Wooldridge Place Nursing Center

In the surveyor’s words

From the most serious findings on record at Wooldridge Place Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 27, 2024

  Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 1 resident reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 15 minutes from 6:00 PM to 6:15 PM on 10/07/24 before a 3rd party called to notify the facility that Resident #1 was walking through a field adjacent to the facility. On 10/18/24 at 2:27 PM, an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF684Mar 30, 2024

  Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke. On [DATE], during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status. An IJ was identified on [DATE]. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on [DATE] at 7:18PM. […]

• Immediate jeopardy, isolatedF689Mar 30, 2024

  Based on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. The facility failed to ensure Resident #1 was adequately supervised while eating lunch. On [DATE], during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died . Resident #2 had a g-tube and was on NPO status. An IJ was identified on [DATE]. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on [DATE] at 7:18PM. […]

• No harm, potential for more than minimal, widespreadF842Oct 27, 2024

  Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 7 (Resident #2, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, and Resident #10) of 7 residents reviewed for clinical records. 1a. The facility failed to ensure that RN A documented Resident #2's blood pressure on the MAR (medication administration record) or in the vital signs when Resident #2 was given medication that would decrease her blood pressure in 5 of 16 opportunities reviewed for medication administration. 1b. […]

• No harm, potential for more than minimal, patternF695Feb 26, 2026

  Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 5 of 8 (Resident #82, Resident #21 , Resident #53 , Resident #32, and Resident #1) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #82's oxygen was administered at the correct setting of 3 liters per minute on 2/24/2026 as ordered by the physician. 2. The facility failed to ensure Resident #21's oxygen was administered at the correct setting of 2 liters per minute on 2/24/2026 as ordered by the physician. 3. […]