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 Woodlands The during CMS and state inspections, most recent first.
A staff member did not report a suspected abuse incident involving a cognitively impaired resident who was combative and refused medication. An LPN, after being unable to administer medication, handed over the task to an RN and a QMA, who entered the resident's room and closed the door. The resident was heard yelling in protest, and the QMA later stated they managed to administer some medication despite resistance. The LPN did not report the incident, and facility leadership was unaware until interviewed, in violation of the facility's abuse reporting policy.
The facility removed seating and furniture from common areas, including the nurses' station and TV lounge, disrupting residents' established routines and preferred gathering spaces. Staff and family members reported increased confusion, stress, and a rise in falls among residents with cognitive impairments following these changes. The actions were taken without soliciting staff feedback and did not align with care plans emphasizing consistent routines for residents with dementia.
A resident with Alzheimer's disease and moderate cognitive impairment was involuntarily secluded when a DDCS directed her to sit alone in the activities room, deviating from her usual routine of sitting near the nurse's station. The resident became confused and distressed by the unexplained change, and staff observed her emotional upset before assisting her back to a communal area.
A cook at the facility was observed engaging in unsanitary food handling practices, including using the same gloves to touch various surfaces and food items, potentially impacting all 69 residents receiving meals. Despite washing hands and changing gloves, the cook continued to contaminate food by touching meal tickets, countertops, and food items with soiled gloves. The cook admitted to not following proper food handling procedures.
The facility failed to manage funds for two residents using acceptable accounting principles. Envelopes with money were improperly stored in the medication room, and hand-written money logs were found in the narcotic reconciliation book. The residents had a history of misplacing money, and the Business Office Manager was unaware of the nursing-controlled logs. The facility lacked a policy for keeping resident funds outside the trust.
A resident at risk for pressure ulcers did not have the prescribed low air loss mattress in place, despite ongoing pain and a care plan indicating its necessity. Staff interviews confirmed the absence of the mattress, and the clinical record lacked documentation for this oversight, violating the facility's policy on skin integrity and pressure ulcer prevention.
The facility failed to properly label and dispose of insulin pens on the Hickory Hall 2 medication cart. An undated NovoLog Flexpen and an expired lispro KwikPen were found during an observation. The LPN acknowledged the error, noting that insulin should be dated when opened and is only good for 28 days. The DON confirmed the expectation for staff to date and check insulin pens to prevent expired medication use. Nine diabetic residents were affected by this oversight.
The facility failed to follow infection control practices during medication administration for two residents, as an LPN did not perform hand hygiene or use gloves. Additionally, the facility did not implement enhanced barrier precautions for a resident with a wound and urinary catheter, as staff did not wear gowns or follow EBP protocols. The facility's policy required EBP for residents with wounds or indwelling devices, but staff were unaware and did not implement these precautions.
The facility failed to consistently update the daily nurse staffing information, as required by policy. Observations showed that the staffing boards were not updated on multiple occasions, displaying outdated information. The DON, responsible for this task, acknowledged the oversight due to the recent addition of this responsibility and the absence of a scheduler.
The facility failed to employ a qualified Food Services Director, impacting all 70 residents. The director, employed since 2020, lacked necessary certifications and qualifications. The Assistant Dietary Manager was also not certified, and the Registered Dietician visited only weekly. Facility policy requires a qualified individual to oversee food services, which was not met.
A resident's morphine medication was misappropriated by an LPN, who admitted to taking the pills due to personal stress. The incident was discovered during a shift change medication count, and the resident was assessed for pain but reported no concerns. The facility initiated an investigation, and the LPN was suspended and later terminated.
The facility failed to ensure anti-depressant and mood stabilizer medications were not started without proper indication for a resident diagnosed with dementia and agitation. Following an incident where the resident allegedly pushed another resident, the facility prescribed Depakote and Celexa without adequate documentation or non-pharmacological interventions, contrary to their policy on unnecessary medication.
Failure to Report Suspicion of Abuse for Cognitively Impaired Resident
Penalty
Summary
A staff member failed to report a suspicion of abuse involving a resident with severe cognitive impairment. The incident occurred when an LPN was unable to administer medication to the resident, who was combative and refused the medication. The LPN informed an RN of the situation, who, along with a QMA, took over the medication administration. The QMA and RN entered the resident's room, closed the door, and the resident was heard yelling that she did not want the medication. Afterward, the QMA reported that they were able to get some medication into the resident, despite her fighting and spitting it out. The LPN did not witness the interaction but did not report the incident to facility leadership. The facility's abuse policy required any staff member with a suspicion of abuse or mistreatment to immediately notify the Executive Director. However, the LPN did not report the incident, and facility leadership, including the Regional President, Regional Clinical Director, and DON, were unaware of the event until the survey interview. This failure to report delayed the initiation of an investigation and notification to the appropriate agencies, as required by facility policy.
Failure to Support Resident Choice and Routine by Removing Common Area Seating
Penalty
Summary
The facility failed to honor and support resident self-determination and choice by removing furniture from common areas, including the nurses' station, dining room, activities room, and TV lounge, which had previously served as gathering spaces for residents. The Divisional Director of Clinical Services (DDCS) directed staff to return residents to their rooms after meals or activities and discouraged them from gathering at the nurses' station. Staff reported that these changes caused confusion and stress among residents, as they were accustomed to using these areas for socialization and rest. The removal of seating also led to residents being redirected when they attempted to move chairs to their preferred locations. Multiple staff interviews indicated that the changes disrupted established routines and increased resident confusion. Certified Nursing Assistants (CNAs) observed that residents viewed the area around the nurses' station as a communal living space and that the lack of seating caused distress. The previous Director of Nursing (DON) and other staff noted an increase in falls following the removal of seating, particularly among residents who were known to rest at the nurses' station after meals. The clinical records of four residents with cognitive impairments, histories of falls, and other medical conditions documented falls occurring in their rooms after the changes were implemented. Care plans for these residents emphasized the importance of consistent routines and environments to reduce confusion. Interviews with family members and staff further confirmed that the removal of furniture negatively impacted residents' ability to socialize and maintain their routines. The Regional Director of Clinical Services (RDCS) and DDCS acknowledged that the changes were part of a pilot project to encourage engagement with activity stations, but admitted they had not solicited or followed up on staff feedback regarding the impact of these changes. Facility policy reviewed during the survey affirmed residents' rights to self-determination and a dignified existence, which were not upheld in this instance.
Involuntary Seclusion of Resident Due to Unexplained Change in Routine
Penalty
Summary
A resident with Alzheimer's disease, severe protein-calorie malnutrition, and a history of stroke was involuntarily secluded when the Divisional Director of Clinical Services (DDCS) directed her into the activities room, left her alone, and did not provide an explanation for the change from her usual routine. The resident, who had moderate cognitive impairment and was accustomed to sitting outside the nurse's station as part of her preferred daily activities, was found confused and distressed by the change, expressing concern about what she had done wrong and whether she was in trouble. Staff members observed the resident's confusion and emotional distress, and one CNA eventually assisted her back to a communal area with other residents. The facility's care plan for the resident emphasized maintaining a consistent routine due to her cognitive impairment. The facility's policy, as reviewed, prohibits involuntary seclusion and requires residents to be free from such practices. The DDCS indicated a preference for not having chairs around the nurse's station due to fall risks but did not provide a specific reason to the resident for the change in her routine or her placement in the activities room alone.
Unsanitary Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure food was prepared and served using safe sanitary food preparation and handling methods, potentially impacting all 69 residents who received meals from the kitchen. During lunch meal preparation and service, a cook was observed engaging in several unsanitary practices. The cook touched the refrigerator door with gloved hands, then used the same gloves to handle hot dogs and plates. She also used her gloved hands to adjust her clothing before continuing to handle food items. The cook washed her hands and donned new gloves but continued to engage in unsanitary practices by touching meal tickets, countertops, trays, lids, and utensil handles with the same gloves. She then left the meal service area, retrieved a bag of hot dog buns, and handled the buns and hot dogs with the same soiled gloves. The cook continued to touch various food items, including hamburger buns and tartar sauce packets, with contaminated gloves. During an interview, the cook acknowledged that she was not supposed to handle or serve food with her gloved hands, indicating a lack of adherence to the facility's safe food handling policy.
Improper Management of Resident Funds
Penalty
Summary
The facility failed to manage resident funds using acceptable accounting principles for two residents. During observations, it was noted that small labeled and dated envelopes containing dollar bills were left in plain view on a storage shelf in the medication room. These envelopes were labeled with the names of two residents and dated from previous months. Additionally, hand-written money logs for these residents were found in the narcotic reconciliation book. Interviews revealed that these logs and envelopes were interventions put in place by the business office due to the residents' history of misplacing money. The clinical records of the two residents indicated that both had a history of misplacing personal items and required money for personal use during offsite hours and weekends. Despite having signed Resident Fund Management Service agreements, their funds were improperly stored in the medication storage room. The Business Office Manager was unaware of the money logs controlled by nursing, and the facility lacked a policy regarding the keeping of resident funds outside the trust. The facility's Resident Trust Policy and Procedures outlined the proper management of resident funds, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement preventative interventions for a resident at risk for pressure ulcers. The resident, who was cognitively intact and dependent on staff for various activities, was observed in a wheelchair and later in bed without the prescribed low air loss mattress. Despite having an order for an airflow mattress and a care plan indicating the need for a pressure-reducing device, the resident's bed was equipped with a standard mattress. The resident reported ongoing pain in the buttocks, and a hydrocolloid dressing was applied to a skin impairment that had healed and then reopened due to friction and shear. Interviews with staff, including an LPN and a Corporate Nurse Consultant, confirmed that the low air loss mattress was not in place as ordered, and there was no documentation explaining its absence. The facility's policy on skin integrity and pressure ulcer prevention was not adhered to, as the clinical record lacked an order to ensure the mattress was in place and functioning. The deficiency was identified through observations, record reviews, and staff interviews, highlighting a failure to follow the care plan and implement necessary interventions to prevent pressure ulcers.
Failure to Properly Label and Dispose of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin pens on the Hickory Hall 2 medication cart. During an observation, it was found that a NovoLog Flexpen with 10 units remaining was undated, and a lispro KwikPen, which was dated, had expired with 185 units remaining. The LPN present during the observation acknowledged that insulin should be dated when opened and is only good for 28 days. The expired lispro insulin should not have been administered to residents. There were nine diabetic residents receiving medication from this cart. The Director of Nursing confirmed that the facility's expectation is for staff to date all insulin pens and vials upon opening and to check these dates before each use to ensure they are not expired. The facility's policy, as provided by the Administrator, states that medications should be dated when opened and discarded according to manufacturer guidelines, specifically within 28 days for multi-dose vials unless otherwise specified. This oversight in medication management could potentially impact the care of diabetic residents relying on these medications.
Infection Control Deficiencies in Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. During an observation, an LPN did not perform hand hygiene after administering nasal sprays and insulin to a resident. The LPN also failed to don gloves during these procedures, which was against the facility's policy. The LPN acknowledged the oversight during an interview, and the Director of Nursing confirmed that gloves and hand hygiene were required for these procedures. In another instance, the facility did not implement enhanced barrier precautions (EBP) for a resident with a wound and an indwelling urinary catheter. The resident's clinical record lacked an order for EBP, and the care plan did not include interventions for EBP. During a wound care observation, staff did not wear gowns or follow EBP protocols, despite the resident having a wound and a urinary catheter. Interviews with staff revealed a lack of awareness and implementation of EBP for residents with wounds or indwelling devices. The facility's policy on EBP indicated that such precautions should be used for residents with wounds or indwelling medical devices, even if they are not known to be infected with a multi-drug resistant organism. However, the staff did not follow these guidelines during the care of the resident. The staff development coordinator and other staff members acknowledged the absence of EBP signs and PPE canisters, which are required to indicate the need for enhanced precautions.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily facility census number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily. During observations and record reviews, it was noted that the Nursing Staff Directly Responsible for Resident Care boards were not updated consistently. On multiple occasions, the boards displayed outdated information, failing to reflect the current staffing and census numbers. For instance, on 3/4/25 and 3/5/25, the boards were not updated until later in the day, showing incorrect staffing information from previous days. Interviews revealed that the Director of Nursing (DON) was responsible for updating the staffing information daily, a task recently added to her responsibilities due to the absence of a scheduler. The DON acknowledged the oversight, indicating that she tried to update the information before leaving work on Fridays to cover the weekend but missed updates on certain days. The facility's policy requires that nurse staffing information be posted daily at the beginning of each shift in a prominent place accessible to residents and visitors, which was not adhered to in this instance.
Facility Lacks Qualified Food Services Director
Penalty
Summary
The facility failed to employ a qualified Food Services Director, which had the potential to impact all 70 residents. The Food Services Director had been employed since August 2020 and assumed the director position in May 2022. However, she was not a Certified Dietary Manager nor ServSafe Management certified, lacking the required qualifications for her role. The Administrator acknowledged that the Food Services Director had enrolled in a dietary manager program but failed to obtain certification, although she had re-enrolled. The Assistant Dietary Manager also lacked ServSafe Management certification, and the Registered Dietician only visited the facility once a week. The facility's policy, revised in April 2024, mandates that the Food and Nutrition Services department be directed by a qualified individual with the necessary competencies and skills. In the absence of a full-time dietician, a qualified person should be designated to oversee the department with regular consultations from a dietician. Despite this policy, the facility did not have a qualified individual in the Food Services Director role, as confirmed by the Administrator during the survey conducted from February 4 to February 6, 2025.
Misappropriation of Resident's Medication by LPN
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication, specifically involving Resident C. During a shift change, it was discovered that two morphine sulfate IR 15 mg tablets were missing from Resident C's medication supply. LPN 5 later admitted to taking the medication, citing personal stress as the reason for ingesting the pills at home. The incident was reported to the local police, and an investigation was initiated immediately. Resident C, who had diagnoses including intervertebral disc degeneration, pain, and malignant neoplasm of the liver, was assessed for any signs of distress or pain following the incident and denied any concerns. The resident's clinical records indicated a physician's order for morphine sulfate 15 mg to be administered as needed for pain, which was discontinued on the day of the incident. The resident was discharged home with all remaining morphine tablets on the same day. The facility's investigation involved verifying the medication count by additional nurses, notifying the DON and Administrator, and conducting a urine drug screen on LPN 5, which tested positive for opiates. The facility's policy on abuse and misappropriation of resident property was reviewed, highlighting the definition of misappropriation as the wrongful use of a resident's property without consent. LPN 5 was suspended and subsequently terminated following the investigation.
Inappropriate Initiation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that anti-depressant and mood stabilizer medications were not started without proper indication for use for Resident D. Resident D, who was diagnosed with unspecified dementia with agitation, anxiety disorder, insomnia, and depression, was involved in an incident where he allegedly pushed a female resident, resulting in her being sent to the emergency room. Following the incident, Resident D was placed on one-on-one supervision, and psychiatric services were contacted. Despite the lack of clear documentation indicating the necessity for the medications, Resident D was prescribed Depakote and Celexa shortly after the incident. Resident D's clinical records and care plans indicated that he was severely cognitively impaired and exhibited territorial behavior, particularly over a table and its contents. Multiple behavior notes documented his agitation and verbal aggression towards other residents, but there was no clear evidence of physical aggression prior to the incident. Interviews with staff members, including the Social Service Director, CNAs, and the DON, revealed that Resident D was generally grumpy and territorial but had not shown prior physical aggression. The decision to prescribe Depakote and Celexa was made without adequate documentation of the underlying condition or non-pharmacological interventions. The psychiatric nurse practitioner and the Medical Director both indicated that the medications were prescribed to manage Resident D's behaviors and prevent further incidents. However, the facility's policy on unnecessary medication requires documentation of adequate indications for medication use and the implementation of non-pharmacological approaches before initiating pharmacological treatment. The facility's failure to adhere to this policy resulted in the inappropriate initiation of psychotropic medications for Resident D without proper indication or documentation.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Nursing homes near Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Edge Village | 1.2 mi | ★★★★★ | 5 | 0 |
| Brickyard Healthcare - Muncie Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Bethel Pointe Health And Rehab | 1.7 mi | ★★★★★ | 4 | 0 |
| Morrison Woods Health Campus | 2.4 mi | ★★★★★ | 0 | 0 |
| Westminster Village Muncie Inc | 2.6 mi | ★★★★★ | 10 | 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.