Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Woodside Village Care Center during CMS and state inspections, most recent first.
A CNA physically struck a resident with dementia and behavioral disturbances during breakfast after the resident became combative and attempted to bite the CNA. Witnesses and the CNA confirmed the incident, which violated the facility's abuse prevention policy prohibiting staff from striking residents under any circumstances.
A resident with cognitive impairment and multiple comorbidities became agitated and struck a CNA, who then struck the resident in the face during care. The incident was witnessed by staff and another resident, but was not reported by those present. The DON was informed and confirmed the event through an internal investigation, but neither the DON nor the Administrator reported the results to the State Survey Agency, contrary to facility policy.
A staff member was not removed from resident care duties during an abuse investigation involving a resident with dementia and other complex medical conditions. The staff member continued to work after an incident in which the resident was struck in the face, contrary to facility policy requiring immediate removal pending investigation.
The facility failed to maintain proper infection control practices for water pathogen risk reduction, affecting all residents. There was no water management team, and no logs or documentation of water system assessments or controls like chlorine testing. Interviews confirmed the absence of a water management team and lack of monitoring, with reliance on city-supplied chlorinated water without records.
The facility failed to maintain a clean and sanitary kitchen environment, with a large hole-like area on the wall behind the steamer and a hole in the floor underneath the oven. These issues were confirmed by dietary staff and noted in multiple health inspection reports and facility audits.
The facility failed to provide complete beneficiary notices to three residents, omitting essential information such as the last day of covered services, appeal rights, and notification dates. This affected residents with varying cognitive abilities who were transitioning from skilled services. Interviews confirmed the absence of required details on the forms used by the facility.
The facility failed to update comprehensive care plans for two residents, affecting their fall interventions. One resident's care plan included interventions like hanging a coat on a hook and monitoring orthostatic blood pressures, but these were not implemented in the new room setup. Another resident's care plan included visual reminders for walker use and non-skid footwear, but these were absent, and the rollator walker was cluttered. The DON confirmed the care plans were not updated to reflect changes in interventions.
A facility failed to have physician orders for a treatment being performed on a resident with pressure ulcers and did not clarify treatment orders for existing pressure injuries. The resident had multiple diagnoses and a mild cognitive impairment. An LPN performed wound care, which involved removing barrier cream that had no physician order. The DON confirmed the absence of an order for the barrier cream and noted that Dakin's solution is not typically used on MASD.
A resident with cognitive impairment and a history of Parkinson's disease was dissatisfied with her pureed diet, as she was unaware she could request mechanical soft pleasure foods. Despite having her own teeth and no issues with chewing, the resident was not informed about her dietary options, leading to dissatisfaction. Staff interactions and documentation lacked clarity on the resident's ability to request alternative food options.
A facility failed to provide proper parameters for as-needed pain medication orders and did not document pain levels for a resident with multiple diagnoses, including COPD and low back pain. Nursing staff confirmed the absence of parameters and documentation, contrary to the facility's pain management policy.
A resident with multiple medical conditions experienced a delay in the processing of a diet order change recommended by hospice due to dental pain. The resident's diet was not adjusted to a pureed form until four days after the recommendation, despite the resident having difficulty chewing and swallowing. The DON confirmed the delay in implementing the hospice's dietary recommendation.
The facility failed to adequately inform residents and their representatives about arbitration agreements, affecting four residents. Interviews revealed that residents with varying cognitive abilities did not understand or recall signing the agreements. The facility's policy requires clear explanations, which were not provided, as residents were given electronic forms to sign without sufficient explanation.
Two residents were prescribed Amoxicillin for prophylactic use without adequate justification or proper assessments, leading to a deficiency in the facility's antibiotic stewardship program. Despite the lack of infections and assessments, the antibiotics were administered as ordered, highlighting a failure to optimize infection treatment and reduce adverse events.
The facility failed to conduct reference checks for five newly hired staff members, including RNs, CNAs, and the Administrator, as required by its abuse prevention policy. This oversight, confirmed by administrative management, had the potential to affect all 62 residents, as the personnel files lacked documentation of previous work history or confirmation of reference checks.
A resident with dementia and identified as an elopement risk managed to exit a facility through a window, bypassing the wanderguard system. The incident occurred when a nurse noticed an open window and initiated the elopement protocol. The resident was found nearby without injuries. Staff interviews revealed that the wanderguard system did not function on windows, indicating a lapse in the facility's supervision and security measures.
CNA Strikes Resident During Care in Response to Aggressive Behavior
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically struck a resident during care. The resident, who had diagnoses including dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease, exhibited impaired cognition and required assistance with mobility, transfers, bathing, and feeding. The resident had a documented history of increased agitation and aggressive behaviors, such as hitting and kicking staff during care. On the date of the incident, the CNA was assisting the resident during breakfast when the resident became combative, swinging her arms and attempting to kick and bite the CNA. In response, the CNA held down the resident's arms and, when the resident attempted to bite, struck the resident in the face with an open hand to push her head back. Multiple interviews corroborated the incident, including statements from another resident and a CNA who witnessed the event. The CNA involved admitted to striking the resident, describing it as a knee-jerk reaction to the attempted bite. Review of the facility's Abuse Prevention Program Policy & Procedure confirmed that striking a resident is not acceptable under any circumstances, regardless of intent or whether the action was reflexive. The policy explicitly states that retaliation by staff is considered abuse and is not permitted.
Failure to Report Abuse Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an abuse allegation involving a resident with dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. The resident, who had impaired cognition and required supervision for mobility and transfers, exhibited increased agitation and aggressive behaviors, including hitting and kicking staff. During a breakfast incident, a CNA restrained the resident's arms and, when the resident attempted to bite her, struck the resident in the face with an open hand. Multiple staff and another resident witnessed the event, but the CNA and a witness did not report the incident to management. The Director of Nursing was notified of the incident by an LPN and initiated an internal investigation, confirming that the CNA had struck the resident. However, both the DON and the Administrator concluded that the CNA did not intend harm and, as a result, did not report the incident or the investigation results to the State Survey Agency as required by facility policy and state law. The facility's policy mandates reporting the results of all investigations to the appropriate authorities within five working days, but this was not done in this case.
Failure to Remove Staff from Resident Care During Abuse Investigation
Penalty
Summary
The facility failed to remove a staff member from resident care duties while an allegation of abuse was being investigated. Specifically, a certified nursing assistant (CNA) was involved in an incident with a resident who had dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. During breakfast, the resident became physically aggressive, swinging arms and attempting to kick the CNA. In response, the CNA restrained the resident's arms and, when the resident attempted to bite, struck the resident in the face with an open hand to prevent being bitten. Despite the incident being reported and an investigation initiated, the CNA was not removed from resident care and continued to work during the investigation. The facility's policy required immediate removal of the alleged perpetrator from resident care pending the outcome of the investigation, but this was not followed. The administrator confirmed awareness of the incident and the decision to allow the CNA to continue working, based on the belief that there was no intent to harm.
Inadequate Water Pathogen Risk Reduction
Penalty
Summary
The facility failed to maintain proper infection control practices related to water pathogen risk reduction, which had the potential to affect all residents. During a record review and facility tour, it was found that the facility did not have a water management team in place, nor were there logs or documentation of water system assessments, monitoring, or controls such as chlorine testing. The facility's policy required a water management team to conduct environmental screenings and assessments of the water system, but this was not being followed. Interviews with the Maintenance Director and the Administrator confirmed the absence of a water management team and the lack of water monitoring or documentation. The Maintenance Director acknowledged that a new Legionella Assessment policy had been received, but no actions had been taken to implement it. The Administrator also confirmed the lack of evidence for water management activities and stated that the facility relied on the city for chlorinated water without maintaining records of city water testing or controls.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations and interviews. A large hole-like area was observed on the wall behind the steamer on two separate occasions, and this was confirmed by both the Dietary Supervisor and another dietary staff member. The Local Health Department Inspector noted that this issue had been cited in the last three health inspection reports. Additionally, facility audits from October to December 2024 consistently reported damage to the wall behind the steamer. Furthermore, a hole in the floor underneath the oven was observed and confirmed by the Dietary Supervisor and another dietary staff member. The County Health Department Food Inspection Report also noted damage to the floor near the ovens. Facility audits from October to December 2024 reported damaged areas on the floor. The facility's Kitchen Safety policy emphasized the importance of keeping floors in good repair and free from hazards, which was not adhered to in this case.
Failure to Provide Complete Beneficiary Notices
Penalty
Summary
The facility failed to provide and document all required information when issuing beneficiary notices to residents, affecting three residents. Resident #11, who was cognitively intact, was receiving physical and occupational therapy and had reached a plateau in progress. The intent to discharge form lacked the last day of covered services and a signature section for the resident or representative. The Medicare Coverage Ending notice did not specify which skilled services were ending or include appeal rights, and there was no date indicating when the resident was informed. Similarly, the Advanced Beneficiary Notice of Non-Coverage (ABN) form lacked details about the services ending and appeal rights. Resident #21, with significant cognitive impairment, was receiving speech therapy and had exhausted skilled nursing days. The intent to discharge form did not state the last day of covered services or provide a signature section. The Medicare coverage ending notice failed to include information about appeal rights or the specific services ending, and there was no record of when the resident's representative was informed. The ABN form also lacked details about the services ending and appeal rights. Resident #320, who was cognitively intact, had exhausted skilled nursing days and transitioned to Medicare Part B. The intent to discharge form did not have a signature section. The notice of Medicare coverage ending did not include appeal rights or a notification date. Interviews with Social Services and the Administrator confirmed the absence of required appeal information and notification dates on the forms, and there was no evidence of appeal information being provided to the residents or their representatives.
Failure to Update Comprehensive Care Plans for Fall Interventions
Penalty
Summary
The facility failed to ensure comprehensive care plans were updated for two residents, affecting their fall interventions. Resident #11, who was cognitively intact and independent for transfers, had a care plan that included interventions such as hanging a coat on a hook at the end of the bed and obtaining orthostatic blood pressures every shift. However, upon observation, there was no hook in the resident's new room, and no orthostatic blood pressure monitoring was recorded. The Director of Nursing (DON) confirmed that the care plan was not updated to reflect the resident's new room setup and the discontinuation of certain interventions. Similarly, Resident #29, who was also cognitively intact and required setup or clean-up assistance for activities of daily living, had a care plan with interventions like visual reminders to use a walker and apply non-skid footwear. During observation, no visual reminders were present, and the resident's rollator walker was cluttered with blankets and a pillow. The DON verified that the care plan was not updated to discontinue interventions that were no longer necessary. The facility's policy required comprehensive care plans to reflect changes in residents' preferences and goals, which was not adhered to in these cases.
Lack of Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to have physician orders for a treatment being performed and did not clarify treatment orders for existing pressure injuries for Resident #7. The resident, who was admitted with multiple diagnoses including sepsis, type II diabetes, and chronic obstructive pulmonary disease, had a mild cognitive impairment. The medical record review revealed an order for cleaning the resident's left posterior thigh with Dakin's solution and applying calcium alginate, but there was no order for the application of barrier cream, which was observed to be used. During an observation, an LPN performed wound care on Resident #7, which involved cleansing three wounds with Dakin's solution and applying calcium alginate. The LPN had to remove barrier cream from the resident's buttocks and thigh areas before performing the wound care, despite there being no physician order for the barrier cream. Interviews with the DON confirmed the absence of a current order for the barrier cream and acknowledged that Dakin's solution is not typically used on moisture-associated skin damage (MASD) as it might break down the skin. The DON contacted the physician to clarify the order.
Resident Unaware of Dietary Options Leading to Dissatisfaction
Penalty
Summary
The facility failed to ensure that a resident understood the option of requesting pleasure foods, which led to dissatisfaction with the prescribed diet. The resident, who had a history of Parkinson's disease, cognitive impairment, and other medical conditions, was on a pureed diet with nectar thick liquids. Despite having her own teeth and no reported issues with chewing, the resident was unaware that she could request mechanical soft pleasure foods if she did not like the pureed meals provided. This lack of communication and understanding about dietary options contributed to the resident's dissatisfaction with her meals. The deficiency was further highlighted during interviews and observations, where the resident expressed her dislike for the pureed diet and her ability to chew regular food. Staff interactions revealed a lack of clarity regarding the resident's dietary needs and preferences, as well as the absence of documentation about the resident's ability to request alternative food options. The Director of Nursing confirmed that the diet was downgraded due to previous swallowing difficulties, but there was no consistent documentation or communication to ensure the resident was informed about her dietary choices, leading to the deficiency noted in the report.
Inadequate Pain Management Documentation and Parameters
Penalty
Summary
The facility failed to provide proper parameters for as-needed pain medication orders and did not document pain levels for all uses of as-needed pain medication for a resident. The resident, who had a mild cognitive impairment, was admitted with multiple diagnoses including pneumonia, COPD, and low back pain. The physician orders for the resident included acetaminophen and tramadol for pain management, but lacked specific parameters to guide the administration of these medications based on the resident's pain level. Interviews with nursing staff revealed that there were typically parameters in place to determine which pain medication to administer, but in this case, they were absent. The staff confirmed that pain levels should be documented prior to administering any as-needed pain medication, which was not done in this instance. The facility's pain management policy required pain assessments and documentation, but these were not consistently followed, leading to the deficiency in pain management for the resident.
Delayed Diet Order Processing for Resident
Penalty
Summary
The facility failed to ensure a diet order was processed in a timely manner for a resident with multiple medical conditions, including Parkinson's disease and cognitive impairment. The resident was on a pureed diet with nectar thick liquids and had specific requirements for eating utensils. On a hospice visit, it was noted that the resident had a bad tooth, and the hospice nurse recommended a change to a pureed diet with no ice in drinks. However, the diet change was not implemented until four days later when the resident was observed having difficulty chewing and holding food in her mouth. Interviews revealed that the resident did not like the pureed diet and claimed to have no trouble chewing food, despite being told she had choked once. The Director of Nursing confirmed that the diet was not changed per the hospice recommendation on the date of the visit, but rather on a later date when the resident exhibited issues with food pocketing and swallowing. This delay in processing the diet order highlights a lapse in timely communication and implementation of dietary changes based on the resident's needs.
Failure to Inform Residents About Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were adequately informed about arbitration agreements in a manner that was understandable to them. This deficiency affected four residents who were reviewed for arbitration agreements. The facility had a total of 48 residents with signed arbitration agreements out of a census of 62. The review of medical records and interviews with residents and family members revealed that residents with varying levels of cognitive impairment were not clearly informed about the arbitration agreements. For instance, one resident with moderate cognitive impairment could not recall if the arbitration agreement was explained, and her husband, who signed the paperwork, also had memory issues. Another resident with moderate cognitive impairment did not remember signing an arbitration agreement and could not explain what it was. Interviews with residents who were cognitively intact also indicated a lack of understanding regarding arbitration agreements. One resident stated she did not know what an arbitration agreement was and did not recall signing one. Another resident, who was also cognitively intact, was unaware of signing an arbitration agreement and did not understand its purpose. The facility's social worker explained that residents and their representatives are given a tablet to sign electronic forms, including the arbitration agreement, but the explanation provided was insufficient for the residents to understand the agreement. The facility's policy requires that the arbitration agreement be explained in a form and manner that is understandable to the resident and their representative, including in a language they understand, which was not adhered to in these cases.
Inadequate Justification for Antibiotic Use in Two Residents
Penalty
Summary
The facility failed to provide adequate justification for the use of antibiotic medication for two residents, leading to a deficiency in their antibiotic stewardship program. Resident #7, who had a mild cognitive impairment and multiple diagnoses including sepsis and urinary tract infection (UTI), was prescribed Amoxicillin 500 mg daily for prophylactic use against UTIs. However, the McGeer Assessment completed on 10/30/24 indicated that the antibiotic did not meet the criteria for administration. Despite this, the Amoxicillin was administered as ordered without any further evaluation to determine if it could be discontinued, and there was no infection present in the subsequent months. Similarly, Resident #21, who had significant cognitive impairment and diagnoses including pneumonia and sepsis, was also prescribed Amoxicillin 500 mg daily for prophylactic use against upper respiratory infections (URI). The facility did not complete a McGeer Assessment for either order of Amoxicillin for this resident, and the antibiotic was administered without justification or evaluation for discontinuation. The Director of Nursing confirmed the lack of assessments and justification for both residents, highlighting a failure in the facility's antibiotic stewardship program, which aims to optimize infection treatment and reduce adverse events associated with antibiotic use.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing reference checks for five newly hired personnel, which included two Registered Nurses (RNs), two Certified Nursing Assistants (CNAs), and the Administrator. The personnel files for these staff members lacked documentation of previous work history or confirmation that reference checks had been completed, despite the facility's policy requiring such checks for all new hires. This oversight had the potential to affect all 62 residents in the facility. During an interview, administrative management and the Administrator confirmed that reference checks had not been conducted for the newly hired staff members, acknowledging the deviation from the facility's policy. The facility's abuse prevention policy explicitly states that all applicants for employment must be checked with previous and/or current employers, and reasonable efforts should be made to uncover information about any past criminal prosecutions. The absence of these checks represents a significant lapse in the facility's hiring process, potentially compromising resident safety.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision of a resident, leading to an elopement incident. The resident, who had a history of dementia and was identified as an elopement risk, was supposed to have a wanderguard in place to prevent such incidents. However, the resident managed to exit the facility through a window in the Director of Nursing's office, which did not trigger the wanderguard alarm. This lapse in supervision and security measures allowed the resident to leave the premises unnoticed. The incident occurred when a registered nurse noticed a window open in the Director of Nursing's office and initiated the facility's elopement protocol, known as the 'happy feet protocol.' The resident was found shortly after by a certified nursing assistant on a nearby street, sitting in a driveway. The resident was assessed by emergency medical services and facility staff, who found no injuries or immediate distress. The resident was returned to the facility without further incident. Interviews with staff revealed that the wanderguard system did not function on windows, and this was a known issue. The facility's policy on elopement prevention and management was not effectively implemented, as the resident was able to exit through a window without triggering any alarms. The deficiency was identified during a complaint investigation, highlighting a failure in the facility's supervision and security protocols for residents at risk of elopement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 318 citations issued within 25 miles in the last 12 months — including the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Gilead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morrow Manor Nursing Center | 10.2 mi | ★★★★★ | 16 | 0 |
| Bennington Glen Nursing & Rehabilitation Center | 11.7 mi | ★★★★★ | 15 | 0 |
| Presidential Post-acute | 11.8 mi | ★★★★★ | 19 | 1 |
| Galion Meadows Skilled Nursing And Rehabilitation | 12.5 mi | ★★★★★ | 38 | 0 |
| Galion Pointe, Llc | 13 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodside Village Care Center.
100% money-back within 48 hours.
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.