Woodside Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 16, 2025

  Based on observation, record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect each Residents' right to be free from abuse and neglect when they failed to accurately evaluate the risk for elopement and develop a individualized care plan to address wandering behaviors for Resident #53, and failed to immediately investigate an incident of staff to resident verbal abuse for Resident #5. Resident #53 was admitted to the facility on [DATE] and exhibited behaviors such as yelling out, combativeness and disrobing in the hallways. […]

• Immediate jeopardy, isolatedF689May 16, 2025

  Based on observation, record review, resident representative and staff interviews, the facility failed to ensure processes were in place to ensure the safety of cognitively impaired residents at risk for elopement. The facility failed to accurately assess the risk for elopement and adequately supervise to prevent elopement of 1 (Resident #53) of 1 cognitively impaired, mobile and confused resident with known wandering behavior. Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering. On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision. […]

• Immediate jeopardy, isolatedF835May 16, 2025

  Based on observation, record review and staff interviews, the facility administration failed to utilize its resources effectively to ensure processes were in place and implemented to prevent neglect and maintain the safety of cognitively impaired and confused residents to prevent unsafe wandering and elopement. Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering. On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision. […]

• Actual harm, isolatedF689Dec 19, 2022

  Based on observation, review of facility's policies and procedures, resident and staff interview, the facility failed to provide the necessary supervision and assistance with dining resulting in a burn from hot coffee for 1 (Resident #2) of 3 sampled residents. The findings included: The facility's clinical insight titled Hot Beverage safety dated April 2022 noted, Hot beverages such as coffee, tea, and hot chocolate are prepared and brewed at high temperatures to maximize flavor and quality. However, injuries may occur when skin comes in contact with hot liquids or steam. This may happen with accidental spills or splashes of hot food and beverages. […]

• Actual harm, isolatedF689Apr 4, 2022

  Based on observations, staff interviews, records review and facility policy review the facility failed to ensure reheated food and drink items are given to residents at an appropriate temperature for residents' safety which resulted in first and second degree [CONDITION(S)] for 1 (Resident #1) of 1 resident reviewed. The findings included: Facility policy titled, Food Temperatures at Point of Service, dated 11/2020 stated, Each patient receives, and facility provides: (1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and [CONDITION(S)]. […]