Woodcrest Post Acute & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Woodcrest Post Acute & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 26, 2024

  Based 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). Findings: On April 23, 2024, at 12:37 p.m., a concurrent observation and interview was conducted with Resident 3. Resident 3 was in his room, lying in bed, alert and conversant. Resident 3 stated, he fell in the restroom on April 3, 2024, at approximately 2:30 p.m. […]

• Actual harm, isolatedF689Jan 12, 2023

  Based on observation, interview, and record review, the facility failed to provide supervision consistent with the resident's needs, goals, care plan, and current professional standards of practice, in order to eliminate the risk of an accidental fall, to one of three residents reviewed (Resident A), when Resident A was left unattended while in a wheelchair at Station 3 lobby. This failure resulted in the resident getting up unassisted from the wheelchair, and falling face down to the floor, for the second time in 38 days, sustaining a right frontal subdural hematoma (SDH-a pool of blood between the brain and its outermost covering). Resident A was transferred to the acute care hospital for evaluation. […]

• Actual harm, isolatedF684May 10, 2021

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received necessary care and services to achieve his highest practicable physical, mental and psychosocial well-being when: 1. The facility failed to ensure licensed nursing staff promptly responded, assessed and provided immediate care to Resident 1 when it was reported Resident 1 was unresponsive. This failure resulted in a delay in medical treatment and a decline in physical and mental status, which required Resident 1 to be transferred to the acute hospital for medical treatment due to [CONDITION(S)] (low blood sugar). 2. The facility failed to obtain a physicians order for blood sugar monitoring for Resident 1 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF814Jan 9, 2026

  F814 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.Findings:On January 5, 2026, at 10:03 a.m., during concurrent observation and interview with the Dietary Service Supervisor (DSS), the dumpster was overloaded with garbage bags and the cover was open about a foot and a half. The DSS stated the dumpster was not fully covered. […]

• No harm, potential for more than minimal, widespreadF645Oct 3, 2024

  Based 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. Findings included: A facility policy titled, Admission Criteria, revised in 09/2023, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The policy revealed, a. […]