Westwood Manor Nursing Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Deridder, Louisiana.
- Location
- 714 High School Drive, Deridder, Louisiana 70634
- CMS Provider Number
- 195525
- Inspections on file
- 17
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Westwood Manor Nursing Home, Inc during CMS and state inspections, most recent first.
The facility did not maintain sanitary food storage and handling practices, as multiple opened, unsealed, and undated boxes of food were found in the refrigerator and freezer, along with expired prune juice in dry storage. The Dietary Manager confirmed these items were not properly sealed, dated, or disposed of according to facility policy.
A resident with chronic pain and limited mobility requested a geri chair to improve comfort, but the request was not communicated to management or acted upon by staff. Multiple staff members were either unaware of the request or believed someone else had reported it, resulting in the resident not receiving the requested accommodation.
A resident's admission MDS assessment was not transmitted within the required 14-day period after completion. Facility policy mandates timely completion and transmission of the MDS, but the assessment remained open and untransmitted, as confirmed by an LPN during interview.
A resident with multiple complex diagnoses continued to have oxygen administration interventions listed in their care plan after the physician's order for oxygen was discontinued. Staff confirmed that the care plan was not revised following each assessment, resulting in outdated interventions remaining in place.
A resident with severe cognitive impairment and multiple medical conditions did not receive required nail care as part of ADL assistance. Despite documentation indicating that nail care was performed, observation and staff interviews confirmed that the resident's fingernails were left long and dirty, and the CNA responsible did not clean or cut the nails as required.
Expired Ocuvite Adult 50+ Soft Gels and DiabetiSource AC Complete Nutrition supplements were found stored in a medication room and available for administration. An LPN and the ADON both confirmed that these expired items should not have been present.
A resident with dementia, malnutrition, and aphasia did not consistently receive the physician-ordered amounts of fluids during medication passes and snack times. Staff interviews confirmed that the required fluids were not provided as ordered, and documentation showed the resident neither refused nor consumed the fluids on multiple occasions.
Surveyors observed that garbage and refuse were not disposed of properly, with dumpster lids left open, trash bags placed on the ground, and debris scattered around the dumpster area. Facility staff confirmed that all employees were responsible for disposing of trash correctly and maintaining cleanliness, but these procedures were not followed.
The facility failed to ensure a cognitively impaired resident was treated with respect and dignity, as the resident was observed lying in bed clothed only in a diaper on two occasions. Despite the resident's comprehensive care plan requiring assistance for all ADLs, including dressing, and the RP's requests for the resident to be dressed in a gown, staff were inconsistent and unaware of the resident's needs, leading to the deficiency.
The facility failed to ensure a resident's advance directive was properly reflected in their medical record. Despite the resident's LaPOST indicating DNR status, the EHR bed board listed the resident as full code-CPR, and there was no active physician's order for the code status. This inconsistency was confirmed by interviews with two LPNs and the DON.
The facility failed to maintain a clean environment for a resident with multiple diagnoses, including dementia, by not ensuring that the resident's bed linens were clean. The resident reported that the sheets had not been changed for over three weeks, which was confirmed by a CNA and the Director of Nursing.
A resident reported missing a pair of blue capris and a blanket to the administrator in writing but did not receive any response. The administrator acknowledged receiving the letter but did not initiate a grievance, failing to address the resident's concerns promptly.
The facility failed to implement comprehensive care plans for two residents. One resident was transferred using a mechanical lift by a single CNA instead of the required two-person assist. Another resident's care plan did not include their DNR code status, despite it being documented in their medical records.
The facility failed to provide necessary ADL assistance to two residents, resulting in one resident not being bathed regularly and another having untrimmed, dirty fingernails. Interviews and documentation confirmed these deficiencies.
The facility failed to administer the Pneumococcal Vaccine to a resident despite having a signed consent. The resident, admitted with multiple diagnoses including COVID-19 and Heart Failure, did not receive the vaccine as per the facility's policy. The DON confirmed the oversight but could not explain the reason.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not store food in accordance with professional standards for food service safety. During an observation of the kitchen, multiple opened, unsealed, and undated boxes of food items, including breakfast sausage patties, hamburger patties, cinnamon rolls, raw cookie dough, and pretzel breadsticks, were found in the walk-in refrigerator and freezer. Additionally, three expired cartons of prune juice were found in dry storage. The facility's own policies require that frozen foods be tightly wrapped, labeled, and dated, and that refrigerated foods be wrapped or covered and stored in sanitary containers. The Dietary Manager confirmed that these items were not properly sealed, dated, or disposed of as required.
Failure to Accommodate Resident's Request for Geri Chair
Penalty
Summary
A deficiency occurred when the facility failed to reasonably accommodate the needs and preferences of a resident who requested a geri chair to help manage chronic pain and limited mobility. The resident, who was cognitively intact and had diagnoses including Type 2 Diabetes Mellitus, unspecified osteoarthritis, morbid obesity, muscle spasms of the back, chronic pain syndrome, and restless leg syndrome, reported being able to tolerate sitting in a wheelchair for only about 15 minutes due to back pain. She stated that she had requested a geri chair from staff several months prior but had not received one or been offered the opportunity to use one. Interviews with facility staff revealed a breakdown in communication regarding the resident's request. Multiple staff members, including CNAs and an LPN, either did not recall being notified of the request or assumed another staff member had communicated it. The Social Services Director and Director of Nursing both confirmed they had not been informed of the resident's request for a geri chair. As a result, the resident's expressed need for a more comfortable seating option was not addressed, and no action was taken to evaluate or provide the requested accommodation.
Failure to Transmit Admission MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to transmit an admission Minimum Data Set (MDS) assessment within the required timeframe for one resident. According to the facility's policy, the admission assessment must be completed and transmitted within 14 days of admission, counting the day of admission as day one. Record review showed that a resident was admitted on 07/03/2025, and the admission MDS with an Assessment Reference Date (ARD) of 07/09/2025 remained open and untransmitted as of 07/29/2025. An interview with an LPN confirmed that the assessment should have been completed and transmitted by 07/22/2025, but this was not done.
Care Plan Not Updated After Discontinuation of Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised after each assessment, as required. A review of the medical record for a resident with diagnoses including Alzheimer's Disease, Epilepsy, Gastrostomy, and Quadriplegia showed that the care plan continued to include interventions for oxygen administration, even though the physician's order for oxygen had been discontinued several months prior. The care plan still listed oxygen settings and instructions to administer oxygen as ordered, despite the absence of a current order. Interviews with staff confirmed that the care plan was not updated following the discontinuation of oxygen therapy, and acknowledged that it should have been revised after each assessment.
Failure to Provide Necessary Nail Care During ADL Assistance
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex medical diagnoses, including chronic respiratory failure, severe protein-calorie malnutrition, and hypertensive heart disease, did not receive necessary assistance with activities of daily living (ADLs), specifically nail care. The resident required moderate assistance with personal hygiene and was unable to perform these tasks independently. During an observation, the resident was found to have long fingernails with a large amount of brown substance underneath, and the resident reported having requested nail care from staff the previous week, which was not provided. Review of documentation indicated that ADL care, including nail care, was recorded as completed, but interviews with the CNA responsible for the resident's care confirmed that the CNA did not clean or cut the resident's fingernails during the documented ADL care. Both the treatment nurse and the Director of Nursing acknowledged that the resident's nails should have been cleaned as part of routine ADL care, and that this was not done.
Expired Medications and Supplements Found in Medication Room
Penalty
Summary
Surveyors observed that Room A, used for storing medications and supplements for residents, contained expired items, specifically two unopened bottles of Ocuvite Adult 50+ Soft Gels with an expiration date of 06/2025 and three DiabetiSource AC Complete Nutrition 250mL supplements with an expiration date of 05/23/2025. These expired medications and supplements were found to be available for administration to residents. During the observation, an LPN confirmed the presence of expired items in the medication room and acknowledged that they should not have been there. The ADON also confirmed that expired medications and supplements should not have been available for administration but were present in Room A at the time of the survey.
Failure to Provide Ordered Fluids for Hydration
Penalty
Summary
A resident with diagnoses including dementia, mild protein-calorie malnutrition, and aphasia was admitted to the facility and had physician orders and care plan directives to receive 360mL of fluid by mouth three times daily with medication pass and 360mL of fluid by mouth twice daily at snack times. Review of the resident's medical record, medication administration record (MAR), and electronic fluid intake flowsheets revealed that the resident did not consistently receive the ordered amounts of fluids on multiple dates. Documentation showed that the resident neither refused nor consumed the required fluids during several medication passes and snack times. Interviews with facility staff confirmed the deficiency. A CNA stated that fluid intake was monitored and documented during meals and snack times, while an LPN admitted to providing medications mixed with pudding but not offering the required 360mL of fluid with medication administration. The Director of Nursing confirmed that the resident did not receive the prescribed quantity of fluids each day, as required by the physician's orders and care plan.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. Three facility dumpsters were found with lids left open, and garbage bags were placed directly on the ground instead of inside the dumpsters. Additionally, multiple pieces of debris, including straws, plastic lids, silver spoons, napkins, and other paper products, were scattered around the dumpster area. The Maintenance Supervisor acknowledged that raccoons occasionally entered the dumpster area and contributed to the mess, but also confirmed that staff were responsible for placing trash inside the dumpsters and keeping the area clean. Both the Dietary Manager and Maintenance Supervisor confirmed these findings and acknowledged that the facility's policy requiring closed dumpster lids and a clean surrounding area was not followed. This deficiency had the potential to affect all 95 residents in the facility.
Failure to Ensure Resident Dignity and Appropriate Dressing
Penalty
Summary
The facility failed to ensure a cognitively impaired resident was treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life. Resident #96, who was non-interviewable and dependent on staff for all activities of daily living (ADLs), was observed on two separate occasions lying in bed clothed only in a diaper. The resident's electronic health record indicated multiple diagnoses, including Hypertensive Heart Disease, Chronic Kidney Disease, Parkinson's Disease, and Major Depressive Disorder. The resident's comprehensive care plan required assistance for all ADLs, including dressing, and the resident was receiving hospice services at the time of the observations. Despite this, the resident was not dressed appropriately, which was confirmed through multiple observations and interviews with staff and the resident's responsible party (RP). The RP had requested numerous times for the resident to be dressed in a gown, as the resident would have always wanted to be dressed. Interviews with staff revealed a lack of awareness and inconsistency in addressing the resident's needs. A CNA stated that the resident pulled clothes off when attempts were made to dress him, while an LPN and the Director of Nursing (DON) were unaware of any behaviors related to the resident undressing himself. The DON acknowledged that the resident should be covered or dressed appropriately. This failure to dress the resident appropriately and to honor the RP's requests demonstrated a lack of respect and dignity in the care provided to Resident #96, contributing to the deficiency noted in the report.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that Resident #96's right to formulate an advance directive was properly reflected in their medical record. Despite the resident's LaPOST indicating a DNR (Do Not Resuscitate) status, the EHR bed board listed the resident as full code-CPR. Additionally, there was no active physician's order for the resident's code status in the medical record. This inconsistency was confirmed by interviews with two LPNs and the Director of Nursing (DON), who acknowledged that the medical record contained conflicting information and lacked an updated order for the resident's code status. Resident #96 had multiple diagnoses, including Hypertensive Heart Disease, Chronic Kidney Disease, Parkinson's Disease, and others, and was receiving hospice services. The resident was non-interviewable and dependent on staff for various activities of daily living. The deficiency was identified during a review of the resident's EHR, comprehensive care plan, and physician's orders, which revealed the absence of a consistent and updated code status reflecting the resident's wishes as documented in the LaPOST form.
Failure to Maintain Clean Bed Linens
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for Resident #18 by not ensuring that the resident's bed linens were clean. Resident #18, who has diagnoses including Major Depressive Disorder, Heart Failure, Vascular Dementia, Overactive Bladder, and Unspecified Dementia, was observed with visibly soiled and stained sheets. The resident reported that the sheets had not been changed for over three weeks. This was confirmed by a CNA who was unaware of when the sheets were last changed. The Director of Nursing confirmed that the sheets should have been changed on the resident's bath days and as needed.
Failure to Address Resident's Grievance Promptly
Penalty
Summary
The facility failed to ensure a prompt resolution of an allegation of missing property for a resident. The resident, who had a BIMS score of 15 indicating intact cognition, reported missing a pair of blue capris since December 2023 and a blanket that had been sent to the laundry over a week ago. Despite reporting these missing items to the administrator in writing, the resident did not receive any response or resolution. The administrator acknowledged receiving the resident's letter but did not initiate a grievance as required by the facility's policy. The letter, dated May 11, 2024, detailed the resident's repeated requests for the return of her blue capris and the recent loss of her favorite Christmas blanket. The administrator confirmed that no grievance was initiated upon receipt of the letter, resulting in a failure to address the resident's concerns promptly.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a Comprehensive Person Centered Care Plan (CPOC) to meet the medical needs of two residents. For one resident, the facility did not ensure that the resident was transferred with a mechanical lift by two-person assist as specified in the resident's physician's orders and CPOC. The resident, who had multiple diagnoses including bilateral above-knee amputation and hemiplegia, was transferred by a CNA using the lift without any assistance, contrary to the care plan requirements. Both the CNA and the Director of Nursing confirmed that two staff members should have been present during the transfer. For another resident, the facility failed to include the resident's code status of Do Not Resuscitate (DNR) in the CPOC. The resident, who had multiple diagnoses including hypertensive heart disease and chronic kidney disease, was receiving hospice services and had a documented DNR status in the Louisiana Physician Order for Scope of Treatment (LaPOST). However, the resident's care plan and physician's orders did not reflect this code status. The LPN responsible for developing care plans confirmed that the resident's code status should have been included in the care plan but was not.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Resident #47, who had multiple diagnoses including bilateral above-knee amputation and hemiplegia, required substantial assistance with showering and bathing. Despite being scheduled for baths three times a week, the resident reported not being bathed regularly and documentation confirmed only four baths in a 30-day period. Interviews with the resident and staff corroborated the lack of consistent bathing, highlighting a failure in providing the necessary care as per the resident's care plan. Resident #49, who had severe cognitive impairment and was dependent on staff for all ADLs, was observed with long, jagged fingernails with a brown substance underneath. Interviews with staff confirmed that the resident's nails should have been trimmed and cleaned but were not. Additionally, there was no documentation to suggest that nail care had been provided recently. This indicates a failure to maintain the resident's personal hygiene as required by their care plan.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the Pneumococcal Vaccine to a resident after receiving consent. The facility's policy mandates offering the Pneumococcal immunization to all residents unless medically contraindicated or previously immunized. Despite having a signed consent dated 11/29/2018, the resident, who was admitted with diagnoses including COVID-19, Heart Failure, Acute Upper Respiratory Infection, and other general symptoms, did not receive the vaccine. The Director of Nursing confirmed the oversight but could not provide a reason for the failure to administer the vaccine.
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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