Woodhaven Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Woodhaven Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jul 3, 2025

  Based 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. […]

• Actual harm, isolatedF600Jun 4, 2022

  Based on review of facility policy, job descriptions, and records, and staff interviews, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a worsened pressure injury for one of six residents (Resident R1). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility document entitled, Abuse, dated 11/2021, indicated that each resident has the right to be free from neglect. […]

• Actual harm, isolatedF686Jun 4, 2022

  Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services, consistent with professional standards of practice, to prevent the development and worsening of pressure injuries as required, resulting in the actual harm of a worsened pressure injury, for one of six residents (Resident R1). Findings include: Review of facility document entitled, Pressure Injury Guidelines, dated 11/2021, indicated It is the policy of this facility to provide early identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812May 29, 2026

  Based 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. Findings include: Review of the facility policy Storage of Frozen Foods, dated 3/31/26, with a previous date of 1/1/25, indicated that frozen foods will be stored at appropriate temperatures and methods which promote food quality and safety. […]

• No harm, potential for more than minimal, widespreadF680Jun 13, 2024

  Based 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. Findings include: Review of the Life Enrichment Director job description indicated the qualifications were as required by State and Federal Regulations. Review of Life Enrichment Director Employee E2's personnel record indicated she was hired on 12/27/23. Review of Life Enrichment Director Employee E2's personnel record did not include evidence that Life Enrichment Director Employee E2 had proper qualifications as a Life Enrichment Director. […]