Woodbury Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Woodbury Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 16, 2022

  Based on facility documentation review, facility policy review, medical record review, and interview, the facility failed to ensure residents Advance Directive preferences were accurately reflected in the Electronic Medical Record (EMR) for 1 of 61 sampled residents (Resident #19) reviewed for Advance Directives, placing the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's deficient practice placed 1 resident (Resident #19) in Immediate Jeopardy and Substandard Quality of Care was identified. […]

• Actual harm, isolatedF689Apr 22, 2026

  Based on facility policy review, medical record review, facility investigation review, hospital document review, observation, and interview, the facility failed to implement a care plan intervention after a fall for 1 resident (Resident #7) of 3 residents reviewed for accidents. Resident #7 sustained a fall without injury on 5/15/2025 with a care plan intervention of non-skid strips on the floor at the bedside. The facility failed to implement the care plan intervention of non-skid strips on the floor at the bedside after the fall on 5/15/2025, and on 4/12/2026, Resident #7 sustained a second fall which resulted in a left hip fracture. […]

• No harm, potential for more than minimal, widespreadF812Nov 25, 2024

  Based on facility policy review, temperature log review, facility documentation review, observation, and interview, the facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine for residents in the facility which could affect all residents that receive ice. The facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by undated food items which could affect all residents that receive a meal tray. […]

• No harm, potential for more than minimal, widespreadF880Nov 25, 2024

  Based on facility policy review, observation, interview, and Center for Disease Control (CDC) recommendations, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to limit interactions with other residents when 1 (Resident #50) of 2 residents reviewed on contact precautions was allowed to interact outside of her room with other residents. The facility failed to properly clean a multi-use glucometer prior to and after use for 1 (Resident #286) of 19 residents that received finger-stick blood glucose monitoring. […]

• No harm, potential for more than minimal, isolatedF851Nov 25, 2024

  Based on facility policy review, Quarterly Payroll Based Journal (PBJ) review, and interview the facility failed to report accurate documentation for PBJ for Quarter 1 2024 (October 1 - December 31) and Quarter 2 2024 (January 1 - March 31). The findings include: The facility did not provide a copy of the Staffing Policy. Review of the Quarterly PBJ dated 10/1/2023 - 12/31/2023 revealed, .One Star Staffing Rating .Triggered .Triggered=[equals] Star Staffing Rating Equals 1 . Review of the Quarterly PBJ dated 1/1/2024 - 3/31/2024 revealed, .One Star Staffing Rating .Triggered .Triggered=[equals] Star Staffing Rating Equals 1 . During an interview on 11/20/2024 at 1:10 PM, the Director of Nursing (DON) was asked if the facility had been low on staff. […]