Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Schmitt Woodland Hills during CMS and state inspections, most recent first.
The facility failed to keep care plans current for two residents. One resident’s plan still directed bilateral hand splints even though staff had switched to washcloths because the splints caused redness, and surveyors observed the resident without the ordered hand splints in place. Another resident’s plan still included Norovirus outbreak precautions after the outbreak had ended and still listed fluoxetine-related interventions even though the antidepressant had been discontinued. The DON, ADON, and other staff stated care plan changes should be updated when resident needs change.
A resident with Alzheimer’s disease, severe cognitive impairment, and torticollis did not receive ordered ROM-related care and positioning interventions. Staff observed the resident without bilateral hand splints or wash clothes and without the cervical pillow/rolled blanket in place, and later lying on her back instead of the care-planned right-side positioning after meals. The DON, ADON, and DOR confirmed therapy recommended bilateral hand splints during the day and an elbow splint at night, but the care plan still contained conflicting splint instructions and staff were not following the documented interventions.
Failure to Perform Hand Hygiene During Suprapubic Catheter Care: A CNA provided catheter care for a resident with a suprapubic catheter and history of UTI, but did not perform hand hygiene after removing the soiled dressing and cleansing the catheter site before applying a new dressing. The CNA and DON both acknowledged hand hygiene was expected before and after the procedure and when moving from dirty to clean.
A resident enrolled in hospice with diagnoses including leukemia, anemia, dysphagia, stroke-related weakness, hemiplegia, and hemiparesis did not have a current hospice plan of care available to facility staff. Surveyors found the plan absent from the hospice binders at the nurses' station and not scanned into the EHR, while the DON and ADON acknowledged the facility should have the document and that the ADON was the point person for hospice coordination.
Nurse staffing postings were not updated to show actual hours worked for RN, LPN, and CNA staff and were not revised in real time when staffing changes occurred. Survey review found the postings were completed from the schedule by night shift rather than reflecting call-ins or other changes, and the NHA and DON stated they had been using the same process for years.
The facility failed to maintain professional standards for food safety, with the first-floor dishwasher not reaching required temperatures and staff not following proper hand hygiene practices. The dishwasher logs showed multiple instances of inadequate wash and rinse temperatures, and incorrect test strips were used. Additionally, staff were observed changing gloves without washing hands between tasks, contrary to the facility's policy. These deficiencies could affect the facility's 35 residents by compromising food safety.
A resident with hemiplegia and major depressive disorder was observed to have medications left at her bedside by an RN, despite not being deemed safe to self-administer medications according to the facility's interdisciplinary team assessment. The facility's policy requires a resident to be evaluated and deemed safe for self-administration, which was not adhered to in this case. Interviews confirmed that the resident did not have a care plan for self-administration, and staff were instructed not to leave medications at the bedside without proper assessment.
A resident experienced verbal and mental abuse by a CNA, who was rude, demeaning, and rough during care. Despite the resident's request to avoid further interaction, the CNA continued to serve her, causing ongoing distress. Staff were aware of the situation, but the facility failed to follow its policy to protect the resident from abuse, resulting in continued mental anguish.
A resident reported an incident involving a CNA who was rude and rough during care, which was not reported to the state agency as required. The facility treated it as a grievance rather than an abuse allegation, failing to follow its policy for immediate reporting of such incidents.
A facility failed to conduct a thorough investigation of an alleged verbal and mental abuse incident involving a resident and a CNA. The resident reported the CNA was rude and rough during care, but the investigation was limited and did not include interviews with other staff or residents. The DON treated the incident as a grievance, allowing the CNA to continue working without being removed from resident care.
The facility did not ensure food and drink were palatable and at a safe temperature for residents. A resident reported inedible dry pork, another mentioned consistently dry meat, and a third noted lukewarm food requiring reheating. A test tray confirmed the pork was hard and dry, violating the facility's policy on meal service.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility did not ensure the comprehensive care plan was updated to reflect current care needs for two sampled residents. One resident, R33, had care plan interventions that stated the resident should wear bilateral hand splints, with one section directing the right hand splint at all times except mealtimes and another section directing bilateral hand splints during the day and bilateral elbow splints at night. Survey observations found R33 without hand splints on multiple occasions, including while seated in a Broda chair with both hands curled closed and later while lying in bed with a rolled blanket around the neck and no bilateral hand splints in place. During interview, the DON and ADON stated that washcloths had been placed in the resident’s hands after therapy was consulted because the blue hand splints had rough edges and caused redness to the resident’s palms. They acknowledged that the care plan had not been changed to reflect the use of washcloths instead of the splints. The surveyor also observed that the cervical neck pillow or rolled blanket was not in place during one observation, while the resident’s care plan still contained the splint-related interventions that had not been updated to match current practice. Another resident, R41, had a care plan that still included precautions for a Norovirus outbreak that the facility had concluded, as well as a care plan for fluoxetine use even though the antidepressant had been discontinued. R41 had diagnoses including coronary artery disease, HTN, BPH, arthritis, non-Alzheimer’s dementia, stroke, and hemiplegia, and had a BIMS score of 04 indicating severe cognitive impairment. The record showed the infection-control precautions remained in the care plan after the outbreak ended, and the antidepressant-related interventions remained after the medication was no longer being taken.
Failure to Follow ROM and Positioning Care Plan
Penalty
Summary
The facility did not ensure that a resident with limited range of motion received the treatments and services documented in the care plan and therapy recommendations to maintain or improve mobility and prevent further decline. The resident had diagnoses including Alzheimer’s disease and torticollis, and a BIMS score of 00 indicating severe cognitive impairment. The care plan included interventions for positioning after meals, hand stretches twice daily, proper neck placement with a cervical pillow or rolled blanket, and use of hand and elbow splints to address contractures and limited mobility. During observation, the resident was seen in a Broda chair with both hands curled closed and no hand splints or wash clothes in place, and no cervical neck pillow or rolled blanket around the neck. On another observation, the resident was lying in bed on her back with a rolled blanket around the neck but no bilateral hand splints in place. The CNA stated that wash clothes were being used in place of the blue hand splints and that they would be placed later after the resident dried from a shower, and also stated she was not aware of the care plan direction to lay the resident on her right side after meals. The Director of Rehab stated therapy had recommended bilateral resting hand splints during the day except at meals and an elbow splint at night. The DON and ADON acknowledged that the care plan contained different hand-splint interventions and that the plan had not been updated to reflect the use of wash clothes instead of splints. They also confirmed the resident was observed lying flat on her back and that staff were not aware of the care plan instruction to position her on her right side after meals.
Failure to Perform Hand Hygiene During Suprapubic Catheter Care
Penalty
Summary
The facility did not ensure appropriate treatment and services to prevent UTIs for a resident with a suprapubic catheter when staff failed to perform proper hand hygiene during catheter care. The resident was admitted with diagnoses including neuromuscular dysfunction of the bladder, had a BIMS score of 15 indicating cognitive intactness, and had a care plan noting a 20 French catheter with a 5 cc balloon and a daily suprapubic catheter dressing change with monitoring for infection. During observation, a CNA removed the soiled drain sponge dressing around the suprapubic catheter site, cleansed the catheter site and catheter, and then applied a new drain sponge dressing without performing hand hygiene in between. When interviewed, the CNA stated hand hygiene should be performed before and after the procedure and when moving from dirty to clean, and acknowledged it should have been done after removing the soiled dressing and cleansing the site before applying the new dressing. The DON also stated hand hygiene would be expected prior to starting a procedure, when going from dirty to clean, and with dressing changes.
Missing Hospice Plan of Care for a Resident
Penalty
Summary
The facility did not ensure hospice collaboration and communication processes were established to maintain continuity of care between hospice and the facility for 1 of 2 residents reviewed for hospice services. Resident 1 was admitted with diagnoses including acute monoblastic/monocytic leukemia not having achieved remission, anemia, dysphagia, facial weakness following cerebral infarction, hemiplegia, and hemiparesis, and was enrolled in hospice services on 1/23/26. The facility did not have a record of Resident 1's current hospice plan of care available to staff. The hospice plan of care was not found in the hospice binders at the nurses' station, and it was not scanned into the electronic health record under the miscellaneous tab or elsewhere in the resident's chart. The DON stated the plan of care should be available to staff and that the ADON was responsible for coordinating with hospice, while the ADON stated she did not confirm that the facility had received the hospice plan of care and relied on hospice for issues or supplies.
Nurse Staffing Postings Not Updated With Actual Hours
Penalty
Summary
The facility did not post the actual hours worked for licensed and unlicensed staff on the daily nurse staffing postings and did not update the postings in real time when staffing changes occurred during February and March 2026. Survey review of the facility’s Nursing Staff postings and staff schedules for February 15 through March 2, 2026 found that the postings did not include the actual hours staff worked and were not updated when staffing changes occurred. The report states that the postings were completed on night shift by reviewing the schedule, rather than being updated to reflect changes such as call-ins or additions. During an interview on 3/5/26, the NHA and DON were asked to explain the process for completing the daily census postings. The DON stated that night shift nurses completed the postings by looking at the schedule. When asked whether the postings should be updated to reflect staff call-ins and actual hours worked as they occur, the NHA stated awareness that hours worked needed to be included but had not noticed they were missing, and the DON stated she was not aware and had been completing them the same way for six years. The facility’s postings therefore did not reflect actual staffing hours and were not updated with staffing changes.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by issues with the kitchenette dishwasher and improper hand hygiene practices. The dishwasher on the first floor did not consistently reach the required wash and rinse temperatures, as documented in the facility's logs. On multiple occasions, the wash temperature did not meet the necessary 160 degrees Fahrenheit, and test strips indicated that the rinse temperature of 180 degrees Fahrenheit was not achieved. The Dietary Manager was unaware of these issues, and it was revealed that the facility was using incorrect test strips, contributing to inaccurate temperature readings. Additionally, staff were observed handling food without performing proper hand hygiene. During a dining room service observation, a staff member changed gloves without washing hands between tasks, such as using a phone and touching various surfaces. The staff member believed that hand hygiene was only necessary under certain conditions, contrary to the facility's hand hygiene policy. The Dietary Manager confirmed that staff should wash their hands between glove changes and when switching tasks, but this was not consistently practiced. These deficiencies highlight a lack of compliance with established food safety and hygiene protocols, potentially affecting the entire facility census of 35 residents. The failure to maintain proper dishwasher temperatures and adhere to hand hygiene standards poses a risk to food safety and resident health, as these practices are crucial in preventing contamination and ensuring a safe dining environment.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that all residents were clinically appropriate to self-administer medications, as evidenced by the case of one resident (R4) during a medication pass. R4, who has a history of hemiplegia, hemiparesis, and major depressive disorder, was observed to have medications left at her bedside by an RN, despite not being deemed safe to self-administer medications according to the facility's interdisciplinary team assessment. The facility's policy requires that a resident may only self-administer medications after being evaluated and deemed safe by the interdisciplinary team, and this was not adhered to in R4's case. The surveyor's observation revealed that R4's medications, including Tylenol, atorvastatin, baclofen, carvedilol, and mucus relief, were left on her bedside table without supervision. Interviews with the LPN and DON confirmed that R4 did not have a care plan for medication self-administration and was not evaluated as safe to self-administer medications. Despite R4's request for medications to be left at her bedside, staff were instructed not to comply with such requests unless the resident had been properly assessed and care planned for self-administration, which was not the case for R4.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R19, from verbal, mental, and emotional abuse by a Certified Nursing Assistant (CNA), referred to as CNA E. R19 reported that CNA E was rude, demeaning, and rough during morning care, treating her in a manner that made her feel like she was being treated worse than a dog. Despite R19's request for lotion to be applied before putting on compression stockings, CNA E refused and was rough in her handling, causing R19 to feel unsafe. This incident was not isolated, as CNA E continued to interact with R19 in a manner that caused ongoing distress. Interviews with other staff members, including another CNA and a Licensed Practical Nurse (LPN), confirmed awareness of the situation and described CNA E's behavior as unprofessional and abusive. The LPN acknowledged that CNA E was aware of her anger issues, and the Certified Social Worker (CSW) treated the incident as a grievance rather than abuse. Despite R19's request to avoid further interaction with CNA E, the CNA continued to serve R19, exacerbating her feelings of fear and upset. The Director of Nursing (DON) was aware of the incident and attempted to resolve it by having CNA E apologize to R19. However, the facility did not follow its policy to protect residents from abuse, as CNA E continued to work and interact with R19, causing ongoing mental anguish. The facility's failure to adequately address the situation and protect R19 from further distress was evident, as the issue persisted over a month after the initial incident.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, R19, and a Certified Nursing Assistant (CNA E) to the state agency within the required timeframe. R19, who is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported that on the morning of October 26, 2024, CNA E was rude, demeaning, and rough during morning care. R19 felt disrespected and indicated that CNA E ignored her preferences, such as applying lotion before putting on compression stockings. The incident was reported internally to the Nursing Home Administrator (NHA A), Director of Nursing (DON B), and Certified Social Worker (CSW H), but it was not reported to the state agency as required by the facility's policy. The facility's grievance log recorded the incident on October 28, 2024, and it was treated as a grievance rather than an abuse allegation. CSW H and DON B both believed the situation did not constitute abuse, viewing it as a personality conflict. Consequently, the facility did not follow its policy to report the incident to the state agency. The grievance was addressed internally, with CNA E apologizing to R19, but the facility's failure to report the incident to the appropriate authorities resulted in a deficiency. The facility's policy requires immediate reporting of all allegations of abuse, neglect, or mistreatment to the state agency, which was not adhered to in this case.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged verbal and mental abuse incident involving a resident and a Certified Nursing Assistant (CNA). The resident, who was cognitively intact, reported that the CNA was rude, dismissive, and rough during morning care, and made derogatory comments. Despite the facility's policy requiring a full investigation within five working days, the investigation was limited to a statement from a charge nurse and did not include interviews with other staff or residents, including the accused CNA. The Director of Nursing (DON) treated the incident as a grievance rather than abuse, resulting in a lack of comprehensive investigation and failure to protect residents. The CNA continued to work for nine out of ten days following the incident without being removed from resident care. The facility did not interview other residents to determine if further abuse occurred, contrary to their policy, which mandates immediate reporting and thorough investigation of all abuse allegations.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed in one sampled resident and two supplemental residents, all of whom reported issues with the quality of the food. One resident expressed that the pork served was so dry it was inedible, while another resident stated that the meat was consistently dry, leading to a lack of consumption. A third resident reported that the food served in her room was often lukewarm, requiring reheating. Additionally, a test tray received by the surveyor contained pork that was hard and dry. The facility's policy on Dining Room Service, dated 2019, mandates that meals be served promptly to maintain adequate temperature and appearance, which was not adhered to in these instances.
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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 Richland Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Valley Community Village | 7.9 mi | ★★★★★ | 1 | 0 |
| Rivers Edge Nursing And Rehab | 9.9 mi | ★★★★★ | 34 | 1 |
| Soldiers Grove Health Services | 18.8 mi | ★★★★★ | 0 | 0 |
| Greenway Manor | 20.3 mi | ★★★★★ | 9 | 0 |
| Care And Rehab - Boscobel | 20.8 mi | ★★★★★ | 0 | 0 |
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