Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Wooldridge Place Nursing Center during CMS and state inspections, most recent first.
A facility failed to include a sexual relationship between two residents in either resident's care plan. One resident had moderate cognitive impairment and multiple chronic diagnoses, and the other resident also had moderate cognitive impairment with several medical and psychiatric conditions. Staff and leadership knew about the relationship through observation and word of mouth, the DON spoke with the resident representative, and the residents gave conflicting accounts, but the relationship was not documented in a comprehensive person-centered care plan with measurable goals and interventions.
A facility failed to provide respiratory care consistent with physician orders for several residents on O2 therapy. Multiple residents were observed with concentrator settings below the ordered liter flow, and an LVN or the DON confirmed the mismatches after reviewing the orders. In another case, a resident receiving O2 had no no-smoking/O2 sign posted outside the room, despite staff stating the sign was required for residents using supplemental oxygen.
Failure to document blood pressure before Lisinopril administration. A resident with HTN had an order for Lisinopril 40 mg daily with hold parameters for low BP or pulse. The MAR showed the medication was given on multiple days, but there were no BP readings recorded to coincide with administration, and vital signs did not show morning BP checks on many of those days. The DON and nursing staff stated BP should be checked before giving BP meds, and staff noted the MAR did not appear to provide a place to record the BP with the medication sign-off.
A facility failed to keep a med cart locked when unattended, failed to ensure several OTC liquid and powder medications on two med carts had open dates, and left a diabetic lancet on top of an unattended cart. An LPN acknowledged the cart should not have been unlocked and that the lancet should have been secured, while the DON and ADON stated open dating was needed for certain medications and that the lancet should have remained in the cart until use.
Kitchen sanitation review found dirty ice machine filters, dirty refrigerators and trays, sticky build-up on the juice dispenser, dirty counters, sinks, floors, and utensil drawer, and grime under the sink and dishwasher. Surveyors also found opened and unlabeled food, expired refrigerated and shelf-stable items, boxes of water jugs stored on the floor, and heavily worn pans with Teflon scraping off and burned chips breaking off.
Failure to Maintain Privacy During Medication Administration: An MA and an LVN left the door, curtain, and/or blinds open while checking BP and administering meds, including G-tube meds, for three residents. The staff stated they forgot to close the privacy barriers, and the ADON and DON stated that staff should close the door, curtain, and blinds to protect resident privacy and dignity during care.
Failure to Notify LTC Ombudsman of Discharge: The facility did not send a copy of a resident’s discharge notice, including the reason for transfer or discharge, to the state LTC Ombudsman before the resident was discharged home. The resident had acute respiratory failure with hypoxia, DM2, COPD, HTN, and generalized muscle weakness, and the MDS showed intact cognition. Interviews showed the SSD and BOM were unclear about who was responsible for notifying the Ombudsman, and the Ombudsman representative confirmed no discharge notice was received.
Failure to Administer Ordered Carvedilol: An MA did not give a resident’s ordered Carvedilol after checking BP and incorrectly believing it was out of parameters along with two other BP meds. The resident had HTN, hypertensive heart disease, and a pacemaker, and the DON stated the medication should have been administered because it was within the ordered parameters.
Two residents had infection control lapses during care. An LVN administered meds via a G-tube without the required gown under EBP, and a CNA performed catheter care and then placed a clean brief without changing contaminated gloves between tasks. The DON stated that hand hygiene should have occurred between care steps and that staff are expected to use gown and gloves for EBP high-contact care.
Two medication carts containing drugs, including narcotics, were found unlocked and unattended in a hallway, with keys left on top and residents passing by. The responsible LVNs admitted to forgetting to lock the carts and secure the keys, despite facility policy and prior in-servicing requiring medication carts to be locked when not in use.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required by regulations.
The facility failed to maintain proper food storage, preparation, and sanitation standards, leading to potential risks of foodborne illnesses. Issues included a malfunctioning convection oven, improper placement of personal items on prep tables, and inadequate handwashing by staff. Additionally, dry goods and refrigerated items were not sealed, labeled, or dated properly, and trash bins were not covered. The daily cleaning schedule was not consistently followed, and the nutrition room refrigerator and freezer lacked proper temperature documentation and labeling of items.
The facility failed to ensure proper hand hygiene during wound care for two residents, as the WCN did not scrub hands with soap for the required 20 seconds. This deficiency was observed during care for residents with wound infections and surgical wounds, highlighting a lapse in infection control practices. The WCN admitted to not realizing the shortfall, and the DON confirmed the expectation for staff to follow hand hygiene protocols.
A resident with severe cognitive impairment eloped from a facility and was found walking in a nearby field. The resident was unaccounted for approximately 15 minutes before being located by a passerby and returned by staff. The facility's failure to conduct a timely head count and inconsistencies in staff knowledge of elopement procedures contributed to the incident.
The facility failed to document vital signs accurately when administering medications affecting blood pressure and heart rate for several residents. Interviews revealed that RNs and LVNs often did not document vital signs immediately due to high workloads, leading to potential medication errors. The DON acknowledged the issue and considered adjusting medication pass times to improve documentation practices.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including improper storage of resident briefs, failure to isolate a resident with a positive urine culture for Klebsiella pneumoniae, and expired sterile urinary catheters in the Central Supply room. Staff were unsure about infection control protocols, and there was no specific policy for managing general supplies, posing risks to resident safety.
A resident's dignity and privacy were compromised when their foley catheter drainage bag lacked a privacy cover, leaving it exposed to others. The resident, who had a history of sepsis and cancer, was dependent on staff for toileting. Staff interviews revealed a lack of awareness and training regarding the use of privacy bags, contributing to the oversight.
A resident experienced an unwitnessed fall, resulting in injuries that were not consistently or accurately assessed and documented by the nursing staff. The initial assessment failed to note a hematoma and dried blood observed later by another LVN, leading to incomplete records of the resident's condition. Interviews revealed gaps in documentation and communication, with the DON acknowledging the lack of detailed documentation and measurements of the injuries, which are crucial for monitoring the healing process.
The central supply room door was propped open, allowing access to harmful supplies like razors and lancets. Expired deodorant was also found. The CS staff, responsible for the room, spent most of their time on staffing duties, limiting oversight. The facility lacked specific policies for general supplies, relying on corporate policies.
Failure to Care Plan Resident Relationship
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents who were involved in a sexual relationship. Resident #1 was an older female resident with diagnoses including COPD, unspecified dementia, nontraumatic intracerebral hemorrhage, cognitive communication deficit, muscle weakness, and difficulty walking. Her quarterly MDS reflected a BIMS score of 8, indicating moderate cognitive impairment. Resident #5 was an older male resident with diagnoses including COPD, alcohol dependence with alcohol-induced persisting dementia, muscle weakness, hypertension, and generalized anxiety disorder. His quarterly MDS reflected a BIMS score of 9, also indicating moderate cognitive impairment. Record review showed that Resident #1's care plan did not address her sexual relationship with Resident #5, and Resident #5's care plan did not address his sexual relationship with Resident #1. The DON documented speaking with Resident #1's RP about the relationship and noted that the RP understood the situation. The DON also documented that the physician was aware. During interviews, Resident #5 stated he and Resident #1 were in a romantic relationship and were engaged, and he described spending time with her in his room and planning to move in together. Resident #1, however, denied having a boyfriend, denied a sexual relationship, and denied having sex. Staff interviews reflected that multiple employees were aware of the relationship through observation or word of mouth. LVN A stated the residents had been in a sexual relationship for months. LVN C stated she had seen Resident #1 touching Resident #5 in a sexual manner and that the entire staff was aware of the relationship, but she had not seen anything in writing about it. The SW, MDS nurse, ADON, DON, and Adm all acknowledged awareness of the relationship and stated it should have been care planned. The DON stated the facility had not in-serviced staff about the relationship and did not care plan it because she did not think about it as it was not a common occurrence. The facility policy stated the comprehensive care plan must include measurable objectives, time frames, and interventions to address residents' medical, nursing, mental, and psychosocial needs.
Incorrect Oxygen Settings and Missing Oxygen Sign
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders and the resident care plans for multiple residents receiving oxygen therapy. Resident #82, a female admitted with shortness of breath and COPD, had an order for oxygen at 3 liters per minute continuously by nasal cannula, but during observation the oxygen concentrator was set at 2 liters per minute. The assigned LVN confirmed the setting was incorrect and stated the resident should have been at 3 liters per minute per the physician order. Resident #21, a male with diffuse traumatic brain injury, had a physician order for oxygen at 2 liters per minute continuously by nasal cannula, but an observation showed the concentrator set at 1.5 liters per minute. The DON stated the oxygen should be set at 2 liters per minute and that the setting should not be lower than that order. Resident #53, a male with acute and chronic respiratory failure with hypoxia and COPD, had an order for oxygen at 4 liters per minute continuously by nasal cannula, but the concentrator was observed at 3 liters per minute. The LVN verified the order and the incorrect setting after reviewing the chart. Resident #1, a female with COPD and CHF, had an order for oxygen at 2 liters per minute continuously by nasal cannula, but the concentrator was observed at 1.5 liters per minute. The LVN confirmed the incorrect setting after checking the order. In addition, Resident #32, a male with COPD, primary spontaneous pneumothorax, and CHF, was observed receiving oxygen at 3 liters per minute as ordered, but there was no oxygen sign posted outside the room. Facility staff stated that oxygen signs were required for residents on oxygen and that the sign should be posted outside the room. The facility policy stated that oxygen orders should include the specific liter flow required and that no smoking signs should be posted where supplemental oxygen is in use.
Failure to Document Blood Pressure Before Lisinopril Administration
Penalty
Summary
Ensure that residents were free from significant medication errors was not met for one resident with a diagnosis of essential primary hypertension. Resident #8 was admitted on 02/05/2026 and had a physician order for Lisinopril 40 mg by mouth daily for hypertension, with instructions to hold the medication for blood pressure less than 110/60 and/or pulse less than 60. The resident’s care plan included an intervention to give antihypertensive medications as ordered and observe for side effects such as orthostatic hypotension and increased heart rate. Review of the February 2026 MAR showed Lisinopril was administered daily from 02/06/2026 through 02/24/2026, but there were no blood pressures listed on the MAR to coincide with the medication administration. Review of vital signs showed no morning blood pressures taken to coincide with the blood pressure medication on multiple dates in February. During interview, the DON stated nurses should always check blood pressure prior to administering blood pressure medication and noted she could not find blood pressures listed on the MAR to coincide with the medication. Staff interviews indicated they would normally check blood pressure before giving the medication, and one staff member stated there was no place or line on the MAR to record the blood pressure next to the medication sign-off.
Medication carts left unsecured and OTC medications lacked open dates
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored appropriately for 3 of 4 medication carts reviewed. On the 100 Hall Nurse Med-Cart, an observation found the cart unlocked while parked at the nurses’ station, with the lock popped out and all drawers except the narcotic drawer accessible. The keys for that cart were observed sitting on the cart in the binder containing the narcotic and controlled count sheets. The LVN assigned to the cart stated the cart belonged to her and acknowledged it should not have been left unlocked because residents could have accessed medications not prescribed to them. On the 200/400 Hall Medication Cart and the 300 Hall Medication Cart, several over-the-counter medications did not have an open date written on the bottles. The unlabeled items included liquid and powder medications such as Tussin Guaifenesin Oral Solution, Enulose, Milk of Magnesia, Polyethylene Glycol 3350 powder, and Mylanta. The LVNs responsible for the carts stated that the person who opened the bottles was responsible for labeling them with an open date, and the DON and ADON also stated that open dating was needed for certain medications, although the DON was unsure whether Milk of Magnesia required an open date because it has an expiration date. During an observation of the 200 hall medication cart, a diabetic lancet was found sitting on top of the unattended cart. The LVN stated the lancet was supposed to be secured in the medication cart and that someone could come by and grab it if left on top. The DON later stated the lancet should be kept in the medication cart until use and that leaving it unattended on top of the cart was a safety issue. Facility policy stated med-carts are locked when unattended, controlled medications are stored separately in locked compartments, and the facility’s medication storage and expiration dating policy stated the date opened should be recorded on primary medication containers when medications have a shortened expiration date once opened.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen sanitation review. Observations during the initial kitchen tour found extremely dirty ice machine filters with thick build-up, dirty refrigerator exteriors with spill lines, and a refrigerator containing a large container of thick yellow substance with a use-by date of 02/21/2026. Trays inside the refrigerator were dirty with particles and drips of old food, and large condiment containers sitting on the trays were covered with a sticky build-up. The juice dispenser had sticky build-up on and around the nozzles and on the stainless backsplash, and the kitchen floors had dirt, food, grime, molded vegetables, silverware, and other trash under shelves and counters. Counters and sinks were dirty with build-up and food particles, and the utensil drawer contained old food particles and splatters. The review also found opened and unlabeled packages of bread, cereal, cookies, chips, and peanut butter, expired shelf-stable and refrigerated food, and boxes containing jugs of water stored on the floor in the kitchen storage room. Under the sink and dishwasher there was built-up grime, dirt, and a black substance. The pans being used in the kitchen were scraped so badly that the Teflon was coming off and were burned to the point of black chips breaking off. The Food Services Director stated the filters, floors, counters, walls, equipment, and sinks were cleaned daily, but she could tell the juice machine had not been cleaned. She also stated food not dated or discarded appropriately could make residents sick, boxes of water should not be stored on the floor, and pans with burned material or scraped Teflon should not be used because it could end up in residents' food. A cook also stated pans with burned material or scraped Teflon should not be used because it could end up in residents' food.
Failure to Maintain Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure resident privacy during medication administration for three residents. During an observation on 02/25/2026 at 6:49 a.m., MA E kept the door and curtain open while checking Resident #15's blood pressure and then administered medications. During an observation on 02/25/2026 at 7:06 a.m., MA E again kept the door and curtain open while checking Resident #82's blood pressure and then administered medications. MA E stated that she was supposed to close the door and curtain before checking blood pressures and administering medications to both residents, and that she forgot to do it. She also stated that closing the door and curtain was important to provide privacy. During an observation on 02/25/2026 at 1:27 p.m., LVN F kept the door, curtain, and blinds open while administering medications via G-tube to Resident #21. LVN F stated that she forgot to close the door, curtain, and blinds while providing the medication because she got sidetracked looking for soap to wash her hands with. She stated that she should have closed the curtain and door because she never knew who would walk in while she was providing care, and that she should have provided the resident with privacy. The ADON and DON both stated that staff should close the door, pull the curtain, and close the blinds prior to administering medications, and the facility policy on Resident Rights stated that residents must be treated with respect and dignity and that their rights must be upheld.
Failure to Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of the resident discharge notice, including the reason for transfer or discharge, to a representative of the Office of the State Long-Term Care Ombudsman before the resident was discharged home. Resident #3 was admitted with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, essential hypertension, and generalized muscle weakness. The resident’s latest MDS showed a BIMS score of 14, indicating intact cognition, and the discharge order documented discharge home with medications, home health, occupational therapy, skilled nursing follow-up, and primary care physician follow-up. Record review showed no evidence in the electronic medical record that notice was given to the LTC Ombudsman regarding the resident’s discharge home. During interviews, the SSD stated she was not responsible for notifying the Ombudsman when a resident was discharged and said the BOM was responsible. The state LTC Ombudsman representative stated she had not received any discharge notices. The BOM stated she was not aware that she needed to notify the Ombudsman when a resident was discharged and said she only notified the Ombudsman when there was a 30-day notification for a resident to leave the facility. The facility policy titled Discharge Process and Bed Holds stated that the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
Failure to Administer Ordered Carvedilol
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident when Carvedilol was not administered to Resident #82 as ordered. Resident #82 was an [AGE]-year-old female admitted on 02/17/2026 with diagnoses including Essential Hypertension, Hypertensive Heart Disease, and Cardiac Pacemaker. Her care plan reflected that she had hypertension and included the intervention to administer medications as ordered. Her physician’s order dated 02/24/2026 directed Carvedilol 12.5 mg by mouth twice daily for HTN, with instructions to hold only if SBP was less than 100 or pulse was less than 60, and to give with snack or meals. On 02/25/2026 at 7:07 a.m., an MA checked Resident #82’s blood pressure and obtained 107/63 with a pulse of 63, then stated she would destroy Carvedilol and two other blood pressure medications properly. During interview, the MA stated she was not going to administer Carvedilol because she believed it was out of parameters along with the other two blood pressure medications, and later verified that Carvedilol was supposed to be given because it was within parameters. The DON stated that all three blood pressure medications were supposed to have the same parameters and that the MA should have administered the blood pressure medication that was within parameters. The facility’s medication administration policy stated that staff responsible for medication administration will adhere to the 10 rights of medication administration, including noting the resident’s history and any parameters around drug administration.
Infection Control Failures During EBP and Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents reviewed for infection control practices. One resident had a gastrostomy tube, dysphagia, type 2 diabetes mellitus, and spastic quadriplegic cerebral palsy, and had an order for Enhanced Barrier Precautions due to the G-tube. During observation, an LVN donned gloves but did not wear a PPE gown while administering medications via the G-tube. The LVN stated she was supposed to wear a gown with gloves when entering the resident’s room but forgot, and stated that Enhanced Barrier Precautions require gown and glove use during contact with patient care. A second resident had a stage 4 sacral pressure ulcer, muscle weakness, and an indwelling catheter due to the sacral wound, with a care plan intervention for Enhanced Barrier Precautions. During observation, a CNA entered the room, washed hands, gloved up, and prepared supplies. After catheter care, the CNA discarded gloves, applied hand sanitizer, put on new gloves, and then continued catheter care and placed a new brief on the resident using the same pair of gloves. During interview, the CNA stated the gloves should have been changed after cleaning the Foley catheter to minimize infection and that hand hygiene and glove changes should occur before, during, and after care. The DON stated that after perineum care, hand hygiene should have been performed before moving to the second part of applying the new brief. The DON also stated that staff are educated and observed performing specific care before working independently, and that the practice could put the resident at risk for infection. The facility policy stated that transmission-based precautions are used to mitigate infection spread and that Enhanced Barrier Precautions require gown and glove use during high-contact resident care activities.
Unsecured Medication Carts with Narcotics Left Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required, as observed with two medication carts on the 100 Hall. On two separate occasions, medication carts assigned to two different LVNs were found unlocked and unattended in the hallway, with the keys left on top of the carts. Both carts contained medications, including narcotics, and were accessible to residents who were observed walking by at the time. The locks on the carts were disengaged, allowing all drawers to be opened and accessed. Interviews with the LVNs responsible for the carts confirmed that they had forgotten to lock the carts and secure the keys before leaving the area. Both nurses acknowledged that it was their responsibility to keep the carts locked and the keys secured when not in use. The ADON and Administrator also confirmed that it was the nurse's responsibility to maintain the security of the medication carts and keys, and that staff had been previously in-serviced on this requirement. Review of the facility's policy indicated that medication carts must be locked when unattended and that controlled medications must be stored separately in double-locked compartments.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documented follow-up with the appropriate agencies. The report specifically notes the failure to meet regulatory requirements for reporting and investigation communication.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and sanitation standards in both the kitchen and the nutrition room, leading to potential risks of foodborne illnesses for residents. Observations revealed that the convection oven door was difficult to open, posing a safety hazard, and personal items were improperly placed on prep tables. Additionally, staff failed to wash their hands after handling personal items, leading to potential cross-contamination of food. The kitchen was found to have unclean surfaces, including prep tables and shelves, and a dented can of fruit was not removed from the in-use shelf, which could compromise food safety. Further issues were identified with the storage of dry goods and refrigerated items. Dry goods were not sealed properly, and items in the refrigerator were not labeled or dated, making it difficult to determine their freshness. Trash bins in the kitchen were not covered, and trash was found on a prep table, increasing the risk of contamination. The daily cleaning schedule was not consistently followed, and boxes of frozen food in the walk-in freezer were stacked too high, obstructing water sprinklers and posing a safety hazard. In the nutrition room, the refrigerator temperature was not documented properly, and the freezer lacked a thermometer. Items in the refrigerator and freezer were not labeled or dated, and some were expired. The facility's policies on personal items, handwashing, cleaning schedules, and food storage were not adequately followed, leading to these deficiencies. Interviews with staff revealed a lack of awareness and adherence to proper procedures, contributing to the facility's failure to maintain a safe and sanitary environment for food preparation and storage.
Inadequate Hand Hygiene in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of hand hygiene, which is crucial for preventing the transmission of infections. During observations, the Wound Care Nurse (WCN) did not perform adequate hand hygiene by scrubbing hands with soap for at least 20 seconds before and after providing wound care to two residents. This lapse in protocol was observed during wound care sessions for a resident with a wound infection and another resident with a surgical wound, both of whom required enhanced barrier precautions due to their conditions. The WCN acknowledged the importance of proper hand hygiene and admitted to not realizing the insufficient duration of handwashing due to nervousness. The Director of Nursing (DON) confirmed that all staff are expected to adhere to the 20-second handwashing guideline to prevent infections. The facility's Infection Prevention and Control Program, which is reviewed and updated annually, mandates such practices to ensure a safe and sanitary environment. However, the last skills check for hand hygiene was conducted several months prior, indicating a potential gap in ongoing staff training and compliance monitoring.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was unaccounted for approximately 15 minutes. The resident, who had severe cognitive impairment due to Alzheimer's disease and dementia, was found walking through a field adjacent to the facility. The resident's care plan indicated a risk for falls due to confusion, but there was no indication of exit-seeking behavior prior to the incident. On the day of the incident, the resident was last seen by a charge nurse walking from the dining room down the hallway. Shortly after, a third party called the facility to report seeing an elderly man walking in a field near the facility. The staff began searching for the resident inside the facility, but no one initially went outside to look for him. The resident was eventually found by a fireman and a passerby, unharmed, and was returned to the facility by a staff member. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's elopement procedures. Some staff members were unaware of the emergency color code for a missing resident, and there was a lack of regular elopement drills, particularly for the night shift. The facility's policy required a head count when a door alarm sounded, but this was not effectively implemented during the incident, contributing to the delay in locating the resident.
Deficient Documentation of Vital Signs in Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for seven residents, specifically in documenting vital signs when administering medications that could affect blood pressure and heart rate. The report highlights multiple instances where registered nurses (RNs) and licensed vocational nurses (LVNs) did not document blood pressure and pulse readings on the medication administration record (MAR) or in the electronic health record (EHR) before administering medications. This deficiency was observed across several residents, including those with conditions such as hypertension, heart failure, and dementia, who were receiving medications like Lisinopril, Metoprolol, and Digoxin. Interviews with nursing staff revealed inconsistencies in the documentation process. RN A and LVN E admitted to not always documenting vital signs immediately after taking them, which could lead to potential medication errors. The staff mentioned the high volume of residents they were responsible for medicating within a limited time frame, which contributed to the documentation lapses. The Director of Nursing (DON) acknowledged the issue and mentioned that the facility was considering adjusting medication pass times to alleviate the workload on medication aides. The report also includes insights from the facility's pharmacist and medical director, who emphasized the importance of checking and documenting vital signs before administering medications with hold parameters. The pharmacist noted that the current system did not flag when medications were held, making it difficult to monitor compliance remotely. The medical director expressed concerns about the potential risks of not adhering to medication administration protocols, which could lead to adverse outcomes for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One issue involved the improper storage of resident briefs, which were found in open packages on CNA linen carts and on top of an infection control storage bin. This was acknowledged by the Director of Nursing (DON) and staff members, who recognized the potential for cross-contamination and infection control issues. Despite recent in-service training on infection control, staff members were unsure about the proper handling of resident briefs, indicating a gap in adherence to infection control protocols. Another deficiency was the failure to place a resident on transmission-based precautions after a urine culture tested positive for Klebsiella pneumoniae. The resident, who was cognitively intact, was not isolated, and there was no signage or personal protective equipment (PPE) outside her room. Interviews with nursing staff revealed a lack of clarity on the process for initiating transmission-based precautions, with some staff unaware of the resident's need for isolation. The physician assumed that standard contact precautions would be automatically implemented for infections, but this was not the case, leading to a potential risk of spreading the bacteria. Additionally, the facility was found to have expired sterile urinary catheters in the Central Supply room, which were not discarded as required. The DON and Central Supply staff were unaware of the expired items, and there was no specific policy in place for managing general supplies. This oversight in inventory management posed a risk to resident safety, as expired catheters may no longer be sterile. The facility's infection prevention and control program lacked effective systems for identifying and addressing such issues, contributing to the overall deficiency in maintaining a safe and sanitary environment.
Resident Privacy Compromised Due to Missing Catheter Privacy Bag
Penalty
Summary
The facility failed to ensure that a resident's dignity and privacy were maintained, as evidenced by the lack of a privacy bag on the resident's foley catheter drainage bag. This deficiency was observed during a survey, where the urine in the catheter bag was visibly exposed to visitors, staff, and other residents. The resident involved was an elderly male with a history of sepsis, bacteremia, and cancer of the rectum, who was dependent on staff for toileting hygiene and partially dependent for other activities of daily living. During observations, the resident's room door was open, and the catheter bag was visible from the hallway. Interviews with staff revealed that the resident was not cognitively aware and had frequent moments of confusion. A CNA admitted to being unaware of the missing privacy bag and stated that she did not regularly work on the resident's hallway. The CNA also mentioned that she was still learning the facility's policies and procedures and had not attended any recent in-service training regarding urinary catheter privacy bags. An RN confirmed the absence of the privacy bag and acknowledged the importance of maintaining the resident's privacy. The RN stated that privacy bags were available in the supply closet and that it was the nurse's responsibility to apply them. The Director of Nursing and the Administrator also acknowledged the oversight and stated that the clinical staff should have placed a privacy bag on the resident's catheter upon his return from the hospital.
Inadequate Documentation and Assessment of Resident's Injuries
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified in the case of a resident who experienced an unwitnessed fall, resulting in injuries that were not consistently or accurately assessed and documented. The resident, an elderly female with a history of a cervical vertebra fracture and other medical conditions, was found on the floor by a CNA. Despite the incident being reported, there was a lack of detailed documentation regarding the resident's injuries in her electronic health record. The incident report prepared by an LVN noted that the resident had fallen and hit her right elbow, with an X-ray ordered and a transfer to the emergency room for further evaluation. However, discrepancies arose as another LVN, who took over the shift, observed additional injuries, including a hematoma and dried blood on the resident's head, which were not documented in the initial assessment. This lack of documentation and communication between the nursing staff led to incomplete records of the resident's condition and injuries. Interviews with the nursing staff and the DON revealed gaps in the documentation process and a lack of consistent skin assessments. The DON acknowledged the absence of detailed documentation and measurements of the resident's injuries, which are crucial for monitoring the healing process. The facility's policy required thorough documentation of any new skin alterations, but this was not adhered to in this case, leading to the deficiency identified by the surveyors.
Central Supply Room Safety and Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the central supply room on the 200 hall. The door to the central supply room was propped open with a large roll of plastic, allowing easy access to potentially harmful supplies such as razors and lancets. There were nine full boxes of disposable razors and 33 cases of lancets accessible on the shelves. Additionally, a full case of deodorant was found to be expired. These conditions were observed during a facility inspection, and interviews with the Director of Nursing (DON) and the Central Supply (CS) staff confirmed the oversight. The CS staff acknowledged responsibility for the central supply room, including ordering supplies, ensuring nothing was expired, and keeping the room stocked. However, the CS staff admitted to spending 90% of their time on staffing duties, which limited their ability to monitor the supply room effectively. The CS staff also noted the lack of a specific policy for general supplies and the absence of delegation to check the door regularly. Interviews with the DON and Assistant Director of Nursing (ADON) revealed a lack of understanding of the difference between facility policies and federal regulations, and the facility did not have its own policies, relying instead on corporate policies.
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 129 citations issued within 25 miles in the last 12 months — including the 3 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 Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corpus Christi Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Cimarron Place Health & Rehabilitation Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Mirador | 2 mi | ★★★★★ | 0 | 0 |
| The Palms Nursing & Rehabilitation | 3.1 mi | ★★★★★ | 37 | 0 |
| San Rafael Nursing And Rehabiliation | 5.5 mi | ★★★★★ | 12 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wooldridge Place Nursing 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.