Woodland Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to maintain an acceptable parameter of nutritional status such as usual body weights for one of 24 sampled residents (Resident 50) when Resident 50's severe weight losses (more than 5% weight variance in one month, more than 7.5% weight variance in 3 months and more than 10% weight variance in 6 months) were not consistently identified, interventions were not evaluated for effectiveness, and the physician and responsible party (RP) were not notified of the change in Resident 50's condition. These failures had the potential to cause further nutritional decline and resulted in Resident 50 experiencing the following severe weight losses:- 6/5/25 to 7/1/25: 9 lbs (pounds, a unit of measurement) or 6.6% in a month;- 9/1/25 to 10/3/25: 7 lbs (5.1%) in a month;- 11/2/25 to 12/2/25: 6.8 lbs (5.3%) in a month;- 6/5/25 to 12/2/25: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and treatment according to professional standards of practice for three of 24 sampled residents (Resident 93, Resident 8 and Resident 9) when: 1. Resident 93's PICC line (peripherally inserted central catheter, a type of IV, intravenous line, that is used to deliver fluids or medications into a vein) was not flushed (injection of normal saline solution into an IV catheter to clear the line) prior to and after IV antibiotics (used to treat bacterial infections) were administered; 2. The physician was not notified of Resident 8's blood sugar reading greater than 400 mg (milligrams)/dl (deciliter); and, 3. Resident 9's IV antibiotic was not administered as ordered and the physician was not notified of Resident 9's unavailability of IV access. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures to ensure accurate acquiring, receiving, dispensing, and administering of drugs for four of 24 sampled residents (Resident 8, Resident 93, Resident 17, and Resident 9) when: 1. Resident 93's medication was not available for administration as ordered;2. There was no accurate accountability of controlled medications (high potential for abuse or addiction) for three residents (Resident 93, Resident 8, and Resident 17); and3. Resident 9's medications were not administered as ordered. These failures increased the potential for Resident 93 and 9 to experience adverse effects from not receiving medications and the potential for abuse, misuse, and diversion for controlled medications.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were appropriately stored and not available at bedside for three of 24 sampled residents (Resident 5, Resident 50, and Resident 68) when:Eye drops were observed on top of Resident 68's bedside table;An orange tablet was observed in an unlabeled medication cup on top of Resident 5's bedside table; and,An unlabeled medication cup containing white powder was observed on top of the dresser in Resident 50's room. These failures had the potential for Resident 5, Resident 50, and Resident 68 to receive medications with unsafe or reduced potency from improper storage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were prepared to meet the needs of the residents when the Dietary Aide (DA) did not follow the recipe when preparing a pureed food. This failure had the potential to result in decreased nutritional value or decreased meal satisfaction for residents who receive a pureed diet. A review of the facility's pureed spaghetti recipe for winter menu 2026, indicated .Place portions of regular cooked spaghetti needed into a food processor. Process to a fine texture. For every 5 portions needed, add 1 cup of hot water and 1 tbsp [tablespoon] margarine and nonfat dry milk powder. Process until smooth, pudding consistency is achieved. With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds . During a concurrent observation and interview on 3/18/26 at 9:48 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store food in a safe and sanitary method in accordance with professional standards when:1. The Dietary Aide (DA) did not properly calibrate a thermometer, and2. The cutting boards had crevices, and3. A dietary staff did not wear a beard net in the kitchen, and4. Resident's food in resident refrigerator was not labeled with correct use by date. These failures placed residents at risk for food borne illnesses. 1. During a concurrent observation and interview on 3/18/26 at 10:20 a.m. with the Dietary Aide (DA) and the Dietary Manager (DM), the DA stated she calibrates the thermometers twice a week. Reviewed log of thermometer calibrations that indicated the thermometers had been calibrated to 32 degrees Fahrenheit every morning. The DA stated she only checks the cold temperature not the boiling point. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure required members of the Quality Assurance Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee were present during meetings for a census of 82 when the Medical Director (MD) did not attend the QAPI meetings quarterly. This failure had the potential to negatively impact the quality of resident care. During a review of the facility's quarterly QAPI meeting sign-in sheets, dated 7/29/25 and 1/26/26, the sign-in sheets indicated names and signatures of QAPI committee members who attended the QAPI meeting. The sheets did not indicate that the MD was present during the meetings. During an interview on 3/20/26 at 2:33 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent (process to ensure resident is fully informed of the potential risks and benefits) for one of twenty-four sampled residents (Resident 49) when Resident 49 was administered a psychotropic medication (medication that affects the mind, emotions, and behavior) prior to obtaining an informed consent. This failure had the potential to result in Resident 49 not being fully aware of the medication's benefits, risks, and side effects. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for one of 24 sampled residents (Resident 11) when: Resident 11 was prescribed a psychotropic medication (drug that treats mental illnesses such as anxiety, by altering brain chemistry) Lorazepam (a benzodiazepine used to treat anxiety disorders. Common side effects include dizziness, drowsiness, and weakness) without adequate monitoring. This failure had the potential for Resident 11 to experience drowsiness, dizziness, or weakness increasing Resident 11's risk for falls. During a review of Resident 11's Facesheet (a one-page medical document summarizing a patient's key demographic, insurance, and clinical data) indicated, Resident 11 was admitted to the facility in February 2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated resident assessment tool) accurately reflected the resident's health status for one of 24 sampled residents (Resident 50) when Resident 50's MDS Section K Swallowing/Nutritional Status was not accurately documented. This failure had the potential to result in Resident 50 not receiving treatments and services consistent with Resident 50's needs. During a review of Resident 50's admission records, the records indicated Resident 50 was admitted to the facility in April 2024 with diagnoses that included dysphagia (difficulty swallowing), hypothyroidism (thyroid gland does not make and release enough hormone into the bloodstream), bipolar disorder (sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 34 and Resident 62) were assisted with Activities of Daily living (ADL- normal daily functions required to meet basic needs) when fingernails were long and unclean. These failures had the potential for Resident 34 and Resident 62 to sustain injury and/or infection. 1a. A review of the admission Record indicated Resident 34 was admitted June of 2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), affecting right dominant side and cerebral infarction (a type of stroke, loss of blood flow to a part of the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of care for one of 24 sampled residents (Resident 74) when: 1. Resident 74's nebulizer (a small machine that turns liquid medicines into mist to deliver medication) tubing was not replaced every 7 days; and,2. Resident 74's oxygen use was not accurately documented. These failures had the potential to result in respiratory infection and undetected deterioration of respiratory function for Resident 74. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) had an annual performance review for one of five sampled CNA staff (CNA 3). This failure had the potential for CNA 3 to provide inadequate care to residents. During a concurrent interview and record review on 3/19/26, at 12:14 p.m., with Director of Staff Development (DSD) CNA 3's personnel file was reviewed. CNA 3's personnel file indicated, he was hired on 2/4/25. Personnel file indicated, no annual performance review was completed. DSD stated, I am not sure how we track when they [annual performance reviews] are due. DSD stated, he did not see an annual performance review in the file, and there should be one in the personnel file. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%)) when two medications out of 31 opportunities were not given in accordance with the physician's orders for two residents (Resident 93 and Resident 79). This failure resulted in a medication error rate of 6.45%.1a. A review of the admission Record indicated Resident 93 was admitted [DATE] with diagnoses including acute osteomyelitis (sudden, severe infection of the bone) of left ankle and foot and sepsis (a life- threatening blood infection). A review of Resident 93's Order Summary Report indicated Resident 93 had an order for Prasugrel (antiplatelet or blood thinner- medication used to prevent blood clots) HCL (hydrochloride) 10 milligram (mg, unit of measurement) give 1 tablet by mouth one time a day for Antiplatelet therapy on 3/6/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a written agreement was obtained for services furnished by outside resources for one of 24 sampled residents (Resident 10) receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). This failure had the potential to result in the lack of accountability in the dialysis services. A review of the admission Record indicated Resident 10 was admitted October of 2025 with diagnoses including atherosclerotic heart disease (build up of fat or cholesterol in the heart's arteries causing them to narrow and harden) and end stage renal disease (ESRD, irreversible kidney failure). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection prevention and control practices for two of 24 sampled residents (Resident 15 & Resident 19) when:The facility did not implement Enhanced Barrier Precautions (EBP: an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of carrying multidrug-resistant organisms) for Resident 15 andFacility staff left soiled linens and trash on Resident 19's bed. These failures had the potential to spread communicable disease to an at risk population.1. During an observation on 3/17/26, at 10:21 a.m., Resident 15's room did not have any isolation precautions signs. Multiple care staff were observed entering and exiting Resident 15's room without wearing PPE (Personal protective equipment). During an observation on 3/18/26, at 8:35 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedures to process a refund for one of four sampled residents (Resident 1) when the resident's share of cost (the amount of money an individual is responsible to pay towards their medical related services, supplies, or equipment before Medi-Cal will begin to pay) was not returned to the family within 60 days upon Resident 1's death. This failure had the potential to result in fiduciary abuse and a violation of Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of six sampled Residents (Resident 1) despite Resident 1's admitting diagnosis of stimulant (drugs that increase the activity of the central nervous system) use and a positive illicit drug test results from the urine drug screening during the recent hospitalization. This failure placed Resident 1 at risk for undetected drug use or relapse, undetected overdose that could result in medical emergency and had the potential for delayed delivery of care and mental health decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents (Resident 1) when an allegation of abuse was not reported per facility policy. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care which met professional standards when he was involved in an employee to resident abuse allegation, and it was not documented by nursing and social services department. This failure resulted in inaccurate assessment documentation and had the potential to result in unmet nursing and psychosocial needs for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident privacy when tray tickets were thrown into the trash for a census of 87 who were eating facility prepared meals This failure had the potential for 87 residents' personal and health information unprotected form unintended access.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide care for one of 24 sampled residents (Resident 1) when no wound care orders, monitoring, or care plans were created for Resident 1's left great toe wound. This failure placed Resident 1 at increased risk for wound deterioration and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 87 residents when: 1. An unsealed e-kit (emergency supply kit) was found in the medication storage room, which resulted in prescription medications being at risk for diversion and use without a prescription. 2. An e-kit was previously accessed multiple times without medications being replaced by the pharmacy which had a potential to cause harm by not having enough emergency medication for the residents. These failures had the potential for drug diversion, medication errors, and not having medications readily available in emergency situations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 87 sampled Residents (Resident 10, Resident 30 and Resident 25) were free from unnecessary antipsychotic medications (drugs that alter a person's thoughts, feelings, moods, awareness, and behaviors used to treat mental health conditions) when: 1. An Antipsychotic was prescribed for treatment of schizoaffective disorder (a condition that affects a person's ability to think, feel, and behave clearly with mood symptoms) in a dosage indicative for treatment of sleep disturbance without an FDA approved diagnosis for Resident 10. 2. An Antipsychotic was prescribed for Resident 30 with no previous documented serious mental health diagnosis prior to admission. 3. Resident 25 received an as needed antianxiety medication without a 14 day stop date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for three of four sampled residents (Resident 16, 486, and 55) for a census of 87 when five medication errors occurred out of 29 opportunities that resulted in 17.2% medication error rates. 1. For Resident 16, a Licensed Nurse 2 (LN 2) administered Resident's calcium and vitamin D (a supplement used to raise calcium and vitamin D levels), not in accordance with Physician Orders when one tablet of calcium 600mg (milligram, unit of measurement) + 400 units (unit, a measurement) vitamin D was administered when the physician ordered calcium-vitamin D tablet 600-200mg/unit, give 2 tablets by mouth one time a day. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled correctly, when: 1. Unopened insulin pens were not kept refrigerated, 2. Opened multidose inhalers did not have open dates to determine expiration dates, 3. Personal items and non-pharmaceutical items were stored in a medication cart and a medication room, 4. Expired insulin pens were not discarded and still available for use, 5. Loose pills were found in a medication carts and a medication room, 6. Prescription pharmaceutical products did not have patient specific labels, and 7. A prescription blister pack and a prescription eye drop were dropped in the back of a medication cart and not accessible to be used for Resident's needs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage and preparation in accordance with professional standards for food service safety when: 1. Kitchen containers and steam table pans were found stored wet, 2. Several food items in freezer and refrigerator were not securely closed, 3. A stored steam table pans found to have food residue in the pan, 4. Red cutting board for meat found with deep grooves, 5. Shelf under cook's food preparation table was found with rust and white discoloring, and 6. Floor drain near cook's station had green-colored build up around drain along with chipped and worn flooring. Theses failures had the potential of leading to food borne illness for 87 residents out of a census of 87 who are eating facility prepared foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident refrigerator and microwave for staff to store and heat residents' food. This failure had the potential of leading to poor food intake, weight loss, and food borne illness for the 87 residents eating meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for 4 residents (Residents 32, 53, 61 and 57) in a census of 87 when: 1. Resident 32's nebulizer (machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) and Resident 53 and Resident 61's oxygen tubings were not covered or labeled, and when 2. Resident 57's urinary catheter (a thin tube used to drain urine from the bladder to an outside collection bag) was found touching the floor multiple times during the survey period. These failures increased the potential for infection for the residents .

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of 24 sampled residents (Resident 41) when Resident 41's medication to treat high blood sugars was not given as ordered by the physician. This failure had the potential for Resident 41 to have unmanaged blood sugars.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement wound prevention measures for one of 24 sampled residents (Resident 65) when Resident 65's heel foam protectors were not put on per physician order. This failure had the potential to worsen or complicate Resident 65's wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain Resident 14's weight when resident 14 lost 14.5% of his body weight in a 6-month period. This failure had the potential of leading to malnutrition and increased mortality.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and consistent medical records for two of 24 sampled residents (Resident 1 and Resident 41) when: 1. Resident 1's progress notes (PN) did not include any reason medications were not administered; and 2. Resident 41's insulin (a medication to treat high blood sugars) administration documentation was inconsistent. These failures created inaccurate health records which increased the potential for incorrect assessment of the residents and for creating miscommunication among healthcare professionals regarding the residents health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of sexual abuse was reported within the required timeframe for two of seven sampled residents (Resident 4 and Resident 6), when the Department did not recieve a report of the alleged sexual abuse incident within two hours of occurence. This failure to report timely had the potential to compromise vulnerable residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse when he was struck in the head and chest several times by Resident 2. This failure had the potential to result in serious physical harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the Department until the following day. This failure to report timely had the potential to compromise resident health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were accessible for seven of 28 sampled residents (Resident 70, Resident 43, Resident 6, Resident 26, Resident 10, Resident 27, and Resident 64), when the call light buttons were not reachable. This failure increased the potential staff would not be alerted to resident needs or emergencies, and the residents not attaining their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans for two of 28 sampled residents (Resident 50 and Resident 3), when: 1. No care plan was developed or implemented on smoking for Resident 50; and 2. No care plan was developed or implemented on wound care for Resident 3. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for a census of 85 when an expired E-Kit (Emergency-Kit, storage box containing emergency supplies of medication) was not removed and replaced with the potential for not having all the emergency medications available to the residents and increased risk of drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly according to the facility's policies and procedures for a census of 85, when: 1. An expired medication was available for Resident 17 to use in the medication cart which put residents 17 at risk of receiving an expired medication; 2. A tube of prescription medication was found in a treatment cart without a resident specific pharmacy label; 3. The temperature of a medication refrigerator on the second floor was out of range, which put medication requiring a specific temperature at risk of degradation; and, 4. An opened and used multidose vial of a testing solution, with a shorter expiration date when opened, did not have an open date which put residents at risk of having inaccurate test results.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety, when: 1. Dietary staff and vendors did not wear face masks during a Covid outbreak in the facility; 2. Trays were stored upright to dry; 3. Foods were not labeled with received, opened and/or use by date; and 4. Dietary Aid touched face with gloved hands and then touched the rim of tumblers meant for resident drinks. These failures increased the potential for food-borne illnesses and communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee, a component of the facility's Quality Assurance Performance Improvement (QAPI) for a census of 85, when: 1. The QAA did not meet at least quarterly in 2023; and 2. The QAA committee meeting did not have the required members in attendance. This failure had the potential for quality care improvement activities to not be evaluated and revised as needed and the potential to negatively impact the quality of resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking policies were established, managed and implemented for safety on both smoking and non-smoking residents in accordance with applicable laws and regulations for three out of 28 sampled residents (Resident 4, Resident 50, and Resident 68) in a census of 85, when: 1. Resident 50 possessed and used a cigarette lighter in his room; 2. Resident 4 kept her own smoking paraphernalia in her room and provided cigarettes to other residents; and 3. Resident 68 kept his cigarettes and lighter and went to smoke outside the facility with no staff supervision. These failures had the potential to result in an increased risk of accidents, burns and injuries.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse involving one of 28 sampled residents (Resident 41), when the Department received the report of allegation of abuse greater than two hours after the facility was made aware of the allegation. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the resident's current condition for one of 28 sampled residents (Resident 83), when the discharge MDS indicated the resident was discharged to an acute hospital. This failure resulted in Resident 83's MDS inaccurate assessment data submitted to CMS (Centers for Medicare-Medicaid Services).

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plan after a fall for one of 28 sampled residents (Resident 25). This failure increased the risk Resident 25 would not reach the highest practicable well being and have his needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents' physician was notified when two blood pressure medications were not given to Resident 39. This failure had the potential for Resident 39's blood pressure to be elevated and compromised hemodynamic (basic measures of heart function) stability.

Inspectors wroteBased on interview and record review the facility failed to ensure care and services were met according to professional standards of practice for one of 28 sampled residents (Resident 44) receiving dialysis (procedure to remove waste products and excess fluids from the blood when the kidneys are not able to), when transportation to and from dialysis was not provided timely. This failure resulted in Resident 44's emotional stress, and had the potential to result in undetected complications such as increased fluid retention and toxic substances in the blood.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure irregularities reported by the pharmacist to the attending physician were acted upon for one out of 28 sampled residents (Resident 70) in a census of 85. This failure increased the potential for a PRN (as needed) antipsychotic being given without adequate indication.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor food preferences for one of 28 sampled residents (Resident 435), when the resident did not receive hard boiled eggs at lunch. This failure increased the potential for the resident not to reach his highest practicable well being.

Inspectors wroteBased on observation, interview and record review, the facility failed 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 two out of 28 sampled residents (Resident 40 and Resident 77, and Resident 65) when: 1. Oxygen equipment was uncovered and unlabeled for Resident 65. 2. Stand fan was not cleaned for Resident 77; and 3. Urinal was unlabeled on top of the bedside table for Resident 40, and when 4. Resident 18's oxygen tubing was not changed in a timely matter. 5. Staff were not wearing N95 mask properly. These failures had the potential to result in the transmission of infection in a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device to alert nursing staff when a resident is in need) was functioning for one resident (Resident 74) out of 28 sampled residents. This failure prevented Resident 74 from communicating his care needs and had the potential to delay care and treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure orders were followed for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when Peripherally Inserted Central Catheter (PICC, a long thin flexible tube that is placed into a vein in your arm and goes into larger veins near your heart) care was not performed per professional standards, and medication was not given as ordered to Resident 3. These failures increased the risk for infection, and delayed healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 82 when an externally used topical cream was commingled with oral medications, an opened insulin bottle was not dated, scattered loose pills were found in two medication carts, and an opened bottle acetic acid (liquid used in wound care) did not have an open date. These failures had the potential for residents to receive ineffective medications and placed residents at risk for cross contamination. During a concurrent interview and inspection of medication cart 1-station 1 on [DATE] at 1:44 p.m., with Licensed Nurse (LN 1) 1: [...]