Woodland Springs Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility through his room window after disabling the alarm and leave through a back gate that was unlatched and walk two blocks to a corner store that's a high crime area at a busy intersection. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 02/18/2026 and ended on 02/24/2026. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for accidents, injuries, and hospitalization that could lead to death.

Inspectors wroteBased on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for rights. The facility failed to ensure Resident #1's doctors' orders were followed by not providing his antibiotic medications on 12/23/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of three residents (Resident #1) reviewed for any significant medication errors, in that: The facility failed to ensure Resident #1 received his medications as prescribed by the physician. This failure affected residents by putting them at risk of exacerbation of their health conditions and deterioration of their health.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safetyThe facility failed to correctly label and date items in the dry storage and refrigerated areas. The facility failed to correctly label and date three containers of dry beans. There was one date on the container. No indication of what the items were and when they were placed in the container and when they should be used by. The pantry had several packages of dry cereal and pasta with only a date on the packages. There was no indication of when these items were opened and when the items should be discarded. In the walk-in refrigerator had an expired prepared item stored with a use by 11/15/2025 date stored inside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (halls 100,200 and 300) of three halls reviewed for the pest control program. The facility had live gnats in a resident's room and numerous dead insects found in the catchment trays below the hand sanitizer disbursement units. This failure could place residents at risk for the spread of infection, cross-contamination and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for four (Residents #12, #41 #90, and #91) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #41, #90, #12, and #91. These failures could place residents at risk for equipment in unsafe operating condition, that could cause injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for one (Hall 300) of three halls reviewed for environment. The facility failed to ensure bathroom floors and fixtures were in good repair for room numbers 350, 352, 354, and 355. This failure could place residents at risk for diminished quality of life due to the lack of a well-kempt environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity for one (Resident #38) of eighteen residents reviewed for resident rights. The facility failed to ensure CNA A did not stand over Resident #38 while assisting the resident with his meal in the dining room on 12/02/2025. This failure could place residents at risk of feeling rushed to eat or not interested in eating, which could result in weight loss and decreased psycho-social well-being of anguish or frustration.

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 1 of 2 (CNA B) staff members and 1 of 2 residents (Resident #19) reviewed for infection control procedures. CNA B failed to change their soiled gloves and perform hand hygiene during incontinent care for Resident #19. These failures could place residents at risk for cross contamination and infections.

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 one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to prevent a diversion of Resident #1's Hydrocodone-Acetaminophen Oral 10-325 MG tablet, 60 tablets reported missing on 08/18/2025. The failure could place residents at risk for medication error and delay therapy.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director (AD) reviewed for qualified professionals, in that: Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director (AD) reviewed for qualified professionals, in that: The facility failed to have a qualified AD to serve as the director of the activities program. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect, in that:Based on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect, in that:The [...]

Inspectors wroteBased on the interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for #25, whose records were reviewed for PASRR services. The facility failed to get a PASRR eval when Resident #25's Level 1 PASRR screening indicated the resident had mental illness diagnoses of schizoaffective disorder, bipolar type, and anxiety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents hazards. The facility failed to ensure Resident #1, who received anticoagulant therapy, received adequate supervision when she experienced blunt trauma on 05/14/25 when she hit her head and, approximately 10 hours later, on 05/15/25, was transferred to the hospital due to vomiting and subsequently passed away. An Immediate Jeopardy (IJ) situation was identified on 05/22/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #2) reviewed for quality of care. 1. The facility failed to ensure that Resident #2 was prepared for his scheduled eye doctor appointments. 2. The facility failed to ensure Resident #2 did not eat prior to his scheduled eye surgery on 7/15/2024. 3. The facility failed to ensure Resident #2 received an exam for medical clearance prior to his eye procedure on 5/21/2025. 4. The facility failed to have Resident #2 at his scheduled appointment on 3/3/2025 and resident was a no call/no show for this appointment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency for incidents of alleged abuse and neglect for one out of eight residents (Resident #1) in that: The facility failed to report to Health and Human Services alleged abuse occurred in the facility secured unit involving Resident #1 and Resident #2. During Resident #1's 05/15/25 LA Update meeting, Resident #1 reported he was hit by Resident #2. The date of alleged occurrence was unknown. This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision for 1 of 1 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. Resident #1 was missing from the facility from approximately 5:00 am to 8:00am am until he was located by police. An IJ was identified on [DATE] at 4:10 PM. While the IJ was removed on [DATE] at 7:45AM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for falls, injuries, dehydration, hospitalization, and death.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from Abuse as defined in this subpart to protect 2 (Resident #42 and Resident #62) of 82 residents from Resident's # 52 aggressive behavior. 1. The facility failed to protect the residents from an aggressive resident with behaviors (Resident # 52). Resident #62 sustained an injury to her foot that required her to be taken to the hospital for evaluation. 2. The facility failed to put interventions in place to ensure the safety of Resident # 52 and other residents at the facility. On 08/30/24 at 6:16 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident's, establish policies and procedures to investigate any such allegations for 3 out of 16 residents reviewed for abuse. The facility failed to follow and implement its policy regarding Resident # 52's verbal and physical abuse of other residents to ensure the safety of all residents . An IJ was identified on 08/30/24. The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure could put all residents at risk from abuse.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment . For 1 (Resident # 52) of 16 reviewed. The facility failed to develop and implement a comprehensive care plan for Resident # 52 that included interventions to ensure safety from the residents aggressive physical and verbal behaviors. On 08/30/24 at 6:16 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for three (Resident #45, Resident #25, and Resident #10) of six residents reviewed for pharmaceutical services., in that: The facility failed to ensure: 1. Resident #45 was administered his prescribed Diltiazem (for hypertension), Gabapentin (for neuropathy), and Amiodarone (for arrhythmia). 2. Resident #25 was administered his prescribed Hydroxyzine Pamoate and Gabapentin (for bipolar disorder), Abilify and Benztropine Mesylate (for Schizophrenia), and Divalproex Sodium ER (for agitation). 3. Resident #10 was administered his Rhopressa Ophthalmic Solution and Simbrinza Suspension (for open angle glaucoma), Tamsulosin HCl (for Genitourinary), and Mylanta Suspension (for gastroesophageal reflux disease). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving Resident to Resident altercations were reported immediately to the administrator or the abuse coordinator and to THHSC within the 2-hour period for 1 of 2 residents (Resident #52 and Resident # 42) reviewed for abuse. The facility failed to ensure allegations of resident abuse with injury were immediately reported to the administrator or abuse coordinator and to the State Agency no later than 2 hours after the incident occurred or was suspected. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Residents #45) reviewed for infection control., as indicated by: MA A did not clean and disinfect the wrist blood pressure monitor while using it on Resident #45. This failure could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for notification of change. The facility failed to: 1. Notify the physician when Resident #1 had a significant change in condition marked by inability to swallow breakfast, then difficulty swallowing morning medications, and then Resident #1 refused his lunch; this resulted in Resident #1 being sent to ER and had pieces of food removed from his throat in the emergency room and was diagnosed with pneumonia and septic shock (life-threatening condition caused by a severe infection that requires immediate medical attention). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to: 1. Ensure staff conducted a thorough assessment of Resident #1 (which delayed Resident #1 from being sent to the emergency room), who was unable to swallow his breakfast on 01/13/24 at 9:00 am and had pieces of food removed from his throat in the emergency room and was diagnosed with pneumonia and septic shock (life-threatening condition caused by a severe infection that requires immediate medical attention) This failure could affect all residents by placing them at risk of not receiving quality care and treatments, injury, hospitalization, and/or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse, as a result Resident #2 struck Resident #1 on the right side of the face and pulled her wig off. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. This was determined to be PNC as the facility had implemented corrective actions prior to entry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for one (the lunch meal on 06/27/23) of three lunch meals reviewed for dietary services. The facility failed to ensure residents on a pureed diet received the pureed bread component on their meal tray. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one (Resident #5) of six residents for care plan revisions, in that: The facility failed to ensure Resident #5's care plan was revised to include her actual advance directive. These failures could place residents at risk of receiving inappropriate care.

Inspectors wroteBased on interviews and record reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for two (Residents #71 and #2) of five residents reviewed for (MRR) Medication Regimen Review. 1. The facility failed to follow up on a recommendation regarding Resident #71's duplicate medications (Diabetic Tussin EX syrup and [NAME]-Tussin Syrup) 2. The facility failed to follow up on a recommendation for GDR regarding Resident #2's Clomipramine and Ativan. These failures placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status.