Woodville Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880May 25, 2022

  Based on interview and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (CNA A) reviewed for infection control: The facility failed to ensure CNA A, who had signs and symptoms related to COVID-19, was screened, tested , or prevented from working. CNA A called in sick on 5/21/22 due to a fever, headache, and vomiting. CNA A returned to work on 05/22/22 without a negative Covid-19 test and did not accurately answer the screening questions. An Immediate Jeopardy (IJ) was identified on 05/25/22 at 10:42 a.m. […]

• Immediate jeopardy, isolatedF580Aug 30, 2022

  Based on interview and record review, the facility failed to immediately consult with the physician when there was a need to alter a resident's treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 of 3 residents (CR #1) reviewed for refusal or treatments. The facility failed to notify and consult a physician for interventions regarding CR #1's discomfort with his [CONDITION(S)] and refusing to wear it during his first two nights in the facility. The second night CR #1 refused to wear his [CONDITION(S)] he had difficulty breathing and went into respiratory distress, 911 was called and after EMS intervention he went into [CONDITION(S)] and died in the facility. […]

• Immediate jeopardy, isolatedF695Aug 30, 2022

  Based on interview and record review the facility failed to ensure that a resident who needs respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care, consistent with professional standards of practice for one (CR #1) of 2 residents reviewed for respiratory care. The facility failed to notify CR #1's physician of his refusal to use the [CONDITION(S)] with his [CONDITION(S)] due to discomfort during his first two nights in the facility and were unable to implement possible physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to provide care to Resident #1 when he experienced difficulty breathing and decreased 02 saturation The facility failed to adequately assess and document CR #1's respiratory status after his [CONDITION(S)]… […]

• No harm, potential for more than minimal, widespreadF812May 3, 2023

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for one of one kitchen reviewed food service safety. * There were unlabeled, undated, and unsealed containers of food items stored in the refrigerator and dry goods storage. * The facility failed to ensure the DM did not handle uncovered food plates with his bare hands. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: 1. During an observation and interview with Dietary Manager (DM) (who identified foods) on [DATE] beginning at 9:37 a.m. […]

• No harm, potential for more than minimal, patternF842Jan 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were completely documented for 2 of 7 residents reviewed for complete medical records. (Residents #1 and #2) * The facility did not have any documentation of Resident #1 having elopement behaviors prior to her placement on the secured unit. * The facility did not have orders for Residents #1 and #2 to reside on the secured unit. This failure could place residents at risk of restraint and isolation. Findings included:1. Record review of a face sheet dated 01/17/26 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. […]