Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodland Care & Rehab Center during CMS and state inspections, most recent first.
Incomplete MAR/TAR Documentation During System Outage: Staff failed to document multiple medication administrations and blood glucose checks for several cognitively intact residents with complex medication regimens, including insulin, anticoagulants, antihypertensives, anticonvulsants, and psychotropics. Both EMR and paper MAR/TAR entries were missing across multiple days, and the records did not include reasons for medications not being marked as administered or progress note documentation of medication administration.
A facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required two-hour timeframe. After a resident with dementia and PTSD reported being grabbed on the forearm by another resident, staff assessed for injury and notified the Administrator, but the incident was not reported to DHSS as required by policy. Staff interviews revealed awareness of the reporting requirement, but the Administrator did not report the incident due to the absence of visible injury at the time.
A resident with bilateral above-the-knee amputations and multiple comorbidities did not receive a drop arm bedside commode as ordered by a physician, despite repeated requests and clear need for increased independence. The order was not entered into the medical record or acted upon promptly, and staff interviews revealed delays, lack of follow-up, and confusion about the ordering process, resulting in the resident continuing to use briefs and requiring staff assistance.
A resident with multiple medical conditions and bilateral amputations suffered burns after independently heating and transporting hot soup, which spilled when their wheelchair struck a door. Staff failed to update the care plan with new interventions or conduct a hot food/liquid risk assessment, and there was no policy or consistent enforcement regarding resident use of microwaves, leaving accident hazards unaddressed.
A resident who was dependent on staff for mobility and toileting was repeatedly spoken to disrespectfully by a CNA, who made comments about back pain and discouraged the resident from wearing an incontinent brief to bed, despite the resident's preference. Other staff confirmed the CNA's behavior and noted the resident felt pressured and uncared for, with the facility's policy requiring respect for resident autonomy and dignity.
A resident with PTSD and a history of trauma did not receive individualized, trauma-informed care, as staff failed to include the resident's specific triggers in the care plan and did not consistently respond to their needs, resulting in repeated distress when the resident was left waiting in bed and staff communicated in ways that triggered their PTSD.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions necessary to address all care needs, as identified during a survey event.
The facility did not ensure that several nurse aides completed required CNA training, competency evaluation, and certification testing within four months of hire, resulting in uncertified staff providing direct care beyond the allowed timeframe. Staff interviews revealed confusion about requirements, delays in enrollment and testing, and a lack of policy or effective tracking system for NA certification status.
A resident with multiple complex medical conditions experienced a significant decline in cognition and required increased assistance with care, but staff failed to promptly notify the provider or family and did not document the change in condition or monitoring as required by facility policy. Despite staff observations of increased confusion, lethargy, and decreased responsiveness, timely assessment and communication were lacking, resulting in delayed medical intervention and eventual hospital transfer for sepsis, UTI, and pneumonia.
An LPN made disrespectful comments and used a harsh tone with three residents, including individuals with parkinsonism, dementia, and a recent amputation. Incidents included telling a resident they were seeking pity, responding rudely to a family member's request for pain medication, and instructing a resident to "pull yourself together" before providing assistance. Staff interviews confirmed these actions were considered disrespectful and not in line with facility policy.
The facility did not consistently complete or document full wound assessments for four residents with pressure ulcers, despite its policy requiring weekly measurements and detailed documentation. After the departure of the wound care nurse, staff interviews revealed confusion about wound tracking responsibilities, and there was no consistent wound log or weekly assessment, resulting in a failure to monitor wound progression.
A resident with neuromuscular bladder dysfunction and severely impaired cognition did not have a care plan addressing the use, care, and monitoring of an indwelling urinary catheter. Staff demonstrated inconsistent practices in catheter care, documentation, and monitoring, with observations showing improper catheter bag placement and lack of intake/output tracking. These deficiencies contributed to a significant change in the resident's condition, resulting in hospitalization.
A resident with multiple chronic conditions, including diabetes and a history of cellulitis, did not receive consistent and accurate skin assessments or timely documentation of wounds by staff. Nursing staff failed to obtain or document wound care orders, and incomplete or missing assessments led to gaps in care. Communication lapses among staff resulted in the resident's wounds not being properly tracked or treated according to facility policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms or indwelling medical devices. Observations showed a lack of signage and PPE, with staff only wearing gloves during care for three residents. Interviews revealed staff were unaware of EBP requirements, and the facility had not developed a policy or trained staff on EBP.
Incomplete MAR/TAR Documentation During System Outage
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents when medication administrations and blood glucose monitoring were not documented during a multi-day internet/phone outage. The report states that staff did not document medication administrations on both the electronic MAR/TAR and the paper MAR/TAR for Resident #1, Resident #2, Resident #3, and Resident #4, and also did not document reasons for medications not being administered. The facility’s policies required medications to be administered in accordance with prescriber orders, with initials entered on the MAR after each dose, and required documentation of medications administered, treatments, and changes in condition in the medical record. Resident #1 was cognitively intact and had diagnoses including traumatic amputation, UTI, and type II diabetes. The resident’s record showed orders for aspirin, fenofibrate, Florasave, furosemide, Novolog sliding-scale insulin, fixed-dose Novolog insulin, levothyroxine, Jardiance, Plavix, and Zoloft, along with blood glucose monitoring four times daily. The EMR and paper MAR/TAR showed multiple missed documentation entries for these medications and blood glucose checks over several days, and the record also showed no paper insulin log and no progress note documentation regarding medication administration. Resident #2 was cognitively intact and had diagnoses including epilepsy, type 2 diabetes, CHF, major depression, and anxiety disorder. The resident had orders for aspirin, atorvastatin, carvedilol, famotidine, gabapentin, Humalog sliding-scale insulin, Lantus, levetiracetam, levothyroxine, lisinopril, metoprolol tartrate, Ozempic, and Zoloft. The EMR and paper MAR/TAR showed multiple dates with no documentation of administration for these medications, including insulin doses and blood sugar checks, and the blood glucose flow sheet showed missing evening and multiple daily insulin administration and blood sugar documentation. The progress notes also did not document medication administration, and the MARs/TARs did not document a reason the medications were not marked as administered. Resident #3 was cognitively intact and had diagnoses including Parkinson’s disease, cellulitis of the right lower limb, delusional disorders, unspecified psychosis, and hypertension. The resident had orders for alprazolam, aspirin, baclofen, bumetanide, cholecalciferol, and Culturelle, and the EMR and paper MAR/TAR showed repeated missing documentation for these medications across multiple days. The report also noted missing documentation for medication administration in the resident’s record, consistent with the same documentation failure seen for the other residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA). Specifically, an incident involving two residents, where one resident entered another's room and grabbed their forearm, was not reported to the Department of Health and Senior Services (DHSS) as required by facility policy and state law. The facility's policy defines abuse and mandates immediate reporting of all allegations to the Administrator, DON, and appropriate authorities, with 'immediately' defined as within two hours. The incident in question involved a resident with diagnoses including dementia, PTSD, and major depressive disorder. This resident reported that another resident entered their room, grabbed their forearm, and only released after being asked. Staff intervened and assessed the resident for injury, initially finding none, but a subsequent assessment revealed a small bruise. Despite the resident reporting the incident to both the Administrator and Social Services Director (SSD), and expressing a desire to file a grievance, there was no documentation or evidence that the incident was reported to DHSS as required. Interviews with staff, including LPNs, CNA, SSD, and the Administrator, confirmed knowledge of the reporting requirement and the two-hour window for notification. However, staff either assumed the Administrator would report the incident or did not believe the incident warranted reporting due to the absence of visible injury at the time. The Administrator acknowledged being notified of the incident but chose not to report it, citing the lack of injury and no prior issues with the resident involved. DHSS records confirmed that the facility did not self-report the altercation or abuse allegation.
Failure to Provide Ordered Commode for Resident with Bilateral Amputations
Penalty
Summary
A deficiency occurred when the facility failed to provide a drop arm bedside commode for a resident with bilateral above-the-knee amputations, despite a physician's order and the resident's expressed preference. The resident, who was cognitively intact and independent in many activities of daily living, had diagnoses including traumatic amputations of both legs, long-term kidney disease, severe obesity, major depressive disorder, anxiety, and PTSD. The resident was at risk for pressure ulcers and had bladder and bowel incontinence, requiring the use of briefs and staff assistance for changing. The resident repeatedly requested a commode to increase independence and dignity, as using briefs was embarrassing and limited autonomy. The process for obtaining the commode was not followed appropriately. Although a handwritten physician's order for a heavy-duty bedside commode with a drop arm was written, it was not entered into the resident's electronic medical record or acted upon in a timely manner. The Director of Rehab provided the order and product information to the Administrator and Social Services Director (SSD), but the SSD delayed ordering the commode, citing being too busy and concerns about cost and delivery time. The SSD also cancelled an initial order due to a long delivery estimate and did not have documentation of the cancelled order. Multiple staff interviews confirmed that the resident's request for a commode was known, but there was no documented follow-up or timely action to fulfill the order. The facility did not have a policy regarding the process for ordering durable medical equipment or handling handwritten physician orders. Staff interviews revealed confusion about the process and responsibilities for ordering equipment. The lack of clear documentation, communication, and timely action resulted in the resident not receiving the commode as ordered, impacting the resident's independence and dignity.
Failure to Prevent Burn Injury and Update Care Plan After Resident Spill of Hot Soup
Penalty
Summary
Facility staff failed to ensure that all residents were kept as free from accident hazards as possible when they did not implement steps to prevent future burns and did not update the care plan regarding a burn incident for a resident who suffered burns after spilling hot soup on themselves. The resident, who was cognitively intact and used both a motorized and manual wheelchair independently, had significant medical history including bilateral above-the-knee amputations, long-term kidney disease, major depressive disorder, anxiety, PTSD, and peripheral vascular disease. The resident was independent at meals and typically heated their own food using a microwave located in a room on the unit hall. On the day of the incident, the resident was carrying a bowl of hot tomato soup in their wheelchair when they ran into a door, causing the soup to spill onto their abdomen and chest. Initial nursing notes indicated that cool cloths were applied and the area was left open to air per physician instructions. However, within two days, the affected areas developed fluid-filled blisters, some of which had popped, requiring wound care treatment. The care plan was not updated to reflect the new risk or to include interventions to prevent future burns, and no hot food/hot liquid risk assessment was completed for the resident. Interviews with staff revealed that there was no policy regarding resident use of microwaves, and the rooms containing microwaves were not locked, allowing any resident access despite signs indicating they were for employees only. Staff reported that residents were not supposed to use the microwaves without assistance, but enforcement was inconsistent, and the resident in question frequently used the microwave independently. There was no documentation of risk assessments or care planning related to hot food or microwave use for any residents, and staff were generally unaware of any such policies or procedures.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident who was dependent on staff for transfers, bed mobility, and toileting. The resident, who had diagnoses including diabetes, heart failure, severe obesity, anxiety disorder, and depression, expressed a preference to wear an incontinent brief to bed and to have his or her sleeping patterns honored, as documented in the care plan. However, Certified Nurse Aide (CNA) A repeatedly spoke to the resident in a disrespectful manner, making comments about back pain caused by assisting the resident and expressing reluctance to help. CNA A also slammed the door when leaving the resident's room, which the resident found hurtful and disrespectful. Multiple interviews with other staff members confirmed that CNA A discouraged the resident from wearing an incontinent brief to bed, insisting it was healthier to sleep without one, despite the resident's stated preference. The resident reported feeling pressured by CNA A to comply with this suggestion, ultimately relenting to avoid conflict, even though it made the resident feel uncared for and diminished. Other CNAs and LPNs corroborated that CNA A's behavior was perceived as disrespectful and that the resident had shared concerns about not receiving timely incontinent care during the night shift. The facility's policy required staff to respect residents' autonomy, dignity, and preferences, including sleeping routines and personal care choices. Despite this, CNA A's actions and comments did not align with these expectations, as evidenced by the resident's repeated experiences of disrespect and disregard for personal preferences. The issue was further compounded by the resident's reluctance to report the behavior due to fear of retaliation and a desire to avoid causing trouble for staff.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and a diagnosis of PTSD received appropriate treatment and services to attain the highest practicable psychosocial well-being. The resident, who was cognitively intact and had diagnoses including PTSD, major depressive disorder, generalized anxiety disorder, and recent bilateral above-the-knee amputations, expressed specific triggers related to their trauma history. These included a strong need to be gotten out of bed immediately upon waking, a preference for the door to be left open, and a light to be left on at night. Despite these clearly communicated needs, the resident's care plan did not include individualized interventions addressing their PTSD triggers, nor did the facility have a policy regarding PTSD or trauma-based care. Staff interactions and documentation revealed repeated instances where the resident was told by nursing staff that it might not be possible to get them up multiple times during the night, or that they would have to wait for assistance due to staffing requirements for Hoyer lift transfers. The resident frequently refused to go to bed out of fear of being left in bed and feeling trapped, which was a direct trigger for their PTSD. Staff notes and interviews indicated that the resident was often left waiting for up to ten minutes or more to be assisted out of bed, and that staff did not always communicate effectively about the wait or the process, further exacerbating the resident's distress. Some staff members did not recognize the connection between the resident's behaviors and their PTSD triggers, and there was a lack of trauma-informed care planning and staff education on the subject. Multiple interviews with staff, including CNAs, RNs, the MDS Coordinator, Social Services Designee, ADON, DON, and the Administrator, confirmed that the resident's specific PTSD triggers were not included in the care plan and that staff were not consistently aware of or responsive to these triggers. Staff acknowledged that it was inappropriate to tell a resident they could not be gotten up as often as they wished, and several staff members were unaware of the need to include trauma-informed interventions in the care plan. The facility's failure to identify, care plan, and provide services responsive to the resident's trauma history and PTSD triggers resulted in the resident experiencing repeated distress and a lack of individualized, trauma-informed care.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that meets all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was cited during a survey event referenced by event ID DE1Z12, with an exit date of 03/22/25.
Failure to Ensure Timely CNA Training and Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed state-approved certified nursing assistant (CNA) training, competency evaluation, and certification testing within four months of hire, as required. Five NAs continued to provide direct care to residents beyond the 120-day limit without having completed the necessary training and certification. Interviews and record reviews revealed that some NAs had not started their CNA classes, while others were delayed in being enrolled or scheduled for testing. The facility did not provide a policy regarding NA training classes, and there was confusion among staff and administration regarding the requirements and tracking of NA certification status. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both indicated a lack of awareness about which NAs were working beyond the allowed timeframe without certification. The ADON described issues with the online training provider, including difficulties enrolling staff and scheduling tests, which contributed to the delays. The Administrator and DON both stated that NAs should be moved to non-care areas if not certified within 120 days, but evidence showed that uncertified NAs continued to provide direct care. The facility census at the time was 87 residents.
Failure to Timely Notify Provider and Address Change in Resident Condition
Penalty
Summary
The facility failed to provide care in accordance with professional standards of quality by not addressing and notifying the provider in a timely manner regarding a resident's significant change in condition. The resident, who had multiple complex diagnoses including acute and chronic respiratory failure, acute kidney failure, malignant neoplasm of the uterus, non-traumatic intracerebral hemorrhage, and pneumonia, experienced a noticeable decline in cognition and required increased assistance with activities of daily living. Staff observations and interviews revealed that the resident, previously able to communicate needs and perform some self-care with limited assistance, became increasingly confused, less verbal, and more dependent on staff for mobility and toileting over a two-day period. Certified Nurse Aides (CNAs) and other staff noted the resident's changes, such as increased confusion, sleepiness, and inability to pivot or stand as usual. These changes were reported to the LPN on duty, who assessed the resident and took vital signs, which were documented as normal. However, there was a lack of timely and thorough documentation regarding the resident's change in condition, monitoring, and physician notification on the first day of the observed decline. The LPN instructed staff to monitor the resident more closely but did not immediately notify the physician or family about the significant changes. The following day, the resident's condition further deteriorated, with continued lethargy, poor responsiveness, and refusal of meals, prompting a delayed call to the provider and eventual transfer to the hospital after family intervention. Facility policy required prompt notification of the provider and family in the event of a significant change in a resident's condition, as well as detailed assessment and documentation. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed expectations for timely assessment, documentation, and communication with the provider and family. Despite these policies, the staff did not follow through with timely notification or documentation, resulting in a delay in appropriate medical intervention for the resident, who was later diagnosed with sepsis, UTI, and pneumonia upon hospital admission.
Failure to Ensure Resident Dignity Due to Disrespectful Staff Interactions
Penalty
Summary
The facility failed to ensure that all residents were treated in a dignified manner, as evidenced by multiple incidents involving a Licensed Practical Nurse (LPN) who made disrespectful comments and used a harsh tone with three residents. The facility's own policy requires staff to promote dignity and respect for residents at all times, but this was not upheld in several documented interactions. For example, one resident with parkinsonism, depression, and neurocognitive disorder reported that the LPN made a comment implying the resident was seeking pity while the resident was sitting in the doorway, visibly upset and in pain. This was corroborated by interviews with staff and the Social Services Director, who confirmed the resident's account and acknowledged the comment as disrespectful. Another incident involved a resident with dementia, whose family member reported that the LPN responded rudely when asked about pain medication, stating that the LPN had many other residents to care for and would attend to the resident when able. When the LPN eventually brought the medication, the resident inquired about it and the LPN reportedly responded in a rude manner before leaving the room abruptly. This interaction was reported by the family to the Social Services Director, who confirmed the details and recognized the behavior as inappropriate. A third resident, who had a history of surgical amputation, chronic kidney disease, and mental health conditions, described being in pain and waiting for assistance to use the bathroom. The resident reported that the LPN told them, in a certain tone, to "pull yourself together" before staff would help, which the resident and other staff members identified as disrespectful. Interviews with other staff, including CNAs and RNs, confirmed that such comments would be considered disrespectful and not in line with facility expectations. These incidents collectively demonstrate a pattern of staff failing to maintain resident dignity and respect as required by facility policy.
Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to provide care in accordance with standard practice for residents with pressure ulcers, specifically by not completing and documenting full wound assessments in a consistent and timely manner. This deficiency was observed in four residents who had identified pressure ulcers. The facility's own policy required charge nurses to document wound characteristics and for the wound nurse to perform weekly measurements and assessments until wounds healed. However, documentation and assessment were lacking for all four residents. One resident with a history of amputation, diabetes, and venous insufficiency developed a new stage three pressure ulcer, but there was no documentation of wound measurements or descriptions for over a month after the ulcer was identified. Another resident with quadriplegia and stage four pressure ulcers had inconsistent wound documentation, with no completed assessments recorded for over a month. A third resident with a recent amputation and diabetic complications had a left heel ulcer, but after an initial assessment, no further complete wound assessments were documented, and wound care company notes were missing from the record. The fourth resident, who had a history of skin impairment and used a wheelchair, developed a stage two pressure injury, but staff did not document a complete assessment or indicate if the ulcer had healed. Interviews with staff revealed confusion and inconsistency in wound tracking and documentation responsibilities, especially after the departure of the facility's wound care nurse. The administrator and DON attempted to track wounds, but there was no consistent wound log or weekly assessment documentation. The lack of clear documentation and assessment practices led to the failure to monitor whether wounds were improving or declining, as required by facility policy.
Failure to Develop and Implement Comprehensive Catheter Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan addressing the use, care, and monitoring of an indwelling urinary catheter for a resident with neuromuscular bladder dysfunction and severely impaired cognition. The resident was dependent on staff for all activities of daily living, including toileting and hygiene, and had physician orders for catheter care every shift and PRN changes for leaking or blockage. Despite these orders and facility policy, the resident's care plan did not include interventions or monitoring related to the indwelling catheter. Observations and interviews revealed inconsistent practices and documentation regarding catheter care and monitoring. The resident's catheter bag was observed resting on a fall mat and under the bed, not consistently kept off the floor or below bladder level as required. Staff interviews indicated varying understandings of catheter care frequency, documentation of intake and output, and reporting of abnormal findings. Some staff reported not documenting urinary output for this resident, and there was no consistent tracking of fluid intake or output in the resident's records. The lack of a comprehensive care plan and inconsistent monitoring contributed to a significant change in the resident's condition, including lethargy, nonresponsiveness, and decreased urine output, which resulted in hospitalization. Upon return from the hospital, the resident continued to have an indwelling catheter, but the care plan still did not address catheter management. Facility policy and staff expectations for catheter care, monitoring, and documentation were not consistently followed or reflected in the resident's care plan.
Failure to Accurately Assess, Document, and Treat Resident Skin Conditions
Penalty
Summary
Facility staff failed to provide care according to standard practice by not accurately and consistently tracking a resident's skin conditions, failing to document timely and complete assessments, and not documenting or obtaining appropriate wound care orders. The resident involved had multiple complex medical diagnoses, including vascular dementia, chronic kidney disease, diabetes, hypertension, anemia, and a history of cellulitis and peripheral arterial disease. The care plan identified the resident as at risk for pressure ulcers and required weekly systematic skin inspections and prompt reporting of any skin breakdown. Despite these requirements, documentation showed incomplete descriptions of the resident's skin condition during weekly assessments, with several instances where the assessments lacked full details of the wounds or changes in skin integrity. There were also periods where no documentation was made regarding the resident's right lower leg and foot, even though the resident had ongoing issues with redness, blisters, and wounds. Staff failed to consistently notify the physician or obtain wound care orders as required by facility policy, and the resident was not listed on the facility's wound logs during periods when wounds were present. Interviews with nursing and aide staff revealed inconsistent practices in skin assessment and reporting, with some staff unaware of the resident's wounds and others noting that wound care orders were not obtained or documented. The wound nurse was not aware of the resident's multiple wounds until prompted by a new order, and there was a lack of communication and follow-through regarding wound care protocols. These failures resulted in the resident's skin conditions not being properly assessed, tracked, or treated according to physician orders and facility policy.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a complete infection prevention and control program by not developing a policy regarding Enhanced Barrier Precautions (EBP) for residents infected with multidrug-resistant organisms (MDRO) or those with chronic wounds and indwelling medical devices. The facility did not train staff on EBP, did not have personal protective equipment (PPE) and signage present for residents meeting EBP guidelines, and did not ensure staff wore PPE in accordance with CDC guidelines. This deficiency was observed in three residents who met the guidelines for EBP, out of a sample of nine residents in a facility with a census of 83. Resident #1, diagnosed with quadriplegia and a colostomy, had an indwelling catheter and multiple pressure injuries. Observations showed no signage on the resident's door indicating EBP, no PPE available, and staff only wearing gloves during catheter care. Resident #2, with multiple sclerosis and quadriplegia, also had an indwelling catheter. Similar observations were made, with no signage or PPE present, and staff not wearing appropriate PPE during care. Resident #3, with chronic kidney disease and urine retention, had an indwelling catheter, and again, no signage or PPE was observed, with staff only wearing gloves during care. Interviews with various staff members, including a Certified Medication Technician, Licensed Practical Nurse, Registered Nurse, and Certified Nurse Aides, revealed a lack of awareness and understanding of EBP. The Assistant Director of Nursing admitted that procedures for EBP had not been implemented, and the Infection Preventionist/Director of Nursing was working on it. The Administrator and DON/IP acknowledged that staff were not aware of residents on EBP and that appropriate PPE was not being used during catheter care.
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 143 citations issued within 25 miles in the last 12 months — including the 1 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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maranatha Village, Inc | 1.4 mi | ★★★★★ | 0 | 0 |
| Wilson's Creek Nursing & Rehab | 5.8 mi | ★★★★★ | 4 | 0 |
| Brookhaven Nursing & Rehab | 5.8 mi | ★★★★★ | 4 | 0 |
| Manor At Elfindale, The | 5.9 mi | ★★★★★ | 10 | 0 |
| Glendale Gardens Nursing & Rehab | 6.6 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodland Care & Rehab Center.
100% money-back within 48 hours.
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.