Woodcrest Post Acute & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary discharge planning was provided according to the facility's policy and procedure, for one of three residents reviewed (Resident 1), when Resident 1's family member (FM) was not informed of the resident's current functional limitations, required level of care, and if the FM was capable of providing care to Resident 1, prior to discharging back to home. This failure resulted in Resident 1 being discharged home and the FM could not provide the required assistance in ADLs (Activities of Daily Living). This failure had the potential for Resident 1's overall health condition to be affected and further decline in ADLs.

Inspectors wroteF814 Dispose Garbage and Refuse ProperlyBased on observation, interview, and record review the facility failed to ensure two of two dumpster bin lids were fully closed. This failure had the potential to cause insects and rodents infestation in the facility and potential for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for two of 28 sample residents (Residents 83 and 100), when:1. Resident 83's refusal of medications was not addressed including identifying the reason for refusal, providing education and interventions, and evaluating the resident's response. There was no consistent documented evidence the physician was notified timely of Resident 83's refusal of medications. This failure had the potential to result in a delay in timely provision of care for Resident 83 and could contribute to complications related to medication not administered.2. Resident 100's abnormal laboratory (Hemoglobin A1C [HgbA1C - measures average blood sugar levels over the past 2-3 months]) result on October 16, 2025, was not addressed according to the facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents when:1. For Resident 76, a discontinued controlled substance (CS) was not removed from active medication storage, tablets continued to be removed from inventory after the physician order was discontinued. In addition, the documentation on the controlled drug record (CDR - medication count sheet, an inventory record used to document the receipt, use, and count of controlled substances) did not reconcile with the Medication Administration Record (MAR) and the CS was administered after the CS was discontinued; and2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and the facility's policies and procedures, when a medication error rate of 20% was identified, with five medication errors out of 25 medication administration opportunities during medication pass observations for three of five residents observed (Residents 22, 61, and 110). These failures included administration of incorrect medication, incorrect dosage form, and incorrect dose, which had the potential to compromise residents' medication therapy and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, for five out of nine residents reviewed for infection control practices when:1. For Resident 61, 110, and 111, nursing staff did not clean and disinfect shared medical equipment, wrist blood pressure (BP) monitor with an attached cuff, before and after each use, in accordance with the facility's infection control policy; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care, for one of one resident reviewed for Activities of Daily Living (ADL) (Resident 94), when her fingernails were observed to be long, yellowish, and with black residue underneath the fingernails. This failure had the potential to result in an increased risk of infection and injury due to unclean fingernails.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the physician orders for oxygen administration, for two of two residents reviewed for oxygen (Residents 21 and 58), when:These failures had the potential to place Residents 21 and 58 at risk for adverse reactions from over-oxygenation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Cook (CK) 1 did not know how to fully test the minced and moist texture (Minced & Moist foods are soft and moist but with no liquid that can leak or drip from the food and no crumbs), based on the standards of practice. This failure had the potential for risk of choking for six residents who had dysphagia (difficulty swallowing) and received minced and moist diet from the kitchen during the lunch meal on January 7, 2026.2. [NAME] (CK) 2 could not articulate the proper cool down process for ambient food (food kept at room temperature 70 F).3. [...]

Inspectors wroteBased on interview and record review, for one of five residents reviewed (Resident 50), the facility failed to ensure a change of condition was identified when Resident 5 had a decline in Activities of Daily Living (ADL) requiring total assistance in eating on July 18 and 19, 2025, and the meal intake was 50% or below on July 19, 2025. This failure had the potential to contribute to a delay in the care and treatment to address Resident 5's change of condition and affect the resident's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with the facility's policy and procedures and physician's order, for four of four residents (Residents 1, 2, 3, and 4). This failure has the potential to result in reduced effectiveness of Residents 1, 2,3, and 4's medications. On July 16, 2025, at 5:06 a.m., an unannounced visit was conducted at the facility to investigate quality of care issues. On July 16, 2025 at 5:23 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated she started the 6 a.m. and 6:30 a.m. medication pass (med pass - the process through which medication is administered to residents) at 4:20 a.m. LVN 1 stated she should start med pass at 5 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident A) received a post-discharge plan of care, which contained the necessary information for the continuation of care after discharge. This failure resulted in Resident A ' s family calling the facility for advice and sending Resident A to the emergency room, within 24 hours of his discharge from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat with respect and dignity, for two of five residents (Residents A and B), when the facility left a deceased resident (Resident C) in the same room with Residents A and B for approximately 12 hours, before removing the body. This failure resulted in Residents A and B ' s experiencing negative psychosocial (a person ' s well-being- mental, emotional, social, and spiritual health) outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to answer the call light within a reasonable time for three of three residents reviewed (Residents 5, 6, and 7). This failure had the potential to result in needs not to be met efficiently for Residents 5, 6, and 7.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the accuracy of Level I preadmission screening and resident review (PASARR) for 2 (Resident #3 and Resident #59) of 2 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on record review and interview, the facility failed to notify the appropriate state-designated authority after a resident was diagnosed with a new mental illness for 1 (Resident #59) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR) requirements.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. This was evidenced by two medication errors out of 33 opportunities, which resulted in a medication error rate of 6.06%, that affected 2 (Resident #10 and Resident #39) of 5 residents observed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered on time as prescribed by the physician and according to the facility ' s policy for three of three residents reviewed (Residents 1, 2, and 3). This failure had the potential to result in an increased risk of changes of condition to Residents 1, 2 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staffing to provide care and services for the residents of the facility. This failure had the potential to cause residents in the facility to experience delays and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure updated staffing information of the total number and actual hours worked by the licensed and unlicensed nursing staff was posted in a prominent place readily available to residents and visitors. This failure had the potential for the facility not to be able to provide and determine the actual nursing hours required for the provision of care and services for the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for one of three residents, Resident 2, had the call light within her reach. This failure had the potential to result for Resident 2 to not be able to call for help.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of two residents, Resident 1, that the responsible party (RP) was notified when Resident 1 had a change of condition (COC) and was transferred out to a general acute care hospital (GACH). This failure resulted in Resident 1 ' s RP to not be aware of Resident 1 ' s health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of one resident, Resident 1, that a physician ' s order for physical therapy was communicated with the hospice (care that focuses on the comfort and quality of life rather than curing a disease) provider. This failure resulted for Resident 1 not receiving physical therapy as ordered by the physician. In addition, this failure resulted for the hospice provider to not be fully aware of Resident 1 ' s overall condition.

Inspectors wroteBased on interview and record review, the facility failed to provide cardiopulmonary resuscitation (CPR - a way to help a person who has stopped breathing, and whose heart may have stopped beating, to stay alive) for one of two sampled residents (Resident 1), when Resident 1 was found unresponsive. This failure resulted in Resident 1 not receiving the necessary life saving measures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when four medications were not administered during the scheduled time with no documentation for one of five residents reviewed (Resident 1). This failure had the potential for Resident 1 to receive inadequate, ineffective medication treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one of three sampled residents (Resident 3) reviewed for falls, when the facility failed to repair a loose toilet seat being used by Resident 3 after it was reported to staff as needing repair on April 2, 2024. This failure resulted in Resident 3 falling off the loose toilet seat and sustaining a broken hip that required surgical repair at the general acute care hospital (GACH).

Inspectors wroteBased on interview and record review, the facility failed to ensure an adequate preparation and orientation for a safe and orderly discharge was afforded to one of two sampled residents (Resident 2) and her family member. Resident 2 was living with a family member, who was not provided adequate preparation and orientation prior to the planned discharge. This failure had the potential for Resident 2 to have an increased risk of accidents and rehospitalization if she was discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the family member (FM), who was designated as the Power of Attorney (POA- a legal document that allows someone else to act on your behalf), was notified about a change of condition, for one of two residents, Resident 2. This failure resulted for Resident 2's FM to not be aware of Resident 2's change in condition and the inability to fulfill POA duties effectively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care according to professional standards of practice for Resident 1 and 2, when the facility failed to: 1. Initiate a care plan, document a Change of Condition (COC), and complete a weekly skin assessment, for Resident 1 ' s stage 2 (shallow, open), coccyx (tailbone), Pressure Injury (PI - Damaged skin integrity due to prolonged pressure). 2. a) Complete a weekly skin assessment on Resident 2 ' s stage 2, coccyx PI; b) Carry over a doctor ' s (Dr ' s) order of Calmoseptine cream (Moisture barrier that helps heal skin) to Residents 2 ' s Treatment Administration Record (TAR); and c) Follow-up on Resident 2 ' s urine culture results from the General Acute Care Hospital (GACH) following treatment for sepsis related to a UTI (Urinary Tract Infection). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was being repositioned in accordance with the care plan. In addition, the facility failed to ensure treatment for the left heel pressure injury was provided in accordance with the physician order. These failures had the potential for Resident 1 to develop pressure injury or can result in worsening of an existing pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the basis for discharge of a resident endangering others were documented as necessary by one of three sampled residents' (Resident 1) physician. This failure has the potential to place the resident at risk for inappropriate discharge which could negatively affect the psychosocial needs of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was permitted to return following hospitalization unless the needs cannot be met, or the resident's behavior posed a danger to other residents at the facility. This failure had the potential to affect continuity of care for a resident who lived and received services from staff familiar to his needs. The resident has a diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities). The resident had to be placed to another skilled nursing facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents reviewed (Resident 1) was free from abuse when Resident 2 grabbed her breast. This failure had the potential for other residents in the facility to experience inappropriate sexual behavior from Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on abuse investigation when a Certified Nursing Assistant (CNA) 1 was not suspended after an allegation of verbal abuse was made by one of three residents reviewed (Resident 1). This failure resulted in CNA 1 to continue caring for other residents exposing residents at risk for potential harm.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of missing money to the State Survey Agency within 24 hours for one of four residents, (Resident 2). This failure increased the risk for further misappropriation due to delayed notification to respond and advocate on behalf of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of four residents (Resident 1), when Resident 1's diagnosis of mental illness and the use of psychotropic (medication capable of affecting the mind, emotions, and behavior) medications were not reflected in the PASRR. This failure had the potential for Resident 1 to not receive services she required in an appropriate setting as determined by the State agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services to achieve and maintain the highest practicable physical, mental, and psychosocial well-being were provided, for five of 25 residents reviewed, when: 1. For Resident 68, Ozempic (an injectable medication to treat diabetes mellitus [DM - abnormal blood sugar]) was not administered as ordered by the physician. This failure had the potential for Resident 68 to have uncontrolled blood sugar levels; 2. For Resident 31, morphine sulfate (a narcotic pain medication) was not administered as ordered by the physician. This failure had the potential for Resident 31 to experience pain and discomfort; 3. For Resident 86, licensed staff did not complete the neurological assessment (neurocheck) after the resident had unwitnessed fall incidents on September 10 and 16, 2021. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff was provided, when: 1. Necessary services to maintain personal hygiene was not provided, for one of one resident reviewed for Activities of Daily Living (ADL) (Resident 27); 2. During the confidential Resident Council (RC- independent group of long-term care facility residents who typically meet regularly to discuss concerns and suggestions in the facility and to plan activities that are important to them) interview, 12 out of 18 residents in attendance stated there was a delay in the staff's response to call lights, and that there was not enough Certified Nursing Assistants (CNA) during night shifts and weekends; and 3. The facility was staffed below the minimum state requirements for direct care service hours per patient day on multiple dates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services in accordance with professional standards of practice were provided to meet the needs of the residents when: 1. Multiple opened emergency kits (e-kit - an emergency storage box containing small quantity of critical medications used in emergent situations) were not replaced within seventy-two hours according to the facility's policy and procedure. In addition, the opened e-kits did not match the medications taken out from it. These failures had the potential to result in a delay in the administration of medications and potential for medication diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) to occur; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained and food was stored in accordance with professional standards for food service safety when: 1. During the initial kitchen tour on September 20, 2021, multiple food items were stored past the use-by date (the last day that the manufacturer vouches for the product's quality); and 2. During dining observation, on September 20, 2021, a ham and cheese sandwich was served to Resident 38 with the use-by date of September 19, 2021. These failures had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when: 1. For Resident 287, the urinary catheter (indwelling catheter - a hollow, flexible tube that collects urine from the bladder) drainage bag was observed on the floor. This failure had the potential for Resident 287 to develop urinary tract infection due to inappropriate placement of the urinary catheter drainage bag; 2. The blood pressure apparatus was not disinfected in between residents' use. This failure had the potential to result in the transmission of infection to the residents in the facility; 3. [...]

Inspectors wroteBased on interview and record review, for two of seven residents reviewed for Advance Directives (AD - a written instruction regarding the provision of health care when the individual is incapacitated) (Residents 86 and 65), the facility failed to ensure: 1. For Resident 86, a follow up with the resident's representative (RR) was conducted regarding obtaining a copy of the resident's AD; and 2. For Resident 65, written information regarding formulating an AD was provided to the resident and/or the (RR). These failures had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves.

Inspectors wroteBased on interview and record review, for one of three residents reviewed (Resident 89), the facility failed to ensure a post-discharge plan of care was completed and provided to the resident upon the resident's discharge from the facility. This failure had the potential for the resident and care giver to not receive the necessary medical information needed for the continuity of care of the resident upon discharge to home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain personal hygiene were provided for one of one resident reviewed for Activities of Daily Living (ADL) (Resident 27). This failure had the potential to result in poor personal hygiene which could negatively affect Resident 27's physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards was provided, for one of five residents reviewed for falls (Resident 6), when the resident did not have a fall/tab alarm placed to prevent falls according to the physician's order and plan of care. This failure resulted to Resident 6 sustaining another fall incident on September 21, 2021. In addition, this failure had a potential to result for further falls and sustain injuries for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and treatment in accordance with the physician's order was provided, for one of one resident reviewed for oxygen use (Resident 34). In addition, the facility failed to ensure infection control measures were implemented when the oxygen tubing and nasal cannula (NC - a device used to deliver supplemental oxygen) were observed to be on the floor. These failures had the potential to result in ineffective oxygen therapy, respiratory distress, infection, and/or decline in the health condition for Resident 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the episodes of behavior related to the use of lorazepam (medication for mood disorder) were properly monitored, for one of five residents reviewed for unnecessary medication (Resident 6). This failure had the potential for Resident 6 to receive unnecessary psychotropic medications (medications used to treat mood disorder).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was below five percent when there were six medication errors out of 38 opportunities observed, for two of five sampled residents (Residents 58 and 15). This failure resulted in a medication error rate of 15.79% and could result in the residents' not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored according to the facility's policy and procedure and per state and federal requirements when controlled medications (regulated and classified medications that can cause physical and mental dependence, and have restrictions on how they can be filled and refilled) were not stored in separately locked compartments and were mixed with non-controlled medications. This failure had the potential for the controlled medications to be accessed by unauthorized personnel, which could potentially lead to diversion or misappropriation of restricted medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the basic metabolic panel (BMP - a laboratory test to measure electrolyte levels) was completed, as ordered by the physician, for one of 25 residents reviewed (Resident 38). This failure had the potential for an abnormal electrolyte level to not be identified timely and could potentially result in the delay in care and treatment for Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required 80 square feet per resident in 11 resident rooms, (Rooms 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39).