Embassy of Woodland Park

In the surveyor’s words

From the most serious findings on record at Embassy of Woodland Park, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 10, 2024

  Based on a review of manufacturer's directions, clinical records, incident/accident reports, staff training records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to ensure that safe techniques were used during a transfer onto a mechanical wheelchair lift for one of three residents reviewed (Resident 2), resulting in a head injury. Findings include: Manufacturer's directions for use of the [NAME] Corporation FMVSS Public Use Lift (the type of lift platform in the facility's wheelchair van), undated, indicated that the lift platform must be positioned at floor level when loading and unloading in and out of the vehicle. […]

• No harm, potential for more than minimal, patternF675Jul 30, 2026

  Based on review of clinical records, as well as resident interviews and staff interviews, it was determined that the facility failed to ensure that residents were provided appropriately fitting incontinence products for three of 11 residents reviewed (Residents 1, 4, 11).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 9, 2026, indicated that the resident was cognitively intact, dependent on two staff for daily care needs including toileting, was frequently incontinent of urine, and weighed 414 pounds. The resident's care plan, dated July 28, 2026, revealed that the resident had an indwelling urinary catheter (tube inserted directly into the bladder for urine drainage). […]

• No harm, potential for more than minimal, patternF552Dec 4, 2025

  Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for five of 35 residents reviewed (Residents 8, 10, 11, 19 and 68). […]

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.Findings include:Observations of the walk in cooler on December 1, 2025, at 9:50 a.m. and December 3, 2025 at 1:43 p.m. respectively, revealed a shelving unit with an opened box of eggs and a box containing cartons of liquid eggs being stored on the bottom shelf, which was approximately 1.0 to 1.5 inches off the ground. On the floor beneath the shelving unit was debris including individual butter containers and brown onion skins.Interview with the Dietary Director on December 3, 2025, at 1:43 p.m. […]

• No harm, potential for more than minimal, patternF803Oct 3, 2024

  Based on a review of facility policy and the facility's written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated March 15, 2024, indicated that menus shall be written in advance and followed. Any menu substitutions shall be made in an emergency situation only and recorded on the substitution log. An interview with a group of residents on October 1, 2024, indicated that the kitchen does not always serve what is on the menu. Observations of the kitchen on September 30, 2024, at 9:58 a.m. […]