Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Transfers: The facility did not notify the LTC Ombudsman of hospital transfers/discharges for two residents. One resident was discharged to an acute care hospital and was not expected to return, but was not listed on the monthly transfer/discharge notice. Another resident had severe RUQ pain, purplish lips, and pursed-lip breathing, was sent by ambulance to the ED, and later returned the same day, but was also omitted from the Ombudsman notice. The Administrator stated one notification was missed and said she did not know emergency transfers required notification if the resident was not admitted.
Failure to Follow Inhaler Administration Instructions: Staff did not follow physician-ordered directions for two residents receiving steroid inhalers. One resident with dementia and severe cognitive impairment received Asmanex without being instructed to rinse and spit, and another resident with intact cognition received Trelegy without being prompted to swish and spit after use. The CMA stated she was unfamiliar with the medication instructions, while the RN and DON confirmed that rinse-and-spit directions should be followed for corticosteroid inhalers.
A facility failed to accurately obtain and implement advanced directives for a resident upon admission. The resident's verbal order for CPR was documented, but no signed document confirmed their wishes for life-sustaining measures. The DON could not locate the resident's IPOST, and although the family communicated a DNR wish, the SSD did not document the contact attempt. The facility's policy on Advanced Directives was not adequately followed.
A resident with severe cognitive impairment and mobility issues was transported in a wheelchair with only one foot pedal, despite staff acknowledging the need for two. The second pedal was broken, and there was no policy for wheelchair transport, leading to a deficiency in ensuring a safe environment.
The facility was cited for a deficiency in the accuracy of MDS assessments, specifically regarding the smoking status of two residents. Despite recent audits, the MDS was inaccurately coded, and the facility lacked a specific MDS policy, relying instead on the CMS Resident Assessment Instrument. The issue was acknowledged by the DON and MDS Coordinator, who planned to submit corrections.
A resident with multiple health conditions, including schizophrenia and diabetes, refused necessary blood draws and experienced a significant change in blood glucose levels. The facility failed to notify the resident's legal guardian of these refusals and changes, despite policy requirements. Interviews with staff revealed a lack of communication and clarity regarding the notification process.
A facility failed to resubmit a PASRR after a resident's mental health diagnoses changed, including major depressive disorder and psychotic disorder. The oversight was identified through observations and staff interviews, revealing a lack of policy and communication during staff transitions. The SSD confirmed the need for a new PASRR, but it was not submitted due to missed communication and absence of auditing procedures.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, missing vital signs documentation on multiple occasions. Staff interviews revealed that the assessments were supposed to be recorded on a communication sheet or in the electronic health record, but were absent. The facility lacked a specific dialysis assessment policy, contributing to the oversight.
The facility inaccurately completed MDS assessments for two residents regarding their tobacco use. Despite documentation and interviews confirming their smoking habits, the MDS indicated they did not use tobacco. The DON and MDS Coordinator acknowledged the errors, and the facility lacked a specific MDS policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to unsecured and unalarmed doors. The resident exited through a series of doors, including one with a disengaged lock, and was found outside without shoes. The facility's interventions, such as a Wander Guard, were insufficient, and staff interviews indicated inconsistent alarm monitoring. Additionally, another resident was injured due to improper lifting methods, highlighting the facility's failure to adhere to care plans and maintain a secure environment.
A facility failed to provide a bed hold notice to a resident or their representative upon hospital transfer, as required by guidelines. The resident, who was cognitively intact and had multiple diagnoses, was transferred for treatment without the necessary documentation. Interviews with staff revealed a lack of clarity and adherence to the Bed Hold Policy, with the responsible nurse admitting to not completing the required form.
The facility failed to accurately code medications on the MDS for two residents. One resident, with diagnoses of Atrial Fibrillation and Heart Failure, was not coded for diuretic and hypnotic medications despite having physician orders. Another resident on anticoagulant therapy with Xarelto was not documented on the MDS. Interviews confirmed the omissions, and the facility lacked a specific MDS policy.
A facility failed to update a care plan for a resident identified as a smoker, despite a Smoking Safety Evaluation indicating balance issues. The resident, cognitively intact with a BIMS score of 15, was observed smoking under supervision. The MDS Coordinator was responsible for care plan updates, but the plan lacked necessary interventions per facility policy, such as supervised smoke breaks and secure storage of smoking items.
A housekeeping staff member failed to follow hand hygiene protocols while handling soiled laundry, using bare hands instead of gloves and neglecting to wash hands afterward. The facility's policy requires staff to wear gloves and perform hand hygiene after handling contaminated items, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of resident transfers and discharges for 2 of 3 residents sampled, including a resident who was discharged to an acute care hospital and was not expected to return, and another resident who was transferred to the emergency department and later returned to the facility. Review of the MDS for one resident showed discharge to an acute care hospital, and the Notice of Transfer Form to the LTC Ombudsman for February 2026 did not list that resident as a hospital transfer/discharge. During interview, the Administrator stated she was responsible for sending monthly notifications of resident transfers and discharges to the LTC Ombudsman and acknowledged that notification had been missed for that resident. For the second resident, the EHR documented severe right upper quadrant pain, purplish lips, pursed-lip breathing, notification of the DON and provider, and an order to transfer to the ED for further evaluation. Nursing notes showed the resident left the facility by ambulance and later returned by ambulance the same day. The Notice of Transfer Form to the LTC Ombudsman for March 2026 did not include the resident’s name for the emergency hospital transfer. During interview, the Administrator stated she did not know she needed to notify the Ombudsman for emergency transfers if the resident was not admitted to the hospital.
Failure to Follow Inhaler Administration Instructions
Penalty
Summary
The facility failed to ensure staff administered medicated inhalers according to physician orders for 2 residents. One resident had a BIMS score of 7 out of 15, indicating severe cognitive impairment, and a diagnosis of dementia. That resident had an order for Asmanex Inhaler, 2 puffs twice daily for COPD with acute exacerbation, with instructions to rinse the mouth with water and spit after use. During observation, a CMA administered the inhaler but did not have the resident rinse and spit afterward. The CMA stated the MAR did not include the rinse-and-spit instruction, while the RN and DON stated the instruction should be included and that residents should rinse and spit after corticosteroid inhaler use. A second resident had a BIMS score of 13 out of 15 and diagnoses including pulmonary embolism and asthma/COPD/chronic lung disease. That resident had an order for Trelegy Ellipta, 1 puff in the morning for COPD with acute exacerbation, with directions to rinse mouth after use and hold breath for 5 to 10 seconds. During observation, the CMA administered the inhaler and the resident held her breath, but she did not swish and spit afterward and the CMA did not prompt her to do so. In later interviews, the CMA stated she was unsure about special instructions for inhalers, then acknowledged that steroid inhalers require swishing and spitting to remove residual particles and prevent fungal infections.
Failure to Implement Advanced Directives
Penalty
Summary
The facility failed to accurately obtain and implement advanced directives for a resident upon admission. The resident, admitted from a short-term general hospital, had a verbal order for CPR documented in their Order Summary Report. However, there was no signed document in the electronic health record to confirm the resident's wishes for life-sustaining measures. The Director of Nursing (DON) was unable to locate the resident's Iowa Physician Orders for Scope of Treatment (IPOST) in the binder, which is essential for communicating preferences for treatments such as CPR and artificial nutrition. The DON later stated that the resident's family had communicated a wish for Do Not Resuscitate (DNR) status, and an IPOST was completed and faxed to the physician for signature. However, the Social Services Director (SSD) acknowledged that an attempt to contact the resident's family was made but not documented. The facility's policy on Advanced Directives requires providing residents or their representatives with information and instructions regarding their rights to make such directives upon admission, which was not adequately followed in this case.
Failure to Ensure Proper Wheelchair Transport
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was equipped with two foot pedals during transport, which is necessary to prevent accidents. Resident #17, who has severe cognitive impairment and uses a manual wheelchair, was observed being pushed by staff with only one foot pedal attached. This occurred on multiple occasions, with staff members acknowledging the need for two foot pedals but continuing to transport the resident with only one. The resident's medical history includes non-Alzheimer's dementia, hemiplegia or hemiparesis, arthritis, and a hip fracture, which further necessitates proper support during wheelchair transport. Interviews with staff revealed that the second foot pedal was broken, and there was no policy in place for wheelchair transport. Staff members were aware of the broken pedal but continued to transport the resident without addressing the issue. The Director of Nursing confirmed the need for two foot pedals when pushing the resident, especially since the resident could not keep her feet on one pedal. Despite this, the facility did not have a policy to guide staff on proper wheelchair transport, contributing to the deficiency.
Deficiency in MDS Accuracy for Smoking Status
Penalty
Summary
The facility was cited for a deficiency related to the accuracy of assessments, specifically under F641, during a recertification survey. The issue was identified through a review of the facility's CASPER report, which indicated that the facility had previously been cited for the same deficiency in February 2024. During the current survey, it was found that the Minimum Data Set (MDS) Comprehensive Assessments for two residents were inaccurately coded as not using tobacco, despite both residents currently smoking at the facility. This discrepancy was acknowledged by the Director of Nursing and the MDS Coordinator, who admitted the coding error and stated that corrections would be submitted. The Administrator expressed surprise at the coding issue, as she had recently audited the MDS for smoking and believed everything was correctly coded. However, during an interview, it was revealed that the facility did not have a specific MDS policy and relied on the CMS Resident Assessment Instrument (User's Manual) for MDS coding. The Administrator, along with the Regional Director of Operations and the DON, acknowledged that the new MDS Coordinator was aware of the plan of correction from the last survey but had focused more on the care plan versus the MDS for smoking issues. The facility's QAPI policy outlines a process for ensuring care and services meet quality standards, but the deficiency indicates a failure to effectively implement these measures in this instance.
Failure to Notify Guardian of Resident's Medical Refusals and Condition Changes
Penalty
Summary
The facility failed to notify the legal guardian of Resident #7 about laboratory refusals and changes in the resident's condition. Resident #7, who has a history of schizophrenia, diabetes mellitus, stroke, aphasia, hemiplegia, and anxiety disorder, was under the guardianship of an agency as per a court order. Despite the resident's moderate cognitive impairment, the facility did not inform the guardian of the resident's refusal to undergo blood draws for essential tests like the Basic Metabolic Panel (BMP) and A1C, nor did they notify the guardian of a significant change in the resident's blood glucose levels. The clinical records showed multiple instances where Resident #7 refused necessary medical procedures, such as blood draws, without the guardian being informed. On one occasion, the resident refused a BMP draw, and although the resident was educated about the purpose, the refusal persisted, and the guardian was not notified. Similarly, when the resident's blood glucose level spiked to 501, the primary care provider was informed, but the guardian was not. Additionally, the resident sustained a minor injury during a transfer, which was also not communicated to the guardian. Interviews with facility staff, including the Assistant Director of Nursing, Licensed Practical Nurse, and Director of Nursing, revealed a lack of clarity and communication regarding the notification process for Resident #7's guardian. The guardian expressed a desire to be involved in the resident's care and was unaware of the refusals and changes in condition until visiting the facility. The facility's policy required notifying the resident's representative of significant changes, but this was not adhered to in Resident #7's case.
Failure to Resubmit PASRR After Change in Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the resubmission of a Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for a resident. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was diagnosed with several mental health conditions, including major depressive disorder, anxiety disorder, and psychotic disorder. Despite these changes in diagnoses, the facility did not update the PASRR, which was initially exempted in 2019 when the resident did not meet the criteria for serious mental illness or developmental condition. The deficiency was identified through observations, clinical record reviews, and staff interviews. The Director of Nursing and the Social Services Director (SSD) acknowledged the oversight, with the SSD confirming that a new PASRR should have been submitted following the new diagnoses. The facility lacked a policy for PASRR submission and did not have procedures in place to audit for missing PASRRs. The Administrator noted that the oversight occurred during a staff transition period, and the new diagnoses were not communicated effectively within the team.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, who required dialysis services. The resident, identified with moderate cognitive loss, had a care plan that included dialysis sessions three times a week. The facility's records indicated an order for vital signs to be taken before and after dialysis sessions. However, there were multiple instances where post-dialysis vital signs were not documented, specifically on four occasions in October and November 2024. Interviews with staff revealed that the post-dialysis assessments were supposed to be documented on a dialysis communication sheet or in the electronic health record. However, these assessments were missing from both the communication records and the electronic health record for the specified dates. The Director of Nursing acknowledged that if the assessments were not documented, they were likely not performed. The facility did not have a specific dialysis assessment policy in place, which contributed to the oversight in documentation.
Inaccurate MDS Coding for Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents regarding their tobacco use status. Resident #49, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was documented in the MDS as not utilizing tobacco. However, multiple sources, including a Smoke Safety Evaluation, progress notes, and interviews with the resident and staff, confirmed that Resident #49 was a smoker and regularly participated in smoking breaks. Similarly, Resident #18, with a BIMS score indicating moderate cognitive impairment, was also inaccurately documented in the MDS as not using tobacco. Interviews with the resident and staff confirmed that Resident #18 was a current smoker who smoked in designated areas with supervision. The Director of Nursing (DON) and the MDS Coordinator acknowledged the inaccuracies in the MDS coding for both residents. The DON expressed confusion over the incorrect coding, while the MDS Coordinator admitted the errors and indicated plans to submit corrections. The facility's Administrator noted that a recent audit of the MDS for smoking should have ensured correct coding, but discrepancies were still present. The facility's reliance on the Resident Assessment Instrument (RAI) for MDS coding was mentioned, but no specific MDS policy was in place. The errors were in violation of federal regulations requiring that assessments accurately reflect residents' statuses.
Failure to Prevent Resident Elopement and Injury
Penalty
Summary
The facility failed to prevent the elopement of a severely cognitively impaired resident identified at risk for wandering. The resident, who had a history of paranoid personality disorder, schizophrenia, and vascular dementia, exited the facility through a series of doors that were not properly secured or alarmed. The resident was last seen by staff standing in his doorway before being found outside the facility without shoes. The doors the resident used to exit were not alarmed to alert the nursing home section, and the lock on the door to the assisted living portion of the facility had not reengaged, allowing the resident to exit unnoticed. The resident had a documented history of wandering and agitation, with multiple notes in the clinical record indicating frequent pacing, entering other residents' rooms, and being easily redirected. Despite these behaviors, the resident was not in a locked unit, and the facility's interventions, such as the use of a Wander Guard, were insufficient to prevent the elopement. Staff interviews revealed that the resident was known to wander and that the alarms on the doors were not consistently functioning or monitored, contributing to the resident's ability to leave the facility. Additionally, the facility failed to adhere to the care plan for another resident who was dependent on a mechanical lift. This resident was lifted using a non-mechanical method, resulting in skin tears and bruising. The facility's lack of adherence to care plans and failure to maintain a secure environment for residents at risk of elopement and injury led to the identification of immediate jeopardy to the health and safety of the residents.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative upon transfer to the hospital, as required by state and federal guidelines. Resident #11, who was cognitively intact with a BIMS score of 12 out of 15 and had diagnoses including Coronary Artery Disease, Heart Failure, and Renal Insufficiency, was transferred to the hospital for intravenous antibiotic treatment for a urinary tract infection. Upon review, the clinical record lacked documentation of a bed hold notice being given to the resident or their representative. Interviews with facility staff, including a Registered Nurse (RN), the Administrator, and the Director of Nursing (DON), revealed that the nurse responsible for sending the resident to the hospital should review the Bed Hold Policy with the resident or family within 24 hours of the transfer. However, the RN admitted to never having filled out the bed hold form and was unsure if it should be documented in the electronic medical record. The Administrator and DON confirmed the policy but could not explain why it was not completed for Resident #11, with the DON noting she was on medical leave at the time.
Failure to Accurately Code Medications on MDS
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Sets (MDS) for two residents, leading to deficiencies in their assessments. Resident #33, who was cognitively intact with a BIMS score of 15, had diagnoses of Atrial Fibrillation, Heart Failure, and Diabetes Mellitus. Despite having physician orders for torsemide, a diuretic, and temazepam, a hypnotic, these medications were not coded on the MDS. Observations and interviews confirmed the resident's use of these medications, yet the Assistant Director of Nursing (ADON) and Director of Nursing (DON) could not explain the omission. Similarly, Resident #38, also cognitively intact with a BIMS score of 15, was on anticoagulant therapy with Xarelto, as indicated in the care plan and physician orders. However, the MDS lacked documentation of this anticoagulant medication. Interviews with the ADON and DON confirmed the resident's use of Xarelto and acknowledged that it should have been coded on the MDS. The facility did not have a specific policy for MDS, relying instead on the guidelines of the RAI Manual.
Failure to Update Care Plan for Smoking Resident
Penalty
Summary
The facility failed to update the care plan for Resident #48 to include smoking as a focus area and necessary interventions to ensure safety. Resident #48, identified as cognitively intact with a BIMS score of 15, has a history of smoking and was observed smoking in the designated area under supervision. Despite a Smoking Safety Evaluation Form indicating Resident #48 as a smoker with balance issues, the care plan last revised did not reflect this information. The resident's smoking habit had been known for at least six months, yet the care plan was not updated accordingly. Interviews with staff revealed that the MDS Coordinator, who recently assumed the role, was responsible for updating care plans. However, any nurse could update them. The facility's smoking policy requires that smoking be addressed in care plans, with interventions such as supervised smoke breaks and secure storage of smoking paraphernalia. Despite these requirements, the care plan for Resident #48 did not include these interventions, indicating a lapse in adherence to the facility's policy.
Failure to Follow Hand Hygiene Protocols in Laundry Handling
Penalty
Summary
The facility failed to adhere to standard hand hygiene precautions for infection control when handling soiled laundry. During an observation, a housekeeping staff member, identified as Staff O, was seen using her bare hands to transfer soiled laundry from a garbage bag into a washing machine without wearing gloves. This incident involved dirty clothing protectors from residents. After handling the soiled laundry, Staff O did not perform hand hygiene, such as washing her hands, before leaving the laundry room. Interviews with the facility's Administrator and the Infection Control and Preventionist revealed that staff are expected to use appropriate personal protective equipment (PPE), including gloves, when handling soiled laundry. The facility's policy mandates hand hygiene before and after glove use and after handling contaminated items. Staff O acknowledged her failure to follow these procedures, admitting she forgot to wear gloves and did not wash her hands before leaving the laundry room. The facility's hand hygiene policy, dated April 28, 2022, outlines the importance of hand hygiene in preventing healthcare-associated infections and specifies when it should be 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 Mount Pleasant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Place | 1 mi | ★★★★★ | 1 | 0 |
| Savannah Heights | 1.2 mi | ★★★★★ | 4 | 0 |
| New London Specialty Care | 8.2 mi | ★★★★★ | 6 | 0 |
| Sunrise Terrace Nursing & Rehabilitation Center | 11.7 mi | ★★★★★ | 0 | 0 |
| Parkview Home | 13.6 mi | ★★★★★ | 0 | 0 |
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