Woodbridge Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Interventions included, but were not limited to, advanced directives reviewed quarterly and as needed, code status as ordered, and honor durable POA's (Power of Attorney) decision. A current physician's order in Resident 19's electronic medical record, dated [DATE], indicated the resident was to be a full code. An out of hospital DNR form, dated [DATE] and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. A physician's order, dated 9/14/24, indicated quetiapine (an antipsychotic medication) 25 mg (milligram) twice a day related to a psychotic disorder with delusions due to a known physiological condition. The diagnosis of psychotic disorder with delusions due to a known physiological condition was added on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure daily weights were obtained as ordered and to ensure the physician was notified of weight changes as ordered for 2 of 2 residents reviewed for quality of care. (Resident 9 and 10) Findings include: 1. During an observation, on 5/28/25 at 11:04 a.m., Resident 9 was lying in bed and had audible wheezes. The clinical record for Resident 9 was reviewed on 5/28/25 at 1:30 p.m. The diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disorder, shortness of breath, acute kidney failure, hypertensive, and type 2 diabetes mellitus. A care plan, dated 3/26/25, indicated the resident had congestive heart failure and had the potential for complications. The interventions included, but were not limited to, obtain weights as ordered. A physician's order, dated 5/29/25, indicated to weigh the resident daily and notify the physician of a weight gain of 2 pounds or greater in one day, or for a plus or minus of 5 pounds in one week. A progress note, dated 5/30/25 at 6:56…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were prescribed as ordered to prevent significant medication errors for 1 of 1 resident reviewed for medication errors. (Resident 202) Findings include: The clinical record for Resident 202 was reviewed on 5/28/25 at 2:40 p.m. The diagnoses included, but were not limited to, a history of a deep vein thrombosis (a blood clot in a deep vein), peripheral vascular disease, hyperlipidemia, anemia, hypertension. Resident 202 was admitted to the facility from the hospital on 5/23/25. An admission observation and data collection form, dated 5/23/25, indicated that the resident would be free from complications and adverse side effects from any medications and administer anticoagulant medications as ordered. A hospital discharge note, dated 5/23/25, indicated Resident 202 was to continue taking the medication Eliquis (an anticoagulant or a blood thinner used to prevent and treat blood clots in various cardiovascular conditions) twice a day for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. underneath the package turkey there was a reddish, brown liquid. The turkey nor the pan was dated to indicate when the thurkey had been thawed At 9:15 AM, on the shelf there was a large clear bag with 2 pizza doughs inside. The prepared date indicated 4/12/24 and use by 4/19/24. At 9:17 AM, on the shelf there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure nonpharmacological interventions were implemented prior to administering a duplicate antianxiety medication, to document potential medication side effects and to ensure a duplicate antianxiety medication had a clinical rationale for the continued use of the medication for 1 of 3 residents reviewed for unnecessary medication. (Resident C) Finding includes: During an interview, on 1/18/24 at 12:22 p.m., an anonymous family member indicated, on 1/7/24 after 12:00 p.m., Resident C was scared, acting differently, and was not able to form words. The resident was able to talk just fine a day later and could not remember the previous day. The staff were aware of the resident not being able to form words and acting differently than usual when the family talked to the staff on 1/7/24 and on 1/8/24. The record for Resident C was reviewed on 1/18/24 at 11:35 a.m. Diagnoses included, but were not limited to, malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, anxiety disorder, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for a resident who was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 1/23/23 at 3:52 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbances, Alzheimer's disease with late onset and major depressive disorder. A PASARR Level I screen, dated 5/9/22, indicated the resident's mental health condition was anxiety. The resident had a diagnosis of dementia and had not received any mental health services in the past. The medication used for the anxiety was Ativan (a benzodiazepine used to treat anxiety). The Level I screen indicated there was no evidence of a serious behavioral health condition and if changes occurred or new information refuted the findings, a new screen must be submitted. A physician's order, dated 11/7/22, indicated to give Zyprexa Zydis (an antipsychotic in orally disintegrating tablets) 7.5 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to assess for edema and notify the physician of a significant weight gain for 1 of 6 residents reviewed for quality of care. (Resident 155) Finding includes: During a wound care observation, with RN 3 on 1/24/23 at 3:11 p.m., Resident 155's legs were elevated on a pillow and appeared swollen. RN 3 indicated the resident had edema off and on in the past. The record for Resident 155 was reviewed on 1/20/23 at 3:16 p.m. Diagnoses included, but were not limited to, dementia unspecified severity, depressive disorder, and hypertension. A physician's order, dated 1/4/23, indicated the resident was to be weighed every Monday between 6:00 a.m., and 10:00 a.m. A care plan, dated 1/11/23, indicated the resident was at risk for malnutrition due to inadequate nutrients. The interventions included, but were not limited to, assist with meals, and obtain weights as ordered. The resident had the following weights: a. On 1/4/23, the weight was 163.8 pounds. b. On 1/9/23, the weight was 168.0 pounds. c. On 1/16/23, the weight was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the consultant pharmacist made recommendations for irregularities in diagnoses and medications prescribed for 1 of 2 residents reviewed for unnecessary psychotropic medications. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 1/23/22 at 3:52 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, Alzheimer's disease with late onset, restlessness and agitation, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder. A physician's order, dated 11/7/22 through 11/29/22, indicated to give lithium carbonate (used to treat bipolar disorder) 300 mg (milligram) once a day for unspecified dementia with behavioral disturbance. A physician's order, dated 11/29/22 through 12/2/22, indicated to give lithium carbonate 300 mg once a day on Sundays, Tuesdays, Wednesdays, Fridays, and Saturdays for unspecified dementia with behavioral disturbance. A physician's order, dated 11/8/22, indicated to give Zyprexa (an antipsychotic not orally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a physician's order for antibiotics was followed for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Finding includes: The record for Resident 19 was reviewed on 1/23/23 at 10:37 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, type 2 diabetes mellitus, and Parkinson's disease. An emergency department note, dated 10/26/22, indicated the resident had redness and swelling to the right lower leg. The assessment/plan indicated cephalexin (an antibiotic) 500 mg (milligram) every 12 hours for 20 doses and doxycycline (an antibiotic) 100 mg twice daily for 20 doses. A physician's order, dated 10/27/22 through 11/5/22, indicated to give cephalexin 500 mg every 12 hours for cellulitis. A physician's order, dated 10/27/22 through 11/5/22, indicated to give doxycycline 100 mg twice daily for cellulitis. A physician's clinic note, dated 10/27/22, indicated the resident was seen in the nursing home by the physician. The resident was seen in the emergency room for cellulitis. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident with dementia had an appropriate diagnosis for the use of an antipsychotic medication and a mood stabilizing medication and to ensure recommendations for parameters of laboratory levels were followed for 1 of 2 residents reviewed for unnecessary psychotropic medications. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 1/23/22 at 3:52 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance, Alzheimer's disease with late onset, restlessness and agitation, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder. A discharge summary from the inpatient psychiatric facility, dated 11/7/22, indicated the resident was admitted to the psychiatric facility, on 10/23/22, due to increased behaviors of physical aggression over a 72-hour time period. The resident was prescribed Zyprexa for dementia with behaviors and lithium for dementia with behaviors. The goal was to keep the lithium level less than 0.6 due to the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.