Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 St Therese Of Woodbury Llc during CMS and state inspections, most recent first.
A resident who was dependent on staff for wheelchair transport fell forward out of a wheelchair when foot pedals were not used as expected and a cushion had been placed in the chair without a safety assessment; the resident sustained a femur fracture and required hospitalization. In a separate event, another resident with a cervical fracture, Aspen collar, and swallowing concerns had an order for full mealtime supervision, but the order did not pull through to the care plan or Kardex, and the resident ate meals in his room unsupervised while staff were unaware of the supervision requirement.
A resident with hemiplegia/hemiparesis, HF, gait impairment, and muscle weakness required max assist with showering and toilet hygiene, and the care plan included keeping the call light within reach. During observation, the resident was seated in a shower chair while an NA left the room, and the bathroom call light box was located across the room next to the toilet, making it unreachable from the shower. Staff and the DON stated residents were not to be left unattended in the shower, but the new call light setup left no accessible call light or cord in the shower area despite the facility policy requiring call lights at the bedside, toilet, and shower/bathing facility.
A resident with intact cognition, clear speech, and occasional urinary incontinence was spoken to in a public hallway about his incontinence brief, with a PT calling it a diaper while a visitor passed by. The resident said he preferred private conversations about his undergarments, and staff interviews confirmed that diaper was considered a demeaning term and that incontinence products should not be discussed in public areas.
A facility failed to accurately transcribe provider orders into the EMR for two residents and failed to accurately receive a verbal order for another resident. One resident with chronic diarrhea had a loperamide order entered as every 6 hours PRN instead of as written, another resident with a cervical fracture did not have a mealtime supervision order entered so it pulled through to the care plan or Kardex and ate without supervision, and a third resident’s apixaban verbal order was documented with an incorrect diagnosis of weight loss instead of A-fib.
The facility failed to maintain food safety standards, as cooks were observed plating food without beard covers, and expired nutritional supplements were found in a unit kitchen. Additionally, the dishwasher temperatures were often below the required 180°F for proper sanitization, with staff unaware of the correct temperature requirements. These deficiencies indicate lapses in adherence to food safety and sanitation protocols.
The facility failed to ensure accurate documentation of code status for two residents, leading to discrepancies between the POLST and EMR. One resident's POLST indicated DNR, while the EMR showed full code, and the other resident's POLST also indicated DNR, conflicting with the provider order. Interviews confirmed the residents' wishes for DNR, but the facility's records did not reflect this, violating policies on treatment and advance directives.
A resident with impaired cognition and multiple medical conditions did not receive proper bowel monitoring as per standing orders. The facility failed to document bowel movements and initiate the protocol for constipation management, which included medication administration and provider notification. Staff interviews revealed inconsistencies in following the protocol, leading to a deficiency in care.
A resident with cognitive impairment, Parkinson's, and dysphagia was not provided with adequate supervision to prevent aspiration, as the facility failed to follow speech therapy recommendations. The resident's care plan and orders did not include a restriction on straw use, leading to the resident using straws despite a sign indicating otherwise. Staff interviews revealed a lack of documentation on the resident's refusal to remove straws, and the care plan was not updated to reflect the necessary dietary modifications.
A resident with specific dietary needs due to IBS did not receive the ordered meal, missing fresh fruit, despite the facility's policy ensuring residents' rights to make choices about their care. The dietary aide acknowledged potential oversights in meal delivery, and the Dietary Director confirmed no shortage of fruit, highlighting a lapse in the meal service process.
A facility failed to monitor a resident's antibiotic use for a UTI. Despite receiving ceftriaxone injections, there was no documentation of symptom monitoring or treatment effectiveness. Staff interviews revealed a lack of monitoring and documentation, contrary to the facility's antibiotic stewardship policy.
Two residents in the facility experienced deterioration of pressure ulcers due to inadequate assessment and monitoring. One resident's stage 1 ulcer progressed to an unstageable ulcer, while another resident's heel ulcer became unstageable with significant eschar. The facility failed to follow its policies for skin assessments and wound management, contributing to the residents' conditions worsening.
A resident with dysphagia received a cold breakfast and requested an alternative meal, which was not provided, leaving the resident hungry. Staff interviews revealed a failure to adhere to facility expectations for meal service, and the dietary policy was not provided.
A resident with a PICC line and pressure ulcers did not receive care in compliance with enhanced barrier precautions (EBP) at a facility. Staff failed to wear gowns during high-contact activities and did not perform hand hygiene after glove removal, despite clear signage and care plan instructions. Interviews confirmed the expectation for EBP use to prevent infection spread, highlighting a deficiency in adherence to infection control protocols.
A facility failed to implement enhanced barrier precautions for a resident with a history of ESBL, and staff did not adhere to proper hand hygiene and glove use during personal care. The resident was not placed on EBP upon admission, and a nursing assistant did not perform hand hygiene or change gloves appropriately while assisting the resident. The infection preventionist and DON confirmed the lapses in following facility policies.
The facility failed to complete a self-administration of medications (SAM) assessment for two residents who were observed with medications at their bedside. One resident with Alzheimer's had a topical ointment left in their room despite being unable to self-administer, while another resident with Parkinson's had pills left at their bedside without a SAM assessment or doctor's order. Staff confirmed that medications should not have been left without proper assessments and orders.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in care. One resident's care plan lacked instructions for a TLSO brace, resulting in improper application due to inadequate staff training. Another resident was not informed of their therapy schedule, as the process to update their whiteboard was not followed. A third resident's need for a back brace was not documented, leading to improper use. These issues highlight a breakdown in communication and documentation within the facility.
A facility failed to conduct weekly wound assessments for a resident with a diabetic foot wound, despite having a care plan and provider orders for dressing changes. The resident's medical record lacked evidence of wound assessments or measurements since admission, and staff relied on an outside provider for wound management without documenting the wound's status. Interviews revealed that the facility did not follow its policy requiring weekly wound assessments.
A resident with left-sided hemiparesis did not consistently receive prescribed ROM exercises and the application of a left hand splint as ordered. Despite being cooperative, the resident reported that staff often neglected these tasks, and documentation confirmed several instances where ROM was not performed. Staff interviews revealed that the care plan was sometimes overlooked, and the hand splint was not consistently applied, contributing to the deficiency.
A resident with COPD was observed receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM due to a failure to document the physician's order in the MAR. The nursing staff was unaware of the correct oxygen level, as confirmed by interviews with the RN, nurse manager, and LPN. The facility's policy did not require checking the LPM each shift, contributing to the oversight.
Unsafe Wheelchair Transport and Missing Meal Supervision
Penalty
Summary
The facility failed to ensure safe wheelchair use for a resident who was dependent on staff for transfers and mobility and was transported in a wheelchair. The resident’s record identified multiple diagnoses, including peripheral vascular disease, hallucinations, lumbar fractures, heart failure, obesity, muscle weakness, and osteoarthritis. The care plan addressed the resident’s ADL deficits and fall risk, including the need for a mechanical lift with two staff for transfers and other fall-prevention measures, but it did not include any intervention or instruction regarding foot pedal use or the placement of cushions in the wheelchair. On the day of the incident, the resident was being pushed in a wheelchair down the hallway when the resident fell forward out of the chair and landed on the floor on the right side. The resident sustained abrasions to the right forehead and right knee and complained of right leg pain. The resident was transported to the emergency room, where x-rays showed a fracture of the right distal femur, and the resident was admitted for surgery. The incident report identified that the resident was being pushed in the wheelchair and fell out, and the medical record lacked documentation that the resident had been assessed for safe transport without foot pedals or for the use of cushions in the wheelchair. Staff interviews showed that the resident disliked the foot pedals and often refused them, but there was no documentation of refusal, risk/benefit discussion, or assessment for safe transport without foot pedals. Staff also reported that a cushion had been placed in the wheelchair behind the resident’s back, and the cushion had not been assessed for safety or approved for wheelchair use. The DON stated the facility did not have a specific policy regarding foot pedal use, and the facility’s investigation identified decreased seating space and the absence of foot pedals as contributing factors to the fall. The facility also failed to provide mealtime supervision for another resident who had swallowing concerns and an order for full supervision and assistance with all PO. The resident had a cervical fracture and wore an Aspen collar, and hospital discharge instructions identified full supervision and assistance with all PO due to swallowing concerns and aspiration risk. However, the admission assessment, care plan, and Kardex did not identify mealtime supervision, and the order did not pull through to the documents used by staff. During observation, the resident ate lunch in his room without supervision while staff walked past the room without entering to monitor the meal. Staff members stated they were unaware that the resident required supervision during meals and relied on the Kardex and nurse communication for such information. The SLP later identified the supervision need and updated the order, and nursing staff then began supervising meals in the dining room. The record showed that the resident had been eating meals in his room without supervision before the order was correctly communicated to staff.
Call Light Not Accessible in Shower Area
Penalty
Summary
A resident who was cognitively intact and had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, heart failure, abnormalities of gait and mobility, and muscle weakness required maximal assistance with showering and toilet hygiene. The resident’s care plan identified an ADL self-care performance deficit and included assistance from one staff member with showering and toilet hygiene, along with ensuring the call light was within reach as a fall-risk intervention. During an observation and interview, the resident was seated in a shower chair with the water running while an NA had left the room after receiving a call on a walkie-talkie. The resident stated the bathroom call light box was located across the room next to the toilet and could not be reached from the shower, leaving the resident unable to contact staff or call for help if needed. Observation confirmed the call light placement and the resident’s inability to access it while in the shower. Staff interviews indicated residents were not supposed to be left alone in the shower, and the DON stated the facility’s new call light system had moved the call light box next to the toilet, leaving no call light box or cord accessible while a resident was in the shower, despite the policy stating a call light should be available at each resident’s bedside, toilet, and shower/bathing facility.
Dignity Not Preserved During Public Discussion of Incontinence Products
Penalty
Summary
The facility failed to preserve the dignity of one resident, R50, during care and communication related to his incontinence products. R50’s MDS identified intact cognition with a BIMS score of 15 out of 15, adequate hearing without hearing aids, clear speech, partial/moderate assistance needed for toileting hygiene, and occasional urinary incontinence. His diagnoses included arthritis, non-Alzheimer’s dementia, and anxiety. The CAA identified him as at risk for incontinence due to dementia, diabetes, congestive heart failure, and diuretic use. His toileting care plan stated he may self-toilet during the day and needs minimum assist of one in the evening and overnight, but it did not mention a preference for staff to call his adult incontinence briefs diapers. During an observation, PT-A spoke to R50 in the public hallway and said, “it looks like your diaper is sagging,” while a visitor walked by. R50 said he thought so also. In interview, R50 stated his brief had been bunched up and confirmed PT-B had called his brief a diaper; he said it had not really bothered him, but he would rather have discussions in privacy rather than in the hallway, especially about his undergarments. Staff interviews showed NA-A and NA-C said staff should use the term briefs rather than diaper because diaper could be demeaning and should not be discussed in public areas. PT-A stated he called the brief a diaper because R50 had used that word before, and PT-B stated a more dignified term would be pad. The DRS stated she would not expect staff to talk about an adult’s incontinence products in a public area and that diaper could be undignified.
Inaccurate transcription of medication and supervision orders
Penalty
Summary
The facility failed to ensure provider orders were transcribed accurately into the EMR for two residents and failed to ensure a verbal order was received accurately for one resident. For one resident with intact cognition, chronic diarrhea, bowel and bladder incontinence, and diagnoses including a left femur fracture and right hand fracture, the admission order for loperamide was entered as a dose range and later clarified by the NP to a 2 mg tablet as needed up to four times daily. The MAR, however, reflected the medication as every 6 hours as needed, and the resident reported that staff were reluctant to give the medication and would make her wait after an initial dose was ineffective. The resident also stated she used Imodium regularly at home and followed package directions for repeated dosing when needed. For another resident admitted with a cervical fracture and an Aspen collar, the hospital discharge instructions required full supervision and assistance with all oral intake because of aspiration concerns. The facility admission assessment, diet order, care plan, and Kardex did not reflect mealtime supervision in a way that staff could see it, and the order did not pull through to the care plan or Kardex. During observation, the resident ate lunch in his room without staff supervision, and the POC charting for several days showed no mealtime supervision was provided. Staff interviews confirmed the order had been entered in a way that was not visible to the staff caring for the resident, and the RN acknowledged the order should have been entered so staff were aware of the supervision requirement. For a third resident with atrial fibrillation and anticoagulant therapy, the AVS indicated apixaban 5 mg twice daily for A-fib, but a later verbal order entered by RN-F and written in the nurse’s station book listed apixaban 2.5 mg twice daily with the diagnosis of weight loss. The EMR also reflected apixaban 2.5 mg twice daily for weight loss, and another order stated to monitor weight and reduce apixaban if weight fell below a specified threshold. Staff interviews confirmed the original medication was for A-fib and that apixaban was not used to treat weight loss. The verbal order process was described as writing the order in the white book, reading it back for clarification, entering it into the EMR, and having another nurse verify it, but the diagnosis associated with the medication was entered inaccurately.
Deficiencies in Food Safety and Dishwasher Sanitization
Penalty
Summary
The facility failed to adhere to professional standards in food handling and sanitation, as observed during a survey. Two cooks were seen plating food without beard covers, which they admitted to not wearing unless instructed by leadership. Additionally, the facility's second-floor unit kitchen contained expired nutritional supplements, which were verified and discarded by a registered nurse. These actions indicate a lack of consistent adherence to food safety protocols, potentially affecting all residents. Furthermore, the facility's dishwasher temperatures were not consistently maintained at the required levels for proper sanitization. Observations revealed that the final rinse temperatures were frequently below the necessary 180 degrees Fahrenheit, with 36 out of 58 recorded instances meeting the required temperature. The dietary aide was unaware of the correct temperature requirements and continued to use the dishwasher despite inadequate temperatures. The Dietary Director acknowledged the issue but was not informed of the temperature discrepancies, indicating a communication gap and lack of oversight in ensuring compliance with sanitation standards.
Inaccurate Code Status Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) accurately reflected the code status wishes of two residents, R147 and R198. For R198, the medical record contained conflicting information regarding the resident's code status. The face sheet and physician orders indicated a full code status, while the POLST signed by the resident indicated a Do Not Resuscitate (DNR) status. Interviews with the resident and nursing staff confirmed that the resident did not wish to receive resuscitation efforts, highlighting a discrepancy between the POLST and the electronic medical record (EMR). Similarly, for R147, there was a mismatch between the POLST and the provider order in the EMR. The POLST indicated a DNR status, while the provider order stated full code. Interviews with the resident confirmed their preference for DNR, yet the care plan and provider order did not reflect this. Nursing staff acknowledged the inconsistency and the need to clarify the correct code status with the provider. The facility's policies on Residents' Rights Regarding Treatment and Advance Directives and Communication of Code Status were not adhered to, as they require accurate documentation and communication of a resident's code status. The failure to ensure that the POLST and EMR matched the residents' wishes could lead to unwanted resuscitation efforts, as noted by the nursing staff during interviews.
Failure in Bowel Monitoring for a Resident
Penalty
Summary
The facility failed to ensure proper bowel monitoring for a resident with moderately impaired cognition and several medical conditions, including chronic diastolic heart failure and benign prostatic hyperplasia. The resident required assistance with most activities of daily living and had a catheter. Despite standing orders for bowel monitoring, the facility did not document bowel movements from March 5 to March 7 and March 15 to March 17, 2025. The standing orders included steps such as rectal checks, fluid intake encouragement, dietary consultations, and administration of medications like Sennoside and Biscodyl if no bowel movement occurred by the third day. However, the resident's records lacked documentation of bowel assessments, administration of PRN medications, or notification of the provider or hospice. Interviews with staff revealed inconsistencies in the implementation of the standing orders. Nursing assistants were responsible for documenting bowel movements, but there was a lack of communication with nurses unless there was an abnormality. Licensed practical nurses acknowledged that the standing orders should have been initiated on the third day without a bowel movement, but this protocol was not followed. The clinical coordinator confirmed the absence of a PRN medication order for constipation and the lack of documentation regarding provider or hospice notification. The director of nursing emphasized the importance of following the standing orders to prevent complications such as bowel obstruction or impaction.
Failure to Follow Speech Therapy Recommendations for Aspiration Risk
Penalty
Summary
The facility failed to follow speech therapy recommendations to minimize the risk of aspiration for a resident with mild cognitive impairment, Parkinson's disease, and dysphagia. The resident required a soft diet with bite-sized food and thin liquids without the use of a straw, as per the speech therapy assessment. However, the resident's provider orders and care plan did not include the restriction on straw use. Observations revealed that the resident was using straws with their drinks, despite a sign in the room indicating no straw use. Interviews with staff and family members confirmed that the resident had been using straws and had refused to have them removed, although there was no documentation of this refusal. The speech therapist was informed of the resident's refusal to remove straws and re-educated the resident after observing coughing when using a straw. The Director of Nursing expected recommendations to be communicated in the care plan and for staff to follow them, with documentation of any resident refusals. The facility's policy required care plan revisions upon status changes, but the care plan was not updated to reflect the no straw recommendation, leading to a failure in ensuring the resident's safety and adherence to dietary modifications.
Failure to Provide Ordered Meal Choices for Resident
Penalty
Summary
The facility failed to ensure that meal choices were provided as ordered for a resident, identified as R147, who was recently admitted following back surgery and had specific dietary needs due to irritable bowel syndrome (IBS). R147's care plan required adherence to a regular diet with thin liquids and avoidance of certain foods due to intolerances. Despite these requirements, R147 reported that the meals provided did not always match what was ordered, leading to frustration and reliance on family-provided food. On one occasion, R147 ordered a plain hamburger with fresh fruit, but the fruit was not delivered, which was confirmed by a registered nurse. The dietary aide responsible for meal delivery stated that meals were checked for accuracy multiple times, but acknowledged that items might be missed due to the volume of trays. The Dietary Director confirmed that fresh fruit should always be available and there was no shortage on the day in question, but admitted that the process was not perfect. The facility's policy on Resident Rights emphasizes the importance of respecting residents' choices regarding their care, which was not upheld in this instance.
Failure to Monitor Antibiotic Use for UTI
Penalty
Summary
The facility failed to ensure proper monitoring of antibiotic use for a resident who was treated for a urinary tract infection (UTI). The resident, who was cognitively intact and had a diagnosis of lung failure, was occasionally incontinent of bowel and bladder. The resident's laboratory results confirmed a UTI, and the provider ordered a 1-gram ceftriaxone intramuscular injection. However, there was no indication in the resident's orders or nursing progress notes that the resident was monitored for symptoms or the effectiveness of the antibiotic treatment. The resident continued to experience symptoms of burning and urgency, and a second round of antibiotics was ordered without documentation of monitoring. Interviews with staff, including a nursing assistant, registered nurse, infection preventionist, and the Director of Nursing, revealed a lack of monitoring and documentation of the resident's symptoms and response to the antibiotic treatment. The facility's antibiotic tracking document also lacked information on whether the resident's symptoms had resolved. The facility's policy on antibiotic stewardship required nursing staff to assess residents suspected of having an infection, notify the provider, and monitor the response to antibiotics, but these actions were not documented in the case of this resident.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess and monitor pressure ulcers for two residents, leading to the deterioration of their conditions. One resident was admitted with a stage 1 pressure ulcer that was not properly assessed or documented, resulting in it developing into an unstageable pressure ulcer. The resident's care plan lacked interventions for pressure ulcer prevention, and the facility did not perform comprehensive skin assessments as required. The resident was eventually sent to the hospital, where the unstageable pressure ulcer was identified, along with a stage 3 pressure ulcer on the coccyx. Another resident was admitted with a pressure ulcer on the left heel, which was not properly assessed or monitored. The resident reported that the pressure sore was not looked at for eight days, and the facility's documentation did not include comprehensive wound assessments. The resident experienced ongoing pain, and the pressure ulcer eventually developed into an unstageable ulcer with significant eschar and slough. The facility's failure to perform regular assessments and follow treatment orders contributed to the deterioration of the resident's condition. Interviews with facility staff, including nursing assistants and registered nurses, revealed that the facility's policies for skin assessments and wound treatment management were not followed. Comprehensive skin assessments were not conducted upon admission or weekly as required, and there was a lack of communication with physicians and family members regarding changes in the residents' conditions. The facility's director of nursing acknowledged the deficiencies in assessing and monitoring the residents' pressure ulcers, which led to their deterioration.
Failure to Serve Palatable Meals and Offer Alternatives
Penalty
Summary
The facility failed to ensure that meals were served in a warm and palatable manner, affecting the quality of life and nutritional intake for a resident on a short-term stay. The resident, who had intact cognition and a diagnosis of dysphagia, was on a mechanically altered diet and required setup assistance with eating. During an observation, the resident received a breakfast tray with cold eggs and turkey sausages and requested an alternative meal option, which was not provided. The resident expressed dissatisfaction with the cold food and requested a sweet roll, but no alternative was offered, and the resident remained hungry. Interviews with staff revealed a lack of adherence to the facility's expectations regarding meal service. The food server acknowledged that an alternative should be offered if food was cold, but failed to address the resident's request. The director of social services and the director of nursing both stated that staff should offer an alternative or reheat the food if it was cold. Despite these expectations, the dietary policy was requested but not received, indicating a possible gap in policy communication or implementation.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure ulcer wound and a peripherally inserted central catheter (PICC), which are critical for reducing the transmission of multidrug-resistant organisms. The resident, identified as R2, had specific care instructions for PICC site maintenance and wound dressing changes. Despite these instructions, during an observation, it was noted that the nursing assistant (NA) and nurse practitioner (NP) did not wear gowns while providing incontinence care, which is a high-contact activity requiring EBP. Additionally, the NA failed to perform hand hygiene after removing gloves, further increasing the risk of infection transmission. The resident's care plan clearly indicated the need for EBP due to the presence of a PICC line and pressure ulcers, with instructions for staff to adhere to these precautions. However, during the observed care, the staff did not comply with the facility's policy, which mandates the use of gowns and gloves during high-contact activities such as toileting and wound care. The facility had signage posted in the resident's room to remind staff of the EBP requirements, yet these were not followed during the observed incident. Interviews with the nursing assistant, registered nurse, and director of nursing confirmed the expectation that EBP should be used for residents with PICC lines or wounds to prevent infection spread. The facility's policy on enhanced barrier precautions and hand hygiene was not adhered to, as evidenced by the staff's actions during the care of the resident. This non-compliance with established infection control protocols led to the deficiency noted in the report.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident colonized with a multidrug-resistant organism (MDRO), specifically extended-spectrum-beta lactamase (ESBL). The resident, who had a history of recurrent urinary tract infections due to ESBL, was not placed on EBP upon admission, as indicated by the absence of signage or a cart outside their room. This oversight was confirmed by the infection preventionist, who acknowledged that the resident should have been placed on EBP due to their medical history. Additionally, the facility did not ensure proper hand hygiene and glove use during personal care for the resident. An observation revealed that a nursing assistant entered the resident's room without performing hand hygiene, assisted the resident with toileting without wearing gloves initially, and failed to change gloves or perform hand hygiene after handling soiled items. The nursing assistant admitted to not following proper procedures, citing the absence of appropriately sized gloves and a misunderstanding of when glove changes were necessary. Interviews with the infection preventionist and the Director of Nursing highlighted the expectation for staff to perform hand hygiene upon entering and exiting resident rooms and to use gloves and gowns during high-contact care activities. The facility's policies on enhanced barrier precautions and hand hygiene were not adhered to, contributing to the deficiency in infection prevention and control measures.
Failure to Complete SAM Assessment for Residents
Penalty
Summary
The facility failed to ensure that a self-administration of medications (SAM) assessment was completed for two residents who were observed with medications at their bedside. The first resident, identified as R15, had severely impaired cognition due to Alzheimer's disease and was dependent on staff for most activities of daily living. Despite a previous SAM assessment indicating that R15 did not wish to self-administer medications, a container of Menthol-Zinc Oxide ointment was found on R15's nightstand. The trained medication assistant confirmed that R15 was unable to self-administer medications and that the ointment should not have been left in the room. The clinical coordinator also stated that a SAM assessment and a doctor's order are required for residents to self-administer medications, which R15 did not have. The second resident, identified as R360, was recently admitted with a diagnosis of traumatic subdural hematoma and Parkinson's disease. R360's medical records lacked evidence of a SAM assessment, and there was no provider order for self-administration of medication. During an observation, a pill cup containing Parkinson's medication was found on R360's bedside table. R360 explained that the medication was left for her to take later, as it was too early to take it at the time it was brought in. The LPN confirmed that no SAM assessment was completed for R360 and that the medication should not have been left in the room. The nurse manager and the director of nursing reiterated that a SAM assessment and a doctor's order are necessary for residents to self-administer medications, and medications should not be left at the bedside without these requirements being met.
Deficiencies in Care Planning and Communication
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for three residents, leading to deficiencies in their care. For one resident, identified as R103, the care plan did not include instructions for the use of a TLSO brace, which was necessary due to a lumbar vertebra fracture. Despite the resident's intact cognition and ability to communicate, staff were not adequately trained on how to apply the brace, resulting in it being applied incorrectly on multiple occasions. Interviews with staff revealed a lack of written instructions and inconsistent training, which contributed to the improper application of the brace. Another resident, R304, experienced a lack of communication regarding their therapy schedule. Although the resident received therapy five times a week, they were not informed of the specific times, which was supposed to be communicated via a whiteboard in their room. Observations confirmed that the whiteboard was not updated with therapy times, and interviews with staff indicated a breakdown in the process of informing residents about their therapy schedules. This lack of communication left the resident unaware of their therapy schedule, contrary to the facility's policy. The third resident, R355, had severe cognitive impairment and required a back brace, but the care plan and Kardex did not reflect this need. The staff were unaware of the specific instructions for the brace, leading to its improper use. Interviews with nursing staff confirmed that the necessary information was not included in the care plan or Kardex, which was crucial for ensuring all staff were informed about the resident's needs. This oversight in documentation and communication resulted in inadequate care for the resident.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly wound assessments were completed for a resident with a non-pressure related wound. The resident, who was cognitively intact, had a diabetic foot wound requiring dressing changes and was followed by an outside provider for wound management. Despite having a care plan and provider orders for dressing changes, the facility did not conduct or document any wound assessments or measurements since the resident's admission. The medical record lacked evidence of wound assessments, and there were no progress notes from the resident's appointments with a vascular provider. Interviews with facility staff revealed that the wound was changed three times a week, but no assessments or measurements were completed by the facility. The staff relied on the outside provider for wound management and did not document the wound's appearance, measurements, or signs of infection. The Director of Nursing expected staff to assess wounds during treatment and receive documentation from the outside provider, but this was not done. The facility's policy required wound assessments upon admission, weekly, and as needed, but this was not followed for the resident in question.
Failure to Provide Prescribed ROM Exercises and Splint Application
Penalty
Summary
The facility failed to ensure that a resident, identified as R16, received the prescribed range of motion (ROM) exercises and the application of a left hand splint as ordered. R16, who was admitted with left-sided hemiparesis due to a previous stroke, required assistance with activities of daily living and was at risk for complications such as contractures. Despite being cooperative with care, documentation revealed that ROM exercises were not consistently performed on several dates, and the left hand splint was not applied as required. Observations and interviews with R16 and staff indicated that the ROM exercises and the application of the hand splint were frequently neglected. R16 reported that staff did not perform the ROM exercises and that he had to remind them to apply the hand splint, which was often left out of reach. Staff interviews confirmed that R16's care plan was not always followed, and there were instances where staff did not have time to complete the ROM exercises. Additionally, the hand splint was not consistently applied, even when R16 expressed a desire for it to be used to prevent his fingers from curling. The facility's policy on the prevention of decline in range of motion emphasized the importance of consistent implementation of care plan interventions, including the use of braces or splints. However, interviews with nursing staff and the director of nursing revealed that the care plan was sometimes overlooked, and staff did not always offer the hand splint to R16, who was sometimes forgetful. The lack of consistent care and adherence to the care plan contributed to the deficiency in providing appropriate ROM exercises and splint application for R16.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer oxygen to a resident, identified as R305, according to the physician's orders. R305, who has chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at 2.5 liters per minute (LPM) instead of the prescribed 2.0 LPM. The physician's order for oxygen was not entered into the computer or medication administration record (MAR), which led to the nursing staff being unaware of the correct oxygen level to administer. This oversight was confirmed through interviews with the registered nurse (RN)-B, nurse manager RN-A, and licensed practical nurse (LPN)-C, who all verified the discrepancy in the oxygen administration. The director of nursing (DON) stated that it was the nurses' responsibility to ensure the oxygen LPM matched the physician's orders and to check it each shift. However, the facility's policy on oxygen administration did not include a requirement for checking the LPM each shift. The lack of documentation in the MAR and the absence of a clear policy contributed to the failure in providing the correct oxygen level, potentially leading to adverse effects such as shortness of breath or low oxygen saturations for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 973 citations issued within 25 miles in the last 12 months — including the 29 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodbury Health Care Center | 1.2 mi | ★★★★★ | 8 | 1 |
| Norris Square | 4.3 mi | ★★★★★ | 5 | 0 |
| Woodlyn Heights Healthcare Center | 5.7 mi | ★★★★★ | 17 | 0 |
| Southview Acres Healthcare Center | 5.7 mi | ★★★★★ | 12 | 0 |
| Good Samaritan Society Inver Grove Heights | 6.2 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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