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🔎 Woodhaven Health And Rehab Center

Inspection Results


Inspection Overview

Woodhaven Health And Rehab Center has been cited for a total of 45 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2025-03-14
Correction Date: 2025-04-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2025-03-14
Correction Date: 2025-04-11
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2025-03-14
Correction Date: 2025-04-11
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2025-01-29
Correction Date: 2025-02-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-06-13
Correction Date: 2024-07-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: F

Ensure the activities program is directed by a qualified professional.

Survey Date: 2024-06-13
Correction Date: 2024-07-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-04-19
Correction Date: 2024-05-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-04-19
Correction Date: 2024-05-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2024-03-08
Correction Date: 2024-03-27
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2024-02-19
Correction Date: 2024-03-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2024-02-19
Correction Date: 2024-03-15
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2024-02-19
Correction Date: 2024-03-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2024-02-19
Correction Date: 2024-03-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2024-02-19
Correction Date: 2024-03-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-02-19
Correction Date: 2024-03-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-12-13
Correction Date: 2024-01-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2023-12-13
Correction Date: 2024-01-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2023-12-13
Correction Date: 2024-01-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2023-12-13
Correction Date: 2024-01-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2023-10-24
Correction Date: 2023-10-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-09-14
Correction Date: 2023-10-25
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-07-07
Correction Date: 2023-08-03
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-07-07
Correction Date: 2023-08-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-07-07
Correction Date: 2023-08-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2023-07-07
Correction Date: 2023-08-03
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-02-16
Correction Date: 2023-03-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-02-16
Correction Date: 2023-03-20
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2022-08-30
Correction Date: 2022-10-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2022-08-30
Correction Date: 2022-10-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2022-08-30
Correction Date: 2022-10-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-06-04
Correction Date: 2022-07-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-06-04
Correction Date: 2022-07-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2021-11-15
Correction Date: 2021-12-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-08-25
Correction Date: 2021-10-05
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2021-08-25
Correction Date: 2021-10-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-08-25
Correction Date: 2021-10-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-08-25
Correction Date: 2021-10-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-08-25
Correction Date: 2021-10-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-02-26
Correction Date: 2021-03-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-07-11
Correction Date: 2019-08-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2019-07-11
Correction Date: 2019-08-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2019-07-11
Correction Date: 2019-08-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2019-07-11
Correction Date: 2019-08-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Survey Date: 2019-07-11
Correction Date: 2019-08-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2019-07-11
Correction Date: 2019-08-20
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**