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 Applewood Nursing Center, Inc during CMS and state inspections, most recent first.
The facility failed to maintain an adequate emergency food supply, using it as part of the daily food stock. Essential items like canned beans, tuna, and chicken were missing from the emergency menu. The FSD could not specify the required inventory levels, and the NHA acknowledged the deficiency without providing further documentation.
The facility failed to maintain a clean environment for two residents with tube feeding systems, resulting in soiled tube feeding poles and areas around the residents. The DON stated that all staff were responsible for cleaning spills, but the deficiency was not addressed until after surveyors' observations.
A resident with multiple sclerosis and a leaking indwelling urinary catheter experienced worsening and infection of a sacral Stage 4 pressure ulcer due to the facility's failure to address the catheter issue. Despite awareness of the problem, the facility did not ensure the resident received a necessary urology appointment, which was canceled due to insurance issues. The facility's care plans and policies did not adequately address the situation, leading to a lack of timely intervention.
A resident with multiple sclerosis and a neurogenic bladder experienced a chronic leaking foley catheter, contributing to a sacral wound reopening. Despite awareness of the issue, the facility delayed scheduling a urology appointment due to insurance problems, and staff acknowledged the catheter's role in the wound's infection and stalled healing. The facility's policy on catheter care was not followed, and the nursing home administrator admitted responsibility for the delayed appointment.
A resident's catheter bag was left uncovered and visible from the hallway, compromising their dignity and privacy. The resident, who has intact cognition and a medical history of obstructive and reflux uropathy, expressed discomfort about the situation. A CNA and the DON acknowledged that catheter bags should be covered to maintain dignity, as per facility policy.
A facility failed to update care plans for a resident with a PEG tube, leading to multiple hospital admissions for tube reinsertion. The resident, with conditions such as hemiplegia and dysphagia, had no care plans addressing tube manipulation or fluid restrictions. Despite multiple hospital transfers, the care plan was not revised, and the Director of Nursing acknowledged the oversight without explanation.
A resident with a PEG tube experienced multiple hospital transfers due to tube dislodgement and blockage. Despite being cognitively intact and requiring assistance with ADLs, the facility failed to implement timely interventions to prevent these issues. The DON was unaware of specific measures to address the problem, and an abdominal binder was not considered until after several hospitalizations. No psychiatric consultation was sought despite concerns about the resident's behavior.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness. Staff members were observed not using hand barriers after washing hands, and hot food items were not held at required temperatures. Additionally, staff did not wash hands before donning gloves after handling various surfaces and food items.
The facility failed to post appropriate isolation directions for a resident with C. Diff and staff did not follow proper contact precautions, including the use of PPE and handling of contaminated items.
The facility failed to ensure dignity for four residents by serving meals with plastic ware and styrofoam containers. Observations and interviews revealed that residents received meals with improperly positioned domes or uncovered food, and expressed concerns about the use of plastic utensils and lack of proper food covering. The Certified Dietary Manager was unaware that this was a dignity concern.
The facility failed to ensure proper nail care and provide appropriate briefs for incontinence care, resulting in unmet hygiene needs and residents being left soiled for extended periods. One resident had long, dirty fingernails and self-inflicted scratches, while others reported a consistent shortage of appropriate-sized briefs, leading to prolonged periods of being left wet and soiled. Staff confirmed the inconsistency in the availability of briefs, despite regular orders.
The facility failed to ensure meals were served at a preferred and palatable temperature for four residents, resulting in complaints of cold food and dissatisfaction with meals. Meals were observed being delivered without domes or coverings, and the Certified Dietary Manager was unaware of the complaints.
The facility failed to maintain the garbage storage area in sanitary conditions, with exterior trash dumpsters observed with open lids and bagged trash and debris present. Both the Environmental Services Director and Dietary Manager acknowledged the issue, indicating a lack of proper oversight and maintenance.
The facility failed to ensure the confidentiality of residents' electronic medical records. Observations revealed that two residents' records were visible on medication cart computer screens with no nurse in attendance. Interviews with staff confirmed that this was against the facility's policy, which requires computer terminals to be shut off when not in use.
The facility failed to maintain a clean and clutter-free environment for two residents, resulting in soiled and cluttered rooms. One resident's room had a soiled curtain and fall mat, while another resident's room was cluttered with various items and had a sticky substance attracting gnats. Staff acknowledged the issues but did not take immediate action.
The facility failed to ensure PASARR forms for Mental Illness/Intellectual Disability/Related Conditions were reviewed, revised, and sent for annual evaluation for two residents. One resident had diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder, while the other had a diagnosis of bipolar disorder. The Social Service Director and Director of Nursing admitted to not following up on the evaluations.
The facility failed to secure two medication carts, leaving them unlocked and unattended, with medications accessible. Interviews confirmed that medication carts should be locked when not attended by nursing staff, as per facility policy.
The facility failed to ensure that a resident's foley catheter tubing did not drag along the floor during ambulation in a wheelchair. Despite staff adjustments, the tubing remained on the floor, posing a risk of getting trapped under the wheelchair wheel. Interviews with the Unit Manager and DON confirmed that the tubing should not have been on the floor, indicating a lapse in proper catheter care and monitoring.
A facility failed to implement a skin care plan for a resident with discitis and moderate risk for skin breakdown upon admission. The resident had redness on the buttocks and required extensive assistance with mobility, necessitating a skin care plan. Despite these needs, no baseline care plan was established, as confirmed by the DON.
The facility failed to consistently administer wound care treatments for a resident with idiopathic scoliosis and muscle weakness, leading to a deficiency in pressure ulcer care. Observations and interviews revealed discrepancies in the documentation and administration of wound care treatments, with missed administrations on multiple dates and incorrect dating of dressings. The DON acknowledged that treatments not signed off would be considered not done, highlighting a failure in adhering to the facility's wound care policy.
Inadequate Emergency Food Supply in Facility
Penalty
Summary
The facility failed to maintain an adequate supply of emergency food, as evidenced by the absence of several items listed on their emergency menu. During an observation and interview with the Food Service Director (FSD), it was revealed that the facility was using its emergency food stock as part of its daily food supply. The emergency food supply, which should consist of canned and shelf-stable items, was stored in the dry food storage room. However, upon review, it was found that essential items such as canned kidney beans, green beans, tuna, beets, chicken, carrots, ravioli, and waxed beans were missing from the emergency stock for the first three days of the emergency menu. The facility's emergency menu, dated 2019, outlines the requirement for a plan to provide subsistence for all persons in the event of an emergency, utilizing shelf-stable items that do not require refrigeration or cooking. The document also specifies that the emergency stock should be inventoried routinely, with items below par level replenished and those nearing expiration replaced. Despite these guidelines, the FSD was unable to provide information on the minimum inventory levels required for the emergency stock. The Nursing Home Administrator acknowledged the deficiency, stating that the facility should have maintained an emergency food supply that aligns with the menu. No additional documentation or information was provided during the exit conference to address this deficiency.
Failure to Maintain Clean Environment for Residents with Tube Feeding
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents, resulting in an unclean and unsanitary environment. Observations revealed that both residents had tube feeding systems that were not properly maintained. One resident was observed with a tube feeding pole and base, a fall mat, and the floor heavily soiled with encrusted tube feeding formula. Another resident's tube feeding pole and base were also soiled with dried formula. The Unit Manager, RN C, acknowledged the unacceptable condition, noting that the dried formula appeared to have been present for an extended period. The Director of Nursing (DON) stated that it was the responsibility of all staff to keep the tube feeding poles clean and that nurses should clean any spillage they observe. However, the DON also mentioned that housekeeping was responsible for cleaning spots on the wall and spills, which should include cleaning the tube feeding poles. Despite these responsibilities, the deficiency was not addressed until after the surveyors' observations, and no additional documentation or information was provided by the Nursing Home Administrator or DON during the exit conference.
Failure to Address Leaking Catheter Leads to Worsening Pressure Ulcer
Penalty
Summary
The facility failed to implement necessary interventions for a resident with a chronic leaking indwelling urinary catheter, which contributed to the worsening and infection of a sacral Stage 4 pressure ulcer. The resident, who had multiple sclerosis and neuromuscular dysfunction of the bladder, reported issues with the catheter leaking, which was documented in their electronic health record. Despite the resident's need for a urology appointment to address the catheter issue, the appointment was canceled due to a lack of insurance, and the resident's condition worsened as a result. Observations and interviews revealed that the resident's catheter had been leaking for several months, and the facility staff, including a registered nurse and licensed practical nurses, were aware of the issue. The leaking catheter was identified as a contributing factor to the resident's wounds not healing and becoming infected. Despite this knowledge, the facility did not take timely action to address the catheter issue or ensure the resident received the necessary medical evaluation. The facility's care plans and policies did not adequately address the resident's leaking catheter, and there was a lack of coordination to resolve the insurance issue and reschedule the urology appointment. Interviews with facility staff, including the business office manager and the director of nursing, highlighted a breakdown in communication and responsibility, as the facility did not take steps to pay for and reschedule the urology appointment, which was acknowledged as their responsibility.
Failure to Provide Comprehensive Foley Catheter Care
Penalty
Summary
The facility failed to provide comprehensive foley catheter care for a resident, resulting in a chronic leaking catheter and concerns about a sacral wound reopening. The resident, who has multiple sclerosis and a neurogenic bladder, was observed with a leaking catheter and reported that it had contributed to the reopening of a sacral wound. The resident's electronic health record indicated a history of pressure ulcers and a need for extensive assistance with bed mobility. Despite the resident's ongoing issues with the catheter, a scheduled urology appointment was canceled due to insurance issues, and the resident was not seen by a urologist for several months. Interviews with facility staff, including a registered nurse, a licensed practical nurse, and the business office manager, revealed that the facility was aware of the resident's leaking catheter and the insurance issues preventing a urology visit. The staff acknowledged that the leaking catheter contributed to the wounds not healing and becoming infected. The facility's policy on indwelling catheter care indicated that catheters should be changed upon clinical indication of infection or obstruction, but this was not adhered to in the resident's case. The nursing home administrator agreed that it was the facility's responsibility to schedule and pay for the urology appointment, which was eventually scheduled months later.
Failure to Maintain Catheter Bag Privacy
Penalty
Summary
The facility failed to maintain catheter bag privacy for a resident, identified as R411, which compromised their dignity and privacy. On multiple occasions, R411's catheter bag was observed hanging on the side of the bed, clearly visible from the hallway and to passersby, without a privacy bag. This visibility was noted at different times on the same day, and the resident expressed discomfort and embarrassment about the situation, especially in the presence of visitors. R411's medical history includes obstructive and reflux uropathy and obesity, and they have intact cognition as indicated by a BIMS score of 15/15. A Certified Nursing Assistant acknowledged the lack of a privacy bag and confirmed that catheter bags should be covered to maintain resident dignity. The facility's Director of Nursing also stated that the expectation is for catheter bags to be covered by a privacy bag, in line with the facility's policy on indwelling catheter care and maintenance.
Failure to Revise Care Plans for Resident with Tube Feeding
Penalty
Summary
The facility failed to develop, implement, and revise care plans for a resident with a tube feeding, resulting in multiple hospital admissions for PEG tube reinsertion. The resident, who was admitted with diagnoses including hemiplegia, vascular dementia, dysphagia with a J/G tube, end-stage renal disease, and hypotension, was cognitively intact and required assistance with activities of daily living. Despite being NPO and receiving tube feeding for nutritional needs, the care plan did not address the resident's behavior of manipulating the PEG tube or the fluid restrictions for enteral feeding and water flushes. Additionally, there were no interventions to reduce the frequency of hospital transfers for PEG tube care. The care plan, dated several months prior, focused on the risk of aspiration due to dysphagia and noncompliance with head-of-bed positioning but had not been updated or revised following the resident's multiple hospital transfers. The Director of Nursing acknowledged the oversight in revising the care plans after each hospital transfer but did not provide an explanation for the lack of identification of this issue as a concern. The facility's care plan policy indicated that any member of the interdisciplinary team could request a special care conference if an issue needed to be addressed, but this was not done in this case.
Failure to Prevent PEG Tube Dislodgement
Penalty
Summary
The facility failed to implement timely interventions to prevent the dislodgement and manipulation of a percutaneous enteral gastrostomy (PEG) tube for a resident, resulting in multiple hospital transfers. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of hemiplegia, vascular dementia, and was NPO, receiving nutrition through a tube. Despite repeated hospitalizations for PEG tube dislodgement and blockage, the facility did not effectively address the issue. The resident was transferred to the hospital on multiple occasions over several months for the same problem, indicating a lack of adequate intervention. Interviews and record reviews revealed that the facility's Director of Nursing (DON) was unaware of specific interventions to prevent the resident from manipulating or dislodging the feeding tube. Although the use of an abdominal binder was eventually considered, it was not implemented until after numerous hospital transfers. The facility's investigation into the issue did not provide a clear explanation for the delay in addressing the problem, and there was no evidence of a referral for psychiatric consultation despite concerns about the resident's behavior. The facility's failure to implement effective interventions led to repeated hospitalizations for the resident.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to an increased potential for cross-contamination of food and foodborne illness. Multiple staff members, including dietary aides and the dietary manager, were observed not using a hand barrier to shut off the faucet after washing their hands. This was observed on several occasions, and the facility's hand hygiene policy did not detail the expectations for staff working with food. The U.S. Public Health Service 2017 Food Code specifies the need for using disposable paper towels or similar clean barriers to avoid recontaminating hands, which was not followed by the staff in this facility. During a facility tour, it was observed that hot food items were not held at the required temperatures. Scrambled eggs and hashbrowns were found holding at temperatures below the minimum hot holding requirement of 135 degrees F. The dietary manager acknowledged the issue but did not provide an immediate solution. Additionally, during meal service, a dietary aide was observed not taking temperatures before serving, and the dietary manager had to intervene to check the temperatures, which were found to be below the required levels. Furthermore, staff members were observed not washing their hands before donning gloves after handling various surfaces and food items. This was observed multiple times with different staff members, including dietary aides and the cook. The facility's policies did not detail the hand hygiene expectations for staff working with food, and the U.S. Public Health Service 2017 Food Code specifies the need for handwashing before engaging in food preparation and before donning gloves, which was not adhered to by the staff in this facility.
Failure to Follow Isolation Protocols for C. Diff Resident
Penalty
Summary
The facility failed to post the appropriate directions for isolation care for a resident (R32) who was in isolation for Clostridium Difficile (C. Diff). On observation, a sign titled Enhanced Barrier Precautions was posted on R32's door, which did not align with the physician's order for Contact Isolation. The Infection Preventionist acknowledged the discrepancy between the posted sign and the facility's policy for C. Diff isolation, which requires handwashing with soap and water before leaving the isolation room. Additionally, the sign on R32's door incorrectly indicated the use of hand sanitizer instead of soap and water for hand hygiene. Further observations revealed that a Certified Nursing Assistant (CNA) failed to follow proper contact precautions when delivering and removing lunch trays from R32's room. The CNA did not don gloves or a gown before entering the room and did not handle R32's dirty dishes separately from other residents' dishes. The facility's policy for Transmission-Based/Contact Precautions and Clostridium Difficile requires staff to wear gowns and gloves for all interactions with the resident and to use disposable or dedicated patient-care equipment. The Director of Nursing and a Registered Nurse confirmed the need for appropriate PPE use and the proper handling of contaminated items to prevent cross-contamination.
Failure to Ensure Dignity in Meal Service
Penalty
Summary
The facility failed to ensure dignity for four residents on unit 200 by serving meals with plastic ware and styrofoam containers. Observations revealed that residents who ate in their rooms received meals with domes that were not positioned correctly or with food that was not covered during transport. Residents expressed concerns about the use of plastic utensils and the lack of proper food covering, indicating a preference for regular silverware and covered food. One resident mentioned that plastic utensils were not sturdy enough to cut food properly, and another resident noted that they were always the last to be served and had to use plastic ware and paper goods. Interviews with the Certified Dietary Manager revealed that staff sometimes ran out of silverware, but the manager was unaware that this was a dignity concern for the residents. The facility's policy on dignity, revised in April 2024, did not address dietary concerns related to dignity. The observations and interviews highlighted a consistent issue with the use of plastic ware and styrofoam containers, which affected the residents' dining experience and sense of dignity.
Deficiency in Nail Care and Incontinence Supplies
Penalty
Summary
The facility failed to ensure proper nail care and provide appropriate briefs for incontinence care for several residents, resulting in unmet hygiene needs and residents being left soiled for extended periods. Resident R128 was observed with long, dirty fingernails and self-inflicted scratches on the face. The resident confirmed that nail care was only performed during weekly showers, contrary to the Director of Nursing's statement that nail care should occur daily. The care plan for R128 did not address nail care, despite the resident's dependence on staff for all activities of daily living due to moderate cognitive impairment and other medical conditions such as aphasia and cerebral infarction. Resident R25 reported a consistent shortage of appropriate-sized briefs, leading to prolonged periods of being left wet and soiled. The resident and a roommate confirmed that aides often borrowed briefs from other residents, resulting in a lack of supplies when needed. Observations of the supply room and linen cart confirmed the absence of 2X-large and 3-4X-large briefs. The unit clerk responsible for ordering supplies stated that orders were made twice a week, but the amount ordered had not changed, despite the ongoing shortage. R25's medical history includes diabetes, Parkinson's disease, and peripheral vascular disease, and the resident requires assistance for activities of daily living. Other residents, including R15 and R7, also reported issues with the availability of appropriate briefs. R15 described having to use makeshift briefs due to the lack of medium-sized briefs and expressed concern for other residents who could not voice their frustrations. R7 mentioned buying personal briefs due to the facility's shortage and being left wet multiple times. Interviews with staff, including an LPN and the unit clerk, confirmed the inconsistency in the availability of briefs, despite regular orders. The Nursing Home Administrator acknowledged the facility's responsibility to provide adequate supplies and ensure residents are not left wet for extended periods.
Failure to Serve Meals at Preferred Temperature
Penalty
Summary
The facility failed to ensure meals were served at a preferred and palatable temperature for four residents, resulting in complaints of cold food and dissatisfaction with meals. During a breakfast meal observation, residents voiced concerns that their meals were always cold when delivered to their rooms. The meals were observed being delivered without domes or coverings, contributing to the temperature issue. One resident stated there was no place to have meals reheated or warmed, and other residents shared similar concerns. Another resident mentioned that they could no longer receive certain hot food items like hot dogs or hamburgers and resorted to ordering food from outside the facility. During a lunch meal observation, a resident's meal tray was used as a test tray, and the temperatures of the food items were found to be significantly below acceptable levels. The Certified Dietary Manager confirmed that the facility no longer offered hamburgers on the menu and was unaware of the residents' complaints about cold food. The residents involved were all cognitively intact, with a Brief Intellectual Mental Status score of 15/15, indicating they were fully aware of the issue and able to communicate their dissatisfaction clearly.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the garbage storage area was maintained in sanitary conditions, resulting in an increased potential for the harborage and feeding of pests. During a tour of the facility, the surveyor observed exterior trash dumpsters with lids in the open position and a variety of bagged trash and debris in the area. When inquired, the Environmental Services Director acknowledged the issue and mentioned the absence of a waste disposal policy. Similarly, the Dietary Manager was unsure about the state of the area, suggesting a lack of proper oversight and maintenance. The 2017 U.S. Public Health Service Food Code mandates that receptacles and waste handling units for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment, which was not adhered to in this case.
Failure to Ensure Confidentiality of Residents' Electronic Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of residents' electronic medical records for two residents. During an observation on Station Two, one resident's electronic medical record was visible on a medication cart computer screen with no nurse in attendance, allowing any passerby to see the confidential information. Similarly, on Station Three, another resident's electronic medical record was visible on a medication cart computer screen with no nurse in attendance, with approximately 10 residents in the area at the time. Interviews with the Unit Manager and Director of Nursing confirmed that residents' electronic medical records should not be visible to others. The facility's policy on confidentiality, last reviewed in November 2022, states that computer terminals should be shut off when not in use.
Failure to Maintain Clean and Clutter-Free Environment
Penalty
Summary
The facility failed to ensure a clean and clutter-free homelike environment for two residents, resulting in soiled and cluttered resident rooms. Resident R27's room was observed with a soiled curtain divider and a cracked, soiled fall mat. Despite the resident's moderately impaired cognition, the soiled items were not addressed promptly. Housekeeping and environmental staff acknowledged the issues but did not take immediate action to clean or replace the soiled items. The Nursing Home Administrator also agreed that these items should be cleaned or replaced in a timely manner but did not ensure it was done promptly. Resident R88's room was found to be cluttered with soiled clothes, bags of groceries, over-the-counter medications, blankets, shoes, assistive devices, and cardboard boxes. The clutter extended from the entrance of the room to the pathway of the roommate's bed, and a sticky substance on the floor was attracting gnats. Despite being cognitively intact and using a wheelchair, R88 was informed by the Environmental Supervisor that she had to clean the room herself, which she was unable to do. The Environmental Supervisor acknowledged the need for cleaning but did not provide an alternative solution for the storage of clutter.
Failure to Complete PASARR Evaluations
Penalty
Summary
The facility failed to ensure the Preadmission Screening/Annual Resident Review (PASARR) forms for Mental Illness/Intellectual Disability/Related Conditions Identification (DCH-3877) were reviewed, revised, and sent to the local state agency for annual evaluation for a Level II determination for two residents. Resident 7, admitted on 5/25/2018 and most recently readmitted on 1/29/2024, had diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder. A review of Resident 7's electronic medical record did not reveal a Level II evaluation or a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. The Social Service Director admitted that the previous social worker did not request the Level II evaluation after entering the 3877 form and did not follow up when no one came to do the evaluation. Resident 31, admitted and readmitted on unspecified dates, had a diagnosis of bipolar disorder. A review of Resident 31's electronic medical record revealed that a Level II evaluation had not been completed on either admission. The Director of Nursing reported that when the 3877/78 form was submitted on 9/22/2023, she was not aware that a request for evaluation had to be made and did not follow up when a Level II evaluation was not received in a timely manner. The facility's PASARR policy, last revised in 7/2018, needed updating to reflect changes in submitting 3877/78 forms and requesting Level II evaluations.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to provide adequate supervision for two unlocked medication carts out of nine. On 4/30/24 at 6:30 AM, a medication cart on Station Two was observed unlocked and unattended, with medication drawers accessible. On 5/2/24 at 8:45 AM, another unlocked medication cart on Station Three was observed with medications on top of the cart, in an area with approximately 10 residents. Interviews with the Unit Manager and the Director of Nursing confirmed that medication carts should be locked when not attended by nursing staff. The facility's policy on Medication Administration, last reviewed in 11/2021, also states that medication carts should never be left open and unattended.
Failure to Prevent Catheter Tubing from Dragging on Floor
Penalty
Summary
The facility failed to ensure that the foley catheter tubing for a resident did not drag along the floor during ambulation in a wheelchair. On multiple occasions, the resident was observed with the catheter tubing on the floor, including in the dining area and while wheeling independently through the hall. Despite a staff member adjusting the catheter bag, the tubing remained on the floor, posing a risk of getting trapped under the wheelchair wheel. The resident's clinical record indicated cognitive impairment and a need for partial to moderate assistance with activities of daily living, and the care plan documented the presence of an indwelling catheter due to obstructive uropathy. Interviews with the Unit Manager and the Director of Nursing revealed uncertainty about why the tubing was on the floor and confirmed that it should not have been. The Unit Manager mentioned the resident had an anchor but was unsure if the lack of an anchor was the reason for the tubing being on the floor. The Director of Nursing acknowledged that the tubing should never be on the floor, indicating a lapse in proper catheter care and monitoring for the resident.
Failure to Implement Skin Care Plan Upon Admission
Penalty
Summary
The facility failed to implement a skin care plan upon admission for a resident diagnosed with discitis, who was at moderate risk for skin breakdown. Upon admission, the resident had redness on the bilateral buttocks, indicating a need for immediate skin care intervention. The Minimum Data Set (MDS) assessment showed the resident required extensive assistance with bed mobility and transfers, further emphasizing the need for a skin care plan. Despite these indicators, the facility did not establish a baseline care plan for skin integrity at the time of admission. The Director of Nursing acknowledged that a care plan should have been implemented given the resident's condition and risk factors.
Failure to Consistently Administer Wound Care Treatments
Penalty
Summary
The facility failed to consistently administer wound care treatments for a resident, leading to a deficiency in pressure ulcer care. The resident, who had diagnoses of idiopathic scoliosis and muscle weakness, required extensive assistance with Activities of Daily Living (ADLs) and had intact cognition. During a wound care observation, it was noted that the foam dressings on the resident's heels were dated 4/27/24, but the treatment administration record (TAR) indicated that the dressings were applied on 4/28/24. Additionally, there were missed administrations of wound care treatments on multiple dates, including 4/13/24, 4/22/24, and discrepancies in the documentation of wound care on 4/30/24. Interviews with the nursing staff and the Director of Nursing (DON) revealed that wound care should be administered as ordered by the physician and should not be signed off if not completed. The DON acknowledged that if a treatment is not signed off, it would be considered not done. The facility's policy on dressing application, last reviewed in January 2022, required documentation on the electronic health record (EHR) or treatment administration record sheet that the dressing was completed. The failure to consistently administer and accurately document wound care treatments led to the deficiency in pressure ulcer care for the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 681 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aberdeen Rehabilitation And Skilled Nursing Center | 0.8 mi | ★★★★★ | 14 | 0 |
| Aerius Health Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Rivergate Terrace | 4.2 mi | ★★★★★ | 13 | 0 |
| Rivergate Health Care Center | 4.2 mi | ★★★★★ | 4 | 0 |
| Belle Fountain Nursing & Rehabilitation Center | 4.3 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.