Above average — CMS composite of the measures below.
The next survey window likely opens 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 Woodland Country Manor Inc during CMS and state inspections, most recent first.
RN Coverage Not Maintained: The facility failed to provide RN services for at least 8 consecutive hours each day. Records showed only one RN on file, and that RN worked less than 8 hours on multiple days. The Administrator confirmed the facility could not meet RN coverage requirements because there was only one RN, who was not salaried and part of management due to a lack of applicants.
Missing Water Management Plan: The facility did not have a comprehensive WMP to assess, measure, monitor, and prevent Legionella and other opportunistic waterborne pathogens in its water systems. The infection control manual contained no WMP, and an LPN confirmed one was not in place. Records showed repeated flushing of resident room sinks, showers, toilets, and other outlets with water temperatures documented across multiple months.
A resident with dementia and a history of pelvic fractures had multiple unwitnessed falls and one witnessed fall, but thorough fall investigations, fall assessments, and neuro checks were not completed. The resident was found on the floor beside the bed after one fall, later diagnosed with a pelvic ring fracture, and another fall from a wheelchair in the dining room was not fully investigated; the DON also confirmed there was no documented evidence that a seizure caused that event.
A resident with dementia and a known risk for elopement exited the facility through a dining room window without staff detection, despite wearing a wander guard and having interventions in place. Staff discovered the resident missing during checks and later found her outside. The facility's investigation was incomplete, lacking interviews with all staff on duty and a thorough assessment of the window and other potential exit points.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure services were provided by a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of schedules and timecard punches from 10/21/25 to 12/01/25 showed documentation of hours for only one RN, RN #378. RN #378 worked less than eight hours on multiple days, including 10/22/25, 10/26/25, 10/27/25, 10/29/25, 11/02/25, 11/03/25, 11/05/25, 11/06/25, 11/10/25, 11/13/25, 11/15/25, 11/16/25, 11/18/25, 11/20/25, 11/24/25, and 11/25/25. During an interview on 12/01/25 at 3:39 P.M., the Administrator verified the facility had been unable to meet RN coverage requirements and stated the facility only had one RN, RN #378, who was not salaried and part of management because of a lack of applications for the position.
Missing Water Management Plan
Penalty
Summary
The facility failed to have a comprehensive Water Management Plan to assess, measure, monitor, and prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. Review of the Infection Control Manual on 12/02/25 at 3:00 P.M. showed no Water Management Plan in place, and LPN #383, identified as the infection control nurse, confirmed the facility did not have one. The deficiency was identified through record review, staff interview, and review of CDC online resources describing the steps for developing a water management program. Review of the Water Flushing & Temperature Monitoring forms showed repeated flushing of resident room sinks, showers, and toilets across multiple months, with water temperatures documented between 101 and 115 degrees F in January and February 2025, and between 110 and 113 degrees F in March and May 2025. Additional monthly flushing logs documented outlets flushed in the 300, 200, and 100 areas, rehab area, kitchen area, activities area, office wing, and conference room from June through October 2025. The report states the facility had 52 residents, and the absence of a comprehensive Water Management Plan was noted in the facility's infection control documentation.
Failure to Investigate Repeated Falls and Complete Neuro Checks
Penalty
Summary
The facility failed to complete thorough investigations following a resident’s repeated falls and failed to perform neurological checks after unwitnessed falls. Resident #57 was admitted with multiple pelvic fractures, unspecified dementia, and no documented history of seizures. The record showed multiple unwitnessed falls on 05/08/25, 05/09/25, 06/27/25, 06/30/25, 07/13/25, 07/14/25, and 08/15/25, along with a witnessed fall on 08/31/25. The Falls Report indicated that thorough investigations, neuro checks, and fall assessments were not completed, and there was no Interdisciplinary Team follow-up for these events. After the fall on 07/14/25, the resident was found on the floor beside the bed, sent to the ER for hip pain, and diagnosed with a pelvic ring fracture. The fall intervention documented was staff education on placing pressure alarms on the resident’s wheelchair and bed. Following the fall on 08/31/25 in the dining room, the resident fell from the wheelchair and was sent to the hospital, but a thorough root cause investigation was not completed. The DON confirmed that neuro checks were not completed after the resident’s unwitnessed falls and that thorough investigations or fall assessments were not completed. The DON also stated there was no documented evidence confirming a seizure caused the 08/31/25 fall, although the incident report noted a seizure. Staff interviews indicated the resident was a very high fall risk and that pressure alarms were intended to help prevent falls.
Failure to Prevent Resident Elopement and Incomplete Investigation
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to prevent a resident with dementia, delirium, insomnia, depression, and auditory hallucinations from leaving the facility unsupervised. The resident, identified as an elopement risk and wearing a wander guard, was able to exit the building through a dining room window during the early morning hours. Staff discovered the resident missing during routine checks and later found her outside in a parking lot adjacent to the facility. The window used for the exit was found to be easily opened and the screen could be removed without difficulty, as confirmed by the facility administrator and maintenance director. The care plan for the resident included interventions such as distraction, structured activities, one-to-one talks, walking the halls, and the use of a wander alert device. Despite these measures, the resident was able to leave the facility undetected, and no alarms were triggered. The resident had a documented history of wandering, exit-seeking, and expressing a desire to return home. Staff interviews confirmed that the resident was frequently observed packing her belongings and attempting to leave, and that she was often awake and wandering at night. The facility's investigation into the incident was incomplete. Only two LPNs provided witness statements, and no interviews or statements were obtained from other staff present during the incident, including several CNAs who were on duty. The investigation lacked specific details such as the last time the resident was seen, how she was found, and which staff were involved. There was also no assessment of the window used for elopement or of other windows in the facility, and no evidence of new interventions to prevent similar incidents. The facility's policy required a thorough investigation and timely reporting, which was not followed in this case.
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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 Somerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Knolls Of Oxford | 4.6 mi | ★★★★★ | 3 | 0 |
| Golden Years Nursing Center | 8.2 mi | ★★★★★ | 0 | 0 |
| Westover Retirement Community | 10.1 mi | ★★★★★ | 6 | 0 |
| Berkeley Square Retirement Cen | 10.3 mi | ★★★★★ | 6 | 0 |
| Jamestowne Rehabilitation | 10.5 mi | ★★★★★ | 0 | 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.