Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Woodville Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical problems repeatedly requested ER evaluation for severe wrist/hand pain, but an LPN redirected him and did not send him despite his repeated demands and attempts to walk to the hospital. He later went to the ER, where he was diagnosed with a wrist sprain and resolving pneumonia. Interviews confirmed staff understood he had the right to seek medical attention, and the facility resident rights policy states residents may request treatment and choose health care services.
Surveyors found that two residents with dementia were residing on a secured memory care unit without complete documentation or physician orders supporting their placement. For one resident, elopement risk assessments and nurse notes initially showed no exit-seeking behaviors, yet she was later moved to the secured unit with no corresponding order or documented behaviors in the record. For the other resident, nurse notes described agitation, paranoia, refusal of medications, and packing belongings to go home, and she was transferred from another hall to the secured unit, but her MDS still showed no behaviors and there was no physician order for secured-unit placement. Staff interviews and facility policy confirmed that residents should meet defined criteria, have interdisciplinary assessment, documented justification, and a physician order before being placed on the secured memory care unit, which was not reflected in these two residents’ medical records.
The facility failed to maintain complete and accurate clinical records for two residents on the secured unit. One resident was admitted without a physician order or elopement assessment, and another was transferred without the necessary documentation. The DON acknowledged these oversights, which could lead to staff being unaware of residents' needs.
The facility failed to maintain an effective infection control program, as evidenced by the lack of appropriate droplet isolation signage for a resident with MRSA and improper infection control measures during care for another resident with pneumonia. The absence of correct signage and failure to adhere to hand hygiene protocols could increase the risk of infection transmission.
A resident with cerebral palsy was admitted without a timely PASARR Level 1 screening, which was only completed after surveyor intervention. The MDS Nurse was unaware of the requirement to complete and transmit the PL1 before admission, leading to a delay in necessary services. The DON confirmed the expectation for timely completion and transmission of the PL1.
A facility failed to implement a comprehensive care plan for a resident with dementia, who was assessed as a moderate risk for elopement. Despite residing on a Secured Unit, the resident's care plan lacked interventions for elopement prevention, contrary to the facility's policy. The DON acknowledged the oversight, which could lead to staff being unaware of the necessary care.
A facility failed to update a resident's care plan to include a UTI diagnosis and antibiotic treatment. The resident, who was severely cognitively impaired and had an indwelling catheter, was at risk for infection. Despite a physician's order for antibiotics, the care plan was not revised, potentially leaving staff unaware of the resident's needs. The Infection Control Nurse, responsible for updating care plans related to infections, acknowledged the oversight.
A resident with atrial fibrillation was administered Eliquis, a blood thinner, despite orders to hold the medication following a procedure. The LVN failed to update the electronic MAR, leading to the medication being given five times when it should have been withheld. This error was confirmed by the DON, who noted the lack of documentation in the MAR as the cause.
Resident denied requested ER transfer
Penalty
Summary
The facility failed to treat a resident with dignity and respect when an LVN denied multiple requests for transfer to the local ER. The resident was a cognitively intact male with diagnoses including lung abscess with pneumonia, arthritis of the right wrist, anxiety disorder, pain, and skin cancer. His care plan noted limited physical mobility, ADL self-care deficits, and resistance to care, and it also included allowing him to make decisions about his treatment regimen and providing a sense of control. On the evening of the incident, the resident was awakened for a routine nebulizer treatment and began moaning and yelling that he was in pain, stating that his hands hurt and demanding to go to the ER. Staff attempted to calm him, and he later agreed to topical diclofenac gel to his right hand. He continued to request hospital transfer, walked down the hall without oxygen and only a T-shirt on, and stated he was going to the hospital himself. The LVN notified the DON, the resident refused vital signs, and the NP was later notified with new orders received. The next day, the resident was seen in the ER for right arm swelling and pain. The ER documented a sprain of the wrist with no fracture and resolving pneumonia, and the resident reported that he had told the nurse his arm was hurting but was not brought to the ER despite repeated requests. During interviews, the LVN stated she had redirected him and tried to prevent unnecessary ER visits, while the Administrator and Interim DON stated staff should have transferred him when he repeatedly requested medical attention. The facility resident rights policy stated residents have the right to request treatment, choose health care services, and be free from interference in exercising those rights.
Incomplete Documentation and Missing Orders for Placement on Secured Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and professionally accurate medical records for two residents placed on a secured memory care unit. For the first resident, a female with Alzheimer’s disease and dementia, documentation showed an initial elopement risk assessment indicating no history of elopement or attempts to leave home or the facility, no verbalization of wanting to go home, and no wandering with a specific destination. Her quarterly MDS documented severely impaired cognition with a BIMS score of 0 and no behaviors, and nurse notes over several weeks showed no exit-seeking behaviors. Although her care plan identified risk for wandering/elopement with interventions, there was no physician order in the January orders for placement on the secured unit, and no documentation in the record of elopement behaviors prior to her transfer, despite staff interviews stating she had been moved to the secured unit a few weeks earlier due to exit-seeking behaviors. For the second resident, who had dementia and moderately impaired cognition with a BIMS score of 8, an elopement risk assessment initially indicated no history of elopement or attempts to leave home or the facility, and no verbalization of wanting to go home or packing belongings to leave. Nurse notes documented increasing agitation, restlessness, paranoia, refusal of medications, and statements that staff were trying to poison her or keep her like a prisoner, as well as concerns about family and money. A subsequent elopement risk assessment documented that she had been seen packing belongings to go home without a discharge plan. Nurse notes recorded that she was moved from another hall to the secured unit, with the responsible party notified and the resident tolerating the room change. Her quarterly MDS still reflected no behaviors, and January physician orders contained no order for placement on the secured unit, even though her care plan identified her as at risk for elopement with a history of attempts to leave and wandering. Interviews with administrative and nursing staff confirmed that facility policy required residents placed on the Memory Care (secured) unit to meet specific criteria, be assessed by the interdisciplinary team, have documentation in the clinical record supporting elopement risk, obtain physician orders for placement, and involve the resident’s representative. The Memory Care Program policy stated that admission to the secured unit must be based on interdisciplinary assessment of cognitive and functional status, a determination of need for a safer environment or wandering/elopement risk, and approval by the IDT, with the patient representative contacted regarding placement. Staff, including the administrator and nursing personnel, acknowledged that there should be documentation and a physician order for placement on the secured unit, and that without such documentation the record would be incomplete. Despite this, both residents were observed residing on the secured unit without corresponding physician orders or complete supporting documentation in their medical records.
Deficiencies in Clinical Record Maintenance for Secured Unit Residents
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for two residents on the secured unit. For Resident #32, there was no physician order for placement on the secured unit and no elopement assessment upon admission. The resident, a female with vascular dementia, delusional disorder, and amnestic disorder, was admitted without the necessary documentation, which was only completed almost two months later. The Director of Nursing (DON) acknowledged the oversight, noting that an elopement risk assessment should have been conducted on the day of admission. Similarly, for Resident #7, the facility did not have a physician order for placement on the secured unit, nor was there an elopement risk assessment completed before the transfer. The resident, who had severe cognitive impairment and was at risk for wandering, was transferred to the secured unit for safety reasons without the required documentation. The DON was unsure if a physician order was necessary and admitted that the care plan should have included the intervention of secure unit placement. The lack of proper documentation could lead to staff being unaware of the resident's needs and inconsistencies in nursing care.
Inadequate Infection Control Measures and Signage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of appropriate signage for droplet isolation for Resident #102. Despite the resident being on droplet precautions due to MRSA of the sputum, the signage outside the resident's room only indicated enhanced barrier precautions. This oversight was observed multiple times on the same day, and the Director of Nursing (DON) acknowledged that the missing signage could lead to visitors not taking necessary precautions, such as wearing masks or face shields, thereby increasing the risk of exposure to infections. Additionally, the facility did not ensure proper infection control measures were implemented while providing care for Resident #252, who was on droplet isolation due to pneumonia caused by methicillin-susceptible staphylococcus aureus. During an observation, an LVN was seen reaching under her isolation gown to retrieve a saline flush and heparin flush from her pocket without performing hand hygiene or changing gloves. This action was acknowledged by the LVN as inappropriate, as it could contaminate her gloves and the items retrieved from her pocket. The facility's policies on transmission-based precautions and droplet precautions were not adhered to, as evidenced by the lack of proper signage and the failure to maintain hand hygiene and glove changes during care procedures. These deficiencies could potentially expose residents, staff, and visitors to infectious diseases, as the necessary precautions were not communicated or followed effectively.
Failure to Conduct Timely PASARR Screening
Penalty
Summary
The facility failed to ensure that a preadmission screening for mental disorders or intellectual disabilities (PASARR) was conducted for a resident identified with a developmental disability, specifically cerebral palsy. The resident, a male, was admitted without a PASARR Level 1 (PL1) screening, which was only completed after surveyor intervention. The absence of this screening was noted in the electronic records from early May to mid-June, and the PL1 was not transmitted to the Local Intellectual and Developmental Disability Authority (LIDDA) until mid-June, well after the resident's admission. Interviews revealed that the MDS Nurse was not aware of the requirement to complete and transmit the PL1 before admission, as she was instructed to date the PL1 with the intended completion date when submitting it late. The marketing staff, responsible for notifying the MDS Nurse of potential PASARR-positive admissions, was unavailable for comment. The Director of Nursing (DON) confirmed that the expectation was for the PL1 to be completed and transmitted prior to admission, and acknowledged that the delay could impact the resident's access to necessary services.
Failure to Implement Elopement Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident on the Secured Unit, specifically lacking an Elopement care plan. The resident, a female with dementia and severely impaired cognition, was assessed as a moderate risk for elopement. Despite this assessment, the care plan did not include any interventions or assessments for elopement prevention, as required by the facility's policy. The Director of Nursing acknowledged that the care plan should have included measures for elopement prevention and that it was her responsibility to ensure its completion. The absence of this care plan could lead to nursing staff being unaware of the necessary care for the resident, potentially placing her at risk. The facility's Accident/Incident policy mandates that an Elopement Risk Care Plan be completed for all patients based on their Elopement Risk Assessment, which was not adhered to in this case.
Failure to Update Care Plan for UTI and Antibiotic Treatment
Penalty
Summary
The facility failed to ensure that a resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan for a resident with a diagnosis of urinary tract infection (UTI) and administration of antibiotics was not updated to reflect these changes. The resident, who was severely cognitively impaired and had an indwelling catheter, was at risk for infection due to his condition. Despite having a physician's order for antibiotic treatment, the care plan did not address the UTI, which could lead to staff being unaware of the resident's needs. Interviews with the Director of Nursing (DON) and the Infection Control Nurse revealed that the responsibility for updating care plans related to infections and antibiotics was assigned to the Infection Control Nurse. However, the care plan for the resident's UTI was overlooked and not revised, which could result in nursing staff not being aware of changes in care. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, but this was not adhered to in this case.
Failure to Hold Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Eliquis, a blood thinner. The resident, an elderly female with a diagnosis of atrial fibrillation, was prescribed Eliquis 2.5 mg twice daily. Following an outpatient minimally invasive procedure, the resident's cardiologist ordered the Eliquis to be held until a specified date. However, the medication was administered on multiple occasions when it should have been withheld, as documented in the resident's Medication Administration Record (MAR). The error occurred because the Licensed Vocational Nurse (LVN) who received the order to hold the medication did not update the electronic MAR to reflect this change. As a result, the medication was administered five times when it should have been on hold. The Director of Nursing (DON) confirmed that the medication error was due to the failure to document the hold order in the electronic MAR, which was visible to other staff responsible for medication administration. This oversight could have placed the resident at an increased risk of bleeding following the procedure.
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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 Woodville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dogwood Trails Manor | 1.7 mi | ★★★★★ | 8 | 0 |
| Pine Ridge Health Care Llp | 20.5 mi | ★★★★★ | 0 | 0 |
| Timberidge Nursing And Rehabilitation Center | 26.9 mi | ★★★★★ | 3 | 0 |
| Rayburn Health Care & Rehabilitation | 27 mi | ★★★★★ | 8 | 0 |
| Corrigan Ltc Nursing & Rehabilitation | 28.2 mi | ★★★★★ | 12 | 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.