Above average — CMS composite of the measures below.
The next survey window likely opens around June 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 Woodward Skilled Nursing And Therapy during CMS and state inspections, most recent first.
Insufficient staffing led to a resident at risk for pressure ulcers remaining in the same position for hours without repositioning, despite a care plan for q2h turns and heel offloading. Staffing also led to dependent residents being brought to the dining room well before meals; one resident with stroke and hemiplegia was seated in the dining room for an extended period before food was served, and staff said this happened because only one aide was assigned to the hall.
The facility failed to complete annual CNA skill reviews for 2 CNAs sampled for employee training review. One CNA had no documented annual skills review after the first year of employment, and another CNA also had no documented annual skills review after the first year of employment. The administrator stated the required annual reviews were not conducted.
Failure to maintain an effective pest control program. Surveyors observed flies on a dining table during meal service, on the steam table while food was being prepared and served, on residents' plates, and on clean wound care supplies. Staff reported ongoing fly problems, use of fly bait, fly spray, and blue lights, and stated sticky traps were not allowed.
A resident with severe cognitive impairment and on Eliquis was observed with circular bruising on the upper arm after the family reported the bruising to the DON and said it resembled fingerprints. The facility did not report the alleged physical abuse to the State Agency within the required 2-hour timeframe, and the administrator acknowledged the initial report was sent after more than 2 hours had passed.
Failure to Reposition Resident With Pressure Ulcer: A resident with very limited mobility, severe cognitive impairment, and an acquired heel pressure ulcer was observed lying on the same side in bed for an extended period without staff checking on them. The care plan called for turning every 2 hours and heel offloading, but CNA staffing on the hall was insufficient to complete repositioning as intended, and the DON stated it was not acceptable to keep the resident in the same position for more than 2 hours.
Urinary catheter bag placed on trash can and touching floor. A resident with an indwelling urinary catheter was observed in a recliner with the catheter bag hanging on a small trash can and touching the floor on two occasions. The resident had an order for catheter care every shift and as needed, severe cognitive impairment, and renal disease. CNA and LPN interviews confirmed staff routinely hung the bag on the trash can when the resident sat in the recliner, and the DON and regional nurse consultant stated this was a concern for infection control.
A resident with severely impaired cognition and a care plan requiring two-person assistance for transfers was injured when a staff member, aware of the protocol, repositioned and lifted the resident alone and without a gait belt, resulting in a fractured right humerus.
A resident with depression, anxiety, and diabetes did not have a significant change assessment completed by the required ARD date. The MDS coordinator confirmed the absence of a specific policy for timely MDS completion, relying instead on the RAI manual, and acknowledged the oversight.
A facility failed to accurately code a resident's assessment, marking clopidogrel bisulfate (Plavix) as an anticoagulant instead of an antiplatelet. The resident had a history of coronary artery bypass and heart disease. The MDS coordinator admitted the error during an interview, despite following physician orders.
A resident with multiple health issues experienced a decline in their ability to perform ADLs, requiring increased assistance. Despite assessments indicating this decline, the care plan was not updated to reflect the resident's needs. The Corporate Nurse Consultant was unable to confirm the facility's policy for revising care plans and acknowledged the oversight.
Insufficient staffing affected resident repositioning and meal timing
Penalty
Summary
Sufficient staffing was not provided to meet resident needs for turning and repositioning. Resident #3, whose admission assessment showed severely impaired cognition with a BIMS score of 0 and risk for pressure ulcers, was observed lying on the right side in bed continuously from 8:49 a.m. to 11:39 a.m. without staff checking on or repositioning the resident during that period. The care plan directed that the resident be turned every two hours, heels offloaded with pillows, and assisted frequently with turning and repositioning. CNA #4 stated they had set a phone reminder to reposition the resident every two hours but could not do so because they were the only staff member assigned to that hall, and the DON stated it was not acceptable to keep a resident in the same position for more than two hours if they were unable to reposition. Sufficient staffing was also not provided to prevent dependent residents from being taken to the dining room too early before meals. Resident #9, who had intact cognition with a BIMS score of 14, was dependent on staff for ADLs including transfers and use of a manual wheelchair and had diagnoses of stroke and hemiplegia. The resident was observed in the main dining room at 10:59 a.m. drinking coffee and tea without food, and food was not served until 11:51 a.m.; the resident stated they did not like sitting in the dining room for so long and that it hurt their butt waiting for food. Dietary staff, CNA #1, and LPN #1 stated dependent residents were brought to the dining room starting at 10:30 a.m. because there was only one aide on the hall and it took a long time to get residents up. The DON stated staff should get residents up in their wheelchairs and leave them in their rooms with the call light instead of taking them to the dining room about 10:45 a.m.
Failure to Complete Annual CNA Skill Reviews
Penalty
Summary
The facility failed to ensure annual nurse aide skill reviews were completed for 2 of 2 nurse aides sampled for employee training review. CNA #2’s employee file showed a hire date of 10/16/24, and there was no documentation that an annual skills review was completed in or after 10/2025. CNA #3’s employee file showed a hire date of 01/08/25, and there was no documentation that an annual skills review was completed in or after 01/2026. On 07/16/26 at 12:51 p.m., the administrator stated the required annual skills reviews for CNA #2 and CNA #3 were not conducted.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of pests. During lunch meal service, surveyors observed three flies on a dining table while residents drank coffee, eight flies landing on the steam table while food was being prepared and served, flies landing on residents' plates containing food, and a blue light hung on the dining room wall. During a wound care observation, multiple flies were also seen landing on clean wound care supplies. The facility's Pest Control policy stated that the facility was to maintain an effective pest control program so the facility would be free of pests and rodents. Staff interviews reflected ongoing fly problems: the maintenance supervisor said fly bait and fly spray had been tried and an indoor solution had been requested, an LPN stated a room had a lot of flies and that the facility used blue lights because corporate did not allow sticky traps, and another LPN stated the flies were terrible in the facility.
Failure to Report Alleged Physical Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported to the State Agency within the required two-hour timeframe for one resident. Resident #3 had severe cognitive impairment with a BIMS score of 0 and was receiving anticoagulant medication. On 07/14/26 at 1:18 p.m., the resident was observed sitting in a wheelchair with four round purple and yellow areas of circular bruising on the left upper arm. The resident’s family member stated they showed the DON the bruising on 07/10/26. The facility policy required allegations of abuse to be reported immediately, but not later than 2 hours if the allegation involved abuse or serious bodily injury. The DON later stated the bruising appeared to resemble fingerprints and acknowledged the resident was receiving Eliquis. The administrator stated more than two hours had elapsed between the allegation and the initial report to OSDH.
Failure to Reposition Resident With Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure a resident with a pressure ulcer received repositioning every two hours. During continuous observation on 07/14/26 from 8:49 a.m. to 11:39 a.m., Resident #3 was observed lying on their right side in bed throughout the entire observation period, and staff were not observed checking on the resident. The resident had very limited mobility and required moderate to maximum assistance with friction and shear, according to the Braden Scale dated 06/10/26. Resident #3’s care plan dated 06/12/26 included turning every two hours, offloading heels with pillows, and assisting with frequent turning and repositioning. The admission assessment showed the resident was admitted on 06/10/26, had a BIMS score of 0, was severely impaired in cognition for daily decision making, and was at risk for pressure ulcers. Records showed an acquired left heel pressure ulcer documented as unstageable on 06/16/26 and later described as stage 2 on wound records dated 06/16/26, 06/23/26, and 07/07/26, with measurements increasing from 4 cm by 4.2 cm to 4 cm by 5 cm. CNA #4 stated they used a phone reminder to reposition the resident every two hours but did not have enough time to do so because they were the only staff member assigned to that hall, and the DON stated it was not acceptable to keep a resident in the same position for more than two hours if they were unable to reposition.
Urinary catheter bag placed on trash can and touching floor
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure urinary catheter bags were not placed on trash cans or allowed to touch the floor for one resident with an indwelling urinary catheter. Resident #7 was observed in the room sitting in a recliner with the urinary catheter bag hanging on a small trash can beside the recliner and touching the floor on two separate observations. The resident had a physician's order for catheter care every shift and as needed, a significant change assessment showing severely impaired cognition with a BIMS score of 2, and a diagnosis of renal disease. The resident's care plan stated the resident had an indwelling urinary catheter and that the catheter bag and tubing should be positioned below the level of the bladder. During interview, CNA #1 stated they always hung the catheter bag on the trash can when a resident was in a recliner. LPN #1 stated the catheter bag was always hung on the trash can when a resident sat in their recliner, but it should not touch the floor. The DON stated staff was encouraged not to hang the urinary catheter bag on the trash can, and the regional nurse consultant stated a urinary catheter bag hung on the trash can and allowed to touch the floor caused a concern for infection control.
Failure to Follow Two-Person Transfer Protocol Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident who required assistance from two staff members for transfers. The resident, who had severely impaired cognition and no upper extremity impairment at the time of the initial assessment, was involved in an incident where a staff member repositioned and lifted the resident under the arms without assistance from a second staff member and without using a gait belt, as required by policy and the resident's care plan. This resulted in the staff member hearing a pop and the resident complaining of pain in the right arm, which was later diagnosed as a broken right humerus. The care plan for the resident clearly indicated the need for two-person assistance during transfers, and this requirement was accessible to all staff. Despite this, the staff member admitted to being aware of the two-person assist requirement and the need to use a gait belt but did not follow these procedures. The incident was documented in an incident report and confirmed through staff interviews and review of the resident's care plan and assessments.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who was part of a sample of 12 residents reviewed for assessments. The resident had diagnoses including depression with psychotic features, anxiety, and diabetes mellitus. According to the RAI manual, a significant change MDS must be completed no later than 14 days from the ARD and no later than 14 days after determining that the criteria for a significant change in status assessment (SCSA) were met. However, the significant change assessment for this resident, dated 09/15/24, was not completed by the ARD date. During an interview on 10/04/24, the MDS coordinator confirmed that there was no specific policy for completing an MDS in a timely manner and that they referred to the RAI manual for guidance. They acknowledged that the significant change assessment had not been completed by the ARD date.
Inaccurate Assessment Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments, specifically for one resident among the 12 sampled. This resident had a medical history that included coronary artery bypass, heart disease with heart failure, and congestive heart failure. A physician's order dated October 4, 2024, prescribed clopidogrel bisulfate (Plavix), an antiplatelet medication. However, a significant change assessment dated July 10, 2024, incorrectly documented Plavix as an anticoagulant instead of an antiplatelet. During an interview on October 4, 2024, the MDS coordinator acknowledged the error, stating that they had mistakenly marked Plavix as an anticoagulant, despite following physician orders.
Failure to Update Care Plan for Resident's Decline in ADLs
Penalty
Summary
The facility failed to revise and update the care plan for a resident who experienced a decline in their ability to perform activities of daily living (ADLs). The resident had a history of insomnia, anxiety, acute kidney issues, urethritis, chronic urinary tract infections, and urinary retention. Initially, the care plan, dated December 23, 2023, indicated that the resident would not experience a decline in functional status. However, a quarterly assessment on July 26, 2024, showed that the resident required supervision to moderate assistance with ADLs. A subsequent significant change assessment on August 23, 2024, documented that the resident required maximum assistance with ADLs. Despite these assessments indicating a decline, the care plan was not updated to reflect the resident's increased need for assistance. When questioned, the Corporate Nurse Consultant was unable to confirm the facility's policy for revising care plans and acknowledged that the care plan had not been updated.
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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 Woodward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town Of Vici Nursing Home | 19 mi | ★★★★★ | 0 | 0 |
| Shattuck Nursing Center | 29 mi | ★★★★★ | 0 | 0 |
| Seiling Nursing Center | 31.1 mi | ★★★★★ | 4 | 0 |
| Western Skilled Nursing And Therapy | 32.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.