Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woods On French Creek Nursing & Rehab Center The during CMS and state inspections, most recent first.
Care plans were not updated to match the individualized needs of two residents. One resident had an unstageable sacral pressure injury on admission and later developed two open thigh wounds, but the care plan only addressed general skin risk and did not include wound-specific needs. Another resident had severe cognitive impairment, dysphagia, a G-tube, and malnutrition, but the care plan did not include any goals or interventions for G-tube care or management.
Failure to provide ordered care for a resident’s G-tube. A resident with dysphagia, severe protein-calorie malnutrition, and severe cognitive impairment had a patent G-tube, but the chart contained no active orders or evidence for tube access, care, or management, and no care plan focus or interventions related to the tube. During observation, the stoma was open to air with dried crusting and no split gauze dressing was in place; the RN and DON confirmed the lack of specific G-tube orders.
A facility failed to timely act on a pharmacist’s recommendation regarding a resident’s haloperidol order. The resident had diagnoses including seizures, major depressive disorder, and type 1 DM, with moderate cognitive impairment and no documented verbal or physical behaviors. The pharmacist asked whether the antipsychotic order could be updated to include an accepted diagnosis, the PCP noted to ask psych, but no change was made and the ADON verified the facility did not contact the psychiatrist or another provider.
A resident with seizures, major depressive disorder, and type 1 diabetes received Haldol for anoxic brain damage despite no documented diagnosis of schizophrenia or Tourette’s disorder. The MDS showed moderate cognitive impairment and no behaviors, behavior logs showed only isolated crying and yelling/screaming, and the FDA med guide listed Haldol indications that were not present in the record. A pharmacy review requested an accepted diagnosis for the antipsychotic order, but no change was documented, and the ADON confirmed the medication was given without an appropriate indication.
Unsanitary Laundry Room Conditions: The laundry room had an empty dirty-laundry cart with debris, garbage on the floor, splattered dirt throughout the area, a lint- and dirt-covered window screen, and a large pile of an unknown white substance near the drain. In the clean laundry area, a dryer had clothing inside, a heavily lint-covered screen, and large piles of lint underneath, with no lint removal documentation for multiple morning checks. The LA confirmed the dirty floors and uncleaned lint filters, and the DES stated staff were expected to clean lint screens after every load.
A resident with significant mobility and cognitive impairments fell out of bed and was assisted back without a nurse assessment or proper documentation. The resident's complaints of leg pain and vomiting were not immediately reported, and the day shift was not informed of the incident. Only after the resident exhibited severe pain during care was a thorough assessment performed, revealing bilateral femur fractures that required surgery. Staff interviews indicated confusion about fall protocols and failure to follow the facility's fall management policy.
A resident with impaired cognition, hemiplegia, and high fall risk was found after sliding from bed and was moved back into bed before a thorough RN assessment. Staff did not promptly report the fall or the resident’s pain, and the next day the resident screamed during care, had swollen legs, and was found to have bilateral femur fractures requiring hospital transfer and surgery.
A resident suffered a distal posterior tibial fracture when a dental assistant improperly transported them in a wheelchair, causing the resident's foot to hit a door frame. The resident, who was dependent on staff for mobility, experienced severe pain and required orthopedic follow-up and a protective boot. Staff interviews revealed that vendors were not supposed to transport residents, indicating a breach in protocol.
Care plans did not reflect residents’ wound and gastrostomy tube needs
Penalty
Summary
The facility failed to ensure care plans were developed and updated to reflect the individualized needs of two residents. For Resident #79, the record showed admission with an unstageable dark purple/red area on the sacrum and an admission MDS indicating an unstageable pressure ulcer. Later documentation identified two open wounds on the right mid-thigh. The care plan initiated after admission addressed risk for altered skin integrity with general interventions such as skin assessment, heel elevation, turning and repositioning, skin inspection, and physician notification, but it did not identify the unstageable sacral wound on admission or the later development of the two mid-thigh wounds and their related needs or services. The wound CNP stated she was consulted for wounds that were previously healed surgical incisions reopened and draining fluid, and the DON verified that a wound care plan specific to the resident’s wound care needs and services was not implemented. For Resident #9, the record showed diagnoses including encephalopathy, dysphagia, gastrostomy status, and severe protein-calorie malnutrition, with severe cognitive impairment on the most recent MDS and dependence for all ADLs. Progress notes showed the resident had a gastrostomy tube placed at the hospital, and the hospital discharge instructions directed staff to place a single layer of four-by-four gauze under the gastrostomy tube bumper and avoid stacking multiple layers of gauze. The care plan updated during the stay did not include any focus area, goals, or interventions related to the gastrostomy tube or its care and management. The Administrator and Infection Control Nurse verified that the care plan did not include goals or interventions specific to the gastrostomy tube.
Failure to Provide Ordered Care for Gastrostomy Tube
Penalty
Summary
The facility failed to provide adequate care and treatment for a resident’s gastrostomy tube. The resident was admitted with diagnoses including encephalopathy, dysphagia, gastrostomy status, and severe protein-calorie malnutrition, and had a BIMS score of 6 indicating severe cognitive impairment and substantial assistance needs for all activities of daily living. The resident had a gastrostomy tube placed during a hospital stay after being admitted for a clogged nasogastric feeding tube, and the hospital discharge instructions directed staff to place a single layer of four-by-four gauze under the gastrostomy tube bumper and avoid stacking multiple layers of gauze under it. Review of the physician orders, medication and treatment administration records, and care plan revealed no active orders or evidence for the access, care, or management of the gastrostomy tube, and no care plan focus, goals, or interventions related to the tube. During observation, the resident’s gastrostomy tube was patent and clamped, the stoma site was open to air with dried crusting, and no split gauze dressing was present over the site. The RN confirmed the resident had no specific orders for gastrostomy tube access, care, or management, and the DON verified there were no active orders and no care plan interventions specific to the gastrostomy tube.
Failure to Address Pharmacist Recommendation for Antipsychotic Order
Penalty
Summary
The facility failed to timely act on a pharmacist’s recommendation to address a medication irregularity in the medical record for one resident. Resident #2 was admitted with diagnoses including other seizures, major depressive disorder, and type one diabetes, and the most recent MDS showed moderate cognitive impairment, need for assistance with ADLs, and no verbal or physical behaviors toward staff or others. Physician orders showed an order for Haldol 1 mg for anoxic brain damage, and that order was later discontinued. A pharmacy recommendation dated 05/13/26 noted that the resident was receiving haloperidol 1 mg TID and asked whether the antipsychotic order could be updated to include an accepted diagnosis for use. The resident’s primary care physician wrote on the recommendation to ask psych, but the medical record showed no change to the Haldol order or diagnoses. The ADON verified that the facility did not engage its psychiatrist or another provider regarding the pharmacist’s recommendation.
Unnecessary Antipsychotic Use Without Valid Indication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when it administered Haldol without a valid clinically appropriate indication. Resident #2 was admitted with diagnoses including other seizures, major depressive disorder, and type 1 diabetes, and the most recent MDS showed moderate cognitive impairment, need for assistance with ADLs, and no verbal or physical behaviors toward staff or others. The physician ordered Haldol 1 mg on 04/23/26 for anoxic brain damage, and the order remained in place until 06/06/26. Behavior tracking records for April, May, and June 2026 showed only one instance of crying and one instance of yelling and screaming, with no other behaviors documented. The FDA medication guide reviewed by surveyors stated Haldol is indicated for schizophrenia and for control of tics and vocal utterances of Tourette’s disorder, and the resident had no diagnoses of either condition in the medical record. The guide also noted Haldol should be used cautiously in individuals with seizure disorders because it may lower the convulsive threshold. A pharmacy recommendation asked that the antipsychotic order be updated to include an accepted diagnosis for use, but no change was documented, and the ADON verified that Haldol was administered without an appropriate diagnosis or indication.
Unsanitary Laundry Room Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, and sanitary laundry room. During observation of the laundry room with the Laundry Aid, the dirty laundry area contained an empty large laundry cart with crumbled paper towels and debris at the bottom, a plastic bag of garbage on the floor in the middle of the room, and multiple areas of splattered dirt and debris along both sides of the washing machines and throughout the laundry area. A window screen under the window was covered with lint and dirt, and behind the washer near the drain was a large pile of an unknown white substance. In the clean laundry area, a dryer filled with clothing had a lint screen heavily covered with lint, with several large piles of lint underneath it, and the floor also had multiple areas of splattered dirt and debris. The dryer filter cleaning log showed no documentation for lint removal at 6:00 A.M., 7:00 A.M., 8:00 A.M., or 9:00 A.M. The Laundry Aid confirmed the dirty floors and lint in the dryer and stated she had completed drying two loads of laundry and had not cleaned the lint filters. The Director of Environmental Services stated late shift staff were responsible for cleaning the floors Monday through Friday and that staff were expected to clean lint screens after every load.
Failure to Timely Report and Assess Resident Fall Resulting in Harm
Penalty
Summary
A deficiency occurred when staff failed to timely report a fall, complete a thorough and prompt assessment, and provide timely care and treatment after a resident experienced a fall. The incident involved a resident with a history of hemiplegia, morbid obesity, dementia, and other significant medical conditions, who was at high risk for falls and required substantial to maximal assistance for mobility and transfers. The resident fell out of bed during the night and was assisted back into bed by staff without a nurse assessment or proper documentation of the event. Following the fall, the resident complained of bilateral leg pain, but this was not immediately reported to the nurse. The resident was also noted to have vomited during the early morning hours, which was reported to the nurse later. The day shift staff were not informed of the fall, and the incident was not documented in the progress notes or communicated during shift change. It was only when the day shift CNA attempted to provide care and the resident screamed in pain that a nurse was notified, leading to a thorough assessment, x-rays, and eventual transfer to the hospital. The delay in assessment and reporting resulted in the resident being diagnosed with bilateral femur fractures, requiring surgical intervention. Interviews with staff revealed confusion about what constitutes a fall and the appropriate post-fall procedures, including the need for a nurse assessment before moving a resident and timely notification of medical providers and family. The facility's fall management policy was not followed, as immediate needs were not assessed, and the incident was not promptly reported or documented.
Delayed Fall Reporting and Assessment After Resident Injury
Penalty
Summary
The facility failed to timely report a fall, failed to complete a timely and thorough resident assessment, and failed to ensure timely care and treatment after a fall for a resident with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, morbid obesity, dementia, and anxiety. The resident’s record showed moderately impaired cognition, substantial to maximal assistance needs for bed mobility and transfers, and a history of being at high risk for falls with injury due to decreased mobility, weakness, unsteadiness, hemiplegia/hemiparesis, and bilateral artificial knees. According to staff accounts, the resident was found during the night with her legs over the side of the bed and was assisted back into bed without a thorough assessment. CNA interviews described the resident as sliding from the bed, landing on her knees or on the floor, and being moved back into bed with a mechanical lift before a nurse had fully assessed her. One CNA stated the resident complained that her legs hurt after the incident, and another stated the resident later complained of bilateral leg pain during incontinence care. The night nurse stated she was told the resident had her legs over the side of the bed, but she was not told the resident had gone to the floor, had pain, or had vomited. The next day, when care was attempted, the resident screamed in pain and her legs appeared swollen. She was then assessed, complained of bilateral hip pain extending to the knees, and x-rays were ordered. The x-rays later showed bilateral femur fractures, and the resident was sent to the hospital, where documentation confirmed a left mid-femoral shaft fracture and a comminuted right distal femur fracture requiring surgical repair. The facility’s fall log noted that the resident suffered a fall, but it did not specify the date or time of the fall.
Resident Injury Due to Improper Transport by Dental Staff
Penalty
Summary
The facility failed to ensure the safe transportation of residents who required assistance with transfers, resulting in actual harm to a resident. The incident involved a dental provider staff member who was transporting a resident in a wheelchair. During the transport, the dental assistant pushed the resident's right foot into a door frame, causing excruciating pain and a subsequent distal posterior tibial fracture to the right foot. The resident, who was cognitively intact and dependent on staff for mobility, required orthopedic follow-up appointments, was required to wear a protective boot, and was non-weight bearing to the right foot until the fracture healed. The resident's medical history included type II diabetes mellitus, congestive heart failure, chronic kidney disease, and anxiety. On the day of the incident, the resident was being wheeled into the therapy gym by a dental assistant when the accident occurred. The resident immediately reported severe pain and suspected a fracture, which was later confirmed by x-ray results showing an acute distal posterior fibial fracture and mild soft tissue swelling. The resident was instructed to wear a boot and remain non-weight bearing. Interviews with staff revealed that it was common knowledge among facility staff that vendors were not to transport residents to and from appointments. However, the dental assistant, who was not a facility staff member, was involved in the transport of the resident, leading to the incident. The facility's failure to adhere to established protocols for resident transport resulted in the resident's injury.
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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) |
|---|---|---|---|---|
| Avon Oaks Nursing Home | 0.6 mi | ★★★★★ | 8 | 0 |
| St Mary Of The Woods | 1.6 mi | ★★★★★ | 1 | 0 |
| Main Street Care Center | 2.7 mi | ★★★★★ | 12 | 0 |
| Avon Place Healthcare Center | 3.3 mi | ★★★★★ | 28 | 0 |
| O'neill Healthcare Bay Village | 4.6 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 October 2026) and official state health department websites.