Pennsylvania Department of Health
WOODHAVEN HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WOODHAVEN HEALTH & REHAB CENTER
Inspection Results For:

There are 214 surveys for this facility. Please select a date to view the survey results.

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WOODHAVEN HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an abbreviated, complaint survey completed on December 11, 2025, at Woodhaven Health &; Rehab Center identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR part 483, Subpart B Requirements for Long Term Care Facilities and 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, as they relate to the health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care and services to two of five residents (Resident R10 and R11).

Findings include:

Review of facility policy "Activities of Daily Living (ADLs), Supporting" dated 6/1/25, indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, Section G: Functional Abilities defined "dependent" as "Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity."

Review of the clinical record revealed Resident R10 was admitted to the facility on 10/29/25.

Review of the Minimum Data Set (MDSn - periodic assessment of resident care needs) dated 11/4/25, included diagnoses of hemiplegia, arthritis, and presence of a pressure ulcer. Review of Section GG: Functional Abilities indicated Resident R10 was totally dependent on staff for bed mobility (rolling left and right in bed) and transfers.

Review of Resident R10's plan of care for "Risk of Falls" initiated 10/30/25, included the interventions of side rails for positioning.

Review of Resident R10's plan of care for "Self-Care and Mobility Deficits" initiated 10/30/25, included the interventions assistance with Mobility: bed mobility (rolling left to right, sitting to lying and lying to sitting), transfers (sit-to-stand, bed-to-chair, toilet transfer), ambulation distances and use of stairs.

Review of a progress note dated 11/28/25, at 4:44 p.m. indicated, "Called into resident's room. Resident sitting on the floor beside her bed. LPN (licensed practical nurse) had been doing dressing change to her buttocks area and she was lying on her left side. LPN stated she "was near the edge and slid off." Resident stated she did not hit her head (witnessed by LPN), landed on her knees then she sat down. Resident was not on her knees when this Supervisor entered the room. Assessed her for injury. No open areas, no bruising, no swelling noted. Moving her upper and lower extremities at baseline. No hip deformity. Neuro at baseline. She denies pain or discomfort. VSS. Resident was lifted back to bed with assist of 3. Call to son. Note to MD. Will continue to monitor for changes."

Review of a witness statement dated 11/28/25, written by LPN Employee E1 stated, "I was packing and redressing [Resident R10's] sacrum pressure sore. She was leaning on her left side near the edge of the bed and slipped off onto the floor. She did not hit her head but landed on her knees. After being helped back onto her bed she claims to be ok and has no pain. Vitals were taken and were normal."

Review of a facility provided "Post Fall Huddle Form" dated 11/28/25, completed by Registered Nurse (RN) Employee E2 revealed the section of "Current interventions" was blank and did not document if Resident R10's side rails were in place. The section for the root cause was answered, "Resident too close to edge of bed."

During an interview on 12/12/25, at approximately3:15 p.m., the Nursing Home Administrator confirmed that the resident's ability to maintain her own position during care is part of bed mobility, and if one staff member cannot do all of the effort (proving wound care while maintaining the resident's position on her side in bed) as Resident R10 is dependent on staff, then two staff members must provide care.

Review of the clinical record revealed Resident R11 was initially admitted on 7/3/25, and readmitted to the facility on 9/10/25, and 10/7/25.

Review of the MDS dated 10/13/25, included diagnoses of subdural hemorrhage and dementia without behavioral disturbances. Review of Section E: Behaviors failed to reveal documentation of hallucinations, delusions, physical or verbal behaviors to others, behavioral symptoms not toward others, rejection of care, or wandering behaviors.

Review of Resident R11's facility diagnosis list failed to include diagnoses of agitation, anxiety, or behavioral disturbances.

Review of Resident R11's plan of care for "Altered Neurological Status" initiated 7/13/25, included the interventions monitor for behavioral changes.

Review of all progress notes from 10/1/25, through 12/6/25, failed to reveal documentation of incidences of behavioral disturbances, aggression, being physically inappropriate, or agitation.

Review of a progress note dated 12/5/25, at 5:43 p.m. indicated, "Resident confused and agitated since night shift. Reported to night RNS (RN Supervisor) to pass to dayshift to see if the doctor could order something to help resident rest. Throughout day shift resident yelling out, putting on the call bell. This nurse had entered room to attempt to comfort and help resident. Upon entering resident grabbed this nurse's wrist. Quickly redirected and asked resident what was wrong. removing bedding and throwing it on the floor. Asked this nurse to put in the laundry which this nurse did. Fluids given, poor appetite with meals. Continued to attempt to get OOB (out of bed). This nurse again redirected/educated that resident was in a nursing home, after resident stated. "I'm walking over to the police station". Spoke with ADON (Assistant Director of Nursing) supervisor after was 3pm, she stated she was going to see if the doctor left any new orders for resident. At 1700 (5:00 p.m.) CNA (nurse aide) alerted this nurse that resident fell OOB. Resident hit head above right eyebrow, right shoulder, right elbow, and left wrist skin tears observed. First aid performed by ADON." "Sent to [hospital] for evaluation, left with 2 EMT's via stretcher @ 1720 (5:20 p.m.)."

Review of the clinical record failed to reveal documentation that the doctor was contacted, or if unable to be contacted, and alternate provider was notified of behavioral disturbances (agitation, yelling out, grabbing staff, throwing linen on floor, and statements to leave) that were not normal behaviors for Resident R11.

Review of a facility submitted report dated 12/6/25, included the above progress note and an update on 12/8/25, of "Follow up: [Resident R11] has been increasingly confused since second admission on 10/7/2025. A subdural hematoma, that was inoperable.

Review of the point of care record for behaviors from 10/7/25, through 12/5/25, failed to reveal documentation of new behavioral disturbances, aggression, being physically inappropriate, or agitation since readmission on 10/7/25.

During an interview on 12/12/25, at approximately 3:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide treatment and services related to activities of daily living for two of five residents.

28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/07/2026

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under the state and federal laws.

Resident R10's care plans was updated to reflect the residents fall precautions.
Resident R11's care plan was updated to reflect the resident's behaviors and fall precautions.
To prevent this from occurring again the facility reviewed all residents with fall potential and complete a facility wide audit for residents with similar diagnosis, risks and care needs.
The Director of Nursing/designee will educate all licensed nursing staff on resident fall precautions and resident behaviors to ensure fall precautions are properly followed and appropriate interventions for behaviors utilized to prevent a fall.
To monitor and maintain ongoing compliance the Director of Nursing/designee will complete a weekly audits x4 and monthly x2 on appropriate fall precautions in care plans and any residents with increased behaviors.
Results will be taken to QAPI for review and revision as needed.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 01/07/2026

Regional Director of Clinical Services will educate the facility NHA, DON and scheduler on the nurse aide staffing ratios implemented on 07/01/2024.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage per regulation of nursing assistance.
To prevent this from happening again the NHA, DON and scheduler will meet five times a week to ensure the CNA ratios are maintained and discuss offering pick up bonuses, utilizing agency staff in the facility, weekly new hire orientations and reviewing wages to ensure we are competitive with other facilities.
To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to QAPI for review and revision as needed.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift and/or one LPN per 40 residents during the night shift on two of 21 days (11/28/25 and 11/29/25).

Findings include:

Review of the nursing schedules and census information for 10/27/25, through 11/8/25 and 11/23/25 through 11/29/25, revealed that the facility failed to meet the following:
11/28/25: Day shift required 34.88 hours of LPN care, facility provided 32.25.

11/29/25: Day shift required 34.88 hours of LPN care, facility provided 20.00.
During an interview on 12/12/25, at approximately 3:15 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one LPN per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the night shift for two of 21 days.

Plan of Correction - To be completed: 01/07/2026

Regional Director of Clinical Services will educate the facility Administrator, Director of Nursing and scheduler on the LPN staffing ratios implemented on 07/01/2023.
Facility Administration will ensure a minimum of one license practical nurse per 25 residents during day shift and 30 residents during the evening shift and 40 residents during the night shift.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage of License practical nurses per regulation.
To prevent this from happening again the facility Administrator, Director of Nursing and Scheduler will conduct a staffing meeting to review staffing ratios and discuss offering pick up bonuses, utilizing agency staff in the facility, weekly new hire orientations and reviewing wages to ensure we are competitive with other facilities. weekly times four weeks then monthly times two month.
To monitor and maintain ongoing compliance the Director of Nursing/designee will audit staffing weekly times four weeks then monthly times two months.
Results will be taken to QAPI for review and revision as needed

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on seven of 21 days (10/30/25, 11/4/25, 11/7/25, 11/23/25, 11/27/25, 11/28/25, and 11/29/25.

Findings include:

Review of the nursing schedules and census information for 10/27/25, through 11/8/25 and 11/23/25 through 11/29/25, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:

-10/30/25, Census 105. PPD 2.97.

-11/4/25, Census 106. PPD 2.94.

-11/7/25, Census 104. PPD 3.09.

-11/23/25, Census 112. PPD 3.14.

-11/27/25, Census 108. PPD 3.09.

-11/28/25, Census 109. PPD 3.03.

-11/29/25, Census 109. PPD 2.92.

During a facility electronic communication on 12/12/25, at 3:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on seven of 21 days.

Plan of Correction - To be completed: 01/07/2026

Regional Director of Clinical Services will educate the facility NHA, DON and scheduler on the total number hours of general nursing care provided in each 24-hour period and the minimum number of 3.2 hours of direct care for each resident.
Facility Administration will ensure the total number of hours of general nursing care provided for each 24-hour period when totaled will be a minimum of 3.2 hours of direct resident care for each resident.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage per regulation of general nursing care.
To prevent this from happening again the NHA, DON and scheduler will meet five times a week to ensure the general nursing care hours are maintained and discuss offering pick up bonuses, utilizing agency staff in the facility, weekly new hire orientations and reviewing wages to ensure we are competitive with other facilities.
To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to QAPI for review and revision as needed.

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