Woodland Post-Acute

In the surveyor’s words

From the most serious findings on record at Woodland Post-Acute, in the surveyor’s own words.

• Actual harm, isolatedF692Mar 20, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF684Mar 20, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF755Mar 20, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF761Mar 20, 2026

  Based 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.During a review of Resident 68's admission records, the records indicated Resident 68 was admitted to the facility in December 2024 with… […]

• No harm, potential for more than minimal, patternF803Mar 20, 2026

  Based 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 . […]