Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woodland Hills Healthcare And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure adequate staffing and resources, particularly in infection prevention. The Administrator acknowledged low weekend staffing for CNAs and inadequate direct care staff ratios. The Infection Preventionist worked part-time, averaging 8.25 hours per week, which was not addressed in the Facility Assessment, potentially affecting all 52 residents.
The facility failed to lock shower rooms, personal care storerooms, and treatment/oxygen rooms, allowing potential resident access to hazardous items. Surveyors found unlocked doors with accessible chemicals, razors, and medical supplies. A medication cart was also left unlocked, exposing sharp items and posing a risk of bloodborne pathogen exposure. Staff confirmed these areas should be secured, but the facility lacked specific policies to ensure this.
A medication cart was found unlocked and unattended in a hallway, containing various medications and supplements. An LPN left the cart unsecured while attending to residents' smoking items, and the surveyor observed the cart's contents. Interviews with staff revealed confusion about who had access to the cart and how long it had been unlocked, violating the facility's medication storage policy.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including unclean vents, floors, and equipment, as well as improper food storage and handling practices. Dietary staff failed to follow handwashing protocols, and hot food items were not maintained at the required temperature. These issues were observed during a survey, highlighting a failure to adhere to professional standards.
The facility failed to maintain a sanitary environment, with observations of unclean conditions in various areas, including a medication cart, beauty shop, shower room, and resident rooms. Equipment used for resident care was not properly cleaned, and the facility lacked a specific infection control policy for housekeeping. The Administrator acknowledged the issues and stated steps were being taken to improve cleanliness.
The facility failed to maintain a functioning call light system for two residents, impacting their ability to contact staff. One resident's call light did not light up or sound an alarm, while another's control panel was hanging by wires. Staff attempted informal fixes, but the lack of a formal reporting and repair process led to delays. The DON and Maintenance Director confirmed that the process relied on verbal communication, often resulting in oversights.
A resident with type I diabetes was not provided with appropriate snacks to manage low blood sugar levels, as the facility failed to maintain a supply of suitable options like peanut butter and cheese. Despite the resident's requests, only high-sugar snacks were available, impacting their quality of life. The Dietary Manager confirmed the lack of these items, and a review of invoices showed no orders for them over a two-month period.
A resident with COPD was observed self-administering an inhaler and updraft medication without proper authorization or staff presence. The resident believed they were allowed to keep the medication for personal use, but there was no assessment or physician's order permitting self-administration. The DON confirmed that staff presence and proper authorization are required, and the facility's policy mandates secure storage of medications and assessments for self-administration rights.
A facility failed to complete a Level 1 PASRR for a resident with bipolar disorder and psychotic features. The resident, admitted with diabetes mellitus II, was assessed as cognitively intact and required extensive assistance for daily activities. The Social Services Director confirmed the absence of PASRR documentation and attempted to obtain it from the contracted company, but the facility could not provide the necessary documentation.
A facility failed to provide a comprehensive discharge summary for a resident, affecting the safe transition of care. The Social Services Director confirmed that her documentation lacked a medication reconciliation or care summary, and the LPN responsible was unaware of the requirement for such a summary. The Director of Nursing and Administrator confirmed the absence of a comprehensive discharge summary, despite the facility's policy requiring sufficient information for safe aftercare.
The facility failed to provide consistent bathing and personal hygiene for four dependent residents, leading to concerns about hygiene and potential skin issues. A resident with dementia and muscle wasting was observed with significant whisker growth, indicating a lack of personal hygiene care. Another resident with Parkinson's Disease expressed an inability to shave. Resident council meeting minutes and grievances highlighted ongoing concerns about not receiving baths/showers. A CNA reported insufficient time to complete all baths, and the facility's policy emphasized the importance of cleanliness and skin condition observation.
The facility failed to maintain safe food temperatures for residents receiving meals in their rooms. During a lunch service, food temperatures dropped significantly below the required levels by the time trays were delivered to residents on the 300 Hall. The Dietary Manager acknowledged the issue, and resident concerns about cold food were documented in previous Resident Council Minutes. The facility's Food Safety Policy aligns with federal standards, which were not met during this meal delivery.
Inadequate Staffing and Infection Preventionist Hours
Penalty
Summary
The facility failed to ensure adequate staffing and resources to meet the needs of its residents, particularly in the area of infection prevention. The Administrator acknowledged issues with low weekend staffing for Certified Nursing Assistants, which had been a problem during the fourth quarter due to several call-ins without replacements. Although the Administrator had hired three weekend-only staff to address this issue, the deficiency persisted. Additionally, the Facility Assessment Tool Staffing Plan revealed inadequate direct care staff ratios, with a 1:6 ratio during the day, 1:9 in the evening, and 1:14 at night. The facility also failed to allocate sufficient hours for the Infection Preventionist (IP) based on the facility's needs and resident population. The IP worked part-time, averaging only 8.25 hours per week, which was not addressed in the Facility Assessment. The Administrator confirmed that the Facility Assessment did not include the IP or specify the minimum working hours required for the IP to meet the facility's current census and specific needs. This oversight had the potential to affect all 52 residents of the facility, as the IP's role in antibiotic stewardship and tracking and trending was crucial for maintaining resident health.
Unlocked Areas and Unsecured Items Pose Risks in Facility
Penalty
Summary
The facility failed to ensure that shower rooms, personal care storerooms, and treatment/oxygen rooms were locked, which could potentially allow residents access to hazardous equipment and substances. Surveyors observed unlocked shower room doors containing items such as shampoo, body wash, soap, and razors. Interviews with staff confirmed that these doors were supposed to be locked to prevent residents from entering and potentially harming themselves. Additionally, the treatment and oxygen room was found unlocked, containing chemicals like hydrogen peroxide, iodine, and isopropyl alcohol, which residents could ingest. Further observations revealed that the personal care room was also unlocked, with various hair appliances, razors, and cleaning chemicals accessible to residents. The Director of Nursing (DON) confirmed that these areas should be secured to prevent resident access and potential harm. The facility lacked specific policies addressing the locking of doors and securing of hazardous materials, although a policy for beautician/barber services indicated that chemicals should be stored to prevent accidental ingestion or misuse. Additionally, a medication cart was found unlocked and unattended, containing hypodermic needles, insulin syringes, and a sharps container without a safety flap, exposing used needles and other sharp items. This posed a risk of exposure to bloodborne pathogens. The Assistant Director of Nursing (ADON) expressed concerns about the unsecured sharps container and the potential for residents or staff to be injured. The facility did have a policy for sharps storage, but it was not being followed, as evidenced by the unsecured sharps container on the medication cart.
Medication Cart Left Unlocked with Access to Drugs
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a locked compartment, as observed with a medication cart left unlocked in the hallway outside the dining room. An LPN was seen leaving the nurse's station to gather residents' smoking items, during which time the medication cart was left unattended and unlocked. The surveyor was able to open the top drawer of the cart and observe medications inside, indicating a lapse in security and adherence to the facility's medication storage policy. The unlocked medication cart contained a variety of medications, including aspirin, vitamin D3, thiamin, vitamin E, and other supplements, as well as prescription medications like antihistamines and bronchodilators. The LPN acknowledged noticing the cart was unlocked but did not secure it before leaving with residents for a smoke break. The presence of numerous medications, some with potential severe side effects if misused, posed a significant risk to residents, especially if accessed by unauthorized individuals. Interviews with facility staff, including the DON, ADON, and other nurses, revealed a lack of clarity regarding who had access to the cart and how long it had been left unlocked. The cart was reportedly not in use since residents were moved to other halls, yet it remained unsecured with medications inside. The facility's medication storage policy mandates that unattended medication carts must remain locked, highlighting a clear violation of this policy and a potential safety hazard for residents.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as evidenced by several observations made during a survey. The kitchen vents were not cleaned, leading to an accumulation of greasy dirt. The floors, dishwasher, kitchen walls, doors, and frames were found to have rotten wood, chipped tiles, debris, dirt, grease, rust, and stains. Additionally, wall tiles were not replaced, and the facility did not ensure that food items stored in the refrigerator were covered or sealed. Expired food items were not promptly removed from stock, and the ice machine and ice scoop holder were not maintained in a clean and sanitary condition. Dietary staff did not adhere to proper handwashing protocols before handling clean equipment or food items. During the survey, it was observed that a dietary aide did not wash their hands after touching dirty equipment and before handling clean equipment. Furthermore, hot food items on the steam table were not maintained at or above 135 degrees Fahrenheit, with several food items being served at temperatures below the required level. This was observed during one of the two meals surveyed. The facility's policy on handwashing, provided by the Dietary Supervisor, indicated that hands should be washed when entering the kitchen at the start of a shift and after engaging in activities that contaminate the hands. However, this policy was not followed, contributing to the unsanitary conditions observed. The survey highlighted multiple deficiencies in the facility's food storage, preparation, and service practices, which were not in accordance with professional standards.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents, as evidenced by multiple observations of unclean and unsanitary conditions. A medication cart was found with a dried reddish-brown substance on the attached sharps container. The beauty shop was unlocked and in disarray, with overflowing trash, hair-covered equipment, and no disinfectant present. The 100-hall shower room was unlocked and had a foul odor, with a slippery residue on the floor and discolored shower equipment. Resident rooms and bathrooms on the 100 hall had bleach odors, sticky substances, and dirt and hair accumulation. The supplemental snack room near the nurse's station had dirty countertops, a non-draining sink with residue, and a refrigerator containing opened drinks. The Director of Nursing confirmed that the refrigerator was used for employee drinks. The beauty shop's clippers, used for trimming residents' facial hair, were not cleaned before or after use, as confirmed by a CNA. The 100 and 300 hall lifts were soiled with dust and unknown substances, and resident rooms had dust and hair in corners and under beds. The Administrator acknowledged the housekeeping issues and stated that steps were being taken to improve cleanliness. However, the facility lacked a specific infection control policy addressing housekeeping concerns. The observations and interviews indicate a systemic failure to maintain cleanliness and sanitation, potentially affecting all 52 residents in the facility.
Removal Plan
- Hiring additional staff to ensure adequate staffing.
- Administration and managers monitor the cleaning process.
- Create a team-like environment for employees to work together.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that residents had a functioning call light system, which is essential for residents to contact staff and have their needs met. This deficiency was observed in two residents, who were unable to use their call lights effectively. One resident's call light did not light up or sound an alarm, and the other resident's call light control panel was hanging by wires, rendering it non-functional. Staff members, including CNAs, attempted to address the issue informally, but there was no formal process in place to ensure timely repairs. The lack of a functioning call light system was confirmed through interviews with staff and observations by the surveyor. The Director of Nursing (DON) and the Maintenance Director revealed that the process for reporting and repairing broken call lights was informal and relied heavily on verbal communication, which often led to oversights. The DON admitted that staff typically informed the Administrator or herself about maintenance issues, but there was no consistent documentation or maintenance log entries for broken call lights. The Maintenance Director confirmed that repairs were sometimes forgotten due to the lack of written reports. This lack of a structured reporting and repair process contributed to the delay in addressing the non-functional call lights, potentially impacting the residents' ability to have their needs met promptly.
Inadequate Snack Options for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate snacks for a resident with type I diabetes, impacting the resident's quality of life. The resident, who was cognitively intact and required minimal assistance with activities of daily living, expressed concerns about the high sugar content of the snacks offered. Despite the facility's claim of offering options like peanut butter with crackers, fresh fruit, and cheese, the resident reported that these options were not available when needed to manage low blood sugar levels. During an interview, the resident described an incident where they requested peanut butter and crackers due to low blood sugar but were only offered a snack cake or fruit cup. The Dietary Manager confirmed the unavailability of peanut butter and cheese, stating they could order peanut butter to arrive by the end of the week. A review of the facility's invoices revealed no orders for peanut butter or peanut butter crackers over a nearly two-month period, indicating a lack of appropriate snack options for diabetic residents.
Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident without self-administration rights was not self-administering medication without approval or staff presence. Resident #351, who has a diagnosis of chronic obstructive pulmonary disease (COPD) and is a current smoker, was observed with an inhaler on the overbed table and later using an updraft mask alone in the room. The resident stated they were told they could keep the medication on their person for use as needed. However, there was no assessment completed to authorize self-administration, and no physician's order was in place for the medication to be kept at the bedside. The Director of Nursing (DON) confirmed that a nurse or respiratory therapist should be present during treatment and that an assessment and physician's order are required for self-administration. The facility's policy mandates that medications must be stored securely and that residents must be assessed for self-administration rights. Despite this, the DON provided a census report indicating no residents had self-administration rights, and there was no documentation of an order or assessment for Resident #351's self-administration of the inhaler or updraft medication.
Failure to Complete PASRR for Resident with Mental Disorder
Penalty
Summary
The facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of bipolar disorder, severe, with psychotic features and panic episodes. The resident was admitted with a primary diagnosis of diabetes mellitus II with unspecified complications. Upon review of the Minimum Data Set (MDS), the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 14, indicating they were cognitively intact, and required extensive assistance for transfers, dressing, and bathing, as well as set-up assistance for meals. However, a Level 1 PASRR was not found in the resident's scanned documents. During an interview, the Social Services Director confirmed the absence of a PASRR pre-screening determination in the resident's chart and stated she would contact the contracted company to obtain a copy. Later, the Social Services Director informed the surveyor that the resident was considered a PASRR I, but the facility could not provide documentation to support this status.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to ensure a comprehensive discharge summary for a resident, which affected the safe transition of care. The deficiency was identified during a review of the resident's medical record, which showed a discharge summary dated 10/16/2024, indicating the resident went home with medications. However, the Social Services Director (SSD) confirmed that her documentation did not include a medication reconciliation or a summary of the resident's care. The SSD stated that nursing was responsible for the discharge summary, but no such summary was documented. Further investigation revealed that the Licensed Practical Nurse (LPN) responsible for the discharge was unaware of the requirement for a summary of the resident's stay, including medication reconciliation. The LPN provided two discharge notes, neither of which included a comprehensive summary or medication reconciliation. The Director of Nursing (DON) and the Administrator confirmed that these notes were the only documentation available for the resident's discharge and were unsure if a summary was required. A review of the facility's discharge policy indicated that sufficient information should be provided to ensure safe aftercare for the resident.
Inconsistent Bathing and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide consistent bathing and personal hygiene for four dependent residents, leading to concerns about hygiene, infection prevention, and potential skin issues. Resident #1, diagnosed with neoplasm of uncertain behavior of the brain, contracture of muscle multiple sites, and dementia, was documented as dependent for bathing. Despite a care plan indicating showers three times weekly, Resident #1 received only five showers in May, with an 11-day gap between showers. Resident #3, with fibromyalgia, diabetes, and impaired motility, also dependent for bathing, reported not having a bath in two weeks, feeling abandoned. Documentation showed only four showers in May, with the last on May 6. Resident #4, with dementia and muscle wasting, was observed with significant whisker growth, indicating a lack of personal hygiene care. The care plan required assistance with showering three times weekly, but only two baths were documented in May. Resident #5, with Parkinson's Disease and Atherosclerotic Heart Disease, was also observed with whisker growth and expressed an inability to shave. The resident's care plan required assistance with personal hygiene. Additionally, resident council meeting minutes and grievances from family and residents highlighted ongoing concerns about not receiving baths/showers. A CNA reported insufficient time to complete all baths, and the facility's policy emphasized the importance of cleanliness and skin condition observation.
Failure to Maintain Safe Food Temperatures for In-Room Meal Service
Penalty
Summary
The facility failed to maintain safe and palatable food temperatures for residents receiving meals in their rooms. On May 22, 2024, the dietary staff documented the temperatures of food items on the steam table before lunch service, which were within the acceptable range. However, during the lunch meal service, trays were observed being loaded onto an open-sided cart for transport to residents on the 300 Hall. By the time the last tray was delivered, the temperatures of the pureed lasagna, greens, and bread had dropped significantly below the required 135 degrees Fahrenheit for hot foods, with readings of 102, 90, and 90 degrees Fahrenheit, respectively. The pureed cheesecake remained within the acceptable range for cold foods at 41 degrees Fahrenheit. The Dietary Manager acknowledged the food was out of temperature range, and the Resident Council Minutes from February, March, and April 2024 documented ongoing resident concerns about cold food. The Director of Nursing confirmed awareness of these concerns and indicated efforts were being made to resolve the issue. The facility's Food Safety Policy and Procedure aligns with the U.S. Department of Health and Human Services Food Code, which mandates 41 degrees Fahrenheit for cold food and 135 degrees Fahrenheit for hot foods, highlighting the deficiency in maintaining these standards during meal delivery to residents' rooms.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 110 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherwood Nursing & Rehabilitation Center, Inc | 4.2 mi | ★★★★★ | 4 | 1 |
| Premier At The Springs | 7.7 mi | ★★★★★ | 6 | 0 |
| Lakewood Health And Rehab, Llc | 8.4 mi | ★★★★★ | 2 | 0 |
| Cabot Health And Rehab, Llc | 8.8 mi | ★★★★★ | 1 | 0 |
| Robinson Nursing And Rehabilitation Center Llc | 9.3 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.