Woodward Hills Health and Rehabilitation Center

Inspectors wroteThis citation relates to Intake 3003663. Based on interview and record review, the facility failed to prevent an avoidable fall for one Resident (R903) of two residents reviewed for falls. This resulted in R903 sustaining a brain bleed, a fractured humerus, and a fractured femur, which required surgery and resulted in increased pain and a functional decline.

Inspectors wroteThis citation relates to Intake 2962105. Based on interview and record review, the facility failed to ensure a change in condition was addressed timely for one Resident (R901) of three residents reviewed for change in condition.

Inspectors wroteBased on observation and interview, the facility failed to ensure the storage of medications were labeled with name of medication and resident specific identifiers in three of five medication carts reviewed for medication storage. Findings Include:On 3/3/26 at 8:36 AM, the 600-hallway medication cart was observed for medication storage with Registered Nurse (RN) C and the Director of Nursing (DON) and revealed on the bottom of drawer two, nine loose medications and bottom of drawer three observed two medications loose with no medication or patient identifiers. Five vials of albuterol (medication for breathing treatments) were observed lying on base of drawer with no patient identifiers. RN C and the DON acknowledged loose medications are not proper storage in the medication cart and disposed per protocol. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain general cleanliness and repair of a cabinet surface, laundry equipment, and plumbing fixture resulting in an increased potential for contamination affecting all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed for safe self-administration of medication for three residents (R27, R134 and R138) of three residents reviewed for self-administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident rights of one Resident (R127) of three residents reviewed for resident rights, related to privacy with opening their own mail.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine bathing was provided for two residents (R186 and R197) of five residents reviewed for activities of daily living (ADL's).

Inspectors wroteThis citation pertains to intake 2745432. Based on interview and record review, the facility failed to ensure medications were available for administration and Physician orders were clarified with the Physician/pharmacy for one resident (R204) of one resident reviewed for medication administration, resulting in R204 having missed doses of their Physician-ordered medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent two accidents with a mechanical lift and remove a malfunctioning lift from circulation for one Resident (R171) of two residents reviewed for accidents.

Inspectors wroteThis citation pertains to intake 2745432. Based on observation, interview and record review, the facility failed to implement timely care and monitoring of a resident's suprapubic urinary catheter (flexible tube surgically inserted into the bladder through the skin of the abdominal wall) which included physician orders and nursing assessment for one (R214) of four residents reviewed for urinary catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate PICC line (Peripherally Inserted Central Catheter) care was provided for one resident (R197) of one resident reviewed for Parenteral/IV fluids.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician ordered laboratory diagnostics (labs) were completed and reported to the Physician in a timely manner for one resident (R52) of one resident reviewed for laboratory diagnostics.

Inspectors wroteBased on observation and interview, the facility failed to provide proper hand hygiene procedures during medication administration for three (R128, R53, R215) residents of four reviewed for medication administration.

Inspectors wroteThis citation is or complaint # 2573833Based on observations, interviews, and record reviews, the facility failed to follow a transfer status and fall protocol for one resident (R303) of three residents reviewed for falls, resulting in R303 obtaining a serious injury.

Inspectors wroteThis citation pertains to intake #2577284. Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment, in multiple resident rooms and throughout the hallways on the 100, 400, 500, 600, and 700 units.

Inspectors wroteThis citation pertains to intake: MI00151510. Based on interview and record reviews the facility failed to address the concerns reported to the facility for one (R202) of three residents reviewed for grievances. Review of a complaint submitted to the State Agency (SA) documented multiple concerns that the complainant attempted to get resolved with the facility staff unsuccessfully. The complainant noted the facility's failure to follow up and the lack of communication to resolve any of their concerns. A review of R202's medical record revealed the resident was admitted to the facility on [DATE] and transferred out to the hospital on 3/27/25. R202 admitted with the primary diagnosis of hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). A review of the progress notes revealed the following: [...]

Inspectors wroteThis citation relates to Intake #MI00151329. Based on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse during two resident-to-resident incidents for two Residents (R205, R206) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #: MI00152670 Based on interview and record review facility failed to investigate (and follow-up) on an injury (skin tear) of unknown origin for one (R207) of three Residents reviewed for abuse resulting in the potential for further unidentified instances of injuries of unknown origin.

Inspectors wroteThis citation pertains to intake: MI00151510. Based on observation, interview and record reviews the facility failed to consistently complete wound treatments (R202), failed to timely identify a left heel wound, timely implement treatment to the left heel wound and consistently completed weekly skin assessment (R209) for two of three residents reviewed for wounds.

Inspectors wroteThis citation pertains to intake: MI00151510. Based on interview and record reviews the facility failed to ensure an initial comprehensive consultation was completed by a Physician for one (R202) of three residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake #MI00149390. Based on interview and record review, the facility failed to ensure treatment in a dignified manner for one resident, (R801) of three residents reviewed for dignity, resulting in feelings of frustration and being ignored.

Inspectors wroteThis citation pertains to intake #MI00149390. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency for one resident (R801) of two residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #MI00149390. Based on interview and record review, the facility failed to prevent an avoidable fall for one resident (R801) of three residents reviewed for falls, resulting in the resident rolling out of bed.

Inspectors wroteThis citation pertains to intake #MI00149390 and #MI00151121. Based on interview and record review, the facility failed to ensure pain was treated per resident request and physician's orders for one resident (R801) of two residents reviewed for pain, resulting in complaints with care and untreated pain.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent a facility acquired pressure ulcer for one (R59) out of four residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (full thickness skin and tissue loss with obscured wound bed) to the left heel and sepsis infection from tight fitting shoes.

Inspectors wroteR59 On 12/2/24 at approximately 8:55 AM, R59 was observed lying in bed. The resident was alert but confused and not able to answer questions asked. On 12/4/24 at approximately 10:01 AM, R59 was observed attempting to get out of their bed. The resident had yellow gripper socks on, was alert, non-combative, but confused as to where they were and where they wanted to go. Their call light was out of reach. CAN S was asked to come assist the resident who appeared confused and was trying to get out of bed on their own. A review of R59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, type II diabetes and atrial fibrillation. A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 1/15 (severely cognitively impaired). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, failed to maintain the microwaves in the Cranbrook and [NAME] pantry in a sanitary manner, and failed to ensure food items were covered while transported through the hallways. This deficient practice had the potential to affect all residents in the facility that consume food.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced resident's dignity for five residents (R53, R286, R292, R336, and R387) of seven residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable ambient air temperatures in multiple resident rooms (Rooms 100, 101, 103, 105, 107, 111, 201, 203, 205, and 207).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all controlled substances were accounted for and accurately documented for one (82) of four residents reviewed for pain management.

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant med error for one (R20) of five residents reviewed for unnecessary medications, resulting in the resident receiving duplicate doses of a diuretic medication (furosemide) on three days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician ordered transmission based precautions (TBP) for one (R20) of one resident reviewed for TBP.

Inspectors wroteBased on interview and record review, the facility failed to ensure a referral was made for a level II evaluation (a comprehensive evaluation completed by the local community mental health agency) in a timely manner for one (R24) of two residents reviewed for PASARR (Preadmission Screening/Annual Resident Review) screenings.

Inspectors wroteThis citation has three (3) deficient practice statements (DPS). DPS #1 Based on observation, interview and record review the facility failed to timely identify and assess a facial bruise for one (R36) of four residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate orders for peripherally inserted central catheter (PICC) dressing changes and monitoring of dressings for two (R387 and R291) of two residents reviewed for PICC lines.

Inspectors wroteBased on interview and record review, the facility failed to follow-up for guardianship for one resident (R49) of one resident reviewed for guardianship.

Inspectors wroteBased on interview and record review the facility failed to ensure monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medication provider for recommendations to act on for one (R3) out of five residents reviewed for unnecessary medications.

Inspectors wroteThis citation pertains to Intake #MI00148355 Based on observation, interview and record review the facility failed to timely provide follow-up dental services to one (R25) out of two residents reviewed for dental services.

Inspectors wroteBased on interview and record review the facility failed to offer the 2024-2025 seasonal influenza (flu)vaccine to one resident (R49) of five residents reviewed for influenza vaccines.

Inspectors wroteThis citation pertains to intake #MI00143872 Based on observation, interview and record review the facility failed to ensure skin assessments were documented, completed accurately and timely for one resident (R901) of two residents reviewed for changes in condition.

Inspectors wroteThis citation pertains to intake #: MI00142021, MI00142120, and MI00141180 Based on interview and record review, the facility failed to provide timely medically related social services and follow up to address behavior changes, care planning reviews, and discharge planning for three (R901, 907, and 910) of four residents reviewed for social services.

Inspectors wroteThis citation pertains to intake #: MI00142195. Based on observation, interview, and record review the facility failed to initiate a timely investigation for an injury (abrasion on left lower extremity) of unknown origin for one (R908) of two Residents reviewed for abuse with potential for further injuries of unknown origin/abuse. A record review revealed R908's most recent readmission to facility was on 7/14/22. R908's admitting diagnoses included dementia, unspecified psychosis, anxiety disorder, and history of multiple falls. Based on the Minimum Data Set (MDS) assessment dated [DATE], R908 had severe cognitive impairment. R908 needed extensive staff assistance with their mobility in bed, transfers, and Activities of Daily Living (ADLs) such as dressing, bathing etc. An initial observation was completed on 2/5/24, at approximately 10:10 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six residents (R34, R49, R60, R63, R80 and R94) of six residents reviewed for medications were assessed for the safe self-administration of medication and to have medication kept at the bedside, resulting in the potential for mismanagement of medication and potential for adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were accessible to four residents (R39, R73, R95 and R111) and an appropriate bed was provided to one resident (R446) of five residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete routine showers for three Residents (R4, R60 and R98) of four reviewed for activities of daily living (ADLs).

Inspectors wroteThis citation pertains to intake #MI00139622. Based on observation, interview and record review the facility failed to provide wound care treatments and accurate and/or timely skin assessments as ordered by the physician for three (R34, R43 and R445) of three residents reviewed for quality of care, resulting in the lack of assessment, monitoring, and potential worsening of the condition and delayed healing.

Inspectors wroteThis citation has two deficient practices. Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure the environment was free from environmental hazards including unsecured sharps containers (a hard plastic container that is used to safely dispose of hypodermic needles and other sharp medical instruments, such as Intravenous/IV catheters and disposable scalpels) and free standing oxygen thanks. This deficient practice had the potential to effect effect one resident (R98) and multiple other residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were properly secured and stored in three medication carts, two medication storage rooms and one resident room (R98) of 5 medication carts and two medication storage rooms reviewed for medication labeling and storage.

Inspectors wroteR98 On 10/5/23 The medical record for R98 was reviewed and revealed the following: R98 was initially admitted to the facility on [DATE] and had diagnoses including Depression, Insomnia and Congestive heart failure. A review of R98's MDS (minimum data set) with an ARD (assessment reference date) of 7/7/23 revealed R98 needed extensive assistance with most of their activities of daily living. R98's BIMS sore (brief interview for mental status) was 13 indicating intact cognition. A Physician's order dated 9/25/23 with a start date of 9/30/23 revealed the following: Prazosin HCl Oral Capsule 2 MG (Prazosin HCl) Give 2 mg by mouth at bedtime for PTSD (Post traumatic stress disorder)/Nightmares A review of R98's October 2023 Medication Administration Record (MAR) revealed R98 had not been administered their Prazosin in October. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate communication devices and services were in place for one resident (R497) of one resident reviewed for communication, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate catheter care was provided and Physician orders were obtained for an indwelling catheter for one resident (R5) of three residents reviewed for Catheters.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a legally incompetent resident was provided a representative that had legal authority to act in the best interest/make informed medical decisions in a timely manner for one resident (R4) of one residents reviewed for medically related social services.

Inspectors wroteThis cite pertains to intake MI00138070. R806 Review of an intake submitted to the State Agency (SA) documented concerns of surgical site dressing changes not being completed. Record review revealed that R806 was admitted to the facility on [DATE] with the diagnoses of Spinal Stenosis lumbar region, Low back pain and encounter for surgical aftercare following surgery on the nervous system. Record review revealed that R806 Brief interview mental status(BIMs) was a 13 and the minimum data set(MDS) showed that they needed moderate assistance with activities of daily living(ADLs). Record review revealed that R806 on 6/21/23 has a spinal stenosis lumbar incision with several sutures. Record review revealed that on 6/25/23 a treatment and care plan was put in place for the surgical site. [...]

Inspectors wroteThis citation pertains to intake(s): MI00136632 and MI00137232. Based on observation, interview and record review, the facility failed to ensure consistent and comprehensive skin assessments and implement interventions for two (R811 and R820) of two residents reviewed for pressure ulcers(PU), resulting in R820 developing an unstageable (the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) PU and R811 developing multiple PU's.

Inspectors wroteThis citation pertains to intake number(s): MI00133087. Based on interview and record review, the facility failed to ensure controlled substances were received, administered, reconciled appropriately, and discrepancies in counts investigated for one (R815) of four residents reviewed for medications, resulting in R815 receiving too much opioid pain medication and the potential for drug diversion.

Inspectors wroteThis citation pertains to intake number(s): MI00138623 and MI00138901. Based on observation, interview, and record review, the facility failed to notify the residents' representatives of a hospital transfer and black eye for two (R804 and R805) of two residents reviewed for notification of changes.

Inspectors wroteThis citation pertains to intake(s): MI00136323 & MI00132921. Based on interviews and record reviews the facility failed to implement their grievance policy for two (R's 817 & 813) of three residents reviewed for grievances.

Inspectors wroteThis citation pertains to intake number(s): MI00139106 and MI00138623 Based on observation, interview, and record review, the facility failed to report allegations of abuse, mistreatment and a black eye of unknown origin to the State Agency for two (R801 and R805) of six residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake number(s): MI00139106 and MI00138623 Based on observation, interview, and record review, the facility failed to investigate allegations of abuse and mistreatment and thoroughly investigate a black eye of unknown origin for two (R801 and R805) of six residents reviewed for abuse.

Inspectors wroteThis cite pertains to intake MI00137696 and intake MI00139186 Based on interview and record review, the facility failed to document, accommodate, and provide routine showers to two(R802 and R807) of two residents reviewed for showers, resulting in skin irritation and the resident's feeling as if they had poor hygiene.

Inspectors wroteThis citation pertains to intake: MI00132921 and MI00132451. Based on interviews and record reviews the facility failed to implement adequate fall interventions for one (R817) a resident with a history of falls, resulting in a fall.

Inspectors wroteThis cite pertains to intake(s) MI00137696 and MI00138070. Based on observation, interview and record review, the facility failed to maintain adequate catheter care for one residents(R806) of one sampled for catheter care, resulting in the potential for urinary tract infections (UTI) and discomfort.

Inspectors wroteThis citation pertains to intake number(s): MI00139106. Based on interview and record review, the facility failed to ensure respiratory care was provided according to standards of practice and the plan of care for one (R801) of two residents reviewed for respiratory care, resulting in R801 experiencing respiratory distress and a transfer to the hospital.

Inspectors wroteThis citation pertains to intake: MI00137355. Based on interviews and record reviews the facility failed to ensure labs were completed as ordered by the physician for one (R809) of seven residents reviewed for pressure ulcer care.