Woodhaven Health & Rehab: Heart Failure Care Failure - PA
The resident at Woodhaven Health & Rehab Center, identified in inspection records only as Resident R1, was showing signs of serious cardiac distress in late July. A nursing note from the morning of July 21, 2025, described her breathing as labored, with wheezing and crackling in both lungs. Her oxygen saturation had dropped to 90 percent even with supplemental oxygen running at three liters through a nasal cannula. She was confused. A nurse supervisor flagged it for the physician during morning rounds.
The doctor came that same morning. The note from that visit recorded concern about congestive heart failure, prompted in part by the daughter's call about her mother's legs.
Two days later, on July 22, a physician was told the resident had gained 13 pounds.
She had gained 23.
The weight records made that clear. Someone had passed the wrong number to the doctor, a 10-pound error in a situation where fluid accumulation was already the central clinical concern. By the following morning, July 23, the physician's note recorded a heart rate elevated into the 120s and fluid visible in the lower left lobe of the lung on a chest X-ray. The resident was started on an increased dose of Lasix, a diuretic used to push excess fluid out of the body.
The question the inspection report leaves sitting is how differently that July 23 visit might have looked if the physician had known on July 22 that the weight gain was not 13 pounds but 23.
Federal inspectors reviewed the records and interviewed staff during a complaint inspection completed September 3, 2025. When they sat down with the Nursing Home Administrator and the Director of Nursing on August 27, both confirmed it: the facility had failed to provide appropriate treatment and services related to heart failure for this resident. That confirmation came from the facility's own leadership, not from a disputed finding.
The deficiency was cited under F0684, which covers the standard that residents receive treatment and care in accordance with professional standards of practice. Inspectors rated the level of harm as minimal harm or potential for actual harm, the lower end of the federal harm scale, and noted that few residents were affected.
What the inspection report captures, in the clinical shorthand of nursing notes and physician visits, is a woman whose body was sending escalating signals across several days. Increased respirations. Accessory muscle use, meaning she was working harder than normal just to breathe. Bilateral wheezing and crackles. Oxygen saturation low enough to be concerning. Confusion. A heart rate that by July 23 had climbed into the 120s. And through that window, the number that mattered most, her weight, was transmitted to her physician with a 10-pound error.
The physician's notes suggest the doctor was engaged, making visits, ordering imaging, adjusting medication. The chest X-ray that revealed lung fluid was ordered. The Lasix dose was increased. But those responses came after the wrong weight had already been reported, and the inspection found that the facility's failure in the accuracy and completeness of what it communicated to the physician constituted a failure in her care.
The facility's plan of correction was not included in the inspection materials reviewed for this article.
What the records do show is a daughter who noticed the swelling in her mother's legs before the clinical team had fully reckoned with what was happening inside them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodhaven Health & Rehab Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
WOODHAVEN HEALTH & REHAB CENTER in MONROEVILLE, PA was cited for violations during a health inspection on September 3, 2025.
A nursing note from the morning of July 21, 2025, described her breathing as labored, with wheezing and crackling in both lungs.
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.