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 Staff confirmed that the care plan was not revised following each assessment, resulting in outdated interventions remaining in place.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
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.
Trusted by long-term care providers and associations.
