Woodside Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free from potential accident hazard for three of 23 sampled residents (Resident 259, Resident 261, and Resident 414), when electrical extension cords were observed laying on the floor inside the rooms of Resident 259 and Resident 261, and hanging unsecured in Resident 414's room. This failure had the potential to result in accidents and falls for Residents 259, 261, and 414.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 55 residents when: 1. Resident 35's controlled drug (medications that the use and possession of are controlled by the federal government) use and removal from Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) was not accurately documented in Resident 35's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and Resident 12's controlled drug use documented in the MAR was not accurately signed out in Resident 12's CDR; and, 2. Resident 16 received expired eye medication for 27 days. These failed practices may contribute to unsafe medication use and risk of controlled drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 55. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of four errors out of 33 opportunities which resulted in a facility wide medication error rate of 12.12 % in three out of 11 residents (Resident 261, Resident 359, and Resident 360) observed for medication administration. These failures had the potential for unsafe and ineffective medication use of Resident 261, Resident 359, and Resident 360 and potential to affect the residents' medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 55 residents when: 1. A total of 3 loose pills were found in medication cart 1- north station and medication cart 2- south station; and, 2. An expired bottle of an opened Latanoprost (a prescription eye drop medication used to treat increased pressure in the eye) for Resident 16 was found stored in medication cart 2- south station. These failures resulted in Resident 16 receiving expired medication with unsafe and/or reduced potency and had the potential for diversion (illegal distribution) of the loose medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food and maintain equipment in accordance with the professional standards for food service safety for a 54 residents out of 54 residents eating facility prepared meals, when: 1. The fruit and vegetable wash sink did not have an air gap (a gap in the draining pipe of a sink to prevent backflow); and 2. Food was expired in the residents' refrigerator. These failures had the potential to result in residents acquiring food-borne illnesses.

Inspectors wrote2. During a review of Resident 41's admission records, the records indicated Resident 41 was admitted in October 2024 with diagnoses that included obstructive sleep apnea (breathing pauses during sleep), chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing), asthma (airways narrow and swell), and dependence on supplemental oxygen. Resident 41's Minimum Data Set (MDS, an assessment tool) indicated Resident 41 had intact cognition. During a review of Resident 41's physician order dated 10/13/24, the order indicated, Supplemental oxygen 2-4L [Liter, a unit of measurement] via NC [nasal cannula] or oxymask [oxygen mask] to keep SpO2 [oxygen saturation, a measurement of how much oxygen the blood is carrying as a percentage] > or = 92% [percent, a unit of measurement] .as needed for SOB/Dyspnea [shortness of breath]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 23 sampled residents (Resident 365) was assisted with nail care as part of her Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when Resident 365 had long fingernails with blackish substance underneath the fingernails. This failure had the potential for Resident 365 to sustain injury and/or for Resident 365 to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 259) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 259's antidepressant was given without appropriate documented diagnosis. This failure decreased the facility's potential to monitor Resident 259's for target behaviors and had the potential to result in Resident 259's increased risk and exposure to side effects associated with psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light system was accessible for one out of 23 sampled residents (Resident 24), when Resident 24's call light was observed under the bed and not within reach. This failure had the potential to negatively affect Resident 24's safety by preventing the resident from communicating a request for assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food and maintain equipment per professional standards for food service safety when: 1. The bananas were stored less than the standard of 6 (inches, a unit of measurement) off the floor; 2. The chest freezer had a brown substance on the inside lid and ice buildup on all four sides inside the freezer extending down approximately 8, and ice buildup on the back ledges that created a poor seal; 3. A large blender with the lid on was stored and ready to use, with noticeable clear liquid dripping down the inside walls and with liquid pooled at the bottom; 4. The can opener was found with a chipped metal tip covered with a brown sticky substance; 5. Two out of four cutting boards were found with deep gouges and discolored; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and reconciliation of controlled medications (those with high potential for abuse or addiction) for two out of two medication carts when controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications) were not completed. This failure had the potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality were met when Rybelsus (medication that lowers blood sugar in adults) was not administered in accordance with the manufacturer's specifications for one of five sampled residents (Resident 40). This failure had the potential to result in ineffective management of Resident 40's diabetes mellitus (DM, a disease where blood sugar is too high).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the continuous positive airway pressure (CPAP- machine used in the treatment of sleep apnea) device was cleaned, labeled, and stored properly for one of 13 sampled residents (Resident 17). This failure had the potential to result in an infection for Resident 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food removed from the freezer and placed in the refrigerator was dated and personal items were not placed in the food storage room when: 1. Undated wrapped bacon was observed thawing in the refrigerator and 2. Personal items were observed in the dry food storage room. This failure had the potential to result in food borne illnesses for 49 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide reasonable accommodation of resident's needs for one of 14 sampled residents (Resident 37). These failures placed Resident 37 at increased risk of her needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities for one of 14 sampled residents (Resident 37). This failure resulted in Resident 37 not being provided with activities of interest which placed Resident 37 at increased risk of psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a method to effectively dispose of controlled medications (those with high potential for abuse or addiction) in a manner that rendered them unusable, when four vials containing crushed and uncrushed tablets and capsules were identified in two out of two medication carts. This failure had the potential for diversion of controlled medications (transfer of a medication from a legal to an illegal use from the individual for whom it was prescribed, to another person for illicit use).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an inhaler, an insulin pen (medication used to treat high blood sugar) and blood glucose (sugar) test strips were labeled with an open date in two of two medication carts inspected. The failure had the potential for the residents to receive expired medication, be given medications beyond their effective dates, or receive inaccurate blood glucose test results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 14 sampled residents (Resident 33) maintained acceptable parameters of nutritional status. This failure resulted in Resident 33's sustaining severe weight loss (10% unplanned weight loss) in less than two months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drug regimen was free of unnecessary psychotropic medications (medications which are intended to have a therapeutic effect on mood and behavior) for one of 14 sampled residents (Resident 25), when resident received two medications from the same pharmacological class without specific target behaviors. This failure had the potential for Resident 25 to experience adverse effects (unwanted, uncomfortable, or dangerous effects), related to the use of psychotropic medications, which may impair resident's psychosocial well-being.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the garbage storage area was maintained in a sanitary manner when garbage and refuse was observed on the ground next to the dumpsters for a census of 52 residents. This failure had the risk potential for harborage and feeding of pests.