Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Woodbury Wellness Center Inc during CMS and state inspections, most recent first.
A resident with asthma and COPD was not given oxygen at the physician-ordered rate, as staff failed to verify and maintain the correct setting on the oxygen concentrator. The oxygen was observed set at 5 liters per minute instead of the ordered 2 liters per minute, and staff interviews confirmed that the required checks were not performed.
A resident with type 1 diabetes experienced a severe hypoglycemic episode with blood glucose levels below 45 mg/dL, but the on-call provider was not notified as required by standing orders. Despite repeated low readings, nursing staff did not follow protocols for provider notification, and long-acting insulin was administered without a documented blood glucose check. The Medical Director confirmed that the provider should have been involved in decision-making due to the resident's lack of response to interventions.
A resident with type 1 diabetes experienced severe hypoglycemic episodes on two consecutive mornings, with blood glucose levels critically low. The facility failed to follow standing orders and notify the provider, leading to improper insulin administration and lack of documentation. The resident's condition was not adequately monitored, resulting in dangerously fluctuating blood glucose levels.
A resident with a tracheostomy and a history of larynx cancer was inaccurately coded in the MDS assessment as not having a tracheostomy. Despite receiving trach care, the 5-day MDS failed to reflect this, due to a coding oversight acknowledged by the QA Nurse, DON, and Administrator.
A resident with dementia and diabetes experienced a severe hypoglycemic event, but the facility failed to document verbal orders for glucagon administration and insulin management. Nurses did not record provider notifications or blood glucose monitoring, leading to incomplete medical records.
A facility failed to allow a resident access to their personal funds after normal banking hours, as revealed through interviews. The resident, who was cognitively intact, reported being unable to access their money after the business office closed and on weekends. The Business Office confirmed this limitation, requiring residents to request funds in advance for weekends. The Administrator was not aware of this deficiency.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with asthma and chronic obstructive pulmonary disease (COPD) was not administered oxygen at the physician-ordered rate. The resident's care plan specified oxygen administration per physician orders, and a standing order required oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%. However, during two separate observations, the resident's oxygen concentrator was set at 5 liters per minute. The resident reported being unable to adjust the oxygen setting without staff assistance and denied making any changes to the regulator. Nursing staff, including the nurse assigned to the resident, had not verified the oxygen setting prior to the observations and acknowledged that the oxygen rate should have been checked at the beginning of the shift. Interviews with the nurse, unit manager, nurse practitioner, DON, and administrator confirmed that staff were expected to ensure oxygen was set at the ordered rate and to follow physician orders. The failure to verify and maintain the correct oxygen flow rate as prescribed led to the deficiency.
Failure to Notify Provider During Hypoglycemic Episode
Penalty
Summary
The facility failed to notify the on-call provider when a resident experienced a hypoglycemic episode with blood glucose levels dropping below 45 mg/dL. Despite standing orders requiring notification of the provider if blood glucose levels remained below 70 mg/dL after a second check, the nursing staff did not follow these protocols. The resident's blood glucose levels were recorded at 37 mg/dL, 44 mg/dL, and 44 mg/dL over a period of more than an hour, yet the on-call provider was not informed, and there was no documentation of continued monitoring after 7:15 AM. The resident, who had a history of type 1 diabetes, dementia, and other health issues, was administered long-acting insulin without a documented blood glucose check later in the morning. Nurse #1, who initially managed the resident's care, did not consider the situation an emergency due to the resident's history of fluctuating blood glucose levels and asymptomatic responses to low readings. However, the Medical Director indicated that the provider should have been involved in decision-making when blood glucose levels were below 50 mg/dL, especially given the resident's lack of response to nutritional interventions. Interviews with the nursing staff and the Medical Director revealed a lack of adherence to the facility's standing orders and a failure to communicate effectively with the on-call provider. The Director of Nursing and the facility's Administrator both acknowledged that the provider should have been notified after the second blood glucose check, highlighting a breakdown in protocol adherence and communication among the nursing staff.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Notify the Medical Director/Provider of resident incidents with no new orders received.
- Complete an audit of all in house residents identified as using insulin for control of diabetes management and identify residents with blood sugars and using the sliding scale for insulins, which could require utilization with the Standing Orders.
- Report the results of this audit to the Medical Director.
- Initiate the education for all Licensed Nurses currently on duty.
- Contact nurses not scheduled for this day shift by phone and provide verbal education and require them to sign the education sign in sheet, confirming receipt, prior to working next scheduled shift.
- Educate new hired Licensed Nurses (including Agency nurses) during the hiring orientation process.
- Include in this education the Standing Orders for Hypo/Hyper glycemia and expectations regarding the use of those orders, including notification of Medical Provider.
Failure to Manage Hypoglycemic Episodes
Penalty
Summary
The facility failed to manage and assess a resident's hypoglycemic episodes on two consecutive mornings. On the first morning, the resident's blood glucose levels were critically low, ranging from 37 mg/dL to 44 mg/dL, and the on-call provider was not notified. The standing orders were not followed, and there was no documentation of continued monitoring after 7:15 AM. Long-acting insulin was administered without a documented blood glucose level, and the resident's refusal of snacks and meals was not adequately addressed. On the second morning, the resident's blood glucose level was so low that the meter read 'LO', indicating less than 20 mg/dL. The nurse contacted the on-call provider and was verbally ordered to administer glucagon, but no written order was documented. There was a significant delay in further blood glucose assessment, and the resident's blood glucose levels later spiked to 343 mg/dL and 400 mg/dL in the afternoon. The nurse practitioner was contacted and gave a verbal order to hold the long-acting insulin, but the short-acting insulin was also withheld incorrectly. The resident involved had a history of type 1 diabetes, dementia, and other conditions, and was dependent on staff for all activities of daily living. The facility's failure to follow standing orders and notify the provider in a timely manner during these hypoglycemic episodes posed a risk of serious harm to the resident. The lack of documentation and communication among staff contributed to the deficiency, affecting the resident's diabetes management and overall care.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Director of Nursing notified the Medical Director/Provider of resident #69's incidents with no new orders received.
- The Facility Director of Nursing and/or her designee completed an audit of all in house residents identified as using insulin for control of diabetes management and identified residents with blood sugars and using the sliding scale for insulins, which could require utilization with the Standing Orders.
- If implementation of Standing Order for Blood Glucose checks and Hypoglycemia occurred or should have occurred for these residents, any failure to implement or follow these standing orders will be reported to the Medical Provider for review.
- The Facility Director of Nursing and/or her designee have initiated the education for all Licensed Nurses currently on duty.
- Nurses not scheduled for this day shift will be contacted by phone by Director of Nursing/Designee and provided verbal education and will be required to sign the education sign in sheet, confirming receipt, prior to working next scheduled shift.
- Staff Development Coordinator educated by Director of Nursing that all future Newly hired Licensed Nurses (including Agency nurses) will be educated during the hiring orientation process.
- Education provided Licensed Nurses includes: Blood Glucose checks: May perform a fingerstick blood glucose level PRN sign/symptoms of hyper/hypoglycemia.
- Hypoglycemia: For Blood sugars less than 70mg/dl: a. Repeat the test b. If the second reading remains below 70, notify the MD for orders. If the reading is below 70mg/dl and the resident is Responsive; may give 15gm of Glucose or 4oz orange juice with one sugar packet by mouth or g-tube. Recheck in 15 minutes and notify the MD. If the resident is Unresponsive, call 911 and administer Glucagon1gm IM. Notify the MD.
- Expectations given along with the use of the Standing Orders: a. You will follow the Standing Order being utilized b. You will enter the orders as a telephone/verbal order c. You will execute those orders d. You will notify the Medical Provider on Call of initiating the standing orders being initiated, obtain any additional orders and transcribe into the clinical orders. e. All and any interventions implemented are to be documented into the clinical record, whether nursing judgements, orders given or monitoring as related.
- Diabetes and Clinical Protocol which includes the following: a. Assessment and Recognition b. Treatment and Management c. Monitoring and Follow-up
- Nursing Care of the Resident with Diabetes Mellitus which includes: A. Conditions associated with Diabetes: Hyperglycemia, Diabetic Ketoacidosis, Hypoglycemia B. Glucose Monitoring C. Management of Hypoglycemia
- The Facility Director of Nursing and/or her designee have initiated the education for all Certified Nursing Assistants currently on duty, and Certified Nursing Assistants not scheduled for today on these shifts will be contacted by phone by Director of Nursing/Designee and provided verbal education and will be required to sign the education sign in sheet, confirming receipt, prior to working next scheduled shift.
- Staff Development Coordinator educated by Director of Nursing that all future Newly hired Certified Nursing Assistants (including Agency CNAs) will be educated during the hiring orientation process.
- Education provided to CNAs includes, but may not be limited to: What is Diabetes, Causes of Diabetes, Types of Diabetes, Typical treatment of Hypo and Hyperglycemia, Signs and symptoms of Hypo/Hyperglycemia, and reporting to nurse of these signs and symptoms, Importance of meal intake (undereating/overeating, etc) with reporting to nurse meal intake of less than 25%
MDS Coding Error for Resident with Tracheostomy
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident, leading to a deficiency in MDS accuracy. The resident in question was admitted with a tracheostomy and a history of malignant neoplasm of the larynx. However, the 5-day MDS assessment incorrectly indicated that the resident did not have a tracheostomy. This discrepancy was identified through a review of records and staff interviews, which confirmed that the resident was receiving tracheostomy care and that the care plan had a focus on long-term tracheostomy management. Interviews with the Quality Assurance (QA) Nurse, Director of Nursing (DON), and the Administrator revealed that the coding error was due to an oversight. All parties acknowledged that the resident had a tracheostomy and was receiving the appropriate care, which should have been accurately reflected in the MDS coding.
Failure to Document Medical Orders and Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was readmitted with diagnoses including dementia and diabetes. On a specific date, a nurse recorded a blood glucose (BG) reading of 'LO' for the resident and administered two nutritional shakes, which increased the BG to 32 mg/dL. The nurse then gave glucagon and two more nutritional shakes. However, there was no evidence in the medical record that verbal orders for glucagon administration and holding long-acting insulin were transcribed. Additionally, there was no documentation of provider notification or monitoring of the resident's BG levels after the initial reading. Interviews with the involved nurses revealed that verbal orders were given but not documented as required. Nurse #3 admitted to not documenting the provider notification and subsequent BG levels. Nurse #2, who took over the shift, also failed to document the verbal order to hold insulin and the hourly BG monitoring from 5:30 AM to 11:30 AM. The Director of Nursing and the Administrator confirmed that all BG checks and verbal orders should have been documented in the resident's medical record.
Deficiency in Resident Financial Access
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs by not allowing access to personal funds after normal banking hours. This deficiency was identified through interviews with a resident and staff. A cognitively intact resident reported being unable to access their money held by the facility after the business office closed and on weekends. The Business Office confirmed that residents could only access their funds during normal banking hours, requiring advance notice for weekend withdrawals. The Administrator was unaware of this issue prior to the survey.
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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 Hampstead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Davis Health Care Center | 10.3 mi | ★★★★★ | 1 | 1 |
| Davis Health And Wellness Center At Cambridge Vill | 13 mi | ★★★★★ | 8 | 0 |
| Northchase Nursing And Rehabilitation Center | 14.5 mi | ★★★★★ | 0 | 0 |
| Bradley Creek Health Center | 16.3 mi | ★★★★★ | 0 | 0 |
| Liberty Commons Rehabilitation Center | 16.4 mi | ★★★★★ | 3 | 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.