Woodbridge Care Center and Rehab

In the surveyor’s words

From the most serious findings on record at Woodbridge Care Center and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Aug 6, 2025

  Based on observations, interviews, medical record review, and facility policy review, the facility failed to ensure the safe and secure storage of all medications and biologicals, including a Schedule II controlled substance for one resident (#78), in one of one medication room, and in four carts (100 front, 100 back, 200 front and 200 back) out of four treatment carts. Findings included: 1. On 8/3/25 at, starting at 8:50 a.m., during a brief initial tour of the facility, observations were made which revealed four out of four treatment carts left unlocked and unattended as follows: 100 hall front revealed a treatment cart marked WCC ST 1 FRONT TX CART which was observed to be unlocked and unattended at 8:59 a.m. Photographic evidence was obtained at 9:00 a.m. […]

• No harm, potential for more than minimal, patternF584Aug 6, 2025

  Based on observations, interviews and record review, the facility failed to ensure resident spaces were maintained in a clean and sanitary manner related to community shower room equipment in 2 of 2 shower rooms and in five resident rooms (222, 225, 128, 226 and 228) in two halls (100 and 200) of four halls observed.Findings included: 1. On 8/3/2025 at 11:00 a.m., 8/5/2025 at 7:45 a.m., 2:00 p.m. and on 8/6/2025 at 8:45 a.m. tours of the facility revealed the following: Upon entering the 200-unit community shower room, there were multiple shower stalls and with one containing a plastic shower bed device. This device is used for residents who lay flat on their back when receiving showers. […]

• No harm, potential for more than minimal, patternF759Aug 6, 2025

  Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was not 5% or greater during two medication administration opportunities out of 27, resulting in a medication error rate of 7.41%. Findings included: While observing Staff G, Registered Nurse (RN) during medication pass on 8/4/25, starting at 6:10 a.m., she was observed to prepare medications for Resident #58. One of the medications observed to be prepared was Divalproex Sodium Capsule Sprinkle 125mg (milligrams): Give 5 capsules by mouth every 8 hours for mood disorder. Staff G was observed to remove one capsule from the pill card and add the contents of the capsule to a small cup with apple sauce. She was observed to pour the other medications as ordered. […]

• No harm, potential for more than minimal, patternF760Aug 6, 2025

  Based on interviews, medical record review, and facility policy review the facility failed to ensure three residents (#10, #113, #114) out of 46 residents reviewed for medications were free from any significant medication errors.Findings included: 1. A record review of Resident #10’s admission Record showed an original admit date of 9/12/2024 with a readmit date of 7/12/2025 and the following diagnoses to include but not limited to essential hypertension, end stage renal disease dependent on dialysis and paroxysmal atrial fibrillation. […]

• No harm, potential for more than minimal, patternF812Aug 6, 2025

  Based on observations, interviews and facility records review, the facility failed to ensure the kitchen implemented safe defrosting methods of raw meat in one refrigerator walk in units of one reviewed. Findings included: Upon entering the Walk -in refrigerator unit on 8/3/2025 at 10:15 a.m., an observation was made of two sides of what appeared to be multi shelving. The back of the unit had a door that lead into a separate walk in freezer unit. Further observations revealed the walk in refrigerator was well stocked with food items. However, the right side of the walk in refrigerator unit revealed a multi tiered shelving system. The third shelf up from the ground, revealed a very large metal tray that contained two long plastic sleeves raw ground meat. […]