Woodstock Valley Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF689May 23, 2024

  5. For Resident #61 (R61), the facility staff failed to assess the resident to safely leave the facility unsupervised in the community. The resident signed themselves out of the facility unsupervised on 15 occasions. R61 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1), unspecified dementia (2), and major depressive disorder (3). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/30/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented no wandering or behaviors observed. […]

• Immediate jeopardy, patternF740Oct 26, 2021

  Based on observation, staff interview, facility document review, clinical record review, and during the course of a complaint investigation, it was determined that the facility staff failed to provide behavioral health services such as conducting individualized assessments and person centered planning, related to residents who demonstrated or expressed suicidal ideation, for six of 41 residents in the survey sample, Resident #230, Resident #59, Resident #20, Resident #24, Resident #61 and Resident #13. On 8/25/21, Resident #230 expressed thoughts of self- injury documented on the MDS-Section D-Letter I., and was not further assessed by facility staff. Safety interventions and behavioral health services were not put in place. […]

• Immediate jeopardy, isolatedF689Sep 26, 2025

  Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision, monitoring, use of safety devices, and fully implement their smoking policy to ensure safety for two of 16 current residents, resident #10 (R10) and R11. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, isolated. Also, the facility staff failed to provide interventions for adequate supervision for one of 16 residents in the survey sample, Resident #7. The findings include:1. […]

• Actual harm, isolatedF600Sep 26, 2025

  Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 16 residents in the survey sample, Resident #2, was free from mental abuse resulting in psychosocial harm on 3/29/25. The findings include: For Resident #2 (R2) the facility staff failed to ensure the resident was free from mental and verbal abuse resulting in psychosocial harm when the facility staff threatened to have the resident sent out of the facility with a temporary detention order.The resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to: diabetes, obesity, high blood pressure, sleep terrors, insomnia, depressive disorder, anxiety disorder, osteoarthritis, post-traumatic stress disorder, and… […]

• Actual harm, isolatedF686May 23, 2024

  2. For Resident #85 (R85), the facility staff failed to initiate treatment for pressure injuries in a timely manner. R85 was admitted to the facility on [DATE]. A weekly skin integrity review dated 5/10/24 documented R85 presented with the following pressure injuries: -an unstageable pressure injury (1) on the right elbow. -an unstageable pressure injury on the coccyx. -an unstageable pressure injury on the right buttock. -a stage three pressure injury (1) on the left buttock. Further review of R85's clinical record revealed treatment for the right elbow, coccyx, and right buttock was not initiated until 5/11/24 and treatment for the left buttocks was not initiated until 5/15/24. […]