Woodland Springs Nursing Center

In the surveyor’s words

From the most serious findings on record at Woodland Springs Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 31, 2024

  Based 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. […]

• Immediate jeopardy, patternF607Aug 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Mar 2, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 11, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Jan 15, 2025

  Based 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. […]