Woodward Hills Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, patternF686Sep 28, 2022

  This citation pertains to intakes: MI 343, MI 649, MI 888, and MI 953. Based on observation, interview and record review, the facility failed to accurately assess, identify, and implement timely treatments and interventions for four (R24, R49, R50 and R122) of nine residents reviewed for pressure ulcers, resulting in the residents developing new and/or worsening pressure ulcers at the facility. Findings include: Review of multiple complaints reported to the State Agency included allegations that the facility failed to provide adequate and appropriate care to prevent and/or treat pressure ulcers. […]

• Actual harm, isolatedF689Jun 15, 2026

  This citation relates to Intake 3003663. Based on interview and record review, the facility failed to prevent an avoidable fall for one Resident (R903) of two residents reviewed for falls. This resulted in R903 sustaining a brain bleed, a fractured humerus, and a fractured femur, which required surgery and resulted in increased pain and a functional decline. Findings include:A complaint was received by the State Agency on 5/05/26, which revealed R903 was admitted to the facility during April 2026, had a prior traumatic brain injury, and wore a yellow bracelet showing they were at high risk for falls. […]

• Actual harm, isolatedF689Aug 5, 2025

  This citation is or complaint # 2573833Based on observations, interviews, and record reviews, the facility failed to follow a transfer status and fall protocol for one resident (R303) of three residents reviewed for falls, resulting in R303 obtaining a serious injury.Findings include:A record review revealed that on 7/8/25 R303 fell from bed while being changed and sustained a head injury and required a higher level of care. According to the incident report R303 was being changed by one certified Nursing assistant (CNA) and rolled out of bed and hit their head. R302 care planned as a two person assist for actives of daily living (ADLs). On 8/5/25 at 10:40 AM, R303 was interviewed, and asked did they remembered how they fell from the bed. […]

• Actual harm, isolatedF686Dec 4, 2024

  Based on observation, interview and record review the facility failed to prevent a facility acquired pressure ulcer for one (R59) out of four residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (full thickness skin and tissue loss with obscured wound bed) to the left heel and sepsis infection from tight fitting shoes. Findings include: On 12/2/24 at approximately 8:55 AM, R59 was observed lying in bed. The resident was alert but confused and not able to answer questions asked. The resident was not wearing shoes and had yellow skid socks on. A review of R59's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, type II diabetes and atrial fibrillation. […]

• Actual harm, isolatedF689Dec 4, 2024

  This citation pertains to Intake Number(s): MI00148148 and MI00147901 Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner, provide adequate supervision, and implement effective interventions to prevent falls for three (R7, R129, R59) of four residents reviewed for accidents, resulting in R7 falling and sustaining a right oblique humerus fracture (broken at an angle) and right fifth digit (finger) fracture which caused a decline with additional assistance needed (substantial to dependent). Findings include: R7 On 12/2/24 at 9:50 AM, R7 was observed seated in a wheelchair in their room. At that time, an interview was conducted with R7 regarding the care in the facility. […]