Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, for one of five residents reviewed (Resident 50), the facility failed to ensure a
change of condition was identified when Resident 5 had a decline in Activities of Daily Living (ADL)
requiring total assistance in eating on July 18 and 19, 2025, and the meal intake was 50% or below on July
19, 2025.This failure had the potential to contribute to a delay in the care and treatment to address
Resident 5's change of condition and affect the resident's overall health condition. Findings:On August 11,
2025, at 10:21 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding
quality of care issue.On August 12, 2025, Resident 5's record was reviewed. Resident 5's admission
Record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic
obstructive pulmonary disease (lung disease), diabetes mellitus (abnormal blood sugar) and heart failure.A
review of Resident 5's Progress Notes, documented by the physician, on July 17, 2025, indicated Resident
5 had the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS a resident assessment tool, dated July 19, 2025, indicated the following:-BIMS (Brief Interview of Mental
Status) score of 12 (cognitively intact); and-Required supervision or touching assistance in eating.A review
of Resident 5's care plan, dated July 16, 2025, indicated,- .Self care deficit related to inability to
independently perform ADL's.Legend.S=Supervision.Eating.S.;- .Altered Nutrition.Goal: will eat greater
than 75% .Interventions.Assist/feed resident.A review of Resident 5's Nutrition Amount Eaten
Documentation Survey Report, indicated the following amount eaten:- .July 17, 2025.7 am.100% .;- .July
17, 2025.12 pm.100% .;- .July 17, 2025.5 pm.100% .;- .July 18, 2025.7 am.75% .;- .July 18, 2025.12
pm.75% .;- .July 18, 2025.5 pm.100% .;- .July 19, 2025,.7 am.50% .; and .July 19, 2025.12 pm.25% .A
review of Resident 5's SBAR (Situation Background Assessment Record) Communication Form and
Progress Note, dated July 19, 2025, at 10:52 p.m., indicated, .the change in condition.Resident unable to
answer simple questions.unable to get words out.lethargic (a state of feeling tired, sluggish, and lacking
energy).started on July 19, 2025 at 5:00 pm.Resident noted to have reduced movement, reduced alertness,
cannot speak or get words out.resident unable to answer stroke (a medical emergency that occurs when
blood flow to the brain is interrupted).MD (physician) notified, ordered to send out for eval (evaluation).A
review of Resident 5's Order Summary Report, dated July 19, 2025, at 11:29 p.m., indicated, .Resident
sent out (name of general acute hospital).rule out Stroke.A review of Resident 5's MDS section GG,
indicated the following self-performance level in eating for the following dates:- July 17, 2025.8:21
am.independent.;- July 18, 2025.5:07 pm.set up assistance.;- July 19, 2025.12:20 pm.dependent.; andJuly 19, 2025.2:41 pm.dependent.On August 12, 2025, at 4:15 p.m., during an interview conducted with
Certified Nursing Assistant (CNA) 1, she stated she was assigned to Resident 5 on July 19, 2025, 3 p.m. to
11 p.m. CNA 1 stated resident 5 was quiet, and not talkative, and had family visiting that evening. CNA 1
stated she went on her lunch break and returned around 7:30 p.m., and the paramedics were there to
Residents Affected - Few
(continued on next page)
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
Page 1 of 2
Event ID:
055474
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055474
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Woodcrest Post Acute & Rehabilitation
8133 Magnolia Avenue
Riverside, CA 92504
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 .
Event ID:
Facility ID:
055474
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the August 12, 2025 survey of WOODCREST POST ACUTE & REHABILITATION?
This was a inspection survey of WOODCREST POST ACUTE & REHABILITATION on August 12, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WOODCREST POST ACUTE & REHABILITATION on August 12, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.