Woodcrest Post Acute & Rehabilitation
WOODCREST POST ACUTE & REHABILITATION in RIVERSIDE, CA — inspection on August 12, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
transfer her to the hospital.On August 12, 2025, at 5:30 p.m., a concurrent interview and record review of Resident 5's record was conducted with the Director of Nursing (DON).
The DON stated when they notice a change of condition, the CNA should report it to the charge nurse.
The DON stated if there is a change of condition from day shift it should be endorsed to the following shift.
The DON stated Resident 5 had a decrease in meal intake or meal percentage on July 19, 2025, starting at breakfast meal at 50% and 25%, respectively for breakfast and lunch.the DON stated Resident 5 was dependent in eating, started on July 18, 2025, which was a decline when she was initially admitted on [DATE].
The DON stated the decrease in Resident 5's food intake and decline in ADL need in eating would be considered a change of condition and the doctor should have been notified.On August 18, 2025, at 12:32 p.m., during a phone interview conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Licensed Nurse (LN) assigned to Resident 5 on July 19, 2025, from 3 p.m. to 11 p.m. LVN 1 stated there was no endorsement from the morning shift LN of any changes with Resident 5. LVN 1 stated when she was passing the medications and reached Resident 5's room, the resident was observed to be lethargic. LVN 1 stated the vital signs were stable, but Resident 5 was not able to answer questions. LVN 1 stated she verified with the family member present at bedside if that was normal for the resident, and the family member stated that was not normal for the resident. LVN 1 stated she was not sure of the time she was able to send out Resident 5 to the acute hospital. LVN 1 stated the physician should have been notified when Resident 5 had a decrease in meal intake as this was a change of condition. On August 18, 2025, at 4:55 p.m., during a phone interview with LVN 2, LVN 2 stated she was the LN assigned to the resident the morning shift of July 19, 2025. LVN 2 stated she did not recall the CAN notifying her of Resident 5's decrease in food intake.
LVN 2 stated she did not recall Resident 5's family member reporting to her that Resident 5 was not her usual self. LVN 2 stated the physician should have been notified if the resident had a poor food intake or a decrease from previous meals. A review of the facility's policy and procedure titled, Acute Condition Changes- Clinical Protocol, revised date March 2023, indicated, .Direct care staff .including nursing assistants .recognizing subtle .significant changes .decrease in food intake .how to communicate .to the nurse . and, before contacting a physician .with an acute change of condition .nursing staff .collect pertinent details .to report to the physician .
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