Woodhaven Health & Rehab Center

Inspectors wroteBased on review of facility policies, observations and staff interview, it determined the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness in one of one deep freezer and one of one milk coolers and failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line, which created the potential for food borne illness.

Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to ensure the availability of the most recent survey results and any plan of correction were accessible to residents and visitors in two of two areas (Lobby and Activity Department). Findings Include: The residents have the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors. Reports of surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years and any plan of correction in effect with respect to the facility. During observations on 5/28/26, at 11:00 a.m. the Nursing Home Administrator and surveyor reviewed the facility posting, indicating the facility prior Department of Health's survey results are available for review in a binder located in the lobby and in the activity department. [...]

Inspectors wroteBased on review of facility policy, resident observations, resident council interview, a confidential staff interview and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of fourteen of twenty-four residents (Residents R78, R83, R120, R700, R701, R702, R703, and R704, R705, R706, 707, 708, 709, and 710). Findings Include: Review of the facility policy Call Light Resident Communication System Policy, reviewed on 3/31/26 with a prior review date of 1/1/25, indicated, attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. [...]

Inspectors wroteBased on a review of facility policy, resident interviews, resident council meeting minutes, resident choice menu selections and staff interview, was determined that the facility failed to provide resident selected menu items for 5 of 12 residents (Resident R707. R708, R709, R710 and R711).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in two of two locations where grievances boxes are located (first and second floors).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift for one of four observed days.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement policies and procedures to report allegations of abuse for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews it was determined that the facility failed to provide activity of daily living (ADL) assistance for five of eleven residents (Residents R19, R20, R23, R25, and R26).

Inspectors wroteBased on review of facility policy and documents, observations and staff interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection for 21 of 28 residents.

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision during bed mobility for one of six residents (Resident R1). This was identified as past-noncompliance.

Inspectors wroteBased on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care and services to two of five residents (Resident R10 and R11).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to provide treatment and services related to heart failure (a progressive heart disease that affects pumping action of the heart muscles) for one of three residents (Resident R1). Findings Include:Review of the Unites States National Library of Medicine information Heart Failure dated 3/11/25, indicated symptoms of heart failure can include: Shortness of breath. Fatigue or weakness. Coughing. Swelling and weight gain from fluid in the ankles, lower legs, or abdomen. Difficulty sleeping when lying flat. Nausea and loss of appetite. Swelling in the veins of your neck. Needing to urinate often. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of the clinical record, physician documents, and staff interviews, it was determined that the facility failed to make certain residents with intellectual disabilities receive appropriate services for one of three residents (Resident R2). Based on review of clinical records, and staff interview it was determined that the facility failed to make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28).

Inspectors wroteBased on review of the clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R2).

Inspectors wroteBased on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents (R2, R11, R58, R73, R86, and R94). Findings Include: Review of facility policy Diabetic Protocol dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. [...]

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were accurate and fully completed for five of twenty-six residents (Resident R14, R22, R25, R36, and R80).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to develop and implement comprehensive care plans for resident and care needs for five of twelve residents (Resident R14, R22, R43, R73 and R85).

Inspectors wroteBased on a review of facility documents, clinical records, and staff interview, it was determined that the facility failed to ensure that the Activities Director accurately completed, and/or directed or delegated the accurate completion of the activities component of the comprehensive assessment and failed to attempt to obtain information on resident preferences from family, significant others, or staff interviews for residents with severe cognitive impairment for 28 of 28 residents (Residents R8, R13, R14, R15, R16, R24, R29, R42, R45, R54, R59, R62, R65, R66, R72, R73, R81, R82, R88, R90, R91, R93, R96, R206, R210, R211, R310, and R311). [...]

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for two of five residents (Resident R22 and R34). This was identified as past non-compliance.

Inspectors wroteBased on facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of sixteen residents (Resident R 21 and R312).

Inspectors wroteBased on observations and staff interviews, it was determined, the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on two of two nursing floors (First Floor and Second Floor).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for four of twelve residents (Residents R14, R36, R66, and R94).

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Resident R203).

Inspectors wroteBased on review of facility policy, clinical record, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R20 and R61).

Inspectors wroteBased on review facility documents, clinical records, and staff and resident interviews it was determined that the facility failed to ensure the physician reviewed the resident's total program of care for one of eight residents (Resident R36).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health services to maintain the highest practicable well-being for one of eight residents (Resident R43).

Inspectors wroteBased on review of the clinical records, resident, and staff interviews, it was determined that the facility failed to provide sufficient and timely social services to meet the residents needs for one of eight residents (Resident R43).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in one of two medication rooms (First Floor Medication Room).

Inspectors wroteBased on review of facility policy, observations, resident, and staff interviews, it was determined that the facility failed to assess and care plan for self-administration of medications for three of twelve residents (Residents R1, R2, and R3).

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 16 of 22 residents (Residents R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17). Findings Include: Review of the facility policy Resident Communication and Call Light Policy dated 6/27/24, indicated staff will respond to call lights promptly. During an observation on 3/14/25, at 9:59 a.m. Resident R4 room smelled strongly of urine and Resident R4 had messy, unkempt hair. During an interview on 3/14/25, at 1:02 a.m. Resident R5 was observed to have messy, unkempt hair. During an interview on 3/14/25, at 10:03 a.m. [...]

Inspectors wroteBased on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of four residents (Resident R7).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family of a change in condition in a timely manner for one of nineteen residents (Resident R1).

Inspectors wroteBased on review of facility policy, personnel records, clinical records and activity calendars, and staff interview, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of five residents reviewed (Resident R38,R57). Findings Include: A review of the facility policy Advanced Directives on 1/1/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. [...]

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to document notification of changes in conditions for three of six residents (Resident R1, R2, and R3).

Inspectors wroteBased on a review of facility policy, resident record, observation, resident interview and staff interview, it was determined the facility failed to provide necessary services to maintain adequate grooming and personal hygiene for ten of 18 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on nursing unit observations, resident observations, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 18 of 23 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18).

Inspectors wroteBased on an observation and staff interview it was determined that the facility failed to maintain a clean and sanitary enviornment in the Main Kitchen. (Main Kitchen)

Inspectors wroteBased on review of facility documents, observations and staff interviews it was determined that the facility failed to meet the physical, mental and psychosocial well being of the residents failing to provide beautician services to residents desiring to have hair grooming services and failed to notify the residents of a proper fee structure for beautician services for residents covered by Medicare and Medicaid insurance providers for eight of eight months. (7/23, 8/23, 9/23, 10/23, 11/23, 12/23, 1/24, and 2/24) .

Inspectors wroteBased on a review of facility policies, documents, resident medical records and staff interviews it was determined that the facility failed to administer medications to six of six residents (Resident R5, R6, R7, R8, R9, and R10) in accordance with physician orders and follow through to make certain that the facility corrected the causes for the medication errors.

Inspectors wroteBased on observations, review of facility standardized recipes and staff interviews, it was determined that the facility failed to properly prepare flavorful, palatable food products by failing to follow facility standardized recipes for the lunch meal on 2/13/24. (lunch meal 2/13/24).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide accurate meal trays for four of 10 residents ( Resident R1, R2, R3 and R4).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to follow the displayed menu for the lunch meal on 2/13/24 as required. (lunch meal 2/13/24).

Inspectors wroteBased on resident, and staff interviews it was determined that the facility failed to provide a dignified dining experience for the Thanksgiving Holiday meal (Thanksgiving Holiday Meal).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to meet the physical, mental and psychosocial well being of the residents by failing to provide beautician services for residents desiring hair grooming services for six months (7/23, 8/23, 9/23, 10/23, 11/23, and 12/23).

Inspectors wroteBased on a review of the facilities four week cycle menu, observations, and resident and staff interviews it was determined that the facility failed to approve the four week cycle menu prior to implementation (Week one, Week Two, Week Three, and Week Four) and provide food products as listed on the menu for the lunch meal on 12/13/23. (Lunch meal 12/13/23).

Inspectors wroteBased on a review of facility policies, documents, observations, test tray audits, and staff interviews, it was determined that the facility failed to to serve food products at palatable temperatures for the lunch meal on 12/13/23. (lunch meal 12/13/23)

Inspectors wroteBased on clinical record record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for one of six residents. (Resident R1)

Inspectors wroteBased on observations, review of facility dish machine temperature logs dated from May 2023 through July 2023, and staff interviews, it was determined that the facility failed to store foods in a sanitary manner to prevent the potential for food borne illness, maintain a sanitary environment in the main kitchen, failed to maintain necessary equipment in proper functioning order and failed to make certain the dish machine was running at proper temperatures.