Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 St Mary Of The Woods during CMS and state inspections, most recent first.
Kitchen Not Maintained in Clean and Sanitary Condition: Surveyors observed extensive grease buildup, food splatter, dirty dishes, wet floors with food particles, dirty equipment surfaces, open ice cream containers without lids, and dirty walls and storage areas. The Exec Chef verified the conditions, stated there was no cleaning schedule or log for hood screen cleaning, and acknowledged the stove did not appear to have been cleaned for a while.
A family member who requested a resident's medical records received not only the requested information but also another resident's personal and clinical details, including date of birth, insurance, diagnoses, and care plan. The DON confirmed the breach and that the facility's policy requires records to be released only with valid requests and in compliance with laws.
A resident with acute respiratory failure and other complex conditions did not receive appropriate oxygen therapy when staff applied a simple mask but failed to increase the oxygen flow rate as required by facility policy. Multiple LPNs were unable to state correct flow rates for oxygen delivery systems, and the contracted RT had not provided staff education on this topic, resulting in improper respiratory care.
Kitchen Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner. During the initial kitchen tour, surveyors observed grease buildup and food spatter on the wall behind the grill and stove, heavy grease on the deep fryer shield, heavy grease on the hood screens above the grill and stove, burnt food and food splatter on the stove, grease buildup and food particles under the steam table, and nine casserole dishes that were dirty with dried food. The reach-in cooler floor was wet with food particles, water was dripping from the ceiling vent, and the outside of the cooler had brown fingerprints and liquid and food splatters. Additional observations included crumbs and grease buildup on the shelf under the microwave, a dirty ice cream freezer exterior with brown and black spots, seven open three-gallon ice cream containers without lids, black buildup and food particles on the floor under the prep table and storage area, and dirty walls with splatters and handprints. The Executive Chef verified all of the dirty areas and stated he did not have a cleaning schedule and did not know when the kitchen was being cleaned. He also verified there was no log showing when the hood screens were last cleaned, even though he stated they are to be cleaned weekly. He stated the stove should be cleaned daily and acknowledged it did not appear to have been cleaned for a while. Review of the facility policy showed cleaning tasks were to be incorporated into a regular schedule, including kitchens, serving areas, and dining rooms, with hood filters cleaned weekly and walls spot cleaned as needed and washed yearly.
Breach of Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records. A family member of one resident requested and received that resident's medical records from the facility, but the packet also included another resident's personal information, including date of birth, insurance details, diagnoses, and complete care plan. Review of the medical record package confirmed that the private and clinical information of the second resident was improperly included. The Director of Nursing verified that the records sent contained the additional resident's confidential information and notified the affected resident's family of the breach. Facility policy requires that all medical records be released only with a valid request and in accordance with state and federal laws.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and facility policy for a resident requiring oxygen therapy. The resident, who had multiple diagnoses including acute respiratory failure with hypoxia, Parkinson's disease, heart failure, and cognitive deficits, required continuous oxygen via nasal cannula at two to three liters per minute. During an episode of shortness of breath and low oxygen saturation (87-89%), a nurse applied a simple mask but did not adjust the oxygen flow rate above 3 liters per minute, contrary to facility policy which requires a minimum of 5 liters per minute for a simple mask. When emergency medical services arrived, the oxygen flow was found to be only 1 liter per minute via simple mask, and the squad had to increase it to 8 liters per minute, resulting in improved oxygen saturation and responsiveness before hospital transfer. Interviews with multiple LPNs revealed a lack of knowledge regarding appropriate oxygen flow rates for different delivery systems, particularly the simple mask. The contracted respiratory therapist confirmed he had not provided education to staff on oxygen flow rates, and the Director of Nursing acknowledged that staff education on this topic had not been conducted. Observation of the facility's respiratory supply room showed the availability of various oxygen delivery devices, but staff were not adequately trained in their use, leading to improper administration of oxygen therapy for the resident.
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What surveyors actually found near you
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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 Avon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woods On French Creek Nursing & Rehab Center The | 1.6 mi | ★★★★★ | 2 | 0 |
| Avon Oaks Nursing Home | 1.6 mi | ★★★★★ | 8 | 0 |
| Avon Place Healthcare Center | 1.7 mi | ★★★★★ | 11 | 0 |
| Main Street Care Center | 2.7 mi | ★★★★★ | 12 | 0 |
| O'neill Healthcare Bay Village | 3.2 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.