Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 William Hood Dunwoody Care Ctr during CMS and state inspections, most recent first.
The facility failed to maintain and inspect its sprinkler system as per NFPA 25 standards, affecting the entire facility. Missing documentation for annual control valve exercises and physical deficiencies, such as missing sprinkler escutcheons and improper anchoring of ceiling wires, were observed. These issues were confirmed during an exit interview with the Administrator and the Director of Maintenance.
The facility did not properly identify portable fire extinguishers, as all recessed, wall-mounted fire extinguisher cabinets lacked indicator signage. This issue was confirmed during an exit interview with the Administrator and the Director of Maintenance.
The facility failed to maintain documentation of weekly battery voltage inspections for the emergency generator, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and Director of Maintenance.
The facility failed to maintain proper building separation in sections classified as other occupancies. An observation revealed that the doorway to Country House, between skilled nursing and assisted living, lacked a 1 1/2 hour fire-resistant door. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance, acknowledging the lack of complete two-hour fire-resistant separation.
The facility was cited for deficiencies in egress door signage and functionality. An SLA egress door lacked required signage for delayed-egress systems, and a door towards the Hood loading dock area had a damaged closure, preventing it from closing properly. These issues were confirmed by the Administrator and Director of Maintenance.
The facility failed to maintain electrical system requirements, with unsecured junction boxes found above the ceiling on the first floor and exposed wiring in the Hood Mechanical Room. These deficiencies were confirmed during an exit interview with the Administrator.
The facility was found to have unsealed penetrations above smoke barrier doors in the trash separation room due to data lines, compromising the required 1/2-hour fire resistance rating. This issue was confirmed during an exit interview with the Administrator and the Director of Maintenance.
A resident with an indwelling catheter experienced a significant change in urinary status, including no urine output in the drainage bag and the presence of bloody, odorous urine with tan sludge after catheter replacement. Although the responsible party was notified, there was no documentation that the physician was informed of this change, resulting in a delay in treatment for a subsequent urinary tract infection. The DON confirmed the lack of physician notification.
A resident developed a new deep tissue pressure injury (DTI) on the left lower back, which was initially assessed and treated, but no further wound care was documented or provided for several days until the resident was sent to the hospital. The DON confirmed the lack of wound treatment during this time.
A resident with dementia and dysphagia experienced significant weight loss over several weeks, but staff did not reweigh the resident within 24 hours, notify the physician promptly, or implement interventions as required by facility policy. The weight loss continued over a three-month period without documented review or action by the nurse or dietitian.
A resident did not receive timely treatment for constipation as per the facility's Bowel Protocol. Despite having a physician's order for Milk of Magnesia, the resident went 15 shifts without a bowel movement before the medication was administered, contrary to the protocol requiring action after 6 shifts.
A resident with Dementia, Anemia, and Anxiety Disorder fell out of bed while receiving morning care from a non-licensed staff member who was unaware that the resident required paired care. The resident sustained a small abrasion but reported no pain. The incident occurred because the staff member did not follow the care plan instructions.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system in accordance with NFPA 25 standards, affecting the entire facility. During a document review on April 17, 2025, it was found that the facility could not provide documentation of an annual exercise of control valves through their complete range of motion. Additionally, observations revealed physical deficiencies, including two missing sprinkler escutcheons in the oxygen room Dundale and a suspended ceiling wire improperly anchored to a sprinkler branch line in the smoke separation vestibule on the first floor, creating an external load on the sprinklers. Further observations on the same day identified another deficiency affecting one of the three levels of the facility. A missing sprinkler escutcheon was noted outside the security office and the mechanical room on the first floor. These deficiencies were confirmed during an exit interview with the Administrator and the Director of Maintenance, highlighting the facility's failure to maintain and inspect the sprinkler system adequately.
Plan Of Correction
Dunwoody will have their sprinkler vendor inspect the sprinkler control valves and will document confirmation that they exercised their complete range of motion by 5/30/2025. This will be completed and documented as part of their annual inspection going forward. Missing escutcheons will be installed by 5/30/2025 by Dunwoody Maintenance staff and checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. The ceiling grid wire will be removed from the sprinkler pipe by 5/30/2025 by Dunwoody's Maintenance staff. All maintenance mechanics will be inserviced on this by 5/30/2025. Missing escutcheons will be installed by 5/30/2025 by Dunwoody Maintenance staff and checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. All maintenance mechanics will be inserviced on this by 5/30/2025.
Lack of Indicator Signage for Fire Extinguishers
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were properly identified throughout the entire facility. During an observation on April 17, 2025, at 11:05 a.m., it was noted that all recessed, wall-mounted fire extinguisher cabinets lacked indicator signage. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance at 11:15 a.m. on the same day.
Plan Of Correction
Dunwoody Maintenance staff will install indicator signs over all fire extinguishers by 5/23/2025. These signs will be checked quarterly as part of our quarterly safety inspections by the Maintenance Manager or designee. All maintenance mechanics will be inserviced on this by 5/23/2025.
Failure to Document Weekly Generator Inspections
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on April 17, 2025, it was discovered that the facility could not provide documentation proving that weekly inspections of the battery voltage were performed. This lack of documentation indicates a failure to adhere to the required maintenance and testing protocols for the emergency generator as outlined by NFPA standards. An exit interview with the Administrator and the Director of Maintenance confirmed the absence of the necessary documentation. This deficiency affects the entire facility, as the emergency generator is a critical component of the essential electrical system, designed to provide power in the event of an outage. The failure to maintain proper records of inspections compromises the facility's ability to ensure the generator's reliability and readiness in emergencies.
Plan Of Correction
The Maintenance Manager or designee will check the battery voltage weekly on the emergency generators and document on the respective generator log. This will be added to the generator logs by 5/16/2025. All maintenance mechanics will be inserviced on this by 5/16/2025.
Failure to Maintain Building Separation
Penalty
Summary
The facility failed to maintain proper building separation in sections classified as other occupancies. During an observation on April 17, 2025, at 9:50 a.m., it was noted that the doorway to Country House, which is situated between the skilled nursing and assisted living areas, did not have a 1 1/2 hour fire-resistant door. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance on the same day at 11:15 a.m., where it was acknowledged that there was a lack of complete two-hour fire-resistant separation as required by the regulations.
Plan Of Correction
2-hour fire resistant doors will be purchased and installed by 7/11/2025 by Dunwoody's General Contractor. The Maintenance Manager or designee will inspect these doors weekly for the initial two months and then annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 7/11/2025. Dunwoody will ask for a TLW as July 11 is close to the 90th day and if there is any type of delay by contractor or delivery or production of door it may be necessary to have the TLW.
Deficiencies in Egress Door Signage and Functionality
Penalty
Summary
The facility was found to have deficiencies related to the egress doors, specifically concerning the delayed-egress locking systems. During an observation on April 17, 2025, it was noted that an SLA egress door outside of elevator 10 lacked the required signage indicating "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance, who acknowledged the absence of the necessary signage for the delayed egress system. Additionally, the facility failed to maintain the means of egress without obstructions. An observation on the same day revealed that the left side door towards the Hood loading dock area on the first level had a damaged door closure, preventing the door from swinging closed properly. This issue was also confirmed during the exit interview with the Administrator and the Director of Maintenance, who acknowledged the malfunctioning door closure.
Plan Of Correction
A 15 second delayed egress sign will be installed on 5/16/2025 by Dunwoody's Maintenance staff. The Maintenance Manager or designee will inspect these doors annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 5/26/2025. The damaged fire door closer will be repaired on or before 5/9/2025 by Dunwoody's Maintenance Staff. The Maintenance Manager or designee will inspect these doors weekly for the initial two months and then annually as part of our Annual Fire Door Inspection. All maintenance mechanics will be inserviced on this by 5/26/2025.
Electrical System Deficiencies Found in Facility
Penalty
Summary
The facility failed to maintain electrical system requirements as per NFPA 70 and NFPA 99, affecting one of two levels of the facility. During an observation on April 17, 2025, between 9:05 a.m. and 9:08 a.m., two unsecured junction boxes were found above the ceiling on the first floor, near the rehab area and in front of the laundry. Additionally, at 10:05 a.m. on the same day, an observation inside the Hood Mechanical Room revealed a metal clad conduit wire with exposed wiring. These deficiencies were confirmed during an exit interview with the Administrator on April 17, 2025, at 11:15 a.m.
Plan Of Correction
The junction boxes will be secured on or by 5/23/2025. The exposed wire will be correct on or by 5/23/2025. Above ceiling audits for unsecure junction boxes will be made part of the Maintenance Quarterly Safety inspections by 5/23/2025. All maintenance mechanics will be inserviced on this by 5/23/2025. The exposed wire will be replaced on or by 5/30/2025 by Dunwoody's contracted electrician. This will be inspected quarterly by the Maintenance Manager or Designee and made part of the Maintenance Quarterly Safety inspections by 5/30/2025. All maintenance mechanics will be inserviced on this by 5/30/2025.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to ensure that smoke barrier walls were free of unsealed penetrations, which is a requirement for maintaining a 1/2-hour fire resistance rating. During an observation on April 17, 2025, at 10:05 a.m., it was noted that there were unsealed penetrations above the smoke barrier doors in the trash separation room due to data lines. This deficiency was confirmed during an exit interview with the Administrator and the Director of Maintenance on the same day at 11:15 a.m.
Plan Of Correction
This penetration will be sealed with a UL approved stop gap penetration system or before 5/16/2025. Above ceiling penetrations will be made part of the Maintenance Quarterly Safety inspections by 5/16/2025. All maintenance mechanics will be inserviced on this by 5/16/2025.
Failure to Notify Physician of Significant Change in Urinary Status
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's urinary status. The resident, who had an indwelling urethral catheter due to urinary retention and neuromuscular dysfunction of the bladder, was found to have no urine output in the drainage bag, while their brief was wet twice. Further assessment revealed that the catheter was outside the body more than it should have been. The catheter was removed and replaced, resulting in immediate output of 1700 cc of red bloody, odorous, and tan sludge urine. The responsible party was notified, but there was no documentation that the physician was informed of this significant change in the resident's condition. Subsequent physician notes indicated that the resident was later found to be somnolent and not as vocal as their baseline, prompting further laboratory tests. Blood work revealed an elevated white blood cell count and urine tests indicated a urinary tract infection, for which the physician was eventually notified and treatment was started. The Director of Nursing confirmed that there was no documented evidence of physician notification at the time of the initial significant change in urinary status, resulting in a delay in treatment.
Failure to Provide Wound Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide wound treatment for a pressure ulcer identified on a resident's left lower back. On March 13, 2025, a new deep tissue pressure injury (DTI) was observed and documented, with the wound initially cleansed and ointment applied, and the nurse practitioner notified. However, review of the resident's treatment administration record (TAR) showed no evidence that wound treatment was administered for the DTI from March 14, 2025, until the resident was transferred to the hospital on March 17, 2025. The Director of Nursing confirmed the absence of documented wound care during this period.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a resident diagnosed with dementia and dysphagia. According to the facility's policy, residents' weights are to be monitored weekly, and any weight change of three pounds or more should be reweighed within 24 hours to verify accuracy. Additionally, weight losses of 5% or more are to be reported to the physician and documented, with a care plan developed to address the concern. In this case, the resident experienced an 8.8-pound (5.81%) weight loss over five days, but there was no evidence that a reweigh was performed within 24 hours, nor that the nurse or dietitian reviewed the weight loss. No interventions were implemented to prevent further weight loss, and the physician was not notified until several weeks later. Further review showed that the resident continued to lose weight, with a total loss of 7.34% from admission over a three-month period. Despite this ongoing decline, there was no documentation of interventions or care plan adjustments to address the continued weight loss. Interviews with the dietitian and DON confirmed that no actions were taken in response to the significant and ongoing weight loss. The facility did not follow its own policies for monitoring, documenting, and responding to significant weight changes.
Failure to Administer Constipation Treatment in a Timely Manner
Penalty
Summary
The facility failed to ensure timely treatment for constipation for one of 18 residents. According to the facility's Bowel Protocol policy, if a resident has not had a bowel movement for 6 shifts, the 3-11 charge nurse is to administer Milk of Magnesia at bedtime. Resident 18 had a physician's order for Milk of Magnesia to be given every 24 hours as needed for constipation. However, the resident had no recorded bowel movement from April 22, 2024, through April 26, 2024, totaling 15 shifts without a bowel movement. The medication was not administered until April 27, 2024. This was confirmed by an interview with a licensed nurse, indicating a failure to follow the protocol and physician's orders.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that Resident 44 was free from accidents during activities of daily living care. On March 20, 2024, non-licensed staff member Employee E1 was providing morning care to Resident 44 when the resident rolled out of bed and fell onto the floor. The clinical record for Resident 44 indicated that the resident required paired care (two staff members) for such activities, as noted in the care plan dated January 20, 2023. However, Employee E1 was not aware of this requirement and was providing care alone, leading to the accident. Resident 44, who has diagnoses including Dementia, Anemia, and Anxiety Disorder, sustained a small abrasion on the left upper forehead but reported no pain following the fall. The facility's investigation confirmed that the fall occurred because Employee E1 did not follow the care instructions specified in the resident's care plan. The Nursing Home Administrator confirmed the incident and reported that Employee E1 was reeducated on following resident care plans.
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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 Newtown Square
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine View Healthcare And Rehabilitation Center | 1.4 mi | ★★★★★ | 44 | 0 |
| Broomall Manor | 1.9 mi | ★★★★★ | 1 | 0 |
| Wesley Enhanced Living Main Line Rehab And Skd Nsg | 1.9 mi | ★★★★★ | 1 | 0 |
| Rosewood Gardens Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 1 | 0 |
| Quadrangle | 3.6 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.