Woodbury Wellness Center Inc

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Jul 24, 2024

  Based on record review, Medical Director interview and staff interviews, the facility failed to notify the on-call provider when Resident #69 had a hypoglycemic episode (blood glucose less than 70 milligrams [mg] per deciliter [dL]). Normal blood glucose ranges from 70 - 100, according to the lab used by the facility. On the morning of 7/6/24, Resident #69's blood glucose (sugar) values were less than 45 mg/dL from 6:03 AM until 7:15 AM. Standing orders were not followed. The on-call provider was not notified of the values or about the resident's refusal of snacks and meal intake, and there was no documentation that Nurse #2 continued to monitor Resident #69's blood glucose (BG) after 7:15 AM. Long-acting insulin was administered by Nurse #2 at 9:00 AM without a documented blood glucose. […]

• Immediate jeopardy, isolatedF684Jul 24, 2024

  Based on record review and interviews with the Nurse Practitioner, Medical Director, and staff, the facility failed to manage and assess Resident #69's hypoglycemic episodes (blood glucose less than 70 milligrams [mg] per deciliter [dL]) on the mornings of 7/6/24 and 7/7/24. Normal blood glucose ranges from 70 - 100, according to the lab used by the facility. On the morning of 7/6/24, Resident #69's blood glucose (sugar) values were less than 45 mg/dL from 6:03 AM until 7:15 AM. Standing orders were not followed. The on-call provider was not notified of the values or about the resident's refusal of snacks and meal intake, and there was no documentation that Nurse #2 continued to monitor Resident #69's blood glucose (BG) after 7:15 AM. […]

• No harm, potential for more than minimal, widespreadF802Mar 2, 2023

  Based on observations, record review, and staff interviews, the facility failed to have sufficient staff to ensure timely meals. This had the potential to affect residents receiving food from the kitchen. Findings included: This tag is cross-referenced to F809. Based on observations, record review, and resident, family, and staff interviews, the facility failed to provide timely meals for 3 of the 3 meals observed. This had the potential to affect all residents receiving food from the kitchen. During observations in the kitchen on 2/27/23 at 10:15 AM and 3/1/23 at 12:00 PM, the Dietary Manager was observed in the cooking area. […]

• No harm, potential for more than minimal, widespreadF809Mar 2, 2023

  Based on observations, record review, and resident, family, and staff interviews, the facility failed to provide timely meals for 3 of the 3 meals observed. This had the potential to affect all residents receiving food from the kitchen. Findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses that included Parkinson's. His quarterly Minimum Data Set (MDS) dated [DATE] indicated a moderate cognitive impairment. During an interview on 2/27/23 at 11:00 AM, Resident #91 indicated that meals were frequently late and always served at different times. During an interview on 2/27/23 at 1:10 PM, a family member indicated she goes to the facility at lunch time to assist her mother. […]

• No harm, potential for more than minimal, widespreadF812Mar 2, 2023

  Based on observation, staff interviews, and record review, the facility failed to date and remove leftover food stored for use in one of one kitchen walk-in refrigerator and failed to discard leftover food in 2 of 3 (100 hall and 200 hall) nourishment room refrigerators. Findings included: 1. A tour was conducted on [DATE] at 10:00 AM with the Dietary Manager of the kitchen walk-in refrigerator. Observations were made of an opened bag of sliced Swiss cheese with no date and an opened bag of shredded cheese with no date. During an interview on [DATE] at 10:05 AM, the Dietary Manager indicated he was told he did not have to label cheese in the walk in. […]