Woodard Creek Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Woodard Creek Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610May 29, 2026

  Based on observation, interview, and record review, the facility failed to identify, report and thoroughly investigate allegation of abuse/neglect for 5 of 8 sample residents (Resident 78, 37, 94, 100, & 131) reviewed for abuse and 20 supplemental residents (Resident 25, 53, 143, 4, 144, 150, 31, 45, 86, 80, 148, 149, 112, 99, 110, 69, 116, 10, 44, & 38) whose reported allegations of potential abuse and neglect were identified upon review of the facility's grievance log. The allegations identified included verbal abuse, rough handling, residents being fearful of staff, lack of incontinence care, not responding to call lights for multiple hours or turning call lights off and leaving without providing the requested care, and failure to provide help with bathing and hygiene for up to a week. […]

• Actual harm, isolatedF561Aug 31, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were permitted to exercise their rights when the facility obtained consent from family members for the placement of wander-guard devices without establishing that the family members had legal authority to make decisions on behalf of 2 of 3 residents (Residents 1 and 6) reviewed for resident rights. This failure caused actual psychosocial harm to Resident 1 by significantly compromising the resident's psychosocial well-being, as evidenced by persistent emotional distress, including crying; repeated statements of feeling imprisoned, trapped, and desperate; and expressions of suicidal ideation when the resident was prevented from attending church. […]

• Actual harm, isolatedF686May 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to prevent the development of avoidable pressure ulcers (PU), and to promote wound healing and prevent further decline of existing PUs for 2 of 3 residents (Residents 11 and 14) reviewed for pressure injuries. Specifically, the facility failed to thoroughly assess resident specific risk factors, develop and implement preventative measures, and timely identify, assess, monitor, treat, and notify the provider of newly developed PUs that direct care staff had knowledge of. These failures placed residents at risk for unidentified wound development and/or deterioration, delayed treatment, and intervention. […]

• Actual harm, isolatedF689Mar 2, 2026

  Based on interview and record review, the facility failed to ensure residents who fell were assessed/evaluated for increased supervision and/or that a resident-specific fall prevention care plan was implemented for 1 of 3 residents (3) reviewed for falls. These failures put residents at risk for further injury, pain, and a decreased quality of life. Resident 3, who was assessed as a known high fall risk, was on blood thinning medication and had severe cognitive impairment, experienced harm when they had an unwitnessed and unsupervised fall, sustained a left hip fracture and experienced extreme pain as evidenced by the resident's grimacing and yelping when rolled to their left side.Findings included.Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia and… […]

• Actual harm, isolatedF689Sep 29, 2021

  Based on observation, interview and record review, the facility failed to ensure staff followed the resident's care plan when providing care by not having two staff present for bed mobility for one of four sampled residents (1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident 1 when she was rolled off the bed to the floor during care. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke, muscle [CONDITION(S)], and contractures (permanent tightening of muscles, tendons, and skin). […]