Woodcrest Post Acute: Missed Decline Sent Resident to Hospital - CA
The nurse, a Licensed Vocational Nurse identified in inspection records only as LVN 1, was working the 3 p.m. to 11 p.m. shift at Woodcrest Post Acute & Rehabilitation. She had discovered the decline while making medication rounds. She sent Resident 5 to an acute care hospital, though she told inspectors she was not sure of the exact time she was able to arrange the transfer.
What the records show is that the warning signs had been there since morning.
Resident 5 had eaten only half her breakfast that day and a quarter of her lunch. That level of decline, according to the facility's own director of nursing, constituted a change of condition. The director told inspectors that a physician should have been notified. Nobody called one.
The morning shift nurse, LVN 2, told inspectors during a phone interview on August 18 that she did not recall being told by a nursing assistant that Resident 5's food intake had dropped. She also said she did not recall the resident's family reporting that something seemed off. LVN 2 acknowledged that a physician should have been contacted if a resident showed a poor or declining food intake. She said she was not contacted about either.
When LVN 1 came on for the evening shift, there was no handoff. LVN 1 told inspectors that the morning shift nurse had not endorsed, meaning passed along, any information about changes with Resident 5 before the shift change. LVN 1 learned what she knew by walking into the room herself.
The director of nursing told inspectors that Resident 5 had become dependent in eating starting July 18, the day before she was found lethargic. That dependency was itself a decline from how she had presented when she was first admitted. The drop in food intake on July 19 came on top of that. Together, the director said, they should have triggered a call to the doctor.
The facility's own clinical protocol, revised in March 2023, described exactly this kind of situation. It directed nursing assistants to recognize and communicate subtle or significant changes, including decreases in food intake, to nurses. It directed nurses, before calling a physician about an acute change of condition, to collect the relevant details and report them. The chain was supposed to move in one direction: aide to nurse to doctor.
On July 19, it did not move at all until a nurse found a woman who could not respond to her own name.
Federal inspectors, who conducted the complaint inspection on August 12, 2025, cited the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification sits near the lower end of the federal severity scale, though it does not capture what Resident 5's family was doing in that room when LVN 1 arrived, or what the evening hours between a quarter-eaten lunch and a hospital transfer looked like for the woman in the bed.
LVN 2, who worked the morning shift, told inspectors she understood what should have happened. LVN 1, who worked the evening, said the same. The director of nursing said the same. The facility's written protocol said the same.
Resident 5 was sent to the hospital. The inspection report does not say what happened to her after that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodcrest Post Acute & Rehabilitation from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
WOODCREST POST ACUTE & REHABILITATION in RIVERSIDE, CA was cited for violations during a health inspection on August 12, 2025.
The nurse, a Licensed Vocational Nurse identified in inspection records only as LVN 1, was working the 3 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.