Woodbine Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Woodbine Rehabilitation & Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Feb 24, 2022

  Based on observation, staff interview, and facility document review, the facility staff failed to ensure a clean environment for 3 of 40 residents in the survey sample (Resident #8, #62, and #143) whose rooms had a dried, light brown substance visible on multiple surfaces in their rooms. For Resident #8, #62, and #143, a dried, light brown substance was visible on multiple surfaces in their rooms. The findings included: 1. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Muscle Wasting and Atrophy, [CONDITION(S)], Essential Hypertension, [CONDITION(S)], Persistent Vegetative State, Protein-Calorie Malnutrition, [CONDITION(S)], Acute Kidney Failure, and Unstageable Pressure Ulcer of Sacral Region. […]

• No harm, potential for more than minimal, patternF684Feb 24, 2022

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow physician's orders for 6 of 40 residents in the survey sample, Residents #8, #92, #143, #180, and #275 . For Resident #8, the facility staff failed to monitor blood pressure prior to the administration of [MEDICATION(S)], a medication used to increase blood pressure, on 42 separate occasions. The resident's [MEDICATION(S)] was not administered on two (2) separate occasions without a documented reason. For Resident #92, the facility staff failed to monitor blood pressure and/or heart rate prior to the administration of [MEDICATION(S)], a medication used to treat high blood pressure and prevent chest pain, on 15 separate occasions. […]

• No harm, potential for more than minimal, patternF760Feb 24, 2022

  Based on staff interview and clinical record review the facility staff failed to ensure 5 out of 40 residents were free of significant medication errors, Resident #249, Resident #380, Resident #8, Resident #92 adn #275. For Resident #249, the facility staff held the resident's blood pressure medication, [MEDICATION(S)], when it should have been administered, and failed to obtain blood pressure prior to administering the blood pressure medication [MEDICATION(S)]. For Resident #380, the facility staff administered the resident's blood pressure medication, [MEDICATION(S)], when it should have been held, on three separate occasion. For Resident #8, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF842Feb 24, 2022

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 8 of 40 residents, Resident #279, #214, #236, #260, #62, #92, #143 and #180. For Resident #279, the nurse practitioner documented the resident expired in the ED (emergency department). When in fact the resident was pronounced and expired at the nursing facility. Resident #214 and Resident #236's clinical documentation failed to include evidence of the collection of laboratory samples for a C. auris test and for a CRE test. Resident #214's clinical documentation failed to include laboratory results for the C. […]

• No harm, potential for more than minimal, patternF880Feb 24, 2022

  Based on observations, interviews, facility document review, and in the course of a complaint investigation, the facility staff failed to implement infection control and prevention program processes, including actions to decrease the risks of transmission of COVID-19 and/or other infectious organisms, for three (3) of 40 residents (Resident #135, Resident #162, and Resident #226. The facility staff failed to ensure a staff member completed COVID-19 screening prior to starting their work shift. For Resident #135, the facility staff failed to implement facility COVID-19 quarantine processes for a readmitted resident who had not yet received the COVID-19 booster. […]