Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Woodlands Health And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and documented allergies to specific COVID-19 vaccines, including prior anaphylaxis, was given a COVID-19 vaccine without staff first checking the allergy list in the EMR. Consent and education were obtained from the resident’s guardian, but the RN administered the vaccine before screening for contraindications, and the EMR allergy alert was recognized only after the order was entered and the dose had already been given. No immediate assessment, monitoring, or vital signs were documented following vaccination, and the resident was not clinically assessed until she later reported feeling unwell, at which time an LPN found her in respiratory distress with tachycardia, hypoxia, and an unobtainable blood pressure, leading to transfer to the ED where she was treated for anaphylaxis and admitted with altered mental status, encephalopathy, and acute hypoxic respiratory failure.
Surveyors found that the facility did not follow its legionella water management plan after a positive legionella result in an ice machine, as required retesting and documentation were not completed or could not be located. Additionally, an LPN performing a pressure ulcer dressing change for a resident with multiple cardiac, renal, and metabolic comorbidities failed to perform hand hygiene after removing gloves and then touched the bed, linens, and other room surfaces. In a separate observation, an LPN administering multiple oral medications and eye drops to a newly admitted resident with Parkinson’s disease, atrial fibrillation, and other conditions left the medication cart to obtain a missing drug, touched environmental surfaces including an elevator and housekeeping cart, and then resumed medication preparation and administration without performing hand hygiene, contrary to the facility’s hand hygiene policy.
Failure to Report RN Job Duty Failure to the Board of Nursing: A licensed RN assigned to care for 24 residents did not administer their bedtime medications during an evening shift after arriving late and refusing assistance from other nurses. Staff reported the residents were upset and did not understand why they were not receiving medications, and the former DON later documented the meds as given despite staff statements that they were not. The RDCS verified there was no documentation that the Board of Nursing was notified about the RN's failure to perform assigned duties.
A resident discharged with multiple medical conditions, including dysphagia and hypertension, did not have a signed discharge summary verifying receipt of wound care instructions, even though the form required a resident or responsible party signature. Record review showed the resident was cognitively intact and required set-up to moderate assistance with ADLs at discharge, yet no signature was present. An RN confirmed she did not obtain the resident’s signature, and leadership later identified that nurses were not consistently obtaining required signatures on discharge summaries, resulting in a cited deficiency related to the discharge process.
Surveyors found that the facility failed to revise a resident’s care plan to correctly classify a right buttock stage III pressure ulcer, which continued to be documented as a surgical wound despite wound assessments and staff acknowledgment that it remained a pressure ulcer. They also found that another resident with GERD and frequent reflux and swallowing difficulties had no individualized care plan interventions addressing reflux, vomiting of undissolved medications, or aspiration risk, and that an episode of vomiting medications and subsequent assessments were not documented in the clinical record.
Two residents with significant ADL dependence and complex medical conditions, including stroke, contractures, amputation, osteomyelitis, and chronic kidney disease, did not consistently receive showers according to their stated preferences and physician orders. Assessments and care plans documented that bathing choices and shower frequency were important to them, yet paper shower sheets frequently showed bed baths, missing bathing-method documentation, or deviations from the ordered schedule, while EMR entries often reflected showers on those same dates. One resident reported not always receiving showers on scheduled days, and staff interviews with CNAs, an LPN, and the DON confirmed that showers were recorded on paper sheets reviewed and signed by nursing, and that the residents’ preferences and scheduled bathing frequencies were not consistently followed.
A resident with stroke, DM2, heart disease, HF, multiple contractures, and functional quadriplegia had a care plan directing staff to keep the call light within reach, but surveyors repeatedly observed the call light placed outside the bed mobility rail and out of reach. An LPN confirmed the resident could use the call light with the left arm and verified it was out of reach; facility policy required the call light to be within easy reach for a resident confined to bed.
Failure to Provide Individualized Activities: A resident with cognitive impairment, total dependence for ADLs, and a history as a DJ had documented preferences for music, TV, family visits, and one-to-one interactions, but activity logs showed he was mainly offered movies with only occasional one-to-one visits. Family reported music was important to him but was not usually playing at the bedside, and activities staff acknowledged the documented activities did not reflect his interests.
A resident with DM and multiple serious diagnoses did not receive BG monitoring or insulin on admission despite hospital records showing he had been receiving long- and short-acting insulin with AC/HS checks. Staff stated there was no insulin order and they were not checking BGs, while the resident’s son reported BG readings over 300 mg/dL and said the facility was not following the hospital orders.
Oxygen and nebulizer equipment was not changed or stored properly for two residents receiving respiratory care. One resident with altered pulmonary status had undated oxygen tubing and nebulizer equipment left uncovered on the bedside stand, with residue noted in the nebulizer reservoir. Another resident with chronic bronchitis and end-of-life oxygen needs had no documentation that the concentrator, tubing, or nebulizer equipment were cleaned or changed, and the nebulizer items were also left uncovered on the bedside stand. An LPN confirmed the equipment handling issues, and a director stated it was not facility policy to date oxygen equipment.
Failure to assess a resident after dialysis return. A resident with ESRD, DM2, heart disease, COPD, HF, reduced mobility, and dependence on renal dialysis returned from scheduled dialysis treatments multiple times without documented post-dialysis VS or refusals in the chart. The record showed no order for post-dialysis VS, and an LPN stated staff were to check VS when the resident returned from dialysis; the Divisional Director of Clinical Education verified the resident was not properly assessed after dialysis.
Pharmacy MRR recommendations for psychotropic medications were not addressed timely for multiple residents. One resident with dementia, anxiety, depression, and other diagnoses had blank, unsigned responses to recommendations to reduce antidepressant therapy and attempt a GDR for lorazepam, with no documentation that the GDR was completed or contraindicated. Another resident with dementia and anxiety had an unsigned recommendation to attempt a GDR for buspirone, and a third resident had an unsigned recommendation to attempt a GDR for mirtazapine that remained in use for months without documented physician action.
Medication administration errors resulted in a 10.7% error rate, exceeding the required threshold. An LPN misread a BP hold parameter and withheld an ordered beta blocker for one resident, and an RN gave another resident an incorrect Atenolol dose while also measuring MiraLAX incorrectly during observed med pass.
Incomplete Documentation of Vomited Medications: A resident with multiple chronic conditions, including CKD, CAD, CVA, GERD, DM, HTN, hyperlipidemia, and hypothyroidism, vomited undissolved medications during morning med pass. An LPN was told by the resident’s son, another LPN later assessed the resident, and the CNP was notified and assessed the resident with no negative findings or signs of aspiration, but none of the incident, notification, or assessment was documented in the clinical record.
A resident with a Foley catheter was observed without a privacy cover on the drainage bag, despite the care plan requiring the use of a protective dignity pouch. A CNA confirmed the expectation for privacy covers, and facility policy emphasized resident dignity. This deficiency was identified during a complaint investigation and could have affected other residents with catheters.
A resident with severe cognitive impairment and multiple diagnoses removed his Foley catheter, resulting in bleeding. An RN discovered the incident, assisted the resident, and reinserted the catheter, but did not notify the physician or family as required by facility policy.
A resident with a recent femur fracture and an order for Tramadol experienced misappropriation of her medication when a nurse removed a dose from the medication cart, placed it in her pocket, and later could not account for it. The nurse claimed to have disposed of the medication but provided no evidence, refused to cooperate with the investigation, and terminated her employment. The facility confirmed the misappropriation of the resident's medication.
A resident with severe cognitive impairment and multiple health conditions was allegedly subjected to physical abuse by a CNA, who was witnessed forcefully applying deodorant and spraying it in the resident's face. The incident was reported by a housekeeper to an LPN, who delayed addressing the concern and did not immediately assess the resident. The DON was informed but did not suspend the CNA right away, contrary to facility policy requiring immediate removal of staff suspected of abuse. The accused staff member was not suspended until several hours after the allegation, resulting in a deficiency for failure to protect residents from potential abuse.
Two residents at high or moderate risk for falls did not have required fall prevention interventions in place or documented at the time of their incidents. One resident was found on the floor without footwear and with unclear access to the call light or proper bed placement, while another did not have a reacher within reach as care planned. Staff interviews and record reviews confirmed these lapses in following fall prevention protocols.
The facility failed to maintain consistent advance directive orders across electronic and paper records for two residents. One resident had conflicting DNRCCA and full measures directives, while another had DNRCC and full measures directives. The DON confirmed these inconsistencies, highlighting the protocol to check both records before proceeding with CPR.
A resident with Huntington's disease and Alzheimer's dementia was not released from a pelvic restraint every two hours as ordered. Observations showed the restraint was not released between 11:00 A.M. and 1:05 P.M. Staff interviews confirmed the oversight, with some unaware of the last release time. The facility's policy requires restraints to be released for at least 10 minutes every two hours, which was not adhered to.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. A resident with severe cognitive impairment was found without dycem on the bathroom grab bar, contrary to the care plan. Another resident with Huntington's disease was observed without ankle weights on her Broda chair, as required. Staff were unaware of these interventions, indicating a lack of adherence to care plans.
Failure to Check COVID-19 Vaccine Allergy and Delay in Post-Vaccination Assessment
Penalty
Summary
The deficiency involves the facility’s failure to verify a resident’s documented COVID-19 vaccine allergies prior to administering a COVID-19 vaccine and the failure to provide timely assessment and medical intervention afterward. The resident had an extensive medical history including end stage renal disease with dependence on dialysis, type 2 diabetes, heart disease, COPD, heart failure, reduced mobility, and need for assistance with personal care. Her allergy list in the medical record documented allergies to the Pfizer mRNA BNT 162b2 COVID-19 vaccine with reactions of altered mental status and anaphylaxis, and to the Moderna mRNA-1273 COVID-19 vaccine with altered mental status, both dated 04/12/24. Guardianship papers showed she had a court-appointed guardian due to being assessed as incompetent to make her own decisions, although a recent MDS assessment documented her as cognitively intact, requiring assistance with ADLs, dialysis, and having a legal guardian. On the day of the incident, the resident returned from dialysis with stable vital signs documented on the dialysis communication form. A physician order dated that same day directed administration of a single dose of Mnexspike 2025–2026 COVID vaccine intramuscularly. The COVID-19 vaccine administration report showed that consent and education were provided to the guardian by an RN, and that the resident received the Moderna mNEXSPIKE COVID-19 vaccine in the left deltoid at 12:10 P.M. The report also indicated that the RN administered the vaccine before assessing or screening the resident for contraindications related to allergies. The facility’s EMR later alerted to the allergy when the ADON entered the vaccine order, but by that time the infection prevention RN had already given the vaccine. Facility policy on General Dose Preparation and Medication Administration required staff to check for allergies prior to administration, but this was not done in this case. Following administration of the contraindicated vaccine, there was no documented immediate assessment, monitoring, or vital sign checks for the resident. Review of progress notes, evaluation screens, and vital sign flow sheets from the date of vaccination through several days afterward revealed no documentation that the resident was assessed after receiving the vaccine or that staff recognized she had been given a vaccine listed as an allergy. The physician was not notified at the time of vaccine administration. The first documented assessment occurred later that night when the resident told a CNA she was not feeling well, and an LPN found her panicked, short of breath, sweating heavily, with a heart rate of 140 bpm, oxygen saturation of 84% on 2 L O2, respirations of 25, and an unobtainable blood pressure. EMS was called and she was transported to the ED, where she was treated for anaphylaxis and admitted with diagnoses including altered mental status, encephalopathy, and acute hypoxic respiratory failure. Interviews with the DON and regional clinical staff confirmed there was no documentation of an assessment after the vaccine administration and that the facility lacked a policy for verbal consent for vaccines, while the Resident Change in Condition policy required recognition, assessment (including vital signs), and provider notification for incidents or reactions to medications or treatments, which did not occur in a timely manner for this resident.
Failure to Follow Legionella Water Management Plan and Hand Hygiene Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its legionella water management plan and to perform required hand hygiene during wound care and medication administration. The facility’s Water Management Plan (WMP) dated 04/12/19 identified the ice machine as a risk factor and required cleaning, disinfection, filter changes, documentation of all cleanings, and specific corrective actions and retesting if legionella was detected. Water testing on 03/10/25 showed the first-floor ice machine had two CFU/mL of legionella detected, while no other sampled areas were positive. A legionella flush-out form dated 03/25/25 documented a seven-day flushing protocol for the first-floor ice machine and beauty shop, with detailed steps including flushing hot and cold water, removing and disinfecting aerators, testing hot water parameters, documenting all activities, and retesting within seven days of the final day of flushing. Despite these requirements, the facility had no documentation of any retesting after the positive legionella result and completion of the seven-day flush-out ending 04/03/25. The Divisional Director of Clinical Education/Registered Nurse reported that follow-up testing was said to have been completed in August 2025 but confirmed that no evidence of such retesting could be located, and that 2026 legionella testing had not yet been completed. The Environmental Services Director did not recall the positive legionella result from March 2025 and did not recall any corrective actions beyond the initial seven-day flush-out, and also could not recall any retesting after the positive result. The facility’s Legionella Assessment and Prevention Program policy, revised 01/10/25, required that after positive results, mitigation steps be documented and water be retested to ensure it was free of bacterial growth, and also required annual testing at four specified water sources, including an ice machine. The deficiency also includes failures in hand hygiene during wound care for one resident. Resident #8, admitted 06/18/22, had multiple diagnoses including congestive heart failure, atrial fibrillation, atherosclerotic heart disease, anemia, hypertension, hyperlipidemia, chronic kidney disease, polyneuropathy, diabetes mellitus, osteoarthritis, gout, restless leg syndrome, benign prostatic enlargement, and cognitive communication deficit. Physician orders dated 02/16/26 directed daily cleansing of sacral and right gluteal pressure ulcer areas with Dakin’s solution, followed by application of pink polymem and foam dressing. During an observed dressing change on 03/31/26, an LPN gathered supplies, sanitized the over-bed table, performed hand hygiene, donned gloves, removed the soiled dressing, discarded it, removed gloves, and performed hand hygiene before donning new gloves and completing the wound treatment according to infection control standards. However, after completing the wound treatment, the LPN removed her soiled gloves and did not perform hand hygiene before touching the bed remote, adjusting the bed, handling bed linens, and touching other room surfaces. The LPN later confirmed she had not performed hand hygiene after glove removal, contrary to the facility’s Clean Dressing Change Policy effective 03/10/24, which required hand hygiene at multiple steps, including after glove removal and at the end of the procedure. A further deficiency was observed in hand hygiene during medication administration for another resident. Resident #100, admitted 03/25/26, had diagnoses including a fractured right humerus, Parkinson’s disease, mood and psychotic disturbance, atrial fibrillation, hypothyroidism, hypertension, hyperlipidemia, lymphedema, gastroesophageal reflux disease, and cognitive communication deficit. Physician orders directed administration of multiple oral medications and Xidra eye drops in the morning time window. During an observed medication pass on 03/31/25, an LPN used hand sanitizer at the medication cart and began dispensing the ordered medications, then discovered that one medication (omeprazole 20 mg) was not in the cart and needed to be obtained from central supply. The LPN locked the cart, used the elevator, moved a housekeeping cart, pushed elevator buttons, went to central supply to obtain the medication, then returned via the elevator and resumed dispensing medications into a medication cup without performing hand hygiene before continuing the task. The LPN then administered the oral medications to the resident. In a subsequent interview, the LPN acknowledged that hand hygiene should have been performed before resuming dispensing and administering medications, which was inconsistent with the facility’s Hand Hygiene Policy effective 09/01/11 that required hand hygiene immediately before touching a resident, before performing an aseptic task, after contact with contaminated surfaces, and immediately after glove removal.
Failure to Report RN Job Duty Failure to the Board of Nursing
Penalty
Summary
The facility failed to notify the Board of Nursing after a licensed RN did not perform assigned nursing duties during an evening shift on the second floor memory care unit. The incident involved 24 residents who were assigned to the RN for care, and the record review and interviews showed that their bedtime medications were not administered as scheduled during the shift when one nurse had called off and the former DON and the Infection Control Preventionist RN were covering the shift. According to the SRI and staff interviews, the RN was expected to assist with care for the 24 residents but arrived late, did not administer the medications, and refused offers from other nurses to help him use the electronic system or assist with medication administration. Staff stated the residents were upset and did not understand why they were not receiving their evening medications. The former DON later entered documentation indicating the medications had been given between 7:00 P.M. and 11:30 P.M., although staff interviews indicated they had not been administered during that time. Interviews with the RN, RN staff, and the RDCS confirmed that the RN had not been trained to administer medications in the facility, had not documented the one acetaminophen dose he said he gave, and was not disciplined for failing to perform the assigned duties. The RDCS also verified there was no documentation that the Board of Nursing was notified regarding the RN's failure to perform RN job duties related to medication administration.
Failure to Obtain Resident Signature on Discharge Summary and Instructions
Penalty
Summary
The facility failed to ensure a resident’s discharge summary was signed to verify receipt of discharge instructions, as required by the form. A closed record review showed that Resident #94, admitted with diagnoses including foreign body in the respiratory tract, dysphagia, hypertension, and anxiety, and documented as cognitively intact and needing set-up to moderate assistance with ADLs at discharge, had a discharge summary with wound care instructions that lacked a signature from either the resident or a family member, despite the form indicating a signature should be obtained. During interview, the RN responsible for the discharge confirmed she did not obtain the resident’s signature on the discharge summary, and the Divisional Director of Clinical Education reported that, after reviewing the complaint involving this resident, they found that nurses were not obtaining signatures from residents or responsible parties on discharge summaries. This deficiency affected one of three residents reviewed for the discharge process and was cited under Complaint Number 2667505. The deficiency centers on the absence of documented acknowledgment of discharge and wound care instructions, as evidenced by the unsigned discharge summary for Resident #94, and confirmed through staff interviews and record review.
Failure to Accurately Revise Wound Care Plan and Individualize GERD Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident care plans were accurately developed and revised based on comprehensive assessments. For one resident with multiple chronic conditions, including congestive heart failure, atrial fibrillation, diabetes, chronic kidney disease, and a history of chronic pressure ulcers on the buttocks and sacral areas, the care plan listed an alteration in skin integrity related to a surgical wound on the right buttock. However, wound assessments documented that the right buttock lesion was a stage III pressure ulcer that had been surgically repaired but remained a pressure ulcer, and observation showed a quarter-sized, approximately 1 cm deep pressure ulcer on the right buttock/sacral area with a red wound bed and scarred, very red surrounding skin. The wound nurse confirmed that the wound was misclassified as a surgical wound on the care plan and acknowledged that the plan of care needed revision to correctly identify it as a pressure ulcer. The deficiency also includes the facility’s failure to develop and individualize care plan interventions for another resident with a diagnosis of gastroesophageal reflux disease (GERD) and multiple comorbidities such as chronic kidney disease, atherosclerotic heart disease, cerebrovascular disease with prior stroke, diabetes, hypertension, and hypothyroidism. During a morning medication pass, the resident’s son reported to an LPN that the resident had vomited undissolved medications into a napkin. Although the clinical record contained a care plan for increased nutrition/hydration risk related in part to GERD, it did not include specific interventions addressing reflux, vomiting of medications, or aspiration risk. Nursing staff and a CNP acknowledged that the resident often experienced reflux and difficulty swallowing food and medications, that the vomiting incident and subsequent assessments were not documented in the clinical record, and that no care plan had been initiated to address the resident’s GERD with individualized interventions for reflux and vomiting of medications.
Failure to Honor Resident Bathing Preferences and Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing in accordance with resident preferences and physician orders, as well as inconsistent and conflicting documentation of showers and bed baths. One resident, identified as Resident #9, had a history of stroke, type 2 diabetes mellitus, heart disease, heart failure, multiple contractures, and functional quadriplegia, and was dependent on staff for all ADLs and incontinent of bowel and bladder. Assessments and observations documented that it was very important to this resident to choose between a tub bath, shower, bed bath, or sponge bath. The care plan documented a self-care deficit related to stroke with interventions for bathing and hygiene assistance by two staff, and a physician order directed showers twice weekly on specific days. Review of the electronic medical record (EMR) shower sign-off for Resident #9 over several months showed multiple entries indicating showers on various dates. However, review of the paper shower sheets for the same time periods showed that on many of those dates the resident actually received bed baths instead of showers, and on at least one date the method of bathing was not documented. Staff interviews with an LPN and a CNA confirmed that showers were documented on paper shower sheets and then reviewed and signed by the nurse, and the DON verified the findings that the resident’s preference for showers was not honored and that multiple bed baths were provided instead. A second resident, identified as Resident #35, had diagnoses including orthopedic aftercare following surgical amputation, osteomyelitis of the left tibia and fibula, stroke, acquired absence of the left leg below the knee, chronic kidney disease, need for assistance with personal care, and acute respiratory failure. On admission observation, this resident expressed a preference for showers and for bathing three times a week. The care plan documented a self-care deficit related to weakness and debility with interventions for assistance with ADLs. Physician orders specified showers twice weekly on designated days, with an order change later to different days. EMR shower sign-off records showed showers provided on multiple dates, but the paper shower sheets documented bed baths on some dates, refusals on one date, showers on some dates, and several dates where the method of bathing was not documented. The resident reported not always receiving showers on scheduled shower days, and staff interviews, along with DON verification, confirmed that the resident was not bathed three times a week as scheduled.
Call Light Out of Reach for Bedbound Resident
Penalty
Summary
The facility failed to ensure the call light was within reach for one resident, who was admitted with diagnoses including stroke, type 2 diabetes mellitus, heart disease, heart failure, contractures of the right hand, thigh, and lower leg, and functional quadriplegia. The quarterly MDS indicated the resident was cognitively impaired, dependent on staff for all ADLs, did not reject care, and was incontinent of bowel and bladder. The care plan identified the resident as at risk for falls related to impaired communication and impaired mobility, with interventions to keep the call light and frequently used items in reach. During observations, the resident’s call light was repeatedly found on the outside of the bed mobility rail and out of reach at 10:44 A.M., 12:19 P.M., and 3:34 P.M. An LPN later confirmed the resident had use of the left arm and could use the call light with that arm, and also verified that the call light was out of reach. The facility policy stated staff were to ensure the call light was within easy reach if the resident was confined to bed.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities to meet Resident #9’s interests. Resident #9 was admitted with diagnoses including stroke, Type 2 diabetes mellitus, heart disease, heart failure, multiple contractures, and functional quadriplegia. The quarterly MDS showed the resident was cognitively impaired, dependent on staff for all ADLs, and incontinent of bowel and bladder. Activities observations documented that it was somewhat important for the resident to listen to music he liked, participate in favorite activities, and have one-to-one activities, with preferred activities including music, TV, family visits, and one-to-one visits; the resident was also noted to have been a DJ prior to admission. The care plan identified impaired daily decision making and included interventions to offer activities that recreate past experiences and use retained long-term memory. However, the activities logs from December through March showed the resident was primarily provided movies, with only occasional one-to-one visits and one celebration documented. During interview, the resident’s family stated music was important to him, but music was not normally playing by the resident’s bed and he could not turn it on or off himself. Activities staff stated movies were considered a one-to-one activity and confirmed the logs did not reflect meeting Resident #9’s interests. The facility policy stated the activity program would be based on comprehensive assessments and care plans and would meet resident interests and abilities, including previous positive lifestyles.
Failure to Provide Ordered Diabetes Monitoring and Insulin
Penalty
Summary
The facility failed to ensure treatment was in place to properly manage a resident’s diabetic needs. Resident #98 was admitted with multiple diagnoses including intracranial hemorrhage, hemiplegia, heart failure, diabetes mellitus, cirrhosis of the liver, COPD, obstructive sleep apnea, and urinary retention. The hospital record showed the resident had diabetes mellitus and had been receiving both long-acting and short-acting insulin, along with blood glucose monitoring before meals and at bedtime, during the hospital stay. After admission to the facility, the Medication Administration Record showed no blood sugar monitoring or insulin administration until three days later. The resident’s son stated he was upset that his father was not receiving insulin and blood glucose checks before meals and at bedtime, and said he had personally checked the resident’s blood sugar and found it to be greater than 300 mg/dL. Two RNs stated they had no order to administer insulin and were not obtaining blood glucose levels before meals and at bedtime, and they were unaware of the family’s request. The CNP stated she was unaware of the family’s request, initially said the resident did not have diabetes mellitus, then confirmed after reviewing the hospital record that he did have diabetes mellitus and had been receiving insulin in the hospital. She also verified that an order for blood glucose monitoring and insulin was not entered until three days after admission.
Oxygen and Nebulizer Equipment Not Changed or Stored Properly
Penalty
Summary
The facility failed to ensure oxygen equipment was changed per physician order and stored appropriately for two residents receiving respiratory care. Resident #35 had diagnoses including orthopedic aftercare following surgical amputation, osteomyelitis of the left tibia and fibula, stroke, acquired absence of the left leg below the knee, chronic kidney disease, and acute respiratory failure. The care plan addressed altered pulmonary status related to a left lung mass, and physician orders included oxygen via nasal cannula as needed to maintain oxygen saturation greater than 92%, cleaning the oxygen concentrator and filter, and changing oxygen tubing every seven days. For Resident #35, the record showed the last documented oxygen tubing change occurred on 01/27/26. During observation on 03/30/26, the oxygen tubing was without a date and was laid directly on the bedside stand while not in use, uncovered. A nebulizer mask and tubing were also undated, laid directly on the bedside stand, and not covered while not in use. The nebulizer medication reservoir had a brown crusty residue inside where medication is dispensed. An LPN stated oxygen tubing was to be dated, changed weekly, and stored in a bag while not in use, and nebulizers were to be changed weekly, dated, and stored in a bag while not in use; the LPN later verified the findings. Resident #49 had diagnoses including heart disease, dementia, chronic bronchitis, muscle weakness, depression, and need for assistance with personal care. The care plan included oxygen related to end-of-life care and shortness of breath related to chronic bronchitis, with physician orders for oxygen via nasal cannula as needed and weekly cleaning of the oxygen concentrator, filter, and tubing. The MAR lacked documentation that the concentrator was cleaned, the oxygen tubing was changed, or the nebulizer equipment was changed. During observation, the resident was using oxygen with a nasal cannula in place; the tubing was dated 03/16/26, but the nebulizer mask and tubing were undated and left uncovered on the bedside stand, with the mask hanging off the stand and touching the back part of it. An LPN confirmed the equipment handling findings, while the Divisional Director Clinical Education stated it was not facility policy to date oxygen equipment.
Failure to Assess Resident After Dialysis Return
Penalty
Summary
The facility failed to ensure Resident #2 was assessed upon return to the facility after dialysis. Resident #2 was admitted on 12/15/11 and re-entered the facility on 11/11/25 with diagnoses including end stage renal disease, dependence on renal dialysis, type 2 diabetes, heart disease, chronic obstructive pulmonary disease, heart failure, reduced mobility, and need for assistance with personal care. The annual MDS indicated the resident was cognitively intact, dependent on staff for toileting hygiene, required maximal assistance for bathing and dressing, moderate assistance for transferring to a chair, required dialysis, and had a legal guardian. The physician orders included dialysis three times weekly on Monday, Wednesday, and Friday, but there was no order for post-dialysis vital sign assessment. Review of the vital sign flow sheet and progress notes for March showed no documented post-dialysis vital signs or resident refusals on multiple dialysis return dates. An LPN stated that when the resident returned from dialysis, staff were to check vital signs and document them, and sometimes the resident refused vital signs. The Divisional Director of Clinical Education verified the resident was not properly assessed after dialysis.
Pharmacy recommendations for psychotropic medication reviews were not addressed timely
Penalty
Summary
The facility failed to ensure that pharmacy medication regimen review recommendations were addressed in a timely manner for residents receiving psychotropic medications. Review of the facility policy showed that consultant pharmacist recommendations were to be provided to identified facility personnel, reviewed by the attending physician, and addressed no later than the next scheduled provider visit, with documentation of any action taken or rationale for no change. The record review and interviews showed that pharmacy recommendations were not consistently signed, acted upon, or documented as reviewed for multiple residents. For one resident with Parkinson's disease, hypertension, depression, anxiety, dementia with behavioral disturbance, and moderate cognitive impairment, pharmacy recommendations dated in August, October, and November identified multiple antidepressants and long-term lorazepam use and requested dose reduction or gradual dose reduction unless clinically contraindicated. The physician response areas were blank and unsigned on those recommendations, and psychiatry notes did not document that a GDR was completed or contraindicated. Interviews with the MD, CNP, and DDCE/RN confirmed the recommendations were handled inconsistently and that the lorazepam GDR was not completed timely, with no evidence that the venlafaxine GDR was attempted or documented as contraindicated. For another resident with dementia, Alzheimer's disease, anxiety, depression, and dysphagia, a pharmacy recommendation identified ongoing buspirone use and requested a GDR unless clinically contraindicated, but the response area was blank and unsigned. Psychiatry notes did not show that a GDR was completed or contraindicated, and staff could not explain the repeated discontinuation and reordering of buspirone at the same dosage and frequency. A third resident with cognitive impairment and multiple fractures had a pharmacy recommendation to attempt a GDR for mirtazapine used for insomnia, but the form was not marked or signed by a physician or CNP, and the medication continued to be administered for months before the recommendation was addressed after a later pharmacy review.
Medication error rate exceeded acceptable threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 3 errors in 28 opportunities for a 10.7% error rate. During observation, record review, and interview, two residents were involved in medication administration errors. Resident #6 had diagnoses including atherosclerotic heart disease, Alzheimer's dementia, high blood pressure, cholesterol, anemia, anxiety, insomnia, GERD, muscle weakness, abnormal gait and mobility, and trouble swallowing. The physician order required Aspirin 81 mg and Metoprolol ER 50 mg with a hold parameter for systolic blood pressure less than 100 and diastolic blood pressure less than 60, but the LPN misread the order and withheld Metoprolol based on an incorrect hold parameter of systolic blood pressure less than 114 mmHg, then discarded the tablet and administered only Aspirin. Resident #50 had diagnoses including chronic kidney disease, stroke, diabetes mellitus, high blood pressure and cholesterol, atherosclerotic heart disease, hypothyroidism, GERD, and osteomyelitis of the vertebra with low back pain. The physician orders included Atenolol 25 mg, Vitamin D3, Duloxetine, Ferrous Sulfate, MiraLAX, Sodium Chloride, and Pantoprazole. During observation, the RN crushed tablet medications and mixed them with applesauce, measured MiraLAX incorrectly, and administered Atenolol 50 mg instead of the ordered 25 mg dose. The RN later checked the order and agreed the Atenolol dose was incorrect.
Incomplete Documentation of Vomited Medications
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the clinical record for one resident. Resident #50 was admitted with diagnoses including chronic kidney disease, atherosclerotic heart disease, cerebral vascular disease with cerebral infarction, GERD, diabetes mellitus, hypertension, hyperlipidemia, and hypothyroidism. During morning medication administration, the resident’s son told an LPN that the resident had vomited her medications into a napkin, and the LPN said she would check on the resident. The clinical record contained no documentation of the vomiting incident, no documentation that the CNP or provider was notified, and no documentation that the CNP assessed the resident after the event. An LPN later stated she assessed the resident after medication administration and found no negative findings. The LPN who was notified stated she informed the CNP, who was present on the unit, and both the LPN and CNP confirmed the resident had vomited undissolved medications and that the CNP assessed the resident with no negative outcome and no signs of aspiration, but none of this was documented in the resident’s record. The RDCS also stated the facility did not have a policy or guidelines for documentation in residents’ clinical records.
Failure to Cover Foley Catheter Drainage Bag in a Dignified Manner
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary (Foley) catheter did not have a privacy cover on the catheter drainage bag, as observed during a survey. The resident was cognitively intact and required staff assistance for several activities of daily living, including toileting and dressing. The care plan for this resident specifically included the intervention to store the collection bag inside a protective dignity pouch, but this was not followed at the time of observation. During the observation and interview, a CNA confirmed that catheter drainage bags should be covered with a privacy bag, and acknowledged that the resident's bag was not covered. The facility's policy on resident rights states that residents are to be treated with courtesy, respect, and full recognition of dignity and individuality. This deficiency was noted as an incidental finding during a complaint investigation and had the potential to affect other residents with Foley catheters.
Failure to Notify Physician and Family After Resident Self-Removes Foley Catheter
Penalty
Summary
The facility failed to notify the resident's physician and family after a resident with severe cognitive impairment removed his Foley catheter, resulting in bleeding. The incident was observed by a registered nurse, who found the resident standing in his room with blood on the floor and the catheter removed. The nurse assisted the resident with a shower and reinserted the catheter without the resident expressing pain. However, the nurse did not inform the resident's physician or family about the incident, despite acknowledging that such notifications are typically required in these situations. Review of the facility's policy confirmed that staff are required to notify the physician and family in the event of an accident, injury, or significant change in the resident's condition. The resident in question had multiple diagnoses, including dementia, repeated falls, and prostate cancer, and was dependent on staff for most activities of daily living. The failure to notify relevant parties following the removal of the Foley catheter and associated bleeding constituted noncompliance with facility policy and regulatory requirements.
Misappropriation of Resident Medication by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her medication. The incident involved a resident who was admitted with multiple diagnoses, including a right femur fracture, and had an order for Tramadol 50 mg every six hours as needed for pain. The resident was cognitively intact and required varying levels of assistance with daily activities. On the evening of the incident, a discrepancy was noted in the narcotic count for the resident's Tramadol, with one pill unaccounted for. A nurse finishing her shift admitted to removing the medication from the cart but stated it was too early to administer, so she placed it in her pocket. When it was time to give the medication, she could not locate it. After assisting another staff member, she claimed to have found the missing pill and disposed of it, but no evidence of the discarded medication was found during a subsequent search. The nurse left the facility before she could be questioned further and refused to return or cooperate with the investigation, ultimately terminating her employment. The facility's investigation included reviewing medical and narcotic records, interviewing staff and the resident, and searching for the missing medication. The incident was reported to the state nursing board, and the investigation could not conclusively determine the outcome of the missing medication. The administrator confirmed that the resident's medication had been misappropriated, constituting a failure to protect the resident's property as required by facility policy.
Failure to Immediately Suspend Staff After Alleged Abuse
Penalty
Summary
The facility failed to ensure residents were free from potential abuse by not immediately suspending a staff member after an allegation of staff-to-resident abuse. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including a history of stroke, hypertension, chronic kidney disease, glaucoma, blindness in one eye, osteoarthritis, diabetes, and dementia. The resident required significant assistance with daily activities and was known to be resistive to care. The deficiency occurred when a housekeeper reported witnessing a CNA forcefully apply deodorant to the resident's arm against his wishes and then spray deodorant in his face after the resident became agitated. The housekeeper immediately reported the incident to an LPN, who continued passing medications for five to ten minutes before addressing the concern. The LPN did not immediately assess the resident, waiting approximately ten minutes, and found no signs of distress or injury. The DON was informed later and instructed the LPN to switch the CNA's assignment but did not suspend the CNA upon learning of the alleged abuse. The facility's policy required immediate removal of staff suspected of abuse from resident care areas, but this was not followed. The CNA was not suspended until several hours after the allegation was reported, and the LPN and housekeeper were also suspended later in the day. The investigation included interviews and assessments, and the allegation was ultimately unsubstantiated, but the delay in removing the accused staff member from resident care constituted the deficiency.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented and that falls were thoroughly investigated for two residents. For one resident with diagnoses including hypertension, dementia, muscle weakness, COPD, and epilepsy, the care plan required the bed to be placed against the wall, the area to be free of clutter, proper footwear, and the call light within reach. After being found on the floor with complaints of pain, the investigation did not document whether these interventions were in place at the time of the fall. The resident was not wearing footwear, and staff could not confirm if the call light was accessible or if the bed was positioned as required. Another resident, with a history of irregular heartbeat, urinary retention, heart failure, hypertension, and kidney disease, was care planned for fall risk interventions such as nonskid strips, toileting assistance, and use of a reacher. Observation revealed that the reacher was not within the resident's reach, and staff confirmed it should have been accessible to help prevent falls. The facility's fall prevention policy required individualized interventions based on assessments, but these were not consistently implemented or documented for the residents involved.
Inconsistent Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that advance directive orders were consistent across electronic and paper medical records for two residents. Resident #5, who had cognitive impairment and required substantial assistance for daily activities, had conflicting advance directives in her records. Her electronic medical record indicated a Do Not Resuscitate Comfort Care Arrest (DNRCCA) directive, while her paper medical record contained both a DNRCCA and a full measures directive. This inconsistency was confirmed by the Director of Nursing (DON), who stated that staff were instructed to check both electronic and paper charts for advance directives before proceeding with cardiopulmonary resuscitation (CPR). Similarly, Resident #29, who had severe cognitive impairment and was dependent on staff for daily activities, also had conflicting advance directives in her records. Her electronic medical record showed a Do Not Resuscitate Comfort Care (DNRCC) directive, while her paper medical record included both a DNRCC and a full measures directive. The DON confirmed the presence of these conflicting directives and reiterated the protocol of checking both electronic and paper charts in the event of a code. The facility's policy on advance directives stated that these should be reviewed annually and maintained consistently across records.
Failure to Release Restraint as Ordered
Penalty
Summary
The facility failed to adhere to the physician's order for releasing a restraint every two hours for a resident diagnosed with multiple conditions including Huntington's disease and Alzheimer's dementia. The resident, who had severely impaired cognition, was observed in a Broda chair with a pelvic restraint that was not released as ordered. Continuous observations revealed that the restraint was not released between 11:00 A.M. and 1:05 P.M., exceeding the two-hour requirement. Interviews with staff members, including two State tested Nursing Assistants and an LPN, confirmed that the restraint had not been released as required. The facility's policy mandates that physical restraints must be released for at least 10 minutes every two hours during normal waking hours. However, staff were either unaware of the last time the restraint was released or confirmed it had been over two hours since the last release. The resident's plan of care included specific interventions for restraint use, which were not followed, leading to the deficiency.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions as outlined in the care plans for two residents, leading to deficiencies in accident prevention and supervision. Resident #29, who has severe cognitive impairment and a history of falls, was observed without the prescribed dycem on the grab bar in the bathroom, contrary to the care plan. This oversight occurred despite a recent fall incident where the resident was lowered to the floor after letting go of the grab bar. The absence of dycem was confirmed by a registered nurse during an observation. Similarly, Resident #22, who suffers from multiple conditions including Huntington's disease and Alzheimer's, was found without the required ankle weights on her Broda chair, as specified in her care plan. The staff, including a licensed practical nurse and a state-tested nursing assistant, were unaware of the order for ankle weights, and the resident had recently received a new Broda chair without them. This lack of awareness and implementation of prescribed interventions highlights a failure in ensuring adequate supervision and adherence to care plans for fall prevention.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 853 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ravenna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Longmeadow Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Arbors At Streetsboro | 6.2 mi | ★★★★★ | 17 | 0 |
| Tamarack Ridge Health And Rehabilitation | 6.3 mi | ★★★★★ | 2 | 0 |
| Altercare Post-acute Rehab Center | 7.2 mi | ★★★★★ | 4 | 0 |
| Majestic Care Of Kent | 7.3 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.