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
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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