Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodbridge Care Center And Rehab during CMS and state inspections, most recent first.
Unsecured medication storage and controlled substance handling: Multiple treatment carts were observed unlocked and unattended, a medication room was left propped open with unlocked cabinets accessible, and a nurse left a pill cup with four pills unattended on top of a cart while administering meds to other residents. A white tablet identified as methylphenidate, a controlled drug prescribed for a resident with ADHD and narcolepsy, was also found on the floor in a shared room/bathroom area, and staff could not confirm when it had been dropped or whether a dose was missing.
A facility failed to keep shower equipment and several resident rooms clean and sanitary. Community shower chairs and a shower bed device had visible biogrowth near wheel castors and fittings, while multiple resident bathrooms and rooms had dirt, food, spills, urine, debris, and dirty toilet surfaces. The HSKP Supervisor said rooms were expected to be cleaned during the shift, but completed assignment sheets were not available for review, and no housekeeping/equipment maintenance policy was provided.
Medication Error Rate Exceeded 5 Percent: An RN made two medication administration errors during a med pass observation, resulting in a 7.41% error rate. She gave only one capsule of an ordered 5-capsule divalproex dose, then signed the MAR as if the full dose had been administered, and she also signed a dextromethorphan dose as given even though it was not available and had not been administered.
Medication Administration Outside Ordered BP Parameters: The facility failed to ensure three residents were free from significant med errors when ordered BP parameters were not followed during med administration. One resident received Metoprolol outside hold parameters and had entries with no documentation, while two residents received Midodrine despite BP readings above the ordered limits. The DON and physicians confirmed the meds should have been held based on the orders.
Unsafe Defrosting and Storage of Raw Meat: A cook was observed placing uncovered raw ground meat to defrost on a tray above ready-to-eat ham and cheese in the walk-in refrigerator, with blood visible on the tray. The cook confirmed raw meat should not be stored above ready-to-eat foods, and the DON stated staff had last received food storage/defrosting training earlier in the year, but no specific policy or training documentation was available for review.
Failure to preserve dignity occurred when a cognitively intact resident was repeatedly sent to dialysis without appropriate clothing, including in a hospital gown or only a T-shirt, brief, and socks with no pants or shorts. The resident stated he wanted to wear regular clothes and found it embarrassing to go out in public dressed that way. A dialysis RN confirmed the resident had arrived from the facility without clothes on multiple treatments, while the care plan was updated to reflect a gown preference without speaking with the resident.
Failure to honor a resident’s food and utensil preferences. A cognitively intact resident with a lung transplant, immunodeficiency, and other chronic conditions said he had repeatedly asked for plastic-wrapped utensils, food opened because of his immunocompromised status, and flavored liquids to take his anti-rejection medication. Observations showed wet utensils, a meal tray that did not match his menu choices, and food items he said he could not eat as served. Staff acknowledged knowing some of his requests but did not communicate them to the kitchen or nurse, and no grievance was documented.
The facility did not keep the daily nursing staffing form updated with the current date. Surveyors observed the posted staffing form showing an old date, and the Staffing Coordinator said the form is normally completed at midnight and checked each morning, but she did not notice the outdated date. The facility policy required daily posting of nurse staffing data and inclusion of the current date.
Unsecured medication storage and controlled substance handling
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments and that controlled substances were separately locked. During observations on the 100 and 200 halls, four treatment carts were found unlocked and unattended, with unsecured topical medications and other items visible in the top drawers. The medication room on the 100 hall was also observed with its door propped open and unattended, and the cabinets used to store bottled medication tablets were unlocked and accessible. Staff observations showed that the unsecured medication storage conditions persisted over time. The assistant director of nursing stated the treatment cart should have been locked and that the medication room door should not have been propped open and should always be closed and locked. The director of nursing stated she was unaware the medication room had been observed propped open with unlocked cabinets for approximately 45 to 55 minutes. On another observation, a nurse left a pill cup containing four pills on top of a medication cart while she went to administer medications to other residents, and the cup remained unattended on the cart during later checks. The report also identified a controlled substance storage issue involving methylphenidate for a resident with diagnoses including ADHD, narcolepsy without cataplexy, major depressive disorder, and anxiety disorder. A white tablet marked "K102" was found on the floor in a shared room/bathroom area, and staff identified it as methylphenidate prescribed for the resident. Staff could not confirm whether the tablet had been missed from the morning or midday dose or whether it was from the prior day, although the MAR showed the doses as administered. The facility policy stated that medications and biologicals must be stored in locked compartments and that Schedule II-V controlled substances must be separately locked in permanently affixed compartments.
Unsanitary shower equipment and resident rooms
Penalty
Summary
The facility failed to maintain resident spaces in a clean and sanitary manner, including community shower room equipment and multiple resident rooms. In the 200-unit community shower room, a plastic shower bed device used for residents who lie flat during showers had heavy pink and black biogrowth on the undercarriage, wheel castors, and white plastic tube fitting areas. A plastic shower chair in the same room also had black and pink biogrowth on three of four plastic tube fittings near the wheel castors. In the 100-unit community shower room, two plastic shower chairs had black and pink biogrowth on two of the four legs near the wheel castors, and one chair had heavy black biogrowth along the edge of the tray guide under the blue plastic seat. In one resident room, the walls, floor, and area under the bed had several pieces of food, and there were liquid spills on the bed, bedside table, floor, and walls. The bathroom toilet seat had spots of dark brownish liquid, the toilet bowl contained dark brown liquid, and the bathroom walls and floor were dirty. The bedside table held three empty Styrofoam cups, the room and bathroom did not have a trash can, and the room was warm with the air conditioner set to heat. In another room, after housekeeping was observed cleaning, the floors and walls remained dirty, and the resident did not allow observation of the bathroom. Additional observations in other resident bathrooms showed a toilet tank lid and outside tank smeared with a dark brown substance, dust and debris around the toilet base, wet washcloths clumped behind a sink faucet, urine and multiple wads of toilet paper in a toilet, and particles and small debris scattered on the floor. One resident stated the bathroom had been like that for a while. A shared bathroom between two rooms had a wet washcloth draped over the sink and an odor of damp towels, mustiness, and urine. The Housekeeping Supervisor stated housekeeping was expected to clean all rooms during the shift, but no completed assignment sheets were available for one date reviewed, and the facility did not provide a policy on housekeeping and equipment maintenance expectations.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with two medication administration errors identified during 27 observed opportunities for a rate of 7.41%. During a medication pass observation, an RN prepared Divalproex Sodium Capsule Sprinkle 125 mg ordered as 5 capsules by mouth every 8 hours for mood disorder, but she removed only one capsule from the pill card, emptied its contents into applesauce, administered the medications, returned to the cart, and signed the MAR as if the full dose had been given. When questioned, she acknowledged that she had only given one capsule and needed to give the rest of the dose. During the same observation, the RN stated she could not locate the ordered Dextromethorphan capsule, 15 mg by mouth every 12 hours, yet after verbally confirming she had completed the resident’s medication pass, the MAR showed the medication as administered. The unit manager later stated the medication should not have been signed as given if it had not been administered and told the RN that when a medication is not given, the doctor should be notified and the medication should be signed as not available. The facility policy required medications to be administered as prescribed and directed staff to use the correct code when a drug is withheld, refused, or given at a time other than scheduled.
Medication Administration Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for three residents reviewed for medication administration. The deficiency involved medications being administered outside of ordered blood pressure parameters, as well as one resident receiving Metoprolol when the medication should have been held based on the physician’s order. The report states that the facility also had instances where medication administration was documented with no entry for Resident #10 during leave of absence periods. Resident #10 had diagnoses including essential hypertension, end stage renal disease dependent on dialysis, and paroxysmal atrial fibrillation. The physician ordered Metoprolol 25 mg twice daily with instructions to hold for BP less than 130/90 or HR less than 65. Review of the July and August 2025 MARs showed multiple administrations outside those parameters, including 14 administrations out of 37 opportunities in July and 3 administrations out of 9 opportunities in August, along with entries with no documentation. Staff I, RN/UM, stated the medication should not have been given based on the physician orders, and the DON stated the medication should have been held and the physician notified. The resident’s primary physician later stated he had been contacted and readjusted the parameters. Resident #113 had an order for Midodrine 5 mg every 8 hours for hypotension with instructions to hold for BP greater than 120/90. Review of the MAR showed doses signed off as administered when the documented BP was above the ordered limit in June, July, and August 2025. The physician confirmed the medication should not be given if the BP was over 120/90 and stated that giving it outside parameters could cause the blood pressure to go higher on rare occasions. Resident #114 had an order for Midodrine 10 mg every 8 hours for hypotension with instructions to hold for BP greater than 110/90. Review of the MAR showed multiple doses signed off as administered when the documented BP exceeded the ordered limit in June, July, and August 2025. During interview, Staff G, RN, acknowledged giving the medication despite the BP reading and stated, "I made a mistake." The DON stated staff are educated to look for parameters during medication passes, and the physician stated the medication should be held when the BP is higher than the parameter.
Unsafe Defrosting and Storage of Raw Meat
Penalty
Summary
The facility failed to ensure safe defrosting and storage of raw meat in the walk-in refrigerator. During an observation on 8/3/2025 at 10:15 a.m., two long plastic sleeves of raw ground meat were found uncovered and left to defrost on a large metal tray on the third shelf of the walk-in refrigerator. Several small pools of blood were visible on the tray. Directly below that tray was a covered metal container holding pre-cooked, ready-to-eat food items, including thick ham slices and cheese slices. At 10:18 a.m., the chef/cook confirmed that raw ground meat should not be placed above ready-to-eat foods while defrosting. He stated he had been moving food items and had just placed the tray there for a short time, although he had not been observed in the walk-in refrigerator during the kitchen tour and had come into the kitchen from outside at approximately 10:08 a.m. The dietary manager later stated staff had last received training on food storage and defrosting techniques in January 2025, but no copies or evidence of that training were provided, and no specific food handling, storage, or defrosting policy and procedure was available for review.
Failure to Preserve Resident Dignity During Dialysis Transport
Penalty
Summary
The facility failed to promote and maintain dignity for one resident who was alert, oriented, and able to make decisions independently. The resident was admitted without clothing and stated he had no clothes in his room. He reported that he had to go to dialysis in a hospital gown and did not like doing so, and he specifically said he wanted to wear a shirt and pants when leaving for dialysis because he did not feel he should be going out in just a gown. On multiple observations, the resident was seen leaving for or returning from dialysis without appropriate clothing. He was observed in a hospital gown, then later in a T-shirt and black shorts, and on another occasion returned from dialysis wearing only a T-shirt, a brief, and socks with no shorts or pants. The resident stated he did not know why he had shorts one day but not the next, and his closet contained only a folded hospital gown, adult briefs, and empty drawers. A dialysis center RN confirmed the resident had come to dialysis from the facility with no clothes on the prior treatments, including one day in only a hospital gown, a brief, and socks, and another day in a T-shirt, a brief, and socks without pants or shorts. Record review showed the resident’s care plan identified him as cognitively intact and able to make decisions independently, with interventions to allow him to make decisions regarding daily cares. However, the MDS RN stated she updated the care plan to reflect a preference to wear a hospital gown to dialysis without speaking with the resident, and the social services assistant stated residents without clothing are normally helped with donated clothing or ordered clothing and would be dressed appropriately for outside appointments unless they refused or preferred a gown. The resident later stated it was embarrassing to go to dialysis with no clothes and just a brief and hospital gown, and that he had never gone out in public like that before.
Failure to Honor Resident Food and Utensil Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident who was cognitively intact and had diagnoses including complications of lung transplant, immunodeficiency due to external causes, and lung transplant status. The resident stated he had been telling staff that he needed utensils specialty wrapped, wanted his food opened because of his immunocompromised status, and wanted to know how his food was prepared and who touched it. During observation, he showed plastic utensils in a plastic bag that his family had brought because he had not been receiving plastic utensils with meals, and he said the utensils provided by staff were wet and unusable. During the same observation, the resident’s bedside table contained a bowl of cereal with a lid dated that day, and he stated he could not eat it because it could be hazardous to his health and recovery. He removed the insulated lid from another food item and revealed eggs, stating he had asked for cheese that morning but was told the facility did not have any. His meal tray also did not include what he had selected on his menu, even though the menu was still present at the bedside. The resident said he was having difficulty communicating with staff and described the interactions as charades. The resident also stated staff told him they could not provide liquids such as cranberry or lemon juice for taking his essential anti-rejection transplant medication, which he described as horrible and disgusting. The care plan directed staff to provide diet and consistencies as ordered, offer and provide alternates as needed, and honor food preferences. Staff interviews showed a CNA knew the resident preferred plastic wrapped utensils and had not communicated his requests to the kitchen or nurse, while the dietary manager said he had not been informed of the resident’s specific needs and preferences and that no staff had communicated the concerns to him. The social service director confirmed that repeated resident concerns should be reported and written as a grievance, but no grievance was documented in the grievance log.
Daily Nursing Staffing Form Posted With Incorrect Date
Penalty
Summary
The facility did not ensure the daily nursing staffing form was updated with the correct current date on one of four days observed. On 8/3/25 at 8:52 a.m., surveyors observed the staffing form posted in the hall by the dining room and in front of the social services office dated 7/30/25 instead of the current date. During an interview on 8/6/25, the Staffing Coordinator stated that Staff O, an LPN/Supervisor/UM, normally completed the daily nursing staffing form during the 11:00 p.m. to 7:00 a.m. shift, and Staff P, an LPN, completed it in Staff O's absence. She said the form is completed daily at midnight and that she checks it each morning when she arrives at 6:30 a.m. She stated that on Sunday, 8/3/25, she saw the form but did not notice it still had the 7/30/25 date, and she thought someone else had updated it. She also stated that as of 7/31/25, Staff O and Staff P were no longer working at the facility. The facility policy required daily posting of nurse staffing data and specified that the form must include the current date.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carrollwood Care Center | 5.1 mi | ★★★★★ | 0 | 0 |
| Aviata At The Bay | 5.8 mi | ★★★★★ | 3 | 2 |
| Rehabilitation And Healthcare Center Of Tampa | 5.8 mi | ★★★★★ | 1 | 0 |
| Aviata At Oldsmar | 6.2 mi | ★★★★★ | 0 | 0 |
| Aviata At The Harbor | 6.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.