Woodbury Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Dec 2, 2025

  Based on interview and document review the facility failed to accurately transcribe a medication order correctly for Bumex (diuretic medication used to remove fluid) for 1 of 1 resident (R1) which resulted in an 18-pound (lb.) weight loss in 12 days, critical labs, vomiting and a hospitalization. In addition, the facility had two additional medication errors and failed to implement appropriate corrective actions to prevent the significant medication error for R1. The facility failure resulted in an immediate jeopardy (IJ) for R1.The IJ began on 11/07/25, when R1 was ordered Bumex (diuretic) 2 milligrams (mg) by mouth (po) QD (daily) x three days. The order was transcribed as Bumex 2 mg po TID (three times daily) with no stop date indicated. […]

• Immediate jeopardy, isolatedF684Mar 7, 2025

  Based on interview and document review, the facility failed to accurately assess and implement interventions to prevent hypoglycemia (low blood sugar) for 1 of 1 resident who was diabetic, had a blood sugar of 30 mg/dl (milligrams per deciliter; normal range is 80-130 mg/dl) and was unresponsive at dialysis. This resulted in an immediate jeopardy for R1 who was hospitalized with hypogylcemia. The IJ began on 3/1/25 at 5:00 p.m. when R1 was admitted to the facility with orders for insulin but lacked orders to check blood sugars. The facility did not implement standing orders or request orders to monitor R1's blood glucose levels, resulting in a severe drop in R1's blood sugar level and hospitalization . […]

• Immediate jeopardy, isolatedF689Jun 14, 2022

  Based on observation, interview, and document review, the facility failed to comprehensively assess fall risk and implement immediate fall interventions upon admission for 3 of 3 residents (R1, R2, R6) who had history of falling with major injury and failed to identify probable root causal factors to determine reason for fall for R2. R1 had a history of falls with fractures and was hospitalized with a head injury and hip pain after a fall within the facility. R2 had a history of falls with fractures and sustained a left hip fracture after a fall within the facility. R6 had a history of falls with fractures and was hospitalized for a lip laceration and facial bruising after a fall within the facility. These deficient practices resulted in immediate jeopardy (IJ) for R1, R2, and R6. […]

• Immediate jeopardy, isolatedF760Apr 21, 2021

  Based on interview and document review, the facility failed to administer insulin as prescribed by the physician for 1 of 1 resident (R1) reviewed for significant medication errors. This deficient practice resulted in an immediate jeopardy (IJ) for R1 when 90 units of short-acting insulin was erroneously injected into her abdomen, rather than being infused by an insulin pump. R1's blood sugar decreased, required emergency treatment, and was hospitalized . The IJ began on 4/16/21, when 90 units of insulin was injected into R1's abdomen rather than being infused via an insulin pump as directed by the physician. The director of nursing (DON) was notified of the IJ on 4/21/21, at 11:52 a.m. […]

• Immediate jeopardy, isolatedF600Mar 2, 2021

  Based on interview and document review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R1) reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R2 was found in R1's room touching her bare breasts and rubbing her thighs and the facility failed to provide immediate interventions to protect other residents. The facility immediately implemented appropriate interventions and corrected the deficient practice on 2/23/21 and is being issued as past noncompliance at Immediate Jeopardy (IJ). The IJ that began on 2/23/21, was corrected on 2/25/21, when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on 3/1/21, at 6:00 p.m. […]