Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Complete Care At Woodlands during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and arterial ulcers did not receive prescribed wound dressing changes as ordered, and nursing staff failed to document the resident's refusals or notify the physician. The wound dressing was not changed according to the schedule, and the medical record did not accurately reflect the missed treatments or refusals, contrary to facility policy.
An LPN crushed and administered Tamsulosin HCl and Risperidone in applesauce to a resident despite the Tamsulosin order stating do not crush, open, or chew and manufacturer guidance against crushing both medications. The resident had diagnoses including TIA, hemiplegia/hemiparesis, muscle weakness, dysphagia, and oropharyngeal phase, and the facility’s medication administration error rate for the observation was 6.45%, above the required threshold.
A resident with hemiplegia, hemiparesis, anxiety, and major depressive disorder experienced vomiting and diarrhea, documented by an LPN. However, there was no RN assessment documented, violating the facility's policy. The RN/Unit Manager admitted to assessing the resident but did not document it, and the DON confirmed the expectation for RN documentation of condition changes.
The facility failed to submit MDS assessments for ten residents within the required timeframes, with delays ranging from three to 26 days. The MDS Coordinator cited being the sole person responsible and waiting on social services as reasons for the delays.
The facility failed to develop baseline care plans within 48 hours for five residents, neglecting to address pain and communication needs for some and not creating plans at all for others. Observations and interviews confirmed these deficiencies.
A resident was served meals with plastic utensils for 14 months despite no assessment indicating she was a danger to herself or others. The resident expressed confusion and frustration, and staff interviews revealed a lack of awareness and communication regarding the reason for the use of plastic utensils.
A resident with respiratory failure, sepsis, and pneumonia was left with unattended medications by an RN, contrary to professional standards. The DON confirmed that medications should not be left unless ordered to be self-administered, which was not the case here.
The facility failed to ensure a safe discharge for two residents who left Against Medical Advice (AMA) by not notifying community agencies and not providing prescriptions for care and medications. Staff did not follow proper procedures, leading to a lack of continuity of care and potential risks for the residents involved.
The facility failed to accurately screen a resident for elopement risk and unnecessarily used a wander guard. Despite the resident's independence and lack of exit-seeking behavior, staff were unsure why the wander guard was in place. The facility's policy on elopement was not followed, leading to the unnecessary use of the wander guard.
The facility staff failed to obtain physician orders for wound care upon admission and when there was a change in treatment for two residents with stage four pressure injuries. The staff did not notify the physician or document the wound treatments properly.
Failure to Follow Wound Care Orders and Document Resident Refusals
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including severe cognitive impairment, diabetes, and arterial ulceration of the right foot, did not receive wound care in accordance with physician orders. The resident's care plan required arterial ulcer dressing changes twice daily and as needed, but documentation showed the dressing was not changed as ordered on several occasions. During an observation, the wound dressing was found to be dated two days prior, indicating it had not been changed per the prescribed schedule. Further review of the medical record and interviews with nursing staff revealed that the resident had refused dressing changes on multiple shifts, but these refusals were not documented in the progress notes as required. Nursing staff admitted to incorrectly marking the treatment as completed on the Treatment Administration Record (TAR) and failing to document the refusal or notify the physician. The Director of Nursing confirmed that the expectation was to attempt the treatment again, document the refusal, and inform the physician if the treatment was not completed. The facility's policies required accurate documentation of wound treatments, including resident refusals and physician notifications. However, there was no evidence that the physician was notified of the missed treatments, and the medical record did not reflect the refusals or the lack of wound care. The physician confirmed not being informed of the refusals and emphasized the importance of notification for continuity of care.
Medication Crushing Error Increased Medication Error Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during medication administration for one resident, resulting in 2 medication errors out of 31 opportunities for error, or a 6.45% medication error rate. During observation of medication administration, an LPN administered Tamsulosin HCl 0.4 mg and Risperidone 3 mg to the resident after crushing both medications and placing them in applesauce. The resident had been admitted with diagnoses including transient cerebral ischemic attack, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness, dysphagia, and oropharyngeal phase. The physician order for Tamsulosin HCl stated to give 1 capsule by mouth daily for dysfunction of the urinary bladder and specifically noted do not crush, open, or chew. The Risperidone order directed 1 tablet by mouth twice daily for mixed bipolar affective disorder. When asked why the medications were crushed, the LPN stated there was a statement at the top of the screen saying to crush and place in applesauce. The DON stated staff had been in-serviced on whether medications can be crushed. Manufacturer information stated Tamsulosin HCl capsules should not be crushed, chewed, or opened, and crushing Risperidone tablets is generally not recommended because it can change how the medication is delivered and work in the body.
Failure to Document RN Assessment for Change in Resident Condition
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who experienced a change in condition. The resident, who had diagnoses including hemiplegia, hemiparesis, anxiety, and major depressive disorder, was observed by a surveyor in a wheelchair and reported that staff responsiveness was inconsistent. The resident's medical records indicated episodes of vomiting and diarrhea over several days, documented by an LPN. However, there was no documented evidence of an RN assessment during these episodes, despite the facility's policy requiring RN assessment and documentation for changes in a resident's condition. Interviews with the RN/Unit Manager and the Director of Nursing confirmed that the facility's policy was not followed. The RN/Unit Manager acknowledged assessing the resident during the time in question but failed to document these assessments. The Director of Nursing stated that any change in a resident's condition should be reported by an LPN to an RN, who should then verify and document the data. The facility's Charting and Documentation policy, revised in January 2023, mandates that all services and changes in a resident's condition be documented in the medical record, which was not adhered to in this case.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for ten residents were transmitted in a timely manner. According to the facility's policy, resident assessments should be submitted to the CMS QIES ASAP system in accordance with federal and state guidelines. However, the review of the MDS assessments for ten residents revealed significant delays in submission, ranging from three to 26 days late. The assessments were identified as either export-ready or in progress but were not submitted within the required timeframes. During an interview, the MDS Coordinator acknowledged the delays and attributed them to being the sole person responsible for MDS assessments and waiting on social services to input their information. The facility's policy and the CMS Long-term Facility Assessment Instrument 3.0 User's Manual specify that assessments should be submitted no later than 14 calendar days after the assessment reference date (ARD). The failure to adhere to these guidelines resulted in the identified deficiencies.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan for five residents within 48 hours of their admission, as required by policy. For Resident 159, who had multiple pressure ulcers and skin wounds, the baseline care plan did not address her pain and discomfort. Observations revealed that Resident 159 was in visible distress and had several skin tears, yet her care plan lacked interventions for pain management. The Director of Nursing (DON) confirmed that pain should have been included in the baseline care plan. Resident 109, who had diagnoses including toxic encephalopathy and Alzheimer's disease, also did not have her pain and communication needs addressed in her baseline care plan. Observations showed that she experienced pain in her right arm, and her family member expressed concerns about her risk of falling. Despite these observations, the baseline care plan did not include interventions for pain or communication needs. The DON acknowledged that these should have been included. Similarly, Resident 160, who had undergone surgery and had a compression fracture, did not have her pain and communication needs addressed in her baseline care plan. Observations indicated that she experienced pain from her surgery and had difficulty communicating in English. Additionally, Residents 45 and 32 did not have baseline care plans developed within 48 hours of admission. The facility's policy requires that a baseline care plan be developed within 48 hours and provided to the resident or their representative, but this was not done for these residents. The DON and unit managers confirmed these deficiencies during interviews.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident (R87) by serving her meals with plastic utensils for 14 months, despite no assessment indicating she was a danger to herself or others. Observations over several days showed R87 consistently using plastic utensils, and interviews with R87 revealed she was unaware of the reason for this. R87 expressed confusion and frustration about the use of plastic utensils, stating she was not suicidal and found it easier to eat with regular silverware. On one occasion, R87 was observed to be very happy when provided with regular silverware. Review of R87's medical records indicated she was cognitively intact with no serious mental illness or behaviors toward herself or others. The records also showed no ongoing monitoring for behavioral needs and no care plan intervention for plastic utensils. Interviews with facility staff, including the Social Service Director, Dietary Manager, and Unit Manager, revealed a lack of awareness and communication regarding the reason for the use of plastic utensils. The facility's policy on suicide assessment did not support the prolonged use of plastic utensils for R87.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility staff failed to follow professional standards of practice by leaving medications at the bedside that were not ordered to be self-administered for Resident 98. Resident 98 was admitted with diagnoses of respiratory failure, sepsis, and pneumonia, and was cognitively intact with a BIMS score of 15 out of 15. An observation on 01/31/24 at 9:38 AM revealed that RN1 left two pills in a medicine cup on the overbed table in Resident 98's room. RN1 returned after five minutes and identified the pills as Lasix and a blood pressure medication, acknowledging that they should not have left the room. The Director of Nursing confirmed that nurses are not to leave medications unattended unless they are self-administered, and a review of the physician orders confirmed that these medications were not ordered to be self-administered.
Failure to Ensure Safe Discharge for Residents Leaving AMA
Penalty
Summary
The facility failed to ensure a safe discharge for residents who left Against Medical Advice (AMA) by not notifying community agencies and not providing prescriptions for care and medications. This deficiency was observed in two residents, R107 and R105, who were reviewed for unplanned discharge. R107, who had severe cognitive impairment and multiple medical conditions, left the facility without proper discharge planning or documentation. The staff did not notify the physician in a timely manner, and R107 was not provided with prescriptions for her medications or wound care supplies. Additionally, there was no evidence of discharge planning or discussions documented in R107's electronic medical record (EMR). R105, who had diagnoses including malignant neoplasm of the cervix and acute kidney failure, also left the facility AMA. The progress notes indicated that R105 left with her daughter, but there was no documentation that the physician had been notified. The staff involved could not recall the specifics of R105's discharge, and the physician confirmed that she was not notified about R105 leaving AMA. The facility's policy required that the physician be notified and that documentation of this notification be entered in the nurses' notes, which was not done in this case. Interviews with staff, including the Licensed Practical Nurse (LPN), Unit Manager (UM), Social Services Director (SSD), and Director of Nursing (DON), revealed inconsistencies in the process of handling AMA discharges. Staff were unsure of the proper procedures and failed to document necessary notifications and actions. The facility's policy on AMA discharges was not followed, leading to a lack of continuity of care and potential risks for the residents involved.
Failure to Accurately Screen for Elopement Risk and Unnecessary Use of Wander Guard
Penalty
Summary
The facility failed to accurately screen residents for elopement risk and ensure that measures were in place for residents with a wander guard. Specifically, Resident 76 was admitted with diagnoses including cerebral infarction, schizophrenia, right bundle branch block, and hemiplegia and hemiparesis. Despite scoring 09 out of 15 on the Brief Interview for Mental Status (BIMS), indicating some cognitive impairment, there was no documented wandering behavior. The resident's care plan included interventions for elopement risk, but the elopement risk assessment indicated that the resident was not at risk for elopement. However, a physician's order required checking the wander guard, which the resident had been wearing for about a year without understanding the reason for it. Staff interviews revealed that the resident was independent, did not exhibit exit-seeking behavior, and staff were unsure why the wander guard was in use. Observations and interviews with staff indicated that Resident 76 was independent in activities of daily living and did not require extra supervision for movement around the facility. The resident was seen walking directly to the TV room without wandering or attempting to exit the facility. Staff, including a CNA and an LPN, confirmed that the resident did not exhibit exit-seeking behavior and were unsure why the wander guard was in place. The Unit Manager and Director of Nursing also acknowledged that the resident was not an elopement risk and that the wander guard was used as a precautionary measure without proper documentation or justification. The facility's policy on elopement and missing residents stated that residents determined to be an immediate risk for elopement would be placed on a wander guard monitoring system. However, the policy was not followed in the case of Resident 76, who was not at risk for elopement but was still required to wear a wander guard. The lack of proper assessment and documentation led to the unnecessary use of the wander guard, causing discomfort to the resident and indicating a failure in the facility's procedures for managing elopement risks.
Failure to Obtain Physician Orders for Wound Care
Penalty
Summary
The facility staff failed to obtain a physician order when there was a change in treatment and failed to obtain a physician order for wound care upon admission for two residents. Resident 45 was admitted with a stage four pressure injury and had a wound vacuum dressing order that was discontinued without a new order for dressing changes. The Unit Manager confirmed that the wound vacuum was stopped and replaced with betadine dressings without notifying the physician or obtaining new orders. The Director of Clinical Services acknowledged the necessity of having an order and notifying the doctor for any change in treatment. Resident 32 was admitted with a stage four pressure injury with eschar present and had no wound care orders documented until four days after admission. The Unit Manager stated that the admitting nurse should follow the orders that come with the resident or use Medi-honey until the wound care team sees them. However, the nurse did not document the wound treatment and did not notify the physician. The Director of Nursing confirmed that the nurse should assess the wound and confer with the doctor for orders upon admission. The LPN admitted to using skin prep and a boot on the wound without documenting or notifying the physician due to being busy with admissions.
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 1,080 citations issued within 25 miles in the last 12 months — including the 23 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 Plainfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Plainfield Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Careone At The Highlands | 0.6 mi | ★★★★★ | 2 | 0 |
| Ashbrook Care & Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Aristacare At Norwood Terrace | 2 mi | ★★★★★ | 0 | 0 |
| Hartwyck At Oak Tree | 2.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Woodlands.
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.