Woodland Park Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Woodland Park Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jul 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Jul 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF656Apr 24, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans. * The facility failed to develop a person-centered care plan with interventions 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. […]

• Immediate jeopardy, isolatedF689Apr 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689May 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1) Resident #1 was assessed as requiring assistance of 2 staff members for bed mobility and total assistance of 1 for bathing. Resident #1 was assisted by one staff member for a bed bath, fell out of the bed, and sustained two brain bleeds. An Immediate Jeopardy was identified on [DATE] at 11:40 a.m. While the Immediate Jeopardy was removed on [DATE] at 04:14 p.m., the facility remained out of compliance at the scope and severity of actual harm and a scope of isolated. […]