Woodbridge Health Campus

In the surveyor’s words

From the most serious findings on record at Woodbridge Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF689May 15, 2023

  Based on observation, interview and record review, the facility failed to ensure staff members followed a resident's plan of care for transfers which resulted in an injury during a transfer with a two-person manual assist and failed to follow post-fall interventions after one resident fell twice sustaining an injury for 2 of 3 residents reviewed for accidents. (Residents B and G) Resident B suffered a left tibial plateau fracture during an incorrect transfer. Resident G suffered a head laceration and two skin tears to her left upper extremity prior to the fall interventions being put into place. Findings include: 1. A document, titled Indiana State Department of Health Survey Report System, dated 5/15/23 at 11:15 a.m., indicated the incident occurred on 5/7/23 at 4:25 p.m. […]

• Actual harm, isolatedF760Feb 18, 2021

  Based on record review and interview, the facility failed to ensure a resident received the appropriate medication for 1 of 3 residents reviewed for dementia care (Resident B). This resulted in harm when the resident received 13 medications which had not been prescribed for her and resulted in a hospitalization for a drug overdose. Finding includes: The record for Resident B was reviewed on 2/18/2021 at 2:25 p.m. [DIAGNOSES REDACTED]. The facility documentation of the incident, dated 12/21/2020 at 7:40 a.m., indicated LPN 2 went to Resident B's room to administer medications. When LPN 2 returned to the medication cart, she realized she administered the wrong medications to the wrong resident. Vital signs were checked twice with the blood pressure results being 107/69 and 92/59. […]

• No harm, potential for more than minimal, patternF812Apr 26, 2024

  Based on observation and interview, the facility failed to ensurefood was handled to maintain food safety related to discarding and thawing. 52 of 52 residents residing in the facility ate food prepared in the kitchen. Findings include: During an Observation of the kitchen on 4/22/24 at 9:10 AM with Dietary Staff 3, on the bottom of the large rack located in the walk in cooler, there was two containers with of poultry stacked on top of each other. The top one was a mid-size container with a label: prep on 4/19/24 at 12:54 PM and use by 4/21/24 end of day. The bottom one was a large size container with a label: prep pan 4/19/24 at 12:54 PM and use by 4/21/24 end of day. At 9:12 AM right above the two large containers of poultry in a large silver sheet pan, was a package turkey. […]

• No harm, potential for more than minimal, isolatedF578Jun 3, 2025

  Based on interview and record review, the facility failed to ensure a resident's advanced directives were updated for 1 of 1 resident reviewed for advanced directives. (Resident 19) Finding Includes: The clinical record for Resident 19 was reviewed on [DATE] at 2:04 p.m. The diagnoses included, but were not limited to, right hip fracture, cognitive communication deficit, metabolic encephalopathy, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation. A current care plan, dated [DATE], indicated Resident 19 had advanced directives. The care plan was not specific on what his advanced directives included. […]

• No harm, potential for more than minimal, isolatedF644Jun 3, 2025

  Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when a resident received a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR. (Resident 46) Findings include: The clinical record for Resident 46 was reviewed on 6/2/25 at 11:30 a.m. The diagnoses included, but were not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, dementia with psychotic disturbance, psychotic disorder with delusions due to a known physiological condition, and depression. A PASARR level I, dated 9/11/24, indicated the resident had a diagnosis of anxiety disorder and depression and no level II was required. […]