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 Wood Aven Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia, CKD, and severe cognitive impairment received Metformin for 8 days even though no DM diagnosis was supported by the record. An NP note added type 2 DM and started Metformin based on an HgbA1c that was not consistent with the resident’s prior normal HgbA1c results, and later staff found no lab evidence to support the diagnosis or order. The guardian questioned the order, and staff could not provide evidence of incident-specific education.
A facility failed to provide transfer notices with a specific reason for transfer for multiple residents, including residents transferred for sepsis/cellulitis, UTI, hyperkalemia, COVID infection, and wound or fall-related hospitalizations. The notices used general language about urgent medical needs or welfare needs instead of the actual basis for transfer, and the Ombudsman notifications for several hospital transfers were delayed for weeks or months. The Social Services Manager stated notifications were usually sent monthly and could not recall why some were delayed.
Failure to Assess Clinical Appropriateness for Self-Administration of Medications: A resident with COPD, weakness, low back pain, and reduced mobility had inhalers and topical pain gel kept in the room and at bedside without an IDT self-administration assessment, physician order, or care plan entry supporting self-administration. Surveyors observed unlabeled and labeled inhalers and multiple tubes of Voltaren gel in the room; the resident gave inconsistent responses about using the inhalers, said he could not reach the meds on the windowsill, and stated CNAs applied the gel during cares. An LPN said the resident could use the inhalers but needed cueing, while the DON stated residents are assessed on admission and medications are not to be left in rooms.
Failure to notify the provider of a resident’s change in condition. A resident with intact cognition and diagnoses including CKD stage 3 had multiple SBP readings below the facility’s standing-order threshold, but no provider notification was documented. ST also documented visual hallucinations, yet there was no documentation that nursing was informed or that the provider was notified. RN, LPN, and DON interviews showed inconsistent understanding of when and how to report abnormal findings.
The facility failed to follow its abuse prevention policy requiring criminal background screening for employees. Record review showed that a CNA did not have updated DOJ and IBIS results on file before starting work, and HR could not provide DOJ or IBIS documentation for a facility driver. Interviews confirmed the missing background information for both employees.
A resident with intact cognition, bilateral upper extremity impairment, and increasing weakness had changing transfer needs documented by therapy, including use of a Hoyer lift when weakness was noted. However, staff continued using an EZ-Stand for transfers, causing bruising and pain, and the resident later fell when her knees gave out during a toilet transfer. The resident’s care plan was not updated with the new transfer status until after the incident, and staff were confused about the difference between transfer devices.
A resident admitted after fractures and a pelvic hematoma had conflicting bladder status documentation, with nursing notes showing continence while CNA tasks showed daily urinary incontinence. Although the resident had prior independence with toileting and the facility policy required an admission bowel and bladder evaluation to guide an individualized toileting program, no bladder care plan, goals, or interventions were developed, and staff were observed not offering or assisting with toileting.
A facility did not ensure appropriate care for two residents with PEG tubes. The facility’s policy allowed tube placement checks by auscultation, and staff used the “whoosh” or “swish” method for tube verification even though it was not a nationally recognized standard of practice. For one resident with dysphagia and aspiration pneumonia, an LPN verified PEG placement by listening for air through a stethoscope before giving meds. For another resident with dysphagia, ALS, and prior aspiration-related illness, an LPN also used auscultation to check placement and did not complete the ordered gastric residual check.
Medication Administration Error with PEG-Tube Bowel Regimen: An LPN did not administer a resident’s ordered Metamucil bowel regimen correctly through a PEG tube. The resident, who had dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia/hemiparesis after cerebral infarction, was ordered Metamucil mixed with 4 to 8 oz of water, but the LPN used only 30 cc, did not stir the medication, and discarded most of the clumped dose. The LPN stated he was unaware of the water requirement and had not been giving extra water as ordered.
The facility did not maintain an infection prevention program for several residents. Staff did not implement EBP for two residents with open wounds, including one with a facility-acquired pressure injury and another with an infected port-a-cath site; both rooms lacked EBP signage and PPE availability as observed by surveyors. In another instance, an RN did not perform hand hygiene during a medication pass while handling the med cart, laptop, narcotic book, stock meds, and assisting a resident with medications.
A resident admitted with nerve pain and spinal stenosis did not receive scheduled doses of Lyrica for pain management due to medication unavailability and delays in pharmacy delivery. Staff documented the issue and attempted to notify the pharmacy and charge nurse, but the medication was not administered for several scheduled doses. The DON was not informed of the missed doses, and the facility lacked a written policy for acquiring medications when not available.
A resident reported feeling degraded by a CNA's comment about his odor, which was not thoroughly investigated by the facility. The investigation did not include interviews with all nursing staff on duty, as required by policy, leading to an incomplete assessment of the mistreatment allegation.
A resident with a history of opiate use and constipation was hospitalized due to fecal impaction after the facility failed to follow its bowel protocol. Despite the resident's complaints of severe pain and a history of fecal impaction, staff did not perform a thorough GI assessment or document interventions. The resident had to call 911 for assistance, highlighting a significant lapse in care.
A dietary aide at a facility was observed not allowing clean dishes sufficient time to air dry before stacking them, leading to standing water in dishes and potential contamination. The dietary supervisor acknowledged the risk and the need for changes in dishwashing practices.
A facility failed to monitor and adjust psychotropic medication dosages for a resident, identified as R19, who was on antipsychotic, antianxiety, and antidepressant medications. Despite the facility's policy requiring gradual dose reductions (GDR) and the absence of documented behavioral concerns, no GDR was attempted. The resident's care plan aimed for the lowest effective dose, but the physician increased the medication dosage without clinical rationale. Observations and staff interviews indicated no behavioral issues, and the facility acknowledged the need for improved monitoring processes.
Unnecessary Metformin Given Without Supported Diabetes Diagnosis
Penalty
Summary
The facility did not ensure that a resident’s drug regimen was free from unnecessary drugs when R2 received Metformin for 8 days despite having no diagnosis of diabetes. R2 was admitted with diagnoses including paranoid schizophrenia and chronic kidney disease, had a BIMS score of 7/15 indicating severe cognitive impairment, and had a legal representative for health care decisions. The care plan identified R2 as at risk for impaired cognitive function and included reviewing medications and causes of cognitive deficit, including new medications. Record review showed an NP progress note documented a diagnosis of type 2 diabetes mellitus and started Metformin ER 1000 mg daily based on an HgbA1c of 12.1%, but later nursing review found no recent HgbA1c results to support the diagnosis or order. R2’s prior HgbA1c values were 5.5 and 5.6, both within normal range. Staff documented that the NP stated the diagnosis had been dictated incorrectly, and Metformin was discontinued. The resident’s guardian was informed of the medication initiation and later questioned the diagnosis and order. Surveyor interviews also found staff could not provide evidence of education specific to the medication error incident, and facility leadership confirmed they could not provide evidence that such education had been given.
Incomplete Transfer Notices and Delayed Ombudsman Notifications
Penalty
Summary
The facility did not ensure that residents or their representatives received transfer notices that included a specific reason for the transfer, and it did not consistently notify the Ombudsman of hospital transfers. Survey review found that for 4 of 5 residents identified in the report, the written transfer/discharge notices stated only that the transfer was necessary for the resident’s welfare or urgent medical needs, but did not document the specific reason the resident was being transferred. The facility policies reviewed required the transfer notice to include the specific reason and basis for transfer, and required physician documentation of the specific resident need that could not be met in the facility. For R8, the resident was admitted, transferred to the hospital, and later readmitted with sepsis and cellulitis, but the transfer notice dated 10/31/25 did not include a specific reason. A later transfer notice dated 11/24/25 also stated only that an immediate transfer was required by urgent medical needs, without a specific reason. The Social Services Manager’s email notifications showed that the Ombudsman was notified of the October hospitalization on 12/16/25, and the manager stated that notifications were usually sent around the 10th of each month after records were cleared up. For R67, the resident was transferred to the hospital and readmitted with UTI and hyperkalemia, and later transferred again for status post COVID infection. Both transfer notices dated 01/13/26 and 02/27/26 lacked a specific reason for transfer. The Ombudsman was notified of the January hospitalization on 03/27/26, and the Social Services Manager could not recall why it was delayed. For R19, the resident had multiple hospital transfers for worsening surgical incision wound, a fall, and later another hospitalization; one transfer had no written notice documented, and the other notices did not include the specific reason for transfer. The Ombudsman notifications for these transfers were delayed or sent months later. For R1, the resident was transferred by ambulance to the hospital for treatment of UTI, and the written notice of transfer did not include the specific reason for transfer.
Failure to Assess Clinical Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility did not determine whether one resident was clinically appropriate to self-administer medications, specifically prescription topical creams and inhalers kept in the resident’s room and at bedside. The resident had diagnoses including COPD, muscle weakness, low back pain, and reduced mobility, and the MDS assessment indicated a BIMS score of 13 and that the resident made his own health care decisions. However, the care plan did not include any information related to self-administration of medications, and there was no physician order for self-administration or for medications to be stored at bedside or in the room. There was also no evidence that an interdisciplinary self-administration assessment had been completed to determine whether the resident could safely self-administer or store medications in the room. During observation, surveyors found four partially used tubes of Voltaren gel on the windowsill, an Advair inhaler on the windowsill without a pharmacy label, and a Spiriva inhaler on a tray table next to the bed with a pharmacy label. The resident stated he used the Spiriva inhaler when having breathing difficulty and said he could not reach the medications on the windowsill. He also stated he was not aware of the Voltaren gel on the windowsill and could not remember whether staff had applied it that day. The resident said CNAs applied the gel during cares because he was unable to reach the buttock area. Later, the resident could not recall whether inhalers had been administered by staff or himself. An LPN stated the resident could self-administer the inhalers but required cueing from staff, and the DON stated residents are assessed upon admission for self-administration and that no medications are to be left in a resident’s room.
Failure to Notify Provider of Low Blood Pressure and Mental Status Change
Penalty
Summary
The facility failed to notify the provider of changes in condition for one resident, R19, despite standing orders requiring provider notification for systolic blood pressure less than 90 or greater than 200. R19 was admitted with diagnoses including cognitive communication deficit, acquired absence of the right leg above knee, and chronic kidney disease stage 3, and the most recent quarterly MDS dated 03/18/26 documented a BIMS score of 15, indicating cognition intact. Surveyor review of vital signs showed multiple low blood pressure readings without documented provider notification, including 83/50 on 10/24/25, 87/56 on 10/25/25, 83/54 on 11/07/25, 89/61 on 11/17/25, and 84/53 on 02/25/26. Surveyor review of progress notes also showed that on 10/27/25 at 1:48 PM, ST documented that R19 reported recent visual hallucinations of seeing animals and spiders in the room, but there was no additional documentation that nursing staff were informed of the change in mental status and no documentation that the provider was notified. During interviews on 04/01/26, RN E stated that other staff such as ST would typically tell the nurse, who would then notify the provider and document it in a progress note. LPN D stated nursing would review the chart and decide whether to report abnormal blood pressure, and DON B stated nursing staff were expected to follow the standing orders and that the low blood pressures should have been reported to the provider.
Missing Background Screening Documentation for Two Employees
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not implement its abuse screening policy for 2 of 8 employees reviewed. The facility’s policy titled "Abuse Prevention" states that all employees will be properly screened for criminal background, but the record review showed that Certified Nursing Assistant P did not have Department of Justice (DOJ) and Integrated Background Information System (IBIS) results on file from the background check completed before starting work on 11/01/24. Instead, the facility only had DOJ and IBIS results from a prior background check dated 10/07/21. During interview, the Regional Human Resource K stated that when the company took over the prior year, a third-party company re-ran all employees’ backgrounds to start fresh, but the updated DOJ and IBIS for CNA P were missing. In a separate interview, the Human Resource Manager L stated that the facility was not able to provide a DOJ or IBIS for Facility Driver O, and the surveyor could not locate those reviews in the record.
Improper Transfer Equipment Used After Change in Transfer Status
Penalty
Summary
The facility did not ensure that the resident’s environment remained as free of accident hazards as possible when staff used the wrong transfer equipment for a resident whose transfer status had changed. The resident was admitted with multiple diagnoses including encephalopathy, UTI, cellulitis, tendon rupture of the right upper arm, polymyalgia rheumatica, peripheral venous insufficiency, GERD, atrial fibrillation, hypertension, and CKD. The resident’s MDS showed intact cognition with a BIMS score of 15/15, but also documented bilateral upper extremity impairment and need for substantial to maximal assistance with transfers. The resident’s care plan reflected extensive assistance for transfers, and later notes showed increasing difficulty with transfers, bruising, and staff concern that the resident was not standing well. Nursing documented bruising to the right lower abdomen and reported that the resident leaned heavily into a toilet paper dispenser when getting off the toilet. Therapy was requested because of worsening transfer ability, and OT later evaluated the resident and documented changing transfer guidance as weakness continued. OT notes indicated that if weakness was noted, a Hoyer lift should be used, and later documentation changed the resident to Hoyer lift status. Despite these changes, staff continued using an EZ-Stand mechanical lift for transfers. Nursing documented that the resident complained of arm pain and believed the bruising came from the machine used to lift her. On 03/29/26, staff were transferring the resident to the toilet when her knees gave out and she was helped to the floor. Surveyor review showed the resident’s care plan was not updated with the transfer changes until 03/31/26, even though therapy had recommended different transfer methods earlier. Interviews with OT, CNA, and the DON confirmed confusion among staff about the difference between transfer devices and that the resident should have been transferred with a Hoyer lift rather than the EZ-Stand.
Failure to Assess and Support Bladder Continence
Penalty
Summary
The facility did not ensure appropriate bowel and bladder assessment and toileting support for a resident who was continent of bladder on admission. R54 was admitted after a fall with a displaced fracture of the left humerus, pubis and hip socket, and a pelvic hematoma involving the urinary bladder. The resident’s records showed a BIMS score of 11/15, prior independence with toilet use and other activities of daily living, and an admission MDS indicating dependence for toileting hygiene, lower body dressing, transfers, wheelchair use, frequent urinary incontinence, and no toileting program attempted. Although the facility policy required bowel and bladder evaluation on admission to determine the appropriate program, the resident’s bowel and bladder evaluation completed on 02/28/26 identified the resident as continent or a good candidate, and no bladder care plan, goals, or interventions were developed. Daily skilled nursing notes from 02/25/26 through 04/01/26 documented the resident as continent of bladder and denying urinary complaints, while CNA task documentation for the same period indicated the resident was incontinent of bladder every day. During interview, the resident stated they now wore a diaper at times, used a urinal, or put on the call light, but staff were busy and the resident did not like to bother them. Surveyor observation showed the resident did not request toileting and staff did not offer or assist with toileting during the observed period. The DON stated the resident had been incontinent in the hospital due to the bladder being shifted from the hematoma, but based on nursing documentation was considered continent on admission, and further assessment, monitoring, or a toileting plan was not developed.
PEG Tube Placement Checks Used Auscultation and Missed Ordered Residual Monitoring
Penalty
Summary
The facility did not ensure that residents receiving enteral feedings were provided appropriate treatment and services to prevent complications for 2 residents with PEG tubes. The facility’s gastrostomy tube care policy allowed verification of tube placement by air auscultation, aspiration of gastric contents, X-ray, or external graduation marks, and staff were unable to identify a nationally recognized standard of practice used to develop the policy. The report states that auscultation is no longer a recommended process for checking tube placement. R10 was admitted with dysphagia and later had a PEG tube inserted after a failed swallow study and aspiration pneumonia. Physician orders directed staff to check gastric residual volume every 8 hours and to check tube placement by auscultation before initiating enteral feeding every shift. During observation, an LPN prepared to administer medications through R10’s PEG tube by gathering a stethoscope and syringe, then placed the stethoscope on the abdomen and pushed air into the tube to listen for a “whooshing” sound. The LPN stated that this was how tube placement was verified, and the DON stated the facility used auscultation and residual volume checks for PEG tube assessment. R55 was admitted with dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia and hemiparesis following cerebral infarction. The care plan and physician orders directed staff to check tube placement by auscultation before enteral feeding and to check gastric residual volume every 8 hours and as needed. During observation, an LPN administered medications through R55’s PEG tube, used a stethoscope and syringe to push air into the tube, and stated, “That sounds good, I heard a swish sound.” The surveyor noted that the LPN did not check gastric residual during the process, and the LPN later stated that he did not check residual as ordered.
Medication Administration Error with PEG-Tube Bowel Regimen
Penalty
Summary
The facility did not ensure that a resident was free from significant medication errors when the resident did not receive bowel regimen medication as ordered. The resident was admitted with dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The physician order dated 03/24/2026 directed Metamucil oral powder 48.57% (Psyllium), 1 tablespoon via PEG tube one time a day for loose stools, mixed in 4 to 8 ounces of free water. The resident’s record showed the last documented bowel movement on 3/28/26 at 7:45 PM as a small formed soft/normal stool. During observation on 03/31/2026, an LPN prepared the Metamucil by placing 1 tablespoon into a 30 cc medication cup and adding 5 cc of water without stirring. The LPN then administered medications through the PEG tube using a 60 cc syringe and gravity-fed 5 cc of water alternating each medication followed by 5 cc of water. The LPN stated the Metamucil was not the right choice for the resident and that it clumps in the cup and tubing. The LPN used only 30 cc of water, which was a quarter of the minimum ordered amount, was unable to administer the full dose, and discarded the majority of the clumped medication in the trash. Record review showed the LPN had administered the medication on four additional dates, and the LPN later stated he was not aware of the order to mix the medication with 4 to 8 ounces of water and had not been administering extra water per the order. Later that day, nursing notes documented that the resident had not had a bowel movement for 3 days and PRN MiraLAX was administered.
Infection Prevention Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent transmission of communicable disease and infection for 3 of 17 sampled residents. For one resident with a facility-acquired stage II pressure injury to the buttock, staff did not initiate enhanced barrier precautions despite the resident having an open wound. The resident’s care plan did not include EBP focus or interventions, no standing orders for EBP were in place, and surveyors did not observe EBP signage outside the room during multiple observations. A CNA assisted the resident into bed with a mechanical stand device without PPE, and a red bag garbage container was observed in the room with gowns and gloves stored inside the doorway rather than with signage or a PPE cart outside the room. A second resident had a port-a-cath in the right anterior chest and later developed a boil/pustule over the port site that was cultured and treated with antibiotics; culture results identified methicillin susceptible Staphylococcus aureus, and the port remained visible through an open wound. This resident’s care plan also lacked EBP focus or interventions, no standing orders for EBP were in place, and surveyors did not observe EBP signage or PPE available in the room. In a third example, during medication administration to another resident, an RN handled the medication cart, laptop, narcotic book, stock medication bottles, and medication cards, then administered medications and assisted the resident with water without observed hand hygiene at any point during the pass. The RN later used hand sanitizer when questioned, and the infection preventionist stated hand hygiene should be performed before preparing medications and before assisting a resident with taking medications.
Failure to Administer Scheduled Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to administer scheduled medications as ordered for one resident who was admitted with diagnoses of radiculopathy and cervical spinal stenosis. Upon admission, an order was entered for the resident to receive Lyrica 25 mg, two capsules by mouth twice daily for pain management. However, the medication was not administered as scheduled for at least two days following admission, as documented in the Medication Administration Record (MAR) and confirmed by nurse notes indicating the medication was unavailable or pending from the pharmacy. Multiple staff members, including medication aides and nurses, documented the unavailability of the medication and reported attempts to notify the pharmacy and the charge nurse. The resident reported increased pain due to not receiving the prescribed medication and communicated this to a family member. The family member also inquired about the missed doses and was informed by staff that the facility had not received the order from the transferring facility on the day of admission. Documentation and interviews revealed that the pharmacy was contacted, but there were delays in response and delivery, and the resident did not receive the medication for several scheduled doses. Further review showed that the facility did not have a written policy outlining the process for acquiring medications when not immediately available. The Director of Nursing was not notified of the missed doses and stated that she would have intervened had she been aware. The facility's policy required nurses to reorder and ensure an adequate supply of medications, but this process was not effectively followed, resulting in the resident missing multiple doses of a routine pain medication.
Incomplete Investigation of Resident Mistreatment Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of mistreatment involving a resident, identified as R3, who was reportedly subjected to derogatory comments by a Certified Nursing Assistant (CNA C). The incident involved CNA C making a comment about R3's odor, suggesting he needed a bath because he smelled like he came out of a barn. R3, a former Social Services Director, found the comment degrading and felt bullied by CNA C's overall disrespectful behavior. The facility's investigation was incomplete as it did not include interviews with all nursing staff working in R3's rehabilitation unit during the time of the incident, as required by the facility's policy. The investigation conducted by the facility included interviews with 12 residents and two staff members, CNA C and CNA D, but failed to interview the remaining nine nursing staff members who were on duty during the relevant period. The Nursing Home Administrator (NHA) acknowledged the oversight and admitted to not having proof of speaking with other staff members. The facility's policy mandates that all staff having contact with the resident and the accused employee should be interviewed to ensure a comprehensive investigation. The deficiency was identified due to the lack of adherence to this policy, resulting in an incomplete investigation of the mistreatment allegation.
Failure to Follow Bowel Protocol Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R321, who has a history of daily opiate use and constipation. The facility's bowel protocol was not followed, and a thorough gastrointestinal (GI) assessment was not completed, leading to actual harm. R321 was hospitalized with severe pain and a fecal impaction after the facility staff did not adequately address his constipation, despite his history and symptoms. R321, who is cognitively intact and dependent on toileting and transfers, reported intense rectal pain to an LPN, who then contacted the charge nurse. However, the charge nurse instructed the LPN to observe R321 for the afternoon instead of taking immediate action. R321, experiencing unbearable pain, requested to be sent to the hospital, but when this did not happen, he called 911 himself. The medical record showed no documentation of abdominal pain prior to the incident, and the facility staff failed to check when R321 last had a bowel movement. The facility's records indicated that R321 had not had a bowel movement for four days, and despite an enema being administered, there was no documentation of its results or notification to the provider. The facility's Director of Nursing acknowledged that the bowel protocol was not followed, and there was no evidence of interventions being performed for R321's constipation prior to his hospitalization. This lack of adherence to the bowel protocol and inadequate response to R321's symptoms resulted in his hospitalization for fecal impaction.
Deficiency in Dishwashing Practices
Penalty
Summary
The facility was found to have a deficiency in its dishwashing and ware washing practices, which had the potential to affect all 76 residents. During an observation, a surveyor noted that a dietary aide, identified as DA C, was not allowing clean dishes sufficient time to air dry before stacking them. The dishes, including coffee cups and bowls, were observed to have standing water in them, indicating they were not completely air dried. Additionally, the bowls were not inverted during storage, which could lead to contamination from airborne particles and dust. The dietary aide, who had been in her position for several years, confirmed that the observed process of washing dishes and immediately stacking them was her usual practice. The surveyor also discussed the issue with the dietary supervisor, DS D, who acknowledged that the current dishwashing process could pose a risk for contamination. The supervisor recognized the need to change the manner in which dishes were stacked and to allow more time for air drying to prevent potential contamination.
Failure to Monitor and Adjust Psychotropic Medication Dosages
Penalty
Summary
The facility failed to effectively monitor psychotropic medications to ensure residents are receiving the lowest possible effective dose, as evidenced by the case of a resident identified as R19. The facility's policy on psychoactive medications mandates that such medications should only be administered when required to treat medical symptoms, with a focus on gradual dose reductions (GDR) to find the optimal dose. However, R19's records indicated that no GDR had been attempted despite the resident being on antipsychotic, antianxiety, and antidepressant medications. The resident's care plan included a goal to prescribe the lowest effective dose of medication, but this was not achieved. R19's medical history includes diagnoses of unspecified dementia with behavioral disturbance, anxiety, and dysthymic disorder. Despite these diagnoses, the resident's records showed no mood or behavioral symptoms, and no targeted behavioral concerns were documented. The facility's consultant pharmacist recommended a GDR for R19's antipsychotic medication, Rexulti, but the physician's response was inconsistent, with an increase in dosage noted without documented clinical rationale based on targeted behaviors. Observations and interviews with staff indicated that R19 did not exhibit behavioral or mood concerns, and the resident's routine was maintained without issues. The facility's Director of Nursing (DON) acknowledged that there was no clinical rationale for increasing R19's medication based on targeted behaviors, and the facility's process for monitoring residents on psychoactive medications needed improvement. The facility had not yet implemented a process improvement plan since its acquisition in November 2024. The lack of a structured process for monitoring and adjusting psychotropic medication dosages contributed to the deficiency identified by the surveyor.
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Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
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Nursing homes near Wausau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amethyst Health Of Wausau | 1.6 mi | ★★★★★ | 37 | 4 |
| Wausau Manor Health Services | 2.2 mi | ★★★★★ | 12 | 0 |
| North Central Health Care | 2.8 mi | ★★★★★ | 22 | 0 |
| Rennes Health And Rehab Center-weston | 7.3 mi | ★★★★★ | 1 | 0 |
| Pride Tlc Therapy And Living Campus | 7.7 mi | ★★★★★ | 8 | 0 |
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