Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 A.g. Rhodes Home Wesley Woods during CMS and state inspections, most recent first.
Failure to assess self-administration before leaving medications at bedside. A resident with moderate cognition and multiple diagnoses, including encephalopathy, TIA, repeated falls, and right knee OA, had Biofreeze roll-on and arthritis pain reliever ointment kept on a dresser near the doorway. The resident said he used the products almost daily and had kept them there since admission, but the record had no self-administration assessment and there was no physician order. An LPN confirmed the items were present, and the DON stated residents must be assessed and approved before self-administering meds.
The facility failed to keep three resident rooms on 300 Hall and 400 Hall safe, clean, comfortable, and homelike. Surveyors observed scuffed and chipped paint, holes in the wall, and a dirty personal fan with fuzzy grayish buildup on its vents. The FMD and ESD confirmed the damaged walls and dirty fan in rooms 304, 410, and 419, and noted that cleaning personal fans had not been part of housekeeping responsibilities.
Incomplete Care Plans for Oxygen Therapy and Hearing Loss: The facility failed to include oxygen therapy in one resident’s care plan and failed to address hearing loss and communication needs for another resident. Staff confirmed the missing care plan elements, and the DON and Administrator stated that oxygen orders and hearing loss should have been care planned.
A facility failed to keep resident rooms free of accident hazards when chemicals were found at bedside for three residents. R131, who had dementia-related diagnoses and was cognitively intact, had two cans of disinfectant spray beside the TV during repeated observations. R122, who was severely cognitively impaired, had a spray bottle of alcohol on the bedside table, and another resident had two aerosol cans of disinfectant in the room. The DON confirmed these residents were not assessed as appropriate to keep these chemicals in their rooms and stated chemicals should not be at bedside.
A resident with CHF, Alzheimer's Disease, and hypertensive heart disease had an order for O2 at 2 LPM PRN for increased work of breathing, with ordered respiratory monitoring each shift. Surveyors observed the O2 concentrator running at 4.5 LPM on multiple occasions. An LPN confirmed the order was for 2 LPM and adjusted the concentrator, while the DON stated the concentrator settings should match the physician order and that there was no process to check settings against orders; the resident's care plan did not address O2 therapy.
A resident fell from a mechanical lift during a transfer, resulting in rib fractures, due to improper attachment of the sling by a CNA. The resident, who had multiple medical conditions and was dependent on staff for transfers, experienced pain and required further diagnostic testing to identify the injuries.
The facility failed to document receive dates on food items, ensure proper hand hygiene among dietary staff, discard expired food items, and properly sanitize dishware. The Dietary Manager and staff admitted to these oversights, which included handling clean dishes without washing hands and not sanitizing kitchenware between uses.
The facility failed to submit Level II PASRR applications for two residents admitted with significant mental health diagnoses, including PTSD, schizophrenia, and major depressive disorder. Despite the facility's policy requiring coordination with the PASRR program, the necessary evaluations were not completed, as confirmed by staff interviews and record reviews.
The facility failed to ensure dietary staff followed recipes for pureed food items, affecting 14 residents. Dietary Cook FF was observed adding unmeasured amounts of ingredients during preparation, and the Dietary Manager confirmed that recipes were not followed as expected.
Failure to Assess Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
The facility failed to assess a resident’s ability to self-administer medications before leaving medications at the bedside for one of 44 sampled residents. The resident had diagnoses including encephalopathy, transient cerebral ischemic attack, difficulty walking, generalized muscle weakness, osteoarthritis of the right knee, benign prostatic hyperplasia, type 2 diabetes mellitus, repeated falls, bone density disorder, and a wedge compression fracture of L1. The resident’s most recent MDS showed a BIMS score of 11, indicating moderate cognition, and the clinical record contained no assessment for medication self-administration. Observation showed a Biofreeze roll-on pain relief bottle and an arthritis pain reliever ointment tube resting on top of a dresser cabinet near the doorway entrance. The resident stated he had kept the items there since admission, used the Biofreeze almost every day, and had never been questioned by nursing staff about having them. An LPN confirmed the items were present and removed them, stating she would speak with the doctor about an order. The DON later confirmed the resident did not have a physician order for the medications, stated residents must be assessed and approved for self-administration, and said there should not be medications left at the resident’s bedside.
Unsafe and Unclean Resident Rooms
Penalty
Summary
The facility failed to ensure residents' living areas were safe, clean, comfortable, and homelike in three rooms on 300 Hall and 400 Hall. Survey observations found scuffed and chipped paint, damaged sheetrock walls with holes, and a dirty personal fan with a fuzzy grayish substance on its vents in resident rooms. Review of the facility policy titled Preventive Maintenance stated that a preventive maintenance program shall be developed and implemented to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During concurrent observation rounds, the Facility Manager Director and Environmental Services Director confirmed the damaged walls, chipped paint, and dirty fan in rooms 304, 410, and 419, and stated that cleaning personal fans had not been part of housekeeping responsibilities.
Incomplete Care Plans for Oxygen Therapy and Hearing Loss
Penalty
Summary
The facility failed to complete and update comprehensive care plans for two of 44 sampled residents. For one resident, the record showed orders for oxygen therapy, but oxygen was not included on the care plan. For another resident, the care plan did not address hearing loss or communication interventions, even though staff identified hearing loss as an ongoing issue affecting communication. During interviews, an LPN confirmed that the resident with hearing loss did not have a care plan addressing communication needs and that staff were currently raising their voices and relying on the resident’s daughter to assist with communication. The MDS Director, DON, and Administrator each confirmed that hearing loss should have been included in the care plan. For the resident with oxygen therapy, the DON confirmed that oxygen settings should match the oxygen order and that oxygen orders should be care planned, and the Administrator also stated that oxygen orders should have been administered as ordered and care planned.
Chemicals Left at Bedside in Resident Rooms
Penalty
Summary
The facility failed to ensure resident rooms remained free of accident hazards by allowing chemicals to be kept at bedside for three sampled residents. Review of the facility policy titled Accident and Supervision stated that the environment should remain free of accident hazards as is possible and that hazards and risks should be identified and addressed. During observations, R131, who had diagnoses including Alzheimer's disease with early onset, unspecified dementia, muscle weakness, neuropathy, spinal stenosis, type 2 diabetes, and chronic kidney disease, was seen in a wheelchair with two cans of disinfectant spray on a stand beside the television in her room on multiple occasions. R131 was also observed watching television and later eating breakfast while the disinfectant sprays remained at bedside. A walk-through of the facility also found R122, whose MDS showed a BIMS score of 7 indicating severe cognitive impairment, with a spray bottle of alcohol on the bedside table, and R48 with two aerosol cans of disinfectant in the room. R122 stated she used alcohol to clean her ears and said her daughter bought it for her. The DON confirmed that there were no residents assessed and deemed appropriate to use rubbing alcohol or disinfectant for disinfection, and stated that R122 and R48 should not have chemicals in their rooms because this posed a potential accident hazard. The DON also stated that chemicals should not be at a resident's bedside and facility chemicals should be locked up when not in use.
Oxygen Therapy Not Administered at Ordered Setting
Penalty
Summary
The facility failed to administer oxygen at the correct ordered setting for one resident receiving oxygen therapy. The resident had diagnoses including chronic diastolic congestive heart failure, Alzheimer's Disease, and hypertensive heart disease. A physician order dated 1/9/2025 directed oxygen at 2 LPM for increased work of breathing as needed, with oxygen saturations on room air, respiratory rate, breath sounds, and documentation to be completed every shift. The quarterly MDS documented a BIMS score of 4, indicating severe cognitive impairment, and the care plan dated 8/14/2025 did not address oxygen therapy. Observations on 9/9/2025, 9/10/2025, and 9/11/2025 showed the oxygen concentrator running at 4.5 LPM instead of the ordered 2 LPM. During an interview and observation on 9/11/2025, an LPN reviewed the physician order, confirmed the concentrator was set at 4.5 LPM, and then adjusted it to 2 LPM. The LPN stated oxygen should be given at the physician-ordered setting and monitored per shift. The DON stated the concentrator settings should match the physician order, oxygen saturation checks should be completed according to orders, there was no process in place to check concentrator settings against physician orders, and oxygen use should be care planned. The Administrator stated oxygen should have been administered as ordered and should have been care planned.
Failure to Ensure Safe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident (R100) using a mechanical lift, resulting in actual harm. On 1/20/2024, R100, who had diagnoses including cerebral vascular accident with left hemiplegia, aphasia, diabetes, dementia, obesity, and depression, fell from a mechanical lift during a transfer from bed to chair. The fall resulted in R100 sustaining fractures to the left and right ribs. The incident occurred because the Certified Nursing Assistant (CNA) BB did not properly attach the sling to the mechanical lift, causing the resident to fall when lifted. The Director of Nursing (DON) confirmed that the mechanical lift and sling were inspected post-incident and found to be functioning correctly, indicating human error in the attachment process. R100 was initially evaluated at a local hospital where multiple radiologic studies showed no injuries. However, subsequent complaints of pain led to further diagnostic testing, which revealed fractures in the eighth and ninth right ribs and the 11th left rib. The resident's cognitive status was assessed as having no cognitive impairment, and they were dependent on staff for all transfers due to impairments in both upper and lower extremities. Interviews with staff revealed that CNA AA, who was assisting in the transfer, had received training on the use of mechanical lifts. During the transfer, CNA AA secured her side of the sling, while CNA BB secured the other side. As the resident was lifted, the sling became disconnected from the hook on CNA BB's side, causing the fall. CNA BB resigned without notice two days after the incident. The facility's policy on Safe Elder Handling-Transfers, which mandates the use of mechanical lifting equipment to prevent manual lifting, was not followed correctly, leading to the resident's fall and subsequent injuries.
Deficiencies in Food Storage, Hand Hygiene, and Sanitation Practices
Penalty
Summary
The facility failed to document receive dates on food items in the dry storage area, as observed on multiple containers of condiments and cans in the storage area. The Dietary Manager (DM) admitted that they did not put receive dates on the dry storage food items and were unaware that it was necessary, relying instead on the expiration or use-by dates indicated on the food items. This oversight was confirmed during an interview with the DM, who acknowledged the lack of receive dates on the items in question. Additionally, the facility did not ensure proper hand hygiene practices among dietary staff. A dietary aide was observed entering the kitchen, placing his coat in the office, and then handling clean dishes without washing his hands. The same aide was also seen loading dirty dishware into the dish machine and then unloading clean dishware without washing his hands in between tasks. The dietary aide confirmed his failure to wash hands and admitted to overlooking this step in his haste to start washing dishes. The DM stated that she expects dietary staff to wash their hands upon entering the kitchen and before starting any task, as well as after handling dirty dishes and before touching clean ones. The facility also failed to discard food items past their best-by dates and did not properly sanitize dishware to prevent cross-contamination. Emergency food supplies included cans of Chili Con Carne with a best-by date of 4/2021, which should have been discarded. The DM admitted to overlooking these items. Furthermore, a dietary cook was observed rinsing a blender bowl, blade, and lid with water only, without sanitizing them, before preparing additional puree food items. The cook confirmed this practice, citing being in a rush as the reason for not properly sanitizing the items. The DM confirmed that she expects dietary staff to properly wash and sanitize kitchenware between uses to prevent cross-contamination.
Failure to Submit Level II PASRR Applications for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to submit an application for Level II Preadmission Screening and Resident Review (PASRR) for two residents, R65 and R116, who were admitted with significant mental health diagnoses. R65 was admitted with diagnoses including PTSD, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. Despite these diagnoses, the PASRR Level One Application for R65 indicated no primary diagnosis of serious mental illness or mental disorder. The Director of Nursing (DON) confirmed that R65 did not have a Level II PASRR, and the Social Service Director (SSD) was unsure about the PASRR Level II process. The SSD also stated that residents with PTSD are seen by psych services every four to six weeks unless there is a change in medications or behaviors, and R65 did not exhibit any behaviors requiring further action. However, the facility policy requires coordination with the PASRR program to ensure appropriate care and services for individuals with mental disorders or intellectual disabilities, which was not followed in this case. Additionally, the SSD mentioned that the Admissions Director or admissions nurse reviews PASRR Level I forms on admission and submits records for Level II evaluations within a year based on admission diagnoses, but this process was not adhered to for R65. The Administrator confirmed that R65 should have had a Level II PASRR completed but did not. Similarly, R116 was admitted with diagnoses of PTSD, schizophrenia, depression, and anxiety disorder. The PASRR Level One Application for R116 also indicated no primary diagnosis of serious mental illness or mental disorder. The SSD confirmed that there were no residents in the facility with a Level II PASRR and reiterated the process for Level II PASRR evaluations, which was not followed for R116. The Administrator also confirmed that R116 should have had a Level II PASRR completed but did not. The facility's failure to submit Level II PASRR applications for these residents indicates a lack of adherence to their own PASRR Program Policy, which requires coordination with the PASRR program to ensure appropriate care and services for individuals with mental disorders or intellectual disabilities. This deficiency was confirmed through staff interviews and record reviews, highlighting a significant oversight in the facility's admission and screening processes for residents with mental health diagnoses.
Failure to Follow Recipes for Pureed Food Items
Penalty
Summary
The facility failed to ensure that dietary staff followed recipes for preparing pureed food items, which compromised the nutritive value and flavor for 14 residents receiving a pureed diet. During the preparation of pureed BBQ chicken, Dietary Cook FF was observed adding unmeasured amounts of steamed diced chicken, chicken broth, BBQ sauce, and food thickener into a blender. Similarly, during the preparation of pureed rice, Dietary Cook FF added unmeasured amounts of cooked rice, hot water, and melted butter into a blender. The cook confirmed that he did not measure any of the ingredients and relied on his experience instead of following the printed recipes available for review. The Dietary Manager (DM) confirmed that the expectation is for dietary cooks to follow recipes and measure ingredients accurately. The cook reviewed the recipe for BBQ chicken and acknowledged that the ingredient amounts listed were not followed. This failure to adhere to recipes was observed during the preparation process and confirmed through staff interviews, highlighting a significant lapse in maintaining the quality and consistency of pureed food items served to residents.
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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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How nearby facilities compare on the same public inspection record.
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| Parkside At Budd Terrace Operating Company Llc | 1.7 mi | ★★★★★ | 22 | 0 |
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| Decatur Center For Nursing And Healing Llc | 3.1 mi | ★★★★★ | 7 | 0 |
| Harborview Decatur | 3.2 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Virginia Park | 3.3 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.