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 August 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.
Failure to follow physician orders during aerosol treatments affected two residents. One resident with COPD and continuous oxygen was found with the nebulizer mask on but no oxygen, and staff confirmed the nurse did not stay with the resident during treatment as ordered. Another resident received a nebulizer treatment without a pre-treatment respiratory assessment and without being observed during the full treatment time, despite the order and facility policy requiring monitoring.
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.
Failure to Follow Respiratory Treatment Orders
Penalty
Summary
The facility failed to ensure staff followed physician orders when administering respiratory aerosol treatments to two residents. For one resident with COPD, emphysema, chronic kidney disease, dysphagia, and other diagnoses, the physician ordered ipratropium-albuterol inhalation solution five times daily while awake, continuous oxygen at five liters per minute, and for the nurse to remain with the resident for the full 15 minutes of treatment to monitor respiratory status. Family members later reported finding the resident connected to the nebulizer mask without oxygen, with oxygen saturation reported at 47 percent and the resident described as blue, and the record documented that the resident had been disconnected from oxygen for a long period of time. Staff interviews confirmed that the ordered oxygen was not consistently provided during the aerosol treatment and that the nurse did not remain with the resident during the treatment as ordered. One LPN stated the family complained that the resident had been found with the aerosol mask in place and no oxygen being administered, and another LPN stated residents with continuous oxygen were supposed to receive oxygen during aerosol inhalation treatments. The nurse who administered the treatment acknowledged she did not remain with the resident during the treatment and could not remember whether she encouraged the resident to wear oxygen during the treatment. The DON agreed the nurse should have stayed with the resident and failed to follow the physician order and facility policy. For a second resident with diagnoses including left kidney cancer, acute kidney failure, stage IV chronic kidney failure, malnutrition with dehydration, and other conditions, the physician ordered ipratropium-albuterol inhalation solution four times daily for shortness of breath and wheezing, with the nurse to observe the resident during the full 15 minutes of treatment for any change in condition. During observation, an LPN administered the aerosol treatment without performing a respiratory assessment before treatment and without observing the resident during the treatment. The LPN verified she should have completed a pre- and post-treatment respiratory assessment and observed the resident during administration, but did not do so. The facility policy for nebulizer therapy required verification of the order, baseline vital signs and respiratory assessment, observation during treatment, and post-treatment respiratory assessment.
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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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 | ★★★★★ | 3 | 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 August 2026) and official state health department websites.