prescribed parameters. These failures could place residents at increased risk for complications due to delayed physician intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 14 (Resident #24) residents reviewed for pain. The facility failed to administer Resident #24's pain medication for scheduled doses on 04/27/25 at 10:00 p.m., 04/28/25 at 8:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #24's pain was not assessed 41 of 90 scheduled times of pain intensity level assessments for April 2025. This failure could place residents at risk for increased pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #28) reviewed for meals. The facility failed to ensure that Resident #28 was served meat and vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen. The facility failed to ensure items stored in the refrigerator, and in the dry storage were labeled and discarded by the expiration date. The facility failed to ensure all staff wore hair restraints which covered all hair while in the kitchen. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to have pest control effectively treat the kitchen for flies on 07/22/25 during lunch meal. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 14 (Resident #14 and Resident #28) residents reviewed for dignity.*The facility failed to ensure Resident #14 was treated with dignity and respect when CNA W told her in public to go to the bathroom before lying down in bed.*The facility failed to give and maintain dignity for Resident #28 by CNA N standing up assisting Resident #28 with feeding instead of sitting down to assist with feeding. This failure could negatively affect and impact residents' quality of life as a result of not giving residents respect and dignity.

Inspectors wroteBased on record review and interviews, the facility failed to assure that each resident receives an accurate assessment reflective of the resident's status at the time of the assessment for Resident #54. The facility failed to ensure Resident #54's Nursing admission Assessment was complete and reflected the resident's status at the time of the assessment. Resident #54's Nursing admission Assessment was incomplete due to unanswered medical history information. This failure could place the residents at risk for not receiving the appropriate care and services. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care and the facility failed to provide the resident and their representative with a summary of the baseline care plan for 1 of 14 residents (Resident #54) reviewed for new admissions The facility failed to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #54, and they failed to give a copy to him or his representative. This failure could lead to residents not receiving necessary care and decreased quality of life. Record review of Resident #54's face sheet, dated 07/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 14 residents (Resident #54) reviewed for medication administration, in that: Resident #54 missed scheduled doses of 9 different medications due to availability from the pharmacy. This failure could place the residents at risk of not receiving necessary medications and a decline in health. Record review of Resident #54's face sheet, dated 07/21/25, reflected Resident #54 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diabetes, obesity, insomnia (a sleep disorder characterized by difficulty falling asleep), and spondylolisthesis (a spinal disorder in which a vertebra slips forward onto the bone below it). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 treatment cart reviewed for storage of drugs and biologicals. The facility failed to ensure the treatment cart was locked and secured when left a medication cart unattended unlocked and unsecured on 07/22/25. This failure could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision and assistance devices to prevent accident for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision. * The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. * The facility failed to ensure Resident #2 had interventions in place after she had 2 falls. * The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 2 residents reviewed for PASRR assessments. (Resident #2) The facility did not provide and arrange for a specialized customized manual wheelchair for Resident #2 as recommended and agreed upon by the IDT within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider for 1 of 3 residents (Resident #1) reviewed for discharge communication documentation. Resident #1 was discharged to her home on [DATE]. She did not receive home health services until 07/09/24. The facility did not ensure the HHA received the required information prior to Resident #1's discharge. This failure placed residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for 1 of 13 residents (Resident #32) reviewed for accidents. The facility failed to ensure the Van Driver transferred Resident #32 safely out of the facility transport van using the mechanical wheelchair lift. Resident #32 fell out of the facility van and sustained a hematoma (a collection of blood outside of a blood vessel, which is caused by injury or trauma) to the back of her head. This failure could place residents at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for 8 at least consecutive hours 7 days a week for 2 of 4 quarters of 2023 (Quarter 4 July 01, 2023 through September 30, 2023 and Quarter 1 October 01, 2023 through December 31, 2023) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 07/08/2023, 10/07/2023, and 10/08/2023. This failure could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the status for 3 of 13 residents reviewed for assessments. (Residents #04, #10, and #41). The facility failed to complete an accurate resident assessment for Resident #04, #10, and #41's. The resident assessment indicated they received anticoagulant medications; however, the residents did not receive anticoagulants. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 13 residents (Resident #10) reviewed for ADLs. The facility failed to ensure Resident #10 received a shower on 06/01/24, 06/04/24 and on 06/06/24. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental, and psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 10 months reviewed. (August 2022 through May 2023) * The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in August 2022, September 2022, October 2022, November 2022, December 2022, January 2023. * The facility did not have RN coverage for 11/24/22 (Thanksgiving Day). * The facility did not have RN coverage for 7 days in February 2023. * The facility did not have the required eight consecutive hours of RN coverage for 4 days in March 2023. * The facility did not have RN coverage for 8 days in April 2023. * The facility did not have RN coverage for 2 days in May 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 4 of 5 residents reviewed for advanced directives. (Residents #16, #23, #31, and #50) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #16, #23, #31, and #50 This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for 1 of 1 resident reviewed for quality of life. (Resident #51) The facility did not ensure Resident #51's orthopedic appointment report and orders were received and initiated causing a delay in her receiving physical therapy services as ordered by her orthopedic physician. This failure could contribute to residents decline in physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen reviewed for the environment. The facility did not maintain an effective pest control program to ensure the kitchen was free of fruit flies. This failure could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS was completed for 2 of 16 residents reviewed for MDS assessment accuracy. (Residents #23 and #46) * The facility did not code Residents #23 and #46 for a daily use of a wander/elopement alarm on the MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #2) reviewed for PASARR. The facility failed to refer Resident #2 for PASARR Level II assessments after their PL 1 (PASARR Level 1 Screening) was negative but had a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #36) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #36's anticoagulant medication, Apixaban. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 16 residents reviewed for unnecessary medication (Resident #36) The facility did not monitor Resident #36 for side effects of the anticoagulation medication apixaban (a blood thinning medication). This failure could place the residents at risk for adverse consequences of the anticoagulant medication.