Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Als Woodstock Inc during CMS and state inspections, most recent first.
A resident with a chronic wound requiring Enhanced Barrier Precautions (EBP) did not receive care in accordance with infection control protocols when an LPN performed a wound dressing change without donning the required PPE. The LPN was unaware that EBP applied to the resident, partly due to unclear signage in a shared room, resulting in a failure to use a gown as required by facility policy.
A resident with a history of behavioral issues and multiple medical diagnoses was placed on 1:1 supervision following an incident of inappropriate sexual behavior. Despite ongoing supervision and awareness of the resident's behavioral concerns, the facility did not develop or implement a behavioral care plan or document interventions addressing these behaviors, as confirmed by staff and record review.
The facility failed to conduct scheduled group activities due to the absence of activity staff, who were escorting a resident to an appointment. This affected 22 residents who regularly attend these activities. Interviews confirmed that activities are sometimes canceled when staff are unavailable, contrary to the facility's policy to promote residents' well-being through activity programming.
A resident with Alzheimer's and other conditions tested positive for COVID-19 and was later sent to the hospital due to increased behaviors. The facility failed to notify the resident's representative of these significant changes in a timely manner, violating their policy.
The facility failed to ensure the Activity Director (AD) was qualified, as the AD was not a licensed professional or had the required experience. The AD was enrolled in a training course but had not completed it, affecting all 39 residents. The Administrator, overseeing the activities department, was certified but not documented as the AD in her contract.
A resident with Parkinson's and diabetes required urgent dental care for decaying teeth, but the facility failed to refer them to an oral surgeon. Despite multiple dental assessments indicating the need for extractions, no follow-up occurred, leading to a severe tooth infection and hospitalization for sepsis. The facility lacked documentation of referrals and adherence to its dental services policy.
The facility failed to complete sufficient smoking assessments for four residents, affecting their safety and supervision needs. Residents with various cognitive and physical impairments, including Alzheimer's, cerebral palsy, and schizophrenia, were not adequately evaluated for smoking safety, despite facility policy requiring such assessments. The DON confirmed the incomplete assessments.
The facility failed to ensure timely physician responses to pharmacy recommendations for four residents, leading to unaddressed medication adjustments. Interviews with staff confirmed that physicians were not notified of the recommendations, resulting in a lack of documented responses for dose reductions or discontinuations of medications.
A facility failed to create a comprehensive care plan for a resident with multiple diagnoses, including a wound on the left medial ankle. The omission was confirmed by the DON, despite the facility's policy requiring individualized care plans.
A resident with multiple medical conditions, including a diabetic foot ulcer, did not have physician orders in place for wound treatment at the LTC facility. The resident missed several wound clinic appointments due to transportation issues, leading to unchanged wound dressings for extended periods. The facility lacked orders and documentation to guide staff on wound care if the dressing was compromised or if appointments were missed, as confirmed by the DON.
A facility failed to document a rationale for the continued use of lorazepam for a resident with multiple diagnoses, including schizophrenia and anxiety. Despite pharmacy recommendations to discontinue or provide a rationale, the physician extended the medication without proper documentation, citing increased behaviors when the medication was reduced or discontinued.
A resident with multiple health conditions did not receive several doses of the prescribed antibiotic Zosyn due to documentation and communication failures in the LTC facility. Despite the pharmacy delivering the required medication, some doses were not administered, and the physician was not notified promptly. The facility's policy on medication administration was not followed, leading to missed doses.
A resident with severe cognitive impairment and a history of wandering eloped from the facility undetected due to a failure in the WanderGuard system and inadequate supervision. The resident was last seen early in the morning and was found hours later outside the facility, unharmed. Staff interviews revealed that the system did not alarm when the resident exited, and the door was left open by EMTs, allowing the resident to leave.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow infection control protocols during a wound dressing change for a resident with multiple medical conditions, including diabetes and a right leg amputation. The resident had an active order for Enhanced Barrier Precautions (EBP) due to a right elbow wound, which required the use of gown and gloves during high-contact care. During observation, the LPN removed the old dressing, cleansed the wound, and applied new dressings as ordered, but did not don the required personal protective equipment (PPE) such as a gown while providing care. The LPN was unaware that the resident was under EBP, mistakenly believing that the precautions applied to the roommate instead. The signage on the door did not specify which resident in the double occupancy room was under EBP, contributing to the confusion. The Director of Nursing confirmed that the signage failed to identify the correct resident requiring EBP. Facility policy required EBP for residents with chronic wounds needing dressings, but this protocol was not followed during the observed wound care event.
Failure to Develop Behavioral Care Plan for Resident on 1:1 Supervision
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavioral issues, specifically following an incident involving inappropriate sexual behavior. The resident in question had a history of medical conditions including diabetes mellitus, stroke with ataxia, depression, and anxiety, and was admitted with intact cognition. After an incident where the resident made a gyration motion in another resident's doorway, the facility placed the resident on one-on-one (1:1) supervision per physician order, and this supervision continued for several days as documented in health status notes. Despite the ongoing 1:1 supervision and the resident's behavioral concerns, a review of the resident's care plan revealed that there were no documented interventions or care plans addressing the resident's behaviors or the need for 1:1 supervision. The lack of a behavioral care plan was confirmed by the MDS Coordinator, who acknowledged that such a plan should have been created given the circumstances. The facility was also aware of a pending court hearing for sexual misconduct involving the resident prior to admission, but this information did not result in a behavioral care plan being developed. The deficiency was discovered during a complaint investigation, which included review of the facility's self-reported incident, medical records, and staff interviews. The investigation also noted that the facility conducted an internal investigation into the allegation of sexual abuse, which was ultimately unsubstantiated. However, the failure to create a behavioral care plan for the resident, despite clear evidence of behavioral issues and the implementation of 1:1 supervision, constituted noncompliance with regulatory requirements for comprehensive care planning.
Plan Of Correction
Resident #11 was discharged from the facility prior to survey visit so the care plan/intervention was unable to be completed. However, on 6/18/2025, the MDS nurse and administrator educated the social service director on the importance of behavior care plans. She was shown the focus, goal, and adding interventions. A new care plan library was created on 6/15/2025 to streamline the process. With no other residents on a 1:1, there are no like residents to audit. Behavioral care plans on all similar/like residents will be audited by the MDS nurse twice a week for two weeks, then once a week for two weeks, and the results will be reviewed in QAPI. Social Services and MDS coordinator completed audits of like residents from 6/18/2025 to 7/9/2025.
Failure to Conduct Scheduled Group Activities
Penalty
Summary
The facility failed to conduct scheduled group activities, as observed on January 21, 2025. The activity calendar indicated a group activity, 'coffee time,' was scheduled for 9:00 A.M. in the activity room, followed by an exercise session at 10:30 A.M. in the dining room. However, observations at 9:07 A.M. and 9:23 A.M. revealed that the activity room was closed and locked, and no group activities were taking place in the common areas or dining room. Interviews with the Assistant Director of Nursing and the Activity Director confirmed that the 9:00 A.M. activity did not occur as planned because the activity staff were out of the facility, escorting a resident to an appointment. Consequently, the exercise session scheduled for 10:30 A.M. was also not conducted as residents were having coffee at that time. The deficiency affected 22 residents who regularly attend group activities, while 17 residents either chose not to attend or were not physically able to participate. Interviews with a Licensed Practical Nurse and a resident confirmed that group activities are sometimes canceled due to the absence of activity staff, who are occupied with transporting residents to appointments. The facility's policy, reviewed in August 2023, mandates providing activity programming to promote the physical, mental, and psychosocial well-being of each resident, which was not adhered to in this instance.
Failure to Notify Resident's Representative of Condition Changes
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, which is a requirement according to their policy. Resident #39, who has medical diagnoses including Alzheimer's disease, alcohol dementia, and peripheral vascular disease, tested positive for COVID-19 on 11/26/24. Although the physician was notified, there was no documentation indicating that the resident's representative was informed of the positive test result. This lack of communication is a violation of the facility's policy, which mandates timely notification of changes in a resident's medical or mental condition. Additionally, on 01/02/25, Resident #39 exhibited increased behaviors, prompting the physician to order a hospital evaluation. The resident was sent to the hospital and returned the following day, yet the representative was not notified until 01/03/25. The delay in communication led to the representative expressing concern over not being informed of the clinical changes. The facility's policy, reviewed in August 2023, clearly states that the resident's representative should be notified of changes in the resident's condition, which was not adhered to in this case.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the employee in the role of Activity Director (AD) was qualified as required by federal, state, and local standards. The AD, hired on October 15, 2024, was not a qualified therapeutic specialist, licensed activities professional, or occupational therapist, nor did they have the requisite two years of experience in a social or recreational program within the past five years. The AD was enrolled in an activity training course but had not completed it at the time of the survey. This lack of qualification had the potential to affect all 39 residents residing in the facility. Interviews with the Regional Nurse and the Administrator confirmed that the AD was still undergoing training and had not yet completed the necessary certification. The Administrator, who was a contracted employee overseeing the activities department, had completed the certification for activities but her contract did not document her role as the AD. The facility's job description for the AD position outlined specific qualifications that were not met by the current AD, as evidenced by the employee file review. This deficiency was identified during a complaint investigation.
Failure to Provide Timely Dental Care Leads to Resident Harm
Penalty
Summary
The facility failed to provide timely dental services for Resident #33, who had been identified as needing all remaining teeth extracted due to being non-restorable and decaying. Despite a dental evaluation in December 2023 and a subsequent visit in June 2024 confirming the need for extractions, the facility did not follow up with a referral to an oral surgeon. This lack of action resulted in Resident #33 developing a severe tooth infection, leading to systemic inflammatory response syndrome and bacteremia, which required emergency medical intervention. Resident #33, who had diagnoses including Parkinson's disease and diabetes mellitus, was assessed as cognitively intact and on a therapeutic diet. The resident's care plan from May 2021 indicated the need for dental care coordination, including transportation and daily oral care. However, despite multiple dental assessments and the resident's expressed desire to have at least one tooth extracted, there was no documented evidence of a referral to an oral surgeon or any follow-up on the dental care plan. The situation escalated when Resident #33 experienced fever and chills, prompting a hospital visit where the resident was diagnosed with sepsis due to a tooth infection. Interviews with facility staff revealed a lack of documentation regarding the referral process and no evidence of oral surgeons refusing treatment due to the resident's elevated hemoglobin A1C levels. The facility's policy stated that routine and emergency dental services should be available, but this was not adhered to in Resident #33's case.
Incomplete Smoking Safety Assessments for Residents
Penalty
Summary
The facility failed to ensure sufficient smoking assessments were completed to determine resident capabilities and deficits regarding smoking safety. This deficiency affected four residents who were reviewed for smoking. The medical records of these residents revealed that their smoking evaluations lacked comprehensive assessment information to determine their safety or clinical suggestions related to smoking needs, particularly in determining if they required supervision while smoking. The facility's policy required residents to be evaluated upon admission and routinely to assess their ability to smoke safely with or without supervision, but this was not adequately followed. Resident #26, who had moderately impaired cognition and was diagnosed with Alzheimer's disease, vascular dementia, and panlobular emphysema, had a smoking evaluation that did not provide sufficient information on safety or supervision needs. Resident #2, with diagnoses including cerebral palsy and epilepsy, was noted to have balance problems but lacked a complete assessment for smoking safety. Resident #13, diagnosed with paranoid schizophrenia and nicotine dependence, was able to smoke independently but subsequent evaluations did not reassess safety needs. Resident #16, with cerebral palsy and paranoid schizophrenia, also had balance issues, yet their smoking evaluations did not fully assess the need for supervision. The Director of Nursing confirmed the incomplete assessments during an interview.
Failure to Ensure Timely Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review and response to pharmacy recommendations by the physician, affecting four residents. For Resident #2, the pharmacy recommended a dose reduction or documentation of the benefit of continuing certain medications. However, there was no documented response from the physician, and interviews with the Medical Doctor (MD) and Assistant Director of Nursing (ADON) confirmed the physician was not notified of the recommendations. Resident #7's records showed a similar issue, where the pharmacy recommended dose reductions or documentation of contraindications for several medications. Again, there was no evidence of a physician response, and interviews with the ADON and MD confirmed the lack of notification to the physician. Resident #9's records revealed pharmacy recommendations for dose reductions and discontinuation of certain medications, but no physician response was documented, as verified by interviews with the MD and Director of Nursing (DON). For Resident #33, the pharmacy recommended discontinuation or documentation of no change for certain medications, but there was no documented physician response. Additionally, a pharmacy recommendation from May 2024 was not documented in the medical records, and the DON confirmed the lack of evidence that the recommendation was communicated to the physician. These deficiencies highlight a systemic issue in the facility's process for handling pharmacy recommendations and ensuring physician responses.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, which is a requirement. The resident, who was admitted with multiple diagnoses including Parkinson's disease, type two diabetes, major depressive disorder, bipolar disorder, hypertension, anxiety, seizures, and varicose veins with an ulcer on the left lower extremity, did not have a care plan addressing the wound on the left medial ankle or the need to visit a wound clinic. This omission was discovered during a review of the resident's medical record and was confirmed by the Director of Nursing during an interview. The facility's policy mandates that the care planning/interdisciplinary team is responsible for creating individualized comprehensive care plans for each resident, which was not adhered to in this case.
Lack of Physician Orders for Wound Treatment
Penalty
Summary
The facility failed to ensure that physician orders were in place to address wound treatments for a resident with multiple medical conditions, including Parkinson's disease, type two diabetes, and a diabetic foot ulcer. The resident was admitted with a stage one pressure ulcer and was seen by a physician who ordered a visit to a wound clinic. However, the resident missed several appointments due to transportation issues, resulting in the wound dressing remaining unchanged for extended periods. The wound clinic documentation indicated that the resident had not been seen for over a month, and there were no orders in place for staff to manage the wound if the dressing became soiled or detached. Interviews and observations revealed that the resident's wounds were only managed by the wound clinic, and the facility did not have any orders or documentation regarding the status of the resident's wound. The Director of Nursing confirmed that there were no orders in the medical record to guide staff on wound treatment if the dressing was compromised or if the resident missed wound clinic appointments. This lack of orders and documentation led to a deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Failure to Document Rationale for Continued Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that psychotropic as-needed medications for a resident had an appropriate stop date or rationale for extending usage, as required by regulations. This deficiency was identified during a review of medical records and staff interviews. The resident in question, who was admitted with diagnoses including paranoid schizophrenia, diabetes type two, depression, anxiety, and muscle weakness, was receiving anti-anxiety medication lorazepam on an as-needed basis without a specified stop date. Despite multiple pharmacy recommendations to either discontinue the medication or document a rationale or time frame for its use, the physician repeatedly extended the medication without providing a rationale in the medical records. The physician's responses to pharmacy recommendations were inconsistent and lacked documentation of a rationale for the continued use of lorazepam. Although the physician verbally communicated the need to continue the medication due to increased behaviors when reduced or discontinued, this explanation was not documented in the medical records. The lack of documentation and rationale for the continued use of lorazepam as needed for the resident represents a failure to comply with regulatory requirements for psychotropic medications, affecting the quality of care provided to the resident.
Failure to Administer Antibiotic as Ordered
Penalty
Summary
The facility failed to administer an antibiotic as ordered by the physician for a resident with multiple diagnoses, including Parkinson's disease and type one diabetes, who was being treated for a urinary tract infection. The resident was ordered to receive piperacillin/tazobactam (Zosyn) intravenously every six hours for seven days, followed by additional administrations. However, the medication administration record (MAR) revealed several doses were not documented as administered on specific dates, and there was no communication with the physician regarding these missed doses until later. The pharmacy had delivered the required vials of Zosyn to the facility, which should have been sufficient to complete the prescribed course. Despite this, the Director of Nursing (DON) confirmed that some doses were not marked as given, and there was no explanation for the missed doses. Additionally, the Assistant Director of Nursing (ADON) found evidence suggesting that an attempt to mix the medication may have failed, leading to wastage, but there was no documentation to support this. Interviews with the resident and staff confirmed the medication was unavailable at times, and the pharmacy was contacted to resolve the issue. The facility's policy required notifying the physician for held medications, but this was not done promptly. The pharmacist verified that the pharmacy had sent enough medication and did not receive any returns, indicating a failure in the facility's medication administration process.
Resident Elopes Due to Inadequate Supervision and System Failure
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision, resulting in a resident with severe cognitive impairment eloping from the facility without staff knowledge. The resident, who had a history of wandering and was at risk for elopement, was equipped with a WanderGuard device. Despite this, the resident managed to leave the facility undetected when emergency medical technicians left a door open during another resident's transfer. The WanderGuard system, which was supposed to lock doors when a resident with a wanderguard attempted to exit, did not function as intended in this instance. The incident occurred when the resident was last seen wandering in the hallway early in the morning. Staff initiated a search after realizing the resident was missing, but it took several hours before the resident was found outside the facility, unharmed. The search involved multiple staff members, including LPNs, STNAs, and non-direct care staff, who conducted both internal and external searches. The police were notified, and the resident was eventually located behind a tree line, approximately 250 feet from the facility's front door. Interviews with staff revealed that the WanderGuard system did not alarm when the resident exited the building, and the door was left open by EMTs, providing an opportunity for the resident to elope. The facility's policy on wandering and elopement was reviewed, which stated that residents at risk should have strategies and interventions in place to maintain their safety. However, in this case, the interventions were not effective in preventing the resident's elopement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Woodstock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gables Of Marysville Health And Rehabilitation | 9.9 mi | ★★★★★ | 21 | 0 |
| Vancrest Of Urbana, Inc | 10.3 mi | ★★★★★ | 0 | 0 |
| Milcrest Nursing Center | 10.5 mi | ★★★★★ | 3 | 0 |
| Urbana Health & Rehabilitation Center | 10.6 mi | ★★★★★ | 1 | 0 |
| Prestige Gardens Rehabilitation And Nursing Center | 10.8 mi | ★★★★★ | 2 | 0 |
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