Woodhaven Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF607Jul 31, 2024

  Based on record review and staff interviews, the facility failed to follow their abuse policy when Confidential Staff #1 allowed Nurse #3 to continue providing care to residents after witnessing Nurse #3 slap Resident #3. Confidential Staff #1 did not report the abuse to the administration resulting in no protection of residents from further abuse, no investigation, and no notification to the state, adult protective services or law enforcement. A second incident of abuse occurred when Nurse Aide #2 and Nurse Aide #3 did not identify abuse when they witnessed Nurse #3 rip a dressing off Resident #3's forearm resulting in the resident experiencing pain and her skin tear reopening and bleeding. Nurse #3 then raised her hand to Resident #3 like she was going to slap her. […]

• Immediate jeopardy, isolatedF600Jul 31, 2024

  Based on record review and staff interviews, the facility failed to protect Resident #3's right to be free from abuse. In March of 2024 Confidential Staff #1 witnessed Nurse #3 slap Resident #3 across the face during care after Resident #3 spit on Nurse #3 twice. In July of 2024 during a weekly skin check Nurse Aide #2 and Nurse Aide #3 witnessed Nurse #3 rip a dressing off Resident #3's forearm resulting in a skin tear reopening and bleeding. Resident #3 repeatedly yelled you're hurting me. Resident #3 then spit on Nurse #3 twice and in response, Nurse #3 raised her hand like she was going to slap Resident #3 when Nurse Aide #2 intervened and Nurse #3 lowered her hand and proceeded to change the dressing. Resident #3 did not have the cognitive capacity to express a psychosocial outcome. […]

• Immediate jeopardy, isolatedF684Jul 31, 2024

  Based on record reviews and interviews with staff, Emergency Medical Services personnel, and the Medical Director, the facility failed to immediately initiate emergency medical services (EMS) on a pulseless, nonbreathing resident who was a full code. On [DATE] at approximately 12:03 AM Resident #1 was found to be unresponsive, pulseless, and not breathing. Nurse #1 began cardiopulmonary resuscitation (CPR) (a way to try to restart the heart and lungs if they stop) and yelled out Code Blue. After approximately 2 minutes of (CPR) no other staff had come to assist Nurse #1 so she went to the door, saw a nurse assistant and yelled Code Blue she then resumed CPR on Resident #1. […]

• Actual harm, isolatedF689Jul 9, 2026

  Based on observation, staff, resident and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when the resident fell from the bed during incontinence care, reported knee and hip pain at a level of 9 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. The resident required evaluation at the emergency department where she was diagnosed with a non-displaced medial femoral condylar fracture (a fracture at the end of the thigh bone near the knee joint where the bones rub together causing pain and requiring strict immobilization for healing). This deficient practice affected 1 of 3 residents (Resident #1) reviewed for accidents. […]

• Actual harm, isolatedF909Jul 9, 2026

  Based on record review and staff interviews, the facility failed to ensure that a circular bed rail was maintained in safe working condition. As a result, the rail did not remain secure, and the resident fell from the bed during care sustaining a fractured femur (the long thigh bone). This deficient practice affected 1 of 1 resident (Resident #1) reviewed for bed rails. Findings included:A review of the facility's Bed and Bedrail Safety Inspection Policy dated 11/2025 indicated that maintenance personnel and clinical staff were responsible for bed safety. The policy indicated that all beds must be inspected regularly to ensure compliance with safety standards. […]