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Woodland Park Nursing: Resident Broke Neck in Fall - TX
A CT scan at the hospital revealed a fractured cervical vertebra....
Latest reports, citations, and penalties from CMS data
A CT scan at the hospital revealed a fractured cervical vertebra....
"I literally spend one third of my time looking for missing items," one staff member told inspectors on January 15....
The violations put 125 residents who receive meals prepared in the kitchen at risk for foodborne illness....
The nurse entered the room, handed R33 her medication cup, and waited in the doorway while the resident took her pills....
Federal inspectors found no documentation of the fall in the resident's medical chart when they arrived August 15....
All three men had been granted approved four-hour passes to leave the facility....
Instead, nurses documented giving the medication while recording dangerous vital signs....
The laundry supervisor didn't know manufacturer guidelines for washing the fabric slings that support residents during transfers....
The violations put residents at risk of receiving ineffective or potentially harmful treatments....
The resident, who has mild intellectual disabilities and cannot make medical decisions, had been wearing the bracelets when staff noticed the odor on March 20....
The violations occurred in plain sight of infection control warnings....
Federal inspectors discovered the oversight during a May inspection when they reviewed the facility's Referral Form for Consultant Dietician....
Resident #3 told inspectors on May 20: "It's hot, it's hot, I am sweating....
The resident had been placed on enhanced barrier precautions since March 25 due to a multidrug-resistant organism infection....
The physician had ordered staff to "rotate injection site" with each dose....
The resident had been picked up from dialysis at 4:30 p.m....
The facility suspended the aide within hours but declared the investigation complete after four days without interviewing key staff or the resident's roommate....
The March 21 incident began around 6:45 a.m....
Federal inspectors documented the failures during an August 2024 visit to the 161-bed facility on Evergreen Avenue....
One resident's mattress was set to the wrong pressure level for months....