Below 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 Woodstock Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia and known behavioral disturbances verbally threatened another resident with violent, profane language in the activities room, leaving the threatened resident confused. The aggressor resident had a documented history of potential for verbal abuse related to mental illness and psychotropic medication use, as well as non‑compliance with medications, yet was still able to direct a specific threat toward another resident. The facility’s investigation substantiated this as an incident of verbal abuse, despite an existing policy prohibiting abuse, neglect, and exploitation.
An LPN signed out controlled medications for three residents in the narcotic log as if administered, but the residents either reported not receiving their scheduled pain or anxiety medications or had documentation indicating late or missing doses. For one resident with chronic back pain on scheduled morphine and another with vertebral fracture and arthritis on scheduled tramadol, the MAR showed the drugs initialed as given, yet there was no clear documentation of the actual administration time or explanation for the missed or delayed doses, and one resident’s pain scores were inconsistently charted. A third resident with anxiety on scheduled alprazolam had the drug signed out in the narcotic book and initialed on the MAR, but progress notes indicated it was not properly signed off in the EMAR. The LPN later stated that, after being asked to leave the facility because she was not formally assigned to the shift, she discarded the medications without a witness, contrary to facility policy requiring two licensed staff to witness and document controlled substance disposal, resulting in discrepancies between the narcotic log and MAR.
Staff did not consistently keep garbage dumpster lids closed and failed to maintain cleanliness around the dumpsters, leaving debris such as used gloves on the ground. Multiple observations confirmed that dumpster doors were left open when not in use, contrary to facility policy, and staff interviews acknowledged responsibility for these tasks.
A review of facility records and staff interviews revealed that the facility did not maintain a surety bond sufficient to cover all resident personal funds on deposit, with account balances exceeding the bond amount for several months. This failure affected the security of personal funds for multiple accounts managed by the facility.
Unsafe Environment With Ongoing Leaks, Wall Damage, and Odors: The facility failed to maintain a safe, clean, comfortable, and homelike environment when ceiling vents continuously leaked water in multiple hallways, offensive odors persisted throughout the lobby and resident areas, and a large hole in a resident’s wall remained unrepaired. Staff reported black mold around the vents, daily water leakage, and an underground sewer pipe break as the odor source. In the dining room, a ceiling leak soaked a table linen and caused CNAs to move two residents away from the table.
Staff did not consistently provide or document required ADL assistance for three residents with significant cognitive and physical impairments. One resident was left in soiled linens without timely incontinence care, another had persistently dirty and untrimmed fingernails despite documentation suggesting care was provided, and a third had no records of receiving showers or bed baths for an extended period, even after a family grievance. Interviews revealed inconsistent practices and incomplete documentation among CNAs and nursing staff.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive physician-ordered TED hose as required, despite documentation in the MAR indicating otherwise. Observations showed the resident without the compression stockings during required times, and staff interviews revealed that LPNs sometimes documented the task as completed without actually applying the hose, with one LPN unaware of the order. The DON confirmed that documentation should reflect real-time care provided.
The facility had a medication administration error rate of 6.45%, exceeding the acceptable limit of 5%. An LPN failed to administer furosemide to a resident and did not perform required respiratory assessments for another resident receiving a nebulizer treatment. The DON confirmed these lapses in protocol.
The facility failed to protect residents from sexual abuse by other residents. One resident was groped by another in a common area, and another resident placed their hand down a different resident's shirt in the dining room. Both incidents involved residents with cognitive impairments and dependency on staff for ADLs. Despite regular staff training on abuse prevention, the facility's measures were insufficient to prevent these occurrences.
A resident with significant medical conditions and dependence on staff for personal hygiene did not receive adequate shower assistance, as documented in the EMR and confirmed through interviews. The DON acknowledged the lack of a dedicated shower team and inconsistent adherence to shower schedules.
A resident with respiratory failure was observed receiving O2 at 3.5 LPM despite a physician's order for 1 LPM. This discrepancy was confirmed by both an LPN and an RN/UM, who acknowledged the physician's order and the current O2 setting. The resident was alert and had no complaints about the care received.
The facility failed to secure resident medications as two medication carts and an IV cart were found unlocked and unattended. Staff confirmed that the carts should not have been left unlocked, and the DON reiterated that medication carts must always be locked when not attended.
The facility failed to properly perform infection control practices during medication administration. One LPN did not disinfect an electronic blood pressure cuff between uses on different residents, and another LPN handled medication with ungloved hands. The DON confirmed that these actions were against the facility's infection control policies.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse when one resident threatened another with violent language. One resident (R7), who had paranoid schizophrenia, used a wheelchair, and had a BIMS score of 15/15 indicating little to no cognitive impairment, told another resident (R8), "I will blow your brains out" with profanity while in the activities room. R8, who had type 2 diabetes, leg pain, unilateral primary osteoarthritis, and a BIMS score of 8/15 indicating moderate cognitive impairment, reported hearing R7 rambling, not understanding what was said, and then hearing the explicit threat directed at her. R8 stated she felt confused afterward. The facility’s own investigation, as documented in the Incident Summary Report, substantiated the allegation of verbal abuse. R7’s care plan, in place prior to the incident, documented that she used psychotropic medications with potential effects on mood and behavior and that she had the potential to demonstrate verbal abuse related to her mental and emotional illness, including paranoid schizophrenia. The NP noted that R7 continued to demonstrate behavioral disturbances, was verbally abusive at times, and was non‑compliant with her medication regimen, though she had not been physically threatening. The DON confirmed familiarity with R7’s history of increased hallucinations, paranoia, and verbal abuse when medication adjustments were needed. Despite this known risk and the facility’s written policy prohibiting abuse, neglect, and exploitation, R7 was able to verbally abuse R8, resulting in a substantiated incident of resident‑to‑resident verbal abuse.
Misappropriation and Poor Accountability of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of medications, specifically controlled substances, and to ensure accurate administration and documentation for three residents. For one resident with chronic pain, muscle spasm, spinal stenosis, osteoarthritis, hypertension, and Alzheimer’s disease, the MDS showed moderate cognitive impairment and ongoing pain requiring scheduled Morphine Sulfate ER 15 mg twice daily. On the date in question, an incident report documented that the DON was notified that this resident and others had not received their scheduled 9:00 AM narcotic medications. The narcotic book showed that an LPN had signed out the Morphine as if administered, but the resident later verbalized that the morning dose had not been received. For a second resident with cerebral infarction, vertebral fracture, arthritis, and hypertension, the MDS indicated moderate cognitive impairment and frequent, almost constant pain that interfered with daily activities, with an order for Tramadol 50 mg twice daily. The incident report again showed that the DON was notified that this resident had not received the scheduled 9:00 AM narcotic medication, while the narcotic book reflected that the LPN had signed out the Tramadol as administered. Review of the MAR for that date revealed conflicting pain scores of 0 and 9 and showed Tramadol initialed as given at 9:00 AM, but there was no documentation of the actual time of administration or explanation for the delayed or missed dose. A progress note indicated that Tramadol was signed out in the narcotic book but not signed off on the MAR. For a third resident with major depressive disorder, anxiety, gout, and psoriasis, the MDS showed little to no cognitive impairment and frequent pain, and the resident had an order for Alprazolam 0.5 mg once daily for anxiety. The incident report documented that the DON was notified that this resident had not received the scheduled 9:00 AM anxiety medication, even though the narcotic book showed the LPN had signed out the Alprazolam as if given. The MAR showed Alprazolam initialed as administered at 9:00 AM, but there was no documentation of the actual time of administration or any accounting for the delayed or missed dose. Progress notes for this resident stated that the medication was not signed off on the EMAR but was signed off in the narcotic book as given at 9:00 AM. Across all three residents, the LPN initially confirmed administration of the medications but later stated that, after being asked to leave the facility because she was not formally assigned to the shift, she discarded the medications without a witness, contrary to facility policy requiring two licensed staff to witness and document any controlled substance disposal. The facility’s written policy on Controlled Substance Administration & Accountability stated that the Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration and, together with the MAR, is the source for documenting any patient-specific narcotic dispensed from the pharmacy. The policy also required that two licensed staff witness any disposal or destruction of a controlled substance and document it on the Drug Disposition Record. In these incidents, controlled substances were signed out in the narcotic log as if administered, residents reported or were documented as having missed or late doses, and there was no proper witnessing or documentation of disposal, resulting in discrepancies between the narcotic log, MAR, and resident reports.
Improper Disposal and Maintenance of Garbage Dumpsters
Penalty
Summary
Staff failed to properly dispose of garbage and refuse in accordance with the facility's policy, which requires dumpsters to be kept covered when not being loaded and the surrounding area to be kept clean. During multiple observations, surveyors noted that the sliding lids of both garbage dumpsters were left open when not in use, and there was debris, including used gloves and other materials, on the ground around the dumpsters. Interviews with the Administrator and Dietary Manager confirmed that staff were responsible for closing the dumpster doors and maintaining cleanliness, but these procedures were not consistently followed, as evidenced by repeated observations of open dumpster doors and debris present in the area. No information about residents or their medical conditions was included in the report, and the deficiency was based solely on staff actions and facility practices related to waste disposal.
Insufficient Surety Bond for Resident Personal Funds
Penalty
Summary
The facility failed to assure the security of all personal funds deposited by residents by not maintaining a sufficient surety bond to cover the total amount of resident funds managed. Review of the facility's policy on Resident Personal Funds indicated that a surety bond or other satisfactory assurance must be in place to secure all resident funds. Examination of bank statements over a six-month period showed that the facility held resident funds exceeding $100,000, with balances ranging from $106,898.12 to $133,831.89 during several months. However, the surety bond in effect during this period was only $100,000, which was not adequate to cover the highest balances held in resident accounts. Interviews with the Administrator and the Director of Regulatory Compliance (DRC) confirmed that the surety bond should be sufficient to cover the total balance of resident funds. The DRC later provided documentation of an increased surety bond amounting to $150,000, but this updated bond only became effective after the period in question and did not retroactively cover the higher balances previously held. As a result, the security of personal funds for 56 accounts managed by the facility was not fully assured during the months when the resident fund balances exceeded the surety bond amount.
Unsafe Environment With Ongoing Leaks, Wall Damage, and Odors
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing ongoing environmental problems to persist, including roof and ceiling leaks, a large hole in a resident’s wall, and offensive odors throughout the building. The facility policy stated that it would provide a safe, clean, comfortable and homelike environment, minimize odors by disposing of soiled linens and reporting lingering odors and bathrooms to housekeeping, and report unresolved environmental concerns to the administrator. R2, who had a BIMS score of 14/15 and was documented as having no cognitive impairment, reported that a large hole in the wall next to her bed had not been repaired despite her repeated complaints. Observation showed the hole was approximately ten inches wide and fifteen inches long, and R2 stated it had been there since she occupied the room. She also stated she was not comfortable in her room and was afraid critters could be hiding in the hole. R72, who also had a BIMS score of 15/15, stated the facility had done nothing to repair the leaking roof and persistent odors for over eight months. Observations showed ceiling vents continuously dripping water in the 100, 200, and 300 hallways, with dark black spots around the vents and lingering odors detected from the front lobby through the resident hallways and into resident rooms. Staff interviews confirmed the facility had been aware of the leaks and odors, with one LPN stating there was black mold around the ceiling vents and daily water leakage, and the Maintenance Director stating the odor source was related to a break in underground sewer pipes. In the dining room, the ceiling leaked directly above two residents, soaking the table linen and prompting CNAs to move the residents away while housekeeping placed linens and a soiled linen tub under the leak.
Failure to Provide Required ADL Assistance and Documentation
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required support due to various medical conditions. One resident with dementia, diabetes, and limited mobility was observed sitting on soiled linens with urine-soaked clothing, despite care plans indicating the need for regular incontinence care and staff checks every two hours. The Director of Nursing confirmed that all nursing staff were responsible for providing this care. Another resident with a history of cerebral infarction, hemiplegia, and vascular dementia was found to have untrimmed and dirty fingernails on multiple occasions, even though documentation on shower sheets indicated that nail care was performed. Interviews with CNAs revealed inconsistencies in nail care practices and documentation, with one CNA expressing discomfort in trimming nails and deferring the task to nursing staff, but without clear follow-up or documentation. A third resident with severe cognitive impairment, Alzheimer's disease, and a history of falls had no documented evidence of receiving showers or bed baths for two months, despite care plans and a grievance from the resident's daughter regarding the resident being wet and needing clean linen. Staff interviews indicated that showers and bed baths were to be provided and documented, but records for the relevant months were missing, and there was no confirmation that the required ADL care was delivered.
Failure to Apply and Accurately Document Physician-Ordered TED Hose
Penalty
Summary
Facility staff failed to follow a physician's order for a resident requiring TED hose (compression stockings) to be applied to both lower extremities each morning when out of bed and removed at bedtime. Despite documentation in the Medication Administration Record (MAR) indicating that the TED hose were applied daily, multiple observations revealed that the resident did not have the TED hose on during the required times. The resident, who was severely cognitively impaired and had diagnoses including cerebral infarction, hemiplegia, and lower leg atrophy, was observed attempting to communicate the need for the TED hose and was seen retrieving them from a drawer himself. Staff interviews confirmed that the TED hose were not consistently applied as ordered. Further review of facility policies showed requirements for accurate and objective documentation, and for staff to sign the MAR only after administration of care or medication. However, interviews with LPNs revealed that staff sometimes documented the application of the TED hose without actually performing the task, with one LPN admitting to marking the MAR without having put on the hose and another stating she was unaware of the order for the TED hose. The Director of Nursing confirmed that it was expected for staff to document care in real time and not to mark tasks as completed if they had not done them.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to ensure that the medication administration error rate was less than 5%, resulting in an observed error rate of 6.45%. During medication administration, an LPN prepared medications for a resident but did not administer furosemide because it was not available. The LPN stated that the medication could be pulled from the automated medication dispensing system but did not do so, leading to the resident missing a dose. The Director of Nursing confirmed that the medication was available in the system and should have been administered to the resident. Another incident involved the same LPN administering medications to a different resident, including a nebulizer treatment. The LPN used a Flonase nasal spray that was not labeled with the resident's name and left the resident unattended during the nebulizer treatment. Additionally, the LPN did not assess the resident's respiratory status before and after the nebulizer treatment, contrary to the facility's policy. The Director of Nursing confirmed that respiratory assessments should be conducted and documented for nebulizer treatments.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by other residents. Specifically, one resident (R52) was groped by another resident (R51) in a common area, and another resident (R270) placed their hand down a different resident's (R8) shirt in the dining room. Both incidents were documented in Facility Incident Report Forms and involved residents with varying degrees of cognitive impairment and dependency on staff for activities of daily living (ADLs). The facility's policy on abuse prevention was not effectively implemented to prevent these incidents from occurring. The first incident involved R51, who has severe cognitive impairment and requires substantial assistance with ADLs, groping R52, who also has severe cognitive impairment and is dependent on staff for most ADLs. The second incident involved R270, who has little or no cognitive impairment but is dependent on staff for ADLs, placing their hand inside R8's shirt. Both incidents were reported to the state and investigated per facility policy. Staff interviews confirmed that they received regular training on abuse prevention and dementia care, and were aware of the procedures for reporting abuse. However, the facility's measures were insufficient to prevent these occurrences of resident-to-resident sexual abuse.
Failure to Provide Adequate Shower Assistance
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) assistance, specifically showers, for a resident (R35) who was dependent on staff for personal hygiene. R35, who had diagnoses including spina bifida, neurogenic bowel, neuromuscular dysfunction of the bladder, and Fournier gangrene, was documented as having little or no cognitive impairment and no behavioral issues. Despite being dependent on staff for bathing, the electronic medical record (EMR) and shower sheets revealed that R35 was only given a shower on five occasions between March and April 2024. Interviews with R35 confirmed that he had not received a shower for two weeks as of mid-May 2024. The Director of Nursing (DON) acknowledged that there was no dedicated shower team, but staff were assigned to give showers daily. However, there were no routine showers scheduled for the night shift unless requested by residents. The DON also stated that if a resident refused a shower, staff would document the refusal and offer the shower again at a different time. Despite these protocols, R35 reported not receiving a shower while his roommates did, indicating a failure in the facility's adherence to its own policies and the resident's care plan, which required extensive assistance with bathing.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders related to oxygen (O2) liter flow for a resident with respiratory failure. The resident, who had a physician's order for O2 at 1 liter per minute (LPM) via nasal cannula (NC) to keep O2 saturation above 92%, was observed on multiple occasions receiving O2 at 3.5 LPM. This discrepancy was confirmed by both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN)/Unit Manager (UM), who acknowledged the physician's order and the current O2 setting. The resident was alert, oriented, and had no complaints about the care received during the observations. However, the facility's failure to adhere to the prescribed O2 flow rate was evident. The resident's electronic medical record (EMR) indicated a history of unspecified respiratory failure and a personal history of COVID-19. The care plan for the resident included O2 therapy to maintain O2 saturation above 92% and monitoring for abnormal breathing patterns. Despite these documented interventions, the resident was consistently provided with a higher O2 flow rate than ordered. The RN/UM mentioned that in cases where a resident needed more O2, the provider would be notified to adjust the order, but there was no indication that such a notification had occurred in this instance.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to safely secure resident medications as evidenced by the observation of two of six medication carts left unlocked and unattended. During an initial tour, the C-Hall (300 hall) medication cart was found unlocked and unattended in the hallway. Upon return, RN QQ admitted that the cart should not be left unlocked but explained it was due to the cart being shared between two charge nurses, with the key left in the narcotic count book for access. Similarly, the B-Hall (200 hall) medication cart was also found unlocked and unattended, and LPN NN confirmed that it should not have been left unlocked. Additionally, the IV cart was noted to be unlocked and this was verified by the Unit Manager. The Director of Nursing (DON) confirmed during an interview that medication carts should always be locked when not attended, especially during the night shift. The facility's policy titled 'Storage of Medications' mandates that all compartments containing drugs and biologicals must be locked when not in use and should not be left unattended if open or potentially available to others. The failure to adhere to this policy resulted in unauthorized access to resident medications, posing a potential risk to residents, staff, and visitors.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to properly perform infection control practices during medication administration, as observed in the actions of two Licensed Practical Nurses (LPNs). One LPN did not disinfect an electronic blood pressure cuff between uses on different residents. Specifically, the LPN checked the vital signs of one resident, placed the cuff back on the medication cart, and then used the same cuff on another resident without cleaning it. When questioned, the LPN admitted forgetting to clean the cuff, despite knowing it was required to prevent cross-contamination between residents. Another LPN was observed handling medication with ungloved hands. This LPN poured Tylenol pills into the lid of the bottle, used her bare hand to hold an extra pill, and then placed the extra pill back into the bottle. She also counted the pills by pouring them onto a tissue and then picked them up with her bare hand to place them back into the medication cup. When asked, the LPN believed it was acceptable to touch the pills with bare hands if hand sanitizer was used beforehand. The Director of Nursing confirmed that the staff were expected to clean the blood pressure cuff after each use and that nurses should not handle pills with bare hands, even if hand hygiene was performed.
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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 Woodstock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marietta Center For Nursing And Healing | 8.8 mi | ★★★★★ | 1 | 0 |
| Tower Road Post Acute, Llc | 9.3 mi | ★★★★★ | 10 | 0 |
| Cherokee Center For Nursing And Healing Llc | 9.3 mi | ★★★★★ | 0 | 0 |
| Roselane Health Center By Harborview | 9.4 mi | ★★★★★ | 14 | 0 |
| East Cobb Center For Nursing And Healing Llc | 9.9 mi | ★★★★★ | 5 | 0 |
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