Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Woodbury Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with COPD, lack of coordination, and anxiety disorder had a prior fall with a care plan intervention for nonskid strips at the bedside. The facility later failed to keep that intervention in place, and the resident was found on the floor beside the bed after hollering for help, resulting in a left hip fracture and surgical repair. Surveyors observed the nonskid strips were not at the bedside, and the DON, ADM, LPN, and RD confirmed they were missing.
The facility failed to properly clean and sanitize the ice machine, leading to potential foodborne illness transmission. Observations revealed unsanitary conditions in the ice machine and undated food items in the kitchen and nourishment rooms. Additionally, 9 of 11 resident room refrigerators were not maintained within the acceptable temperature range, with no rechecks or maintenance notifications, indicating a lack of proper food storage practices.
A LTC facility failed to maintain an effective infection prevention and control program, allowing a resident on contact precautions to interact with others, improperly disinfecting a glucometer, and delaying isolation precautions for another resident. These actions were contrary to facility policy and CDC guidelines, as confirmed by staff interviews and observations.
The facility submitted inaccurate and incomplete PBJ data for the first two quarters of 2024, resulting in a One Star Staffing Rating. The DON admitted that agency staff were initially excluded from reports, and the HR Director acknowledged inconsistencies in data transfer, which she plans to address.
Failure to Implement Fall Intervention After Prior Fall
Penalty
Summary
The facility failed to implement a fall-related care plan intervention for Resident #7 after a fall on 5/15/2025. The resident was admitted with diagnoses including COPD, lack of coordination, and anxiety disorder, and a quarterly MDS assessment indicated a BIMS score of 15, showing the resident was cognitively intact and independent with all aspects of care. After the 5/15/2025 fall, nursing documentation stated the resident was found sitting on the floor after trying to get to the bathroom and slipping, and the incident report identified the root cause as footwear, with a new intervention of nonskid strips to the exiting side of the bed. The comprehensive care plan dated 5/15/2025 included the intervention of nonskid strips to the bedside. However, the facility later failed to have those nonskid strips in place. On 4/12/2026, Resident #7 was again found on the floor beside the bed after hollering for help, and the incident report and nursing note documented the fall. A radiology report from that date showed a left intertrochanteric fracture, and an operative note dated 4/15/2026 documented internal fixation of the left hip. During observations on 4/21/2026, surveyors found no nonskid strips at the bedside, and both the LPN and DON confirmed they were not in place. The DON acknowledged the resident had fallen on 5/15/2025 and that nonskid strips had been the intervention, but they were not present at the time of the later fall. The ADM also confirmed the strips were not in place, and the RD stated they were placed only after the facility was informed on 4/21/2026 that they were missing.
Deficiencies in Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine, which could affect all residents receiving ice. Observations revealed dark orange stains, dark debris, and dark specks in the ice machine on the B Hall, indicating a lack of proper maintenance and cleaning. The Dietary Manager confirmed that maintenance was responsible for cleaning the ice machine, but the Maintenance Director had not been notified of the issue until the state survey. Additionally, the ice scoop storage container was found with white debris, further indicating unsanitary conditions. The facility also failed to ensure food was stored, prepared, and served under sanitary conditions, as evidenced by undated food items in the kitchen and nourishment rooms. Observations in the kitchen revealed undated darkened lettuce, onions, thickened milk, ravioli, and waffles. Similarly, undated and uncovered food items were found in the nourishment room refrigerators on A and B Halls, including Gatorade, chicken/vegetable pie, beans, onion rings, and grilled cheese. The Dietary Manager acknowledged that the food should have been dated and covered. Furthermore, the facility failed to maintain 9 of 11 refrigerators located in resident rooms in proper working order to prevent potential cross-contamination to stored food. Temperature logs for personal refrigerators on the 200 Hall showed multiple instances of temperatures documented higher than the acceptable range of 35-41 degrees Fahrenheit, with no temperature rechecks or notifications to maintenance. Interviews with staff revealed inconsistencies in understanding the correct temperature range and procedures for addressing out-of-range temperatures, contributing to the ongoing issue of improper refrigerator maintenance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. One resident, who was on contact precautions due to a urinary tract infection with ESBL and MRSA, was repeatedly observed interacting with other residents in common areas, contrary to the facility's policy and CDC recommendations. Despite the presence of an isolation sign and PPE caddy on the resident's door, the resident was allowed to leave the room and sit in close proximity to others, increasing the risk of transmission of infectious agents. Another deficiency was noted in the handling of a multi-use glucometer for a resident with diabetes. The LPN responsible for blood glucose monitoring failed to properly disinfect the glucometer between uses, not adhering to the required two-minute wet contact time for the sanitizer wipes. Additionally, contaminated items were improperly handled and stored, further compromising infection control protocols. The DON acknowledged that the staff had been educated on the correct procedures, yet the observed practices did not align with the training provided. The facility also failed to implement contact isolation precautions in a timely manner for a resident with a positive urine screen for ESBL and MRSA. The resident's room lacked appropriate signage and PPE setup, and the staff did not consistently follow sterile techniques during tracheostomy care. The delay in setting up isolation precautions and the improper handling of medical procedures highlighted significant lapses in the facility's infection control practices, as confirmed by interviews with staff and the DON.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to report accurate and complete Payroll Based Journal (PBJ) data for the first and second quarters of 2024. The facility did not provide a copy of the Staffing Policy, and the review of the Quarterly PBJ for both quarters revealed a One Star Staffing Rating. During interviews, the Director of Nursing (DON) acknowledged that agency staff were not initially included in the PBJ reports but are now being included. The Administrator confirmed the submission of inaccurate and incomplete PBJ data by the required deadlines. The Human Resource (HR) Director admitted to inconsistencies in the PBJ data from October 2023 through March 2024, stating that some staff data did not transfer correctly, and she was not monitoring this area but will do so moving forward.
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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.
Illustrative
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Nursing homes near Woodbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Smithville | 16.4 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Murfreesboro | 17.5 mi | ★★★★★ | 5 | 0 |
| Stone River Post Acute | 17.8 mi | ★★★★★ | 4 | 0 |
| Community Care Of Rutherford | 18 mi | ★★★★★ | 0 | 0 |
| Adamsplace, Llc | 18 mi | ★★★★★ | 7 | 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.