The Woodlands Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Leesville, Louisiana.
- Location
- 144 Thad Bailes Rd, Leesville, Louisiana 71446
- CMS Provider Number
- 195482
- Inspections on file
- 33
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at The Woodlands Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide timely ADL care, including toileting, bed mobility, and personal hygiene, to several dependent residents in accordance with its ADL policy and individual care plans. One CNA reported being the only CNA on a hall during the night shift, unable to complete all assigned duties or get multiple residents up in the morning, while CNAs on another hall stated they lacked time to assist outside their own hall. Surveyors observed a resident who required two-person assistance for bed mobility left with legs and feet dangling off the bed after a brief change, and other residents with severe cognitive impairment or total dependence were found with strong urine or BM odors, wet or soiled briefs, and an overfilled Foley catheter bag that had not been emptied. LPNs confirmed that residents needing ADL assistance should receive timely care and not remain in soiled briefs or with unmet ADL needs.
Two residents were found in rooms with strong urine and BM odors, soiled linens, and clothing with visible BM left on the bed and floor after staff had provided only partial incontinence care. One resident reported that staff had not checked on her before she got up, and an LPN confirmed that residents needing ADL assistance should be helped timely and that rooms should not contain soiled linens or clothing.
A resident reported that another resident entered her bathroom, shoved a door into her, pushed her against a wall causing her to fall, got on top of her, pulled her hair, and called her a derogatory name before staff intervened. The resident stated she informed an LPN of the physical and verbal abuse, but there was no documentation of the incident in her record and no internal incident or abuse report was initiated. The LPN and the RN weekend supervisor, both trained in abuse reporting, chose not to report the allegation to administration or complete required documentation because they did not witness the event and believed it did not require reporting, despite facility policy and definitions of abuse requiring that all such allegations be reported and investigated.
Two residents were not treated with dignity during meal and personal care routines. One resident, dependent on staff for eating, was left unserved at the dining table while others finished their meals, as her tray was intentionally prepared last due to her need for feeding assistance. Another resident, with severe cognitive impairment and incontinence, was repeatedly observed in a soiled brief and was offered breakfast without prior incontinence care, which staff acknowledged was inappropriate and could have affected the resident's willingness to eat.
A resident with severe dementia and a DNR order was found to have an outdated care plan that incorrectly listed her as Full Code. The discrepancy was confirmed by an LPN, who acknowledged that the care plan had not been updated after the resident's code status changed to DNR.
A resident with severe cognitive impairment, dysphagia, and a history of choking or coughing during meals had physician's orders for oral suctioning, but the care plan did not include suctioning as an intervention. This omission was confirmed by the DON during interview.
A resident with severely impaired cognition and a history of traumatic subdural hemorrhage had a physician order for DNR with selective treatment, but the care plan continued to indicate Full Code status. An LPN confirmed the care plan was not updated to reflect the current DNR order, resulting in inconsistency between the care plan and the resident's documented treatment preferences.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific staff actions or resident involvement are provided.
A resident's nasal cannula used for oxygen therapy was repeatedly found lying on the floor without being stored in a bag, contrary to facility policy. An LPN confirmed the equipment was not properly labeled or stored between uses, despite the resident's recent use of oxygen.
A medication error rate above 5% was identified when an LPN crushed and administered DR and ER medications, including Pantoprazole, Tolterodine, and Potassium Chloride, inappropriately to a resident. The contract pharmacist confirmed these medications should not have been altered, and no supporting documentation was provided.
Surveyors found that a medication cart contained five unidentified, loose tablets and that two inhalers in use were not labeled with their open dates. An LPN confirmed the presence of the loose pills and the lack of labeling on the inhalers, and the facility's contract pharmacist stated that these inhalers require open-date labeling for proper disposal timelines.
Staff failed to follow infection prevention and control protocols, including not using required PPE for a resident with a gastrostomy tube, improper hand hygiene and glove use during meal service, and inadequate infection control during wound care. These actions resulted in multiple lapses in standard precautions and EBP requirements.
A medication cart was found unlocked and unattended in a high-traffic area, with keys left on top, accessible to unauthorized personnel. Staff interviews confirmed the oversight, with the responsible RN admitting to leaving the cart unattended. The incident posed a potential risk to the 137 residents in the facility.
A facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate. An LPN administered medications incorrectly to a resident, failing to give two medications as ordered and administering a discontinued medication. The LPN did not administer Ticagrelor and Lansoprazole as prescribed and gave Lasix 10 mg, which was discontinued. The error was confirmed through observation, interview, and record review.
A facility failed to maintain an effective infection prevention and control program, as a nurse did not follow proper hand hygiene during wound care for a resident with pressure ulcers. The nurse did not change gloves or sanitize hands after removing a soiled dressing. Additionally, the facility did not provide necessary signage for Enhanced Barrier Precautions (EBP) for the resident, who required such precautions due to pressure ulcers. The absence of EBP signage was confirmed by the Infection Preventionist.
Failure to Provide Timely ADL, Toileting, and Bed Mobility Assistance Due to Inadequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, including toileting, bed mobility, and personal hygiene, to multiple dependent residents in accordance with its own ADL policy and residents’ care plans. The facility’s policy stated that residents unable to carry out ADLs independently would receive appropriate support with hygiene, mobility, elimination, dining, and communication. Despite this, staff interviews and observations showed that residents who were dependent or required substantial/maximal assistance for ADLs were not consistently receiving timely assistance, particularly during the night shift when staffing on one hall was limited to a single CNA. One CNA working the 7:00 p.m. to 7:00 a.m. shift on X hall reported being the only CNA assigned there, stating she was overworked, received no help, and could not complete all assigned duties, including getting approximately seven residents up in the morning. She stated that residents had to wait for the day-shift CNAs, who first had to serve breakfast before assisting them. She also reported that she had repeatedly informed her supervisor about her inability to accomplish her duties alone, but staffing had not changed. Another CNA on Y hall stated that most residents on Y hall were gotten up before the day shift, and that they did not have time to help on X hall because they had to get their own residents up. Surveyor observations with staff confirmed multiple instances of unmet ADL needs. One resident, dependent on staff for toileting and requiring two-person assistance for bed mobility, was observed with both lower legs and feet dangling off the end of the bed after two CNAs had changed the resident’s brief and left him in that position, and the sole CNA on X hall stated she could not reposition him alone. Another resident, requiring substantial/maximal assistance for toileting and personal hygiene, was found with a strong urine odor and a wet brief because rounds had not yet been done. A totally dependent resident with neuromuscular bladder dysfunction, hemiplegia, and a stage 3 sacral pressure ulcer was observed with a strong BM odor, a soiled brief, and a Foley catheter bag containing 1300 cc of urine that had not been emptied. Additional residents who required assistance with toileting were observed with BM or urine odors and soiled or saturated briefs. LPNs on both halls confirmed that residents requiring ADL assistance should be assisted timely and should not remain in soiled briefs or with unmet ADL needs, and one LPN reported that when CNAs from Y hall left to assist on X hall, she was alone and unable to assist residents needing two-person help.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment by not ensuring timely and complete incontinence and housekeeping care for two residents. During an early-morning observation of one resident’s room, surveyors noted a strong bowel movement odor upon entry, and a CNA confirmed that the two CNAs assigned to that hall had just changed the resident. Further observation with the CNA revealed a large amount of smeared bowel movement throughout the resident’s bed linens, indicating the linens had not been changed when the resident’s brief was changed during toileting care, as the CNA stated should have occurred. In a separate room, surveyors observed a strong urine and bowel movement odor, uncontained soiled clothing near the door, and pants on the floor with visible bowel movement. The resident in that room reported that staff had not been by to check on her and that she was up and going to get coffee. An LPN later confirmed that residents who require assistance with ADLs should be assisted in a timely manner and that both residents’ rooms should have been free of soiled linens and bowel movement on clothing.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to identify and report an alleged incident of resident-to-resident abuse involving one sampled resident. A resident reported that while in bed she heard a noise, got up, and found another resident in her bathroom. She stated that the other resident shoved the bathroom door open on her, screamed at her to get out of his room, shoved her against the wall, causing her to fall, then got on top of her, pulled her hair, and called her a “stupid b*tch.” She reported that she yelled for help and that an LPN and a CNA responded and separated the residents. The resident further stated she slapped the other resident after being called a derogatory name and informed the LPN of the shoving, hair pulling, and verbal insult. Review of the medical record showed no documentation of an incident or abuse allegation between the two residents. Interviews with administrative and nursing staff revealed that no incident report or abuse allegation had been reported to the administrator, DON, or ADON, and there were no SIMS reports related to this event. The LPN who responded acknowledged receiving abuse and incident reporting training but stated she did not report or complete an incident report because she did not believe the situation required reporting, citing that she did not personally witness physical contact and did not think the verbal comment constituted abuse. The RN weekend supervisor stated she was informed by the LPN that the resident had reported the other resident “put his hands on” her, but she also did not report the allegation because there were no injuries and she had not witnessed the incident. Both the LPN and RN confirmed they had received abuse training and understood that abuse allegations require reporting, and the DON confirmed that any allegation of abuse required reporting so that an investigation could be completed, which did not occur in this case.
Failure to Maintain Resident Dignity During Meal and Incontinence Care
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, and that their care promoted or enhanced their quality of life. One resident, who required substantial assistance with eating and was unable to communicate effectively, was observed sitting at a dining table during lunch while other residents were served, ate, and left the area. This resident was not served her meal along with the others, and staff interviews confirmed that her tray was intentionally prepared last because she required feeding assistance. The LPN on duty was unaware that the resident had not been served, despite all other residents at the table having completed their meals. Another resident, with severe cognitive impairment and a history of incontinence, was observed multiple times in bed with a soiled brief and a strong odor of feces in the room. Despite these observations, staff attempted to feed the resident breakfast without providing incontinence care beforehand. The LPN confirmed that the resident should have received incontinence care prior to being served breakfast and acknowledged that the lack of care could have contributed to the resident's refusal to eat. The DON also confirmed that incontinence care should have been provided before attempting to feed the resident.
Failure to Update Care Plan Following Change in Code Status
Penalty
Summary
A deficiency occurred when a resident's code status was not accurately reflected in the care plan. The resident, a 93-year-old female with diagnoses including traumatic subdural hemorrhage, severe unspecified dementia, and cognitive communication deficit, was admitted and later re-entered the facility. Her medical record indicated a DNR (Do Not Resuscitate) order with selective treatment, but the care plan continued to list her as having a Full Code status. This discrepancy was identified during a review of the resident's electronic chart and care plan documentation. An interview with an LPN and review of the care plan confirmed that the resident's code status had recently changed to DNR, but the care plan had not been updated to reflect this change. The care plan still instructed staff to treat the resident as Full Code, which was inconsistent with the current physician's order and the resident's wishes. This failure to update the care plan compromised the resident's right to have her treatment preferences honored.
Failure to Care Plan for Suctioning in Resident with Dysphagia and Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with significant medical needs. The resident was admitted with diagnoses including dysphagia, cerebral infarction, and unspecified convulsions, and had a BIMS score of 3, indicating severe cognitive impairment. The resident experienced episodes of coughing or choking during meals or when taking medications. Physician's orders dated 08/08/2025 indicated that oral suctioning may be performed for this resident. However, review of the resident's care plan showed that suctioning was not included as an intervention. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the resident should have been care planned for suctioning but was not.
Failure to Update Care Plan to Reflect DNR Status
Penalty
Summary
The facility failed to update the care plan for a resident to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) as ordered by the physician. The resident, who had a history of traumatic subdural hemorrhage and was assessed as having severely impaired cognition, was admitted with a care plan indicating Full Code status. However, a physician order for DNR with selective treatment was initiated, and this change was not reflected in the resident's care plan. Staff interview confirmed that the care plan had not been revised to match the current physician order, resulting in a discrepancy between the resident's documented treatment preferences and the care plan.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Failure to Properly Store and Label Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident who required oxygen therapy. According to the facility's policy, oxygen equipment should be stored in a covered device, such as a plastic bag or kangaroo pouch, between uses to ensure safe administration and infection prevention. However, observations on two consecutive days revealed that the resident's nasal cannula was found lying on the floor without a bag. The resident confirmed recent use of the oxygen equipment, and an LPN acknowledged that the tubing was not properly stored or labeled as required by facility policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by direct observation of medication administration. During 29 observed medication administration opportunities, an LPN was seen crushing and administering Pantoprazole DR 40mg tablet and Potassium Chloride ER 10meQ tablet, as well as opening a Tolterodine ER 4mg capsule and providing its contents orally to a resident. The LPN confirmed these actions during an interview. The facility's contract pharmacist verified that these extended-release (ER) and delayed-release (DR) medications should not have been crushed or opened, and stated that no documentation existed to support altering these medications in this manner. This practice had the potential to affect all 145 residents receiving medications in the facility.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional principles. During an inspection of medication carts, one cart was found to contain five unidentified and loose tablets in two separate drawers. Additionally, two inhalers—Albuterol and Trelegy Ellipta—were found opened and in use without being labeled with the date they were opened. The LPN present confirmed the presence of the loose, unidentified tablets and acknowledged that the inhalers had been opened and used without proper labeling. The facility's contract pharmacist verified that both types of inhalers require labeling with the date opened to ensure timely disposal according to manufacturer guidelines.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff adherence to established protocols. In one instance, a resident with a gastrostomy tube, who was identified as requiring Enhanced Barrier Precautions (EBP) due to increased risk of multidrug-resistant organism (MDRO) acquisition, did not receive care in accordance with EBP guidelines. The assigned CNA provided a bed bath, oral care, brief change, and linen change to the resident while wearing only gloves, omitting the required gown. The CNA admitted to not using the correct PPE for all EBP-designated residents on her hall, citing lack of PPE availability at the point of care and uncertainty about where to obtain supplies, despite facility policy and signage indicating the need for both gown and gloves during direct care activities. During meal service on another hall, a CNA was observed repeatedly failing to follow proper hand hygiene and gloving procedures. The CNA served and prepared meals while wearing the same pair of gloves, touching various surfaces, utensils, and food items, including bread rolls, without changing gloves or performing hand hygiene between tasks. The CNA also used gloves obtained from a co-worker's pocket and handled clean utensils with unwashed hands after glove removal. The CNA confirmed these lapses in practice, acknowledging that she did not follow the required procedures for hand hygiene and glove use during meal service for multiple residents. Additionally, improper infection control practices were observed during wound care for a resident with pressure ulcers and blisters. The treatment nurse used gloved hands to move the bedside table and then proceeded to apply wound dressings without changing gloves or performing hand hygiene. The nurse also touched her gown and clothing before continuing wound care on a different site, again without changing gloves or sanitizing hands. The nurse confirmed these actions, recognizing that they did not align with proper infection control protocols as outlined in facility policy.
Unattended and Unlocked Medication Cart Found in High-Traffic Area
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles. Specifically, an unattended medication cart, referred to as Cart A, was found unlocked in a high-traffic area on X Hall. The medication keys were left on top of the cart, making them accessible to unauthorized personnel. This oversight was observed on January 27, 2025, at 2:45 p.m., when residents were commuting through the area, posing a potential risk to the 137 residents residing in the facility. Interviews conducted with staff members confirmed the deficiency. S3 LPN acknowledged that Cart A was unlocked and unattended, with the medication keys left on top, and stated that the nurse responsible should have kept the keys with her. S2 RN admitted to leaving Cart A unattended and unlocked while she was in a nursing room, confirming that the keys were left on top of the cart. S1 DON also confirmed that medication carts should always be locked when unattended and that keys should not be left accessible to others.
Medication Administration Errors Result in 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during a survey observation. This deficiency was identified when an LPN administered medications to a resident, failing to give two medications as ordered and administering a discontinued medication. Specifically, the LPN did not administer Ticagrelor 90 mg and Lansoprazole 30 mg as prescribed, and instead administered Lasix 20 mg and Lasix 10 mg, despite the latter being discontinued. The error was confirmed through observation, interview, and record review. The resident involved was observed receiving 8.5 tablets, including medications that were not ordered and one that was discontinued. The LPN confirmed the oversight, stating she was unaware of the discontinuation of Lasix 10 mg. The facility's policy requires medications to be administered according to prescriber orders, with checks to verify the right resident, medication, dosage, time, and method. The failure to adhere to these protocols led to the medication errors observed during the survey.
Infection Control Deficiencies in Wound Care and Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene during wound care for a resident with pressure ulcers. The treatment nurse did not follow the facility's wound care policy, which required removing gloves and sanitizing hands after removing a soiled dressing and before cleaning the wound. During an observation, the nurse was seen holding the resident's foot with one hand while discarding the soiled dressing with the other, and then proceeded to clean the wound without changing gloves or sanitizing hands. Both the treatment nurse and the Director of Nursing confirmed that the correct procedure was not followed. Additionally, the facility did not ensure proper signage for Enhanced Barrier Precautions (EBP) for the same resident, who had pressure ulcers requiring such precautions. The facility's policy required signage to communicate to staff the need for EBP and Personal Protective Equipment (PPE) before high-contact care activities. Observations revealed that there was no EBP signage in or outside the resident's room, and the Infection Preventionist confirmed the absence of signage, acknowledging that it should have been in place to alert staff to use EBP.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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