Woods Health Services
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow its own Unusual Occurrence Reporting policy, which requires that unexpected resident deaths be reported to the State Licensing Agency within 24 hours.This failure resulted in a delay of state regulatory notification, which has the potential to delay timely oversight, review, and investigation of resident safety incidents.Findings: During a review of Resident 1's admission
Record (AR), the facility admitted Resident 1 on [DATE REDACTED], with diagnoses including pneumonia (a lung infection), and sepsis (a life-threatening complication of an infection). During a review of Resident 1's History and Physical (H&P), dated [DATE REDACTED], the H&P indicated Resident 1 had the mental capacity to make medical decisions. During a review of Resident 1's Nurses' Note, dated [DATE REDACTED], the Nurses' Note indicated Resident 1 died on [DATE REDACTED]. During an interview on [DATE REDACTED] at 1:30PM with the Administrator, the Administrator stated the resident's death was considered an unusual occurrence because it was not expected and acknowledged the report was submitted past the 24-hour requirement. During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting Policy, the policy stated: All unusual occurrences, including unexpected resident deaths, must be reported to CDPH (State Licensing Agency) within 24 hours of identification.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
WOODS HEALTH SERVICES in LA VERNE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LA VERNE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WOODS HEALTH SERVICES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.