Woodbury Wellness Center Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and Nurse Practitioner interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 3 residents (Resident #12) reviewed for respiratory care.The findings included:Resident #12 was admitted to the facility on [DATE]. Her diagnoses included asthma, and chronic obstructive pulmonary disease (COPD).Resident #12's care plan had a care focus area initiated on 7/11/25 that indicated that Resident #12 was at risk for altered respiratory status related to COPD and asthma. Interventions included administer oxygen per physician orders.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was cognitively intact. Her diagnoses included asthma and chronic obstructive pulmonary disease. She was coded for shortness of breath or trouble breathing with exertion, sitting at rest and when lying flat.A physician order dated 8/6/25 indicated provide oxygen at 2 liters/minute via nasal cannula for shortness of breath to maintain oxygen…

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 record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 22 residents reviewed for MDS accuracy (Resident #15). Findings including: Resident #151 was admitted to the facility on [DATE] with diagnoses including tracheostomy and personal history of malignant neoplasm of larynx. The 5-day MDS dated [DATE] revealed Resident #151 did not have a tracheostomy. The care plan dated 07/11/2023 had a focus of a long-term tracheostomy related to a history of larynx cancer. An interview with the Quality Assurance (QA) Nurse was conducted on 07/17/24 at 2:18 PM. She stated Resident #151 was receiving trach care and it should have been coded as receiving the care. It was a coding error due to an oversite. An interview with the Director of Nursing (DON) was conducted on 07/18/24 at 10:16 AM. The DON stated Resident #151 did have a trach and received trach care. It was a coding error and should have been coded correctly. An interview with the Administrator…

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 staff interviews and record review, the facility failed to maintain a complete and accurate medical record for 1 of 22 residents' medical records reviewed (Residents #69). The findings included: Resident #69 was readmitted to the facility on [DATE] with diagnoses including dementia and diabetes. A nurse's progress note written by Nurse #3 dated 7/7/2024 at 8:12 AM revealed Resident #69 had a BG reading of LO on the blood glucose meter. Nurse #3 gave 2 nutritional shakes to Resident #69, and her BG increased to 32mg/dL. Nurse #3 then gave glucagon and 2 more nutritional shakes. The oncoming Nurse #2 was made aware. The medical record included no evidence that verbal orders were transcribed for glucagon to be administered and long-acting insulin to be held on 7/7/24 due to severe hypoglycemia. There was also no documentation that the provider was notified or that Resident #69's blood glucose levels were monitored after 8:12 AM. Nurse #3 was interviewed on 7/16/24 at 3:35 PM. She revealed that if she…

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 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. He revealed the cook was out and he was working long days to cover the open positions. During an interview on 3/2/23 at 11:15 AM, the Dietary Manager revealed trays were served late due to being short staffed in the kitchen. He revealed the afternoon cook and two dietary aides were out the week of survey. The dietary manager revealed corporate had sent a regional chef to assist with short staffing and he had been there around 1 month. During an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Lunch trays were often late. Record review of the facility's meal times indicated that the 400 hall was to receive breakfast at 9:15 AM and lunch at 1:30 PM. An observation was made on 3/1/23 at 9:50 AM of breakfast trays delivered to 400 hall. An observation was made on 3/1/23 at 1:50 PM of lunch trays delivered to…

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, 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 2/27/23 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 2/27/23 at 10:05 AM, the Dietary Manager indicated he was told he did not have to label cheese in the walk in. During an interview on 3/1/23 at 11:40 AM, the regional Dietary Manager revealed opened cheese should be dated and thrown away by the discard date. During an interview on 3/1/23 at 3:40 PM, the Administrator revealed the Dietary Manager was responsible for monitoring the kitchen walk-in cooler. 2. Posted signage on the nourishment room refrigerator provided instruction for all items placed in the refrigerator to be labeled with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, the facility failed to honor a resident's preference for a shower for 1 of 32 reviewed for choices (Resident #4). Findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included a stroke. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #4 was cognitively intact. She was totally dependent for bathing. Resident did display behaviors of rejection of care. Resident #4 ' s MDS indicated choosing between a shower and a bed bath was very important to her. Record review of shower logs for Saturday, 2/25/23, indicated Resident #4 refused a bed bath. During an interview on 2/27/23 at 11:15 AM, Resident #4 indicated she did not receive her scheduled shower over the weekend. She indicated her Saturday Nurse Aide (NA) #1 offered a bed bath but she declined stating she wanted a shower. NA #1 said she was not able to give a shower. Resident #4 was unsure why NA #1 could not give her a shower. During an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately for the Preadmission Screening and Resident Review (PASRR) Level II for 2 of 2 residents (Resident #75 and Resident #79) reviewed for PASRR. Findings included: 1. Resident #75 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety, bipolar disorder, and major depression. Review of the PASRR level II referral notification (a determination letter that states if a resident is placed appropriately) dated 07/27/2021 revealed Resident #75 was placed appropriately. Review of the PASRR level I screen dated 7/27/2021 revealed a diagnosis of anxiety, bipolar disorder, and major depression. The annual Minimum Data Set (MDS) dated [DATE] had resident coded as cognitively intact and needed extensive assistance with most Activities of Daily Living (ADLs). The MDS was not coded for PASRR II for Resident #75 An interview with the Social Worker (SW) was conducted on 03/02/2023 at…

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 staff interview and record review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) for a resident with an active diagnosis of a serious mental illness for 2 of 4 residents reviewed for PASRR (Resident #5 and Resident #49). Findings included: 1.Resident #5 was originally admitted to the facility on [DATE] with diagnoses that included depressive disorder and anxiety disorder. Resident #5 medical record revealed on 11/03/2022 she had a new diagnosis of delusional disorder. Resident #5's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was not considered by the state to be a PASARR level II. During an interview on 03/01/2023 at 10:30 AM the Social Worker (SW) stated she was new at the facility, and she had not been aware of the responsibility of referring residents with a new psychiatric diagnosis to PASARR level II evaluation and for the new admission. She indicated moving forward she will make sure the residents who were diagnosed with new…

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.