Westwood Healthcare: Leaking Toilet Fall Hazard - GA
Federal inspectors found three residents with cognitive impairments sharing the water-covered bathroom, all at high risk for falls. One had severe dementia and a history of repeated falls. Another had Alzheimer's disease and was documented as needing fall hazards removed from her pathways.
"Water leaks from the toilet to the floor in the bathroom every time it is flushed," the resident who slipped told inspectors on May 2. "The toilet had leaked for a few months, and she had reported it to staff. She further stated she was afraid of falling because of the water on the floor."
When inspectors observed the bathroom at 8:36 that morning, they watched the resident exit and slip without falling, then documented water pooled around the base of the toilet.
A second resident confirmed the water had been on the bathroom floor "for about one month." The third resident, who had Alzheimer's and a care plan specifically requiring staff to keep pathways "free of clutter and any fall hazards," also used the same bathroom.
The maintenance supervisor and director of nursing confirmed the leaking toilet when inspectors showed them the water. The maintenance supervisor said he was unaware the toilet was leaking.
The administrator also claimed ignorance when questioned two days later. She told inspectors the facility conducted environmental rounds and promised to add checking for leaking toilets to the task list.
None of this should have happened under the facility's own accident prevention policy, which required staff to identify hazards, evaluate risks, implement interventions and monitor for effectiveness. The policy specifically stated that "all staff" should observe and identify potential hazards while considering "the unique characteristics and abilities of each resident."
The residents using the bathroom were exactly the type the policy was designed to protect. The woman who slipped required supervision with walking and used a rolling walker. One of her bathroom-mates had severe cognitive impairment and was documented as being at risk for falls due to "poor safety awareness, weakness, lack of coordination, and pain." The third had Alzheimer's, a history of falling, and needed supervision with walking due to "muscle weakness, pain, difficulty walking, and impaired vision."
Meanwhile, in another part of the facility, a resident with chronic obstructive pulmonary disease and acute respiratory failure wasn't getting the oxygen his doctor ordered. Inspectors found him receiving 2 liters per minute instead of the prescribed 3 liters during multiple observations over two days.
The licensed practical nurse responsible for checking oxygen settings during medication rounds admitted she hadn't verified the rate on either day. When shown the physician's order, she confirmed it called for 3 liters per minute.
"Nurses should check oxygen settings during their medication pass and rounding, since oxygen is a medication," the director of nursing told inspectors. Her own nurse had failed to follow this basic expectation.
A third resident received no mental health services despite a psychiatric nurse practitioner's emergency recommendation after he was found with his hands on another resident's neck and head. The incident occurred February 27, but by May the resident still hadn't been evaluated.
The social worker explained that the resident "had behaviors and sometimes needed redirection" but confirmed he hadn't been referred for behavioral health services as the psychiatric provider recommended. She said there had been no further incidents since February, though the resident's diagnoses included unspecified psychosis, restlessness, agitation, dementia, and mood disorder.
A registered nurse said the facility couldn't arrange the evaluation because the resident was at dialysis on Mondays when the behavioral health provider visited. The director of nursing acknowledged "the facility should have arranged for R306 to be seen on a different day."
The administrator claimed she was unaware the resident hadn't received the recommended services.
The resident's medical record showed he had physical behaviors toward others one to three days during the assessment period, and other behavioral symptoms four to six days. His care plan documented that he needed behavioral health services to reach his "highest level of mental and psychosocial functioning and well-being."
Instead, he got monitoring by a social worker who watched for more incidents of putting his hands around other residents' necks.
These failures occurred at a facility that had written policies covering each area of deficient care. The oxygen policy required physician orders to be followed. The behavioral health policy promised person-centered services reflecting residents' goals while maximizing their dignity and safety. The accident prevention policy demanded hazard identification and intervention.
But policies proved meaningless when a toilet leaked for months in a bathroom used by three residents with dementia and fall risks, when oxygen flowed at the wrong rate for days while nurses didn't check settings, and when a resident who grabbed another's neck waited months for promised mental health evaluation.
The resident afraid of falling on the wet bathroom floor had reported the leak to staff. She used a walker and had moderate cognitive impairment, making the water around the toilet base a serious hazard each time she needed the bathroom.
Her roommates faced the same danger. One had severe dementia and required supervision walking. The other had Alzheimer's, a documented history of falls, and vision problems that made navigating the water even more treacherous.
All three continued using the bathroom while maintenance remained unaware and administrators promised to add toilet checks to their rounds.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Healthcare and Rehabilitation from 2025-05-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
WESTWOOD HEALTHCARE AND REHABILITATION in STATESBORO, GA was cited for violations during a health inspection on May 4, 2025.
Federal inspectors found three residents with cognitive impairments sharing the water-covered bathroom, all at high risk for falls.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.