Woodcrest Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Woodcrest Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Jun 18, 2026

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances in accordance with professional standards of practice and facility policy when staff did not accurately complete and reconcile the Controlled Narcotic Record sheets or sign the Controlled Medication Shift Change Log, for 4 of 6 sampled medication carts.The findings include:Review of the facility's policy titled, Medication Administration Standard of Practice, reviewed 03/2026, revealed the facility required medications to be administered safely and as prescribed. The policy further requires medications to be administered in accordance with physician orders. […]

• No harm, potential for more than minimal, widespreadF880Jun 18, 2026

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to follow infection prevention and control policies to help prevent the development and transmission of communicable diseases and infection for 3 of 4 residents with reusable medical equipment, Resident (R) 32, R59, and R78.Additionally, the facility failed to follow infection control policies for 3 of 8 residents observed for medication administration, R97, R99, and R121. Review of the facility's policy entitled, Infection Control, dated October 2018, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. […]

• No harm, potential for more than minimal, widespreadF880May 22, 2025

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections affecting all facility residents, with a current census of 110 residents. 1. Observation of the Laundry Room on 05/20/2025 revealed the facility laundry area was not maintained in a clean and sanitary manner. 2. Observation of Housekeeper (HSK) 1 on 05/20/2025 revealed she walked into the dirty utility room carrying a bag of contaminated linen slung over her shoulder and up against her person. 3. […]

• No harm, potential for more than minimal, isolatedF645Jun 18, 2026

  Based on interview and record review, the facility failed to ensure each resident had been screened for a mental disorder or intellectual disorder prior to admission for 1 of 6 sampled residents reviewed, Resident (R) (12).The findings include:Review of the facility's policy entitled, Preadmission Screening and Resident Review (PASARR), reviewed on 03/2026, revealed the purpose is to determine if an individual seeking admission has a serious mental illness (SMI), intellectual disability (ID), or related condition (RC), and determine eligibility for nursing facility placement.Review of the facility's policy entitled, Resident Rights Standard of Practice, reviewed on 3/2026, revealed the purpose is to ensure each resident is treated with respect and dignity and cared for in a manner that… […]

• No harm, potential for more than minimal, isolatedF759May 22, 2025

  Based on observation, interview, record review, and review of the facility's job description, the facility failed to ensure that its medication error rate was less than five percent. Two errors out of 33 opportunities resulted in a 6.06% error rate. The findings include: Record review of the Licensed Practical Nurse (LPN) job description, updated 4/19/2024, listed essential functions of this position, including administration of medications and treatments, following approved nursing techniques. Review of the May 2025 Medication Administration Record (MAR) for Resident (R) 1 revealed Atorvastatin 20 milligrams (mg) and Loratadine 10 mg was ordered for administration between 7:00 PM and 10:59 PM. […]