Acadia St Landry Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Church Point, Louisiana.
- Location
- 830 S. Broadway, Church Point, Louisiana 70525
- CMS Provider Number
- 195564
- Inspections on file
- 24
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Acadia St Landry Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A CNA in an LTC facility failed to follow a resident's care plan requiring a mechanical lift and two-person assistance for transfers. The CNA attempted to transfer the resident alone, resulting in the resident falling and sustaining injuries that required stitches. The resident had a history of dementia, anxiety, and repeated falls, and was dependent on assistance for transfers due to limited mobility.
The facility did not ensure residents received mail on Saturdays, affecting 121 residents. During a resident council meeting, three residents with different cognitive statuses reported not receiving mail on Saturdays. The staff responsible for mail delivery confirmed that mail was only delivered Monday through Friday, with Saturday's mail held until Monday.
The facility failed to store and label drugs properly, with loose and expired medications found in two medication carts and improper storage of refrigerated medications. LPNs confirmed the presence of loose tablets and expired medications in the carts, and the Director of Nursing acknowledged the improper storage practices.
The facility's kitchen was found to be unsanitary, with expired food items, poor pest control, and inadequate cleaning practices. Equipment and preparation areas had dried food debris and dust, and food was served at unsafe temperatures. The Dietary Manager confirmed the lack of cleaning schedules and policies, posing a risk of foodborne illnesses to residents.
The facility failed to maintain effective oversight of the kitchen's cleanliness and food service practices, leading to accumulated dirt, debris, and expired food items. Meals were served at inappropriate temperatures, and repeated violations were noted by the State of Louisiana Department of Health. The administrator was unaware of recent inspections, indicating a communication breakdown with the Dietary Manager responsible for kitchen activities.
A resident on contact precautions due to ESBL in urine was improperly handled by staff, who failed to wear necessary PPE and allowed the resident to attend therapy sessions. Staff confusion and lack of communication contributed to the oversight, as therapy staff were unaware of the resident's precautionary status.
The facility failed to report changes in condition for two residents. One resident's bilateral lower extremity edema was not communicated to the physician, despite being observed by an LPN. Another resident's consult for left shoulder pain was not completed, and the physician was not informed of the failed attempt. These lapses in communication highlight deficiencies in the facility's reporting processes.
The facility failed to refer two residents with new mental disorder diagnoses for Level II PASARR evaluation. One resident was diagnosed with Unspecified Psychosis and prescribed Olanzapine, while another was diagnosed with Psychosis and prescribed Quetiapine Fumarate. Interviews with staff confirmed the absence of Level II reviews and a PASARR policy.
A facility failed to implement a care plan for a resident by not completing weekly weight measurements as ordered by the physician. The resident, with moderately impaired cognition and medical conditions including gastrostomy status and acute kidney failure, did not have weights recorded from October 2024 to February 2025. Staff interviews revealed a lack of communication and adherence to procedures for documenting weights.
A facility failed to provide a NOMNC form to a resident discharged from Medicare Part A services before exhausting benefit days. The discharge was facility-initiated, and an LPN confirmed the form was not given, resulting in a deficiency in SNF Beneficiary Notification compliance.
A facility failed to provide necessary communication aids for a Spanish-speaking resident with heart failure and other conditions. Despite a care plan indicating potential communication difficulties, no communication board was available, and staff relied on a Spanish-speaking LPN who was only present during certain hours. The absence of a communication aid and lack of a policy for translation services contributed to the resident's communication challenges.
A facility failed to ensure proper communication and documentation for a resident receiving dialysis services. Missing dialysis communication forms were identified, which are crucial for collaboration between the facility and the dialysis agency. Staff interviews confirmed the absence of these forms in the resident's medical records, with some forms found in the resident's backpack instead.
A resident with no upper extremity impairments was found unable to reach her call bell, which was placed on a nightstand at the foot of her bed. The resident was unaware of its location, and an LPN confirmed it should have been accessible.
A facility failed to create a comprehensive care plan for a diabetic resident with cognitive impairment and neuropathy, leading to severe foot issues. The resident was admitted without preventative foot care orders, resulting in blackened toes and a fungal infection. A subsequent evaluation revealed the need for an amputation. The facility's records lacked evidence of necessary foot care measures, including podiatrist consultations and routine preventive care.
A resident with diabetes and neuropathy experienced harm due to the facility's failure to timely identify skin changes. Despite weekly evaluations showing no issues, significant discoloration was noted, leading to a severe infection and the need for toe amputation. The LPN initially reported no issues, but upon further examination, the NP found a foul-smelling wound with exposed bone, indicating a long-standing condition.
A resident with diabetes and neuropathy suffered severe foot complications due to the facility's failure to provide preventative foot care. The resident was admitted without foot care orders, leading to blackened toes and a deep tissue injury. Staff were unaware of the resident's foot care needs, and the condition worsened over time, resulting in the need for an amputation.
A resident's responsible party was not informed of changes in the resident's skin condition, as required by the facility's policy. An LPN identified discoloration on the resident's toes but failed to notify the responsible party. The oversight was confirmed by both the LPN and the DON.
The facility's kitchen staff failed to follow the menu and serve the correct portion sizes, using incorrect serving utensils for various foods. This deficiency was observed over two days and confirmed by the Dietary Manager and cook, potentially affecting the nutritional needs and dining experience of 111 residents.
The facility failed to ensure that a resident's bed alarm was monitored every shift as ordered, resulting in multiple instances where the alarm was not checked and was found to be non-functional. Staff interviews and record reviews confirmed the deficiency.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in actual harm. A Certified Nursing Assistant (CNA) attempted to transfer a resident from a lying position to a sitting position without the assistance of a second person or a mechanical lift, as required by the resident's care plan. The resident, who had diagnoses including unspecified dementia, psychotic disturbance, anxiety, and a history of repeated falls, was dependent on assistance for transfers due to limited mobility and contractures. The CNA turned away from the resident to retrieve a chair, during which time the resident fell to the floor, sustaining a laceration to the right eyebrow and cheek that required stitches. The resident's care plan specified the need for a mechanical lift and two-person assistance for transfers, which the CNA did not follow. The CNA admitted to not checking the resident's transfer needs and attempted the transfer alone because another CNA was unavailable. The Director of Nursing (DON) and Infection Preventionist (IP) confirmed that the CNA should not have attempted the transfer alone, given the resident's condition and the care plan requirements. The incident was documented in the facility's investigative report, and the resident was treated at the emergency department for the injuries sustained during the fall.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, which affected the communication access for 121 residents. During a resident council meeting, three residents with varying levels of cognitive function expressed that they did not receive or were unsure if they received mail on Saturdays. The Transportation/Social Services Assistant, responsible for delivering mail, confirmed that mail delivery occurred only from Monday to Friday, and mail received on Saturdays was held until Monday for delivery. This practice resulted in a delay in residents receiving their mail on Saturdays.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with accepted professional principles. During an inspection, it was observed that two medication carts, Cart A and Cart B, contained loose and unidentified pills, as well as expired medications. Specifically, Cart A had three loose tablets and expired bottles of Folic Acid and Vitamin B6, while Cart B contained four loose tablets and expired bottles of Nasal Moisturizing Spray, Lutein, and Vitamin E. These findings were confirmed by the LPNs overseeing the carts, who acknowledged that such medications should not have been present. Additionally, the facility did not maintain proper storage temperatures for certain medications. In Medication Storage Room A, two boxes of Latanoprost eye drops, which require refrigeration, were found in an unrefrigerated drawer. This was confirmed by the LPN overseeing the storage room. The Director of Nursing also confirmed that loose tablets, expired medications, and improperly stored refrigerated medications should not have been present in the facility.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which is essential to prevent foodborne illnesses. During an inspection, several expired food items were found in the refrigerated and dry storage areas, including lemon juice, barbecue sauce, whipped topping, sour cream, cabbage, and cookies. Additionally, there were signs of poor pest control, as evidenced by a dead cockroach found under a shelf. The storage areas were also noted to have crumbs, dirt, and dried substances on various surfaces, indicating a lack of regular cleaning and maintenance. The food preparation and equipment areas were observed to be in unsanitary conditions. There was dried food debris on various surfaces, including drawers, walls, and equipment such as the microwave oven, waffle maker, and fryer. Dust and crumbs were found on several kitchen appliances and storage containers, and a black substance resembling mold was noted in the dishwashing area. The lack of documented cleaning schedules and specific cleaning duties contributed to these unsanitary conditions, as confirmed by the Dietary Manager during interviews. Furthermore, the facility failed to serve food at appropriate temperatures, which is critical for food safety. During the inspection, food temperatures were recorded below the required levels, with rice with sausage at 129 degrees, black-eyed peas at 108 degrees, collard greens at 109 degrees, and milk at 51 degrees. These temperatures are not suitable for safe consumption, as confirmed by the Dietary Manager. The absence of policies related to kitchen cleanliness and food safety practices was evident, leading to the potential risk of foodborne illnesses for the 118 residents consuming meals from the facility's kitchen.
Deficient Kitchen Oversight and Sanitation
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, particularly in the oversight of the kitchen's cleanliness, sanitation, and food service practices. During a tour of the facility's kitchen, it was observed that surfaces had accumulated dust, dirt, food residue, and other debris. Additionally, expired food items were found, and meals were served at inappropriate temperatures during tray distribution. These findings were corroborated by a review of the facility's Retail Food Notice of Violations from the State of Louisiana Department of Health, which highlighted repeated issues with non-food contact surfaces, unclean food carts, and dirty floors in various areas of the kitchen. Interviews conducted with the facility's administrator (S1ADM) revealed a lack of awareness regarding inspections performed by the Office of Public Health since 2023. The administrator confirmed the findings in the kitchen and stated that the Dietary Manager (S17DM) was responsible for kitchen activities, including cleanliness. However, the administrator acknowledged having total oversight of the kitchen, indicating a breakdown in communication and responsibility between the administrator and the dietary manager, which contributed to the deficiency.
Failure to Adhere to Contact Precautions for Resident
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a resident on contact precautions. Resident #74, who was diagnosed with a urinary tract infection and had an indwelling catheter, was placed on contact precautions due to ESBL in his urine. Despite this, staff members did not adhere to the required protocols. Observations revealed that a Physical Therapy Tech and a Certified Nursing Assistant interacted with the resident without wearing the necessary personal protective equipment (PPE), such as gowns and gloves. Additionally, the resident was taken to therapy sessions, which was against the infection control guidelines for someone on contact precautions. Interviews with staff members, including the Infection Preventionist and the Restorative Certified Nursing Assistant, highlighted a lack of communication and awareness regarding the resident's contact precaution status. The Restorative CNA admitted to confusing the contact precautions with enhanced barrier precautions, leading to the resident being taken out of his room. The Occupational Therapist confirmed that therapy staff were not informed about the resident's precautionary status, as the Infection Preventionist typically communicated such information but failed to do so in this instance.
Failure to Report Changes in Resident Conditions
Penalty
Summary
The facility failed to ensure immediate reporting of a change in condition for two residents. For one resident, staff did not report the presence of 2+ pitting edema in the bilateral lower extremities to the attending physician. Despite the observation of edema by an LPN, the physician was not informed, and subsequent medical notes indicated the absence of edema, highlighting a communication lapse. The resident had a history of atherosclerotic heart disease and coronary artery issues, which could be relevant to the edema condition. For another resident, the facility failed to notify the physician about the inability to complete a consult for left shoulder pain. The resident, who had a history of peripheral vascular disease, neuropathy, and shoulder pain due to a fall, was supposed to have a consult with an orthopedic physician. However, the appointment could not be arranged because the resident was in rehab, and the transportation/social services assistant did not follow up adequately to inform the nurse or the physician about the failed consult. This lack of communication resulted in the physician being unaware of the situation, preventing alternative arrangements from being made.
Failure to Conduct Level II PASARR for Residents with New Mental Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental disorders or significant changes in their mental condition to the appropriate state-designated authority for Level II PASARR evaluation. Resident #22 was admitted with diagnoses of Insomnia and Anxiety Disorder, and later diagnosed with Unspecified Psychosis. Despite this new diagnosis, there was no evidence in the Electronic Health Record (EHR) that the facility referred the resident for a Level II PASARR. An interview with an LPN revealed a lack of awareness regarding the need for a Level II review following a new diagnosis of a serious mental disorder. Similarly, Resident #74 was admitted with a diagnosis of Psychosis, and a PASARR Level I indicated no mental illness. However, the resident was later prescribed Quetiapine Fumarate for Unspecified Mood Disorder, yet no Level II PASARR referral was made. Interviews with facility staff confirmed the absence of a Level II review for this resident as well. Additionally, it was confirmed that the facility did not have a PASARR policy in place, contributing to the oversight.
Failure to Implement Weekly Weight Monitoring
Penalty
Summary
The facility failed to implement a care plan for a resident, specifically neglecting to complete weekly weight measurements as ordered by the physician. The resident, who was admitted with diagnoses including gastrostomy status and acute kidney failure, had a moderately impaired cognitive status as indicated by a BIMS score of 8. Despite a physician's order for weekly weights every Friday evening, the facility did not record these weights from October 2024 to February 2025. Interviews with facility staff revealed a breakdown in communication and procedure. The Restorative Certified Nursing Assistant was unaware of the weekly weight requirement, and the Director of Nursing confirmed that the weights were not completed as ordered. The process for documenting weights involved recording them in a book, entering them into a kiosk, and then into the EHR, but this process was not followed for the resident in question.
Failure to Provide NOMNC Form to Resident
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non Coverage (NOMNC) form to a resident, leading to a deficiency in compliance with SNF Beneficiary Notification requirements. The resident was discharged from Medicare Part A services before exhausting their benefit days, and the facility initiated this discharge. A review of the resident's electronic health record did not show evidence that the NOMNC form was provided or signed by the resident. During an interview, an LPN confirmed that the discharge was facility-initiated and acknowledged that the NOMNC form was not given to the resident, resulting in a failure to notify the resident of their Medicare coverage status and potential liability for services not covered.
Failure to Provide Communication Aids for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication aids for a resident who was admitted with diagnoses including heart failure, hypertension, and atrial fibrillation. The resident, who was cognitively intact with a BIMS score of 13, primarily spoke Spanish and had a care plan indicating potential communication difficulties. Despite this, the facility did not provide a communication board or chart as outlined in the care plan. Observations and interviews revealed that the resident attempted to communicate by pointing to items, but staff often did not understand him due to the language barrier. Staff interviews confirmed that communication with the resident relied heavily on a Spanish-speaking LPN who was only available during specific hours. When this LPN was not present, staff resorted to using hand gestures, as there was no communication aid available in the resident's room. The Director of Nursing acknowledged the absence of a communication aid and confirmed that there was no policy or procedure in place for communication or translation services, further contributing to the communication deficiency experienced by the resident.
Failure in Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility for a resident requiring dialysis services. The deficiency was identified through a review of the facility's agreement with the contracted dialysis agency, which mandates documented evidence of collaboration and communication between the nursing facility and the dialysis unit. The review of a resident's records revealed missing dialysis communication forms on specific dates, indicating a lack of proper documentation and communication regarding the resident's dialysis care. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of dialysis communication forms in the resident's medical records for several dates. The LPN explained that these forms are essential for communication between the facility and the dialysis agency, detailing vital signs, fluid removal, and any changes in labs or medications. The Director of Nursing verified the missing forms and acknowledged that they should have been present in the resident's records. Further investigation revealed that some forms were found in the resident's backpack, not in the medical records, highlighting a lapse in proper documentation procedures.
Resident Unable to Reach Call Bell
Penalty
Summary
The facility failed to ensure that a resident who was capable of using a call bell had access to it. Resident #60, who was admitted with diagnoses including major depressive disorder and repeated falls, was observed in her room with the call bell placed on the nightstand at the foot of her bed, out of her reach. The resident, who had no upper extremity impairments as per her quarterly MDS, was unaware of the call bell's location. During an interview, an LPN confirmed that the call bell was out of reach and acknowledged that it should have been pinned to the resident's bed for accessibility.
Failure to Develop Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a diabetic resident, resulting in actual harm. The resident, who was cognitively impaired and had neuropathy in the lower extremities, was admitted without preventative foot care orders. On a subsequent skin evaluation, it was discovered that the resident's toes were black, and further assessment revealed a fungal infection and suspected deep tissue injuries. The resident was transferred to another center for treatment, where it was determined that an amputation would be necessary. The review of the resident's medical records showed a lack of orders for podiatrist consultations, nail care, and proper shoe fitting assessments. Additionally, there was no evidence of routine preventive foot care or a care plan addressing the prevention of complications from diabetes. Interviews with the Director of Nursing confirmed the absence of necessary foot care measures in the resident's records, highlighting the facility's failure to provide essential care for the diabetic resident.
Failure to Timely Identify Skin Changes Leads to Harm
Penalty
Summary
The facility failed to ensure that nursing staff identified skin changes in a timely manner for a resident with diabetes and neuropathy, leading to actual harm. The resident, who had severe cognitive impairment, was admitted with diagnoses including Type 2 Diabetes Mellitus and neuropathy. Despite weekly skin evaluations indicating no issues, a significant change was noted on November 19, 2024, when the resident's toes were found to be discolored and black. The Licensed Practical Nurse (LPN) responsible for the resident's weekly assessments reported no skin issues on November 18, 2024, but was informed by a shower aide the following day to examine the resident's foot. Upon examination, the LPN observed black discoloration on the toes and notified the Nurse Practitioner (NP). The NP's evaluation on November 22, 2024, revealed a foul-smelling wound with exposed bone on the second toe, indicating a severe infection that required immediate medical attention. The resident was transferred to a hospital for further evaluation, where it was determined that the condition had likely developed over weeks or months. The resident was diagnosed with osteomyelitis and required an amputation of the affected toe. The facility's failure to identify and address the resident's skin condition in a timely manner resulted in significant harm and necessitated surgical intervention.
Failure to Provide Preventative Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate preventative foot care for a resident with diabetes and neuropathy, leading to significant harm. The resident, who was cognitively impaired, was admitted without any preventative foot care orders. Over time, the resident developed severe foot issues, including blackened toes and a suspected deep tissue injury, which were not addressed until they became critical. The lack of routine foot care assessments, nail care, and proper shoe fitting contributed to the deterioration of the resident's foot condition. On November 19, 2024, a Licensed Practical Nurse was informed by a shower aide about the resident's discolored right foot. Upon evaluation, the nurse observed black skin on the right second toe. A Nurse Practitioner later assessed the resident and found a fungal infection, foul odor, and exposed bone on the second toe, indicating a severe infection. The resident was transferred to a medical center for further evaluation and treatment, where it was determined that an amputation would be necessary. Interviews with facility staff revealed a lack of documentation and awareness regarding the resident's foot care needs. The Director of Nursing and other staff members were unable to confirm when the resident last received toenail trimming or proper shoe fitting. The Medical Doctor involved in the resident's care noted that the condition could have developed over weeks or months, suggesting a prolonged period of inadequate care. The facility's failure to implement a care plan for diabetic foot care and to conduct regular assessments led to the resident's severe foot complications.
Failure to Notify Responsible Party of Skin Condition Change
Penalty
Summary
The facility failed to notify the responsible party (RP) of a change in skin condition for one resident. The facility's policy on Diabetic Skin and Foot Care requires notifying the medical doctor and responsible party of any changes in skin integrity. On November 19, 2024, a Licensed Practical Nurse (LPN) identified skin issues on the resident's toes, noting discoloration. However, there was no evidence in the nurse's progress notes that the RP was informed of these changes. The resident's RP expressed dissatisfaction on November 25, 2024, for not being informed in a timely manner about the discoloration and changes in skin integrity. Interviews conducted with the LPN and the Director of Nursing (DON) confirmed that the RP was not notified of the findings. The LPN acknowledged the oversight, and the DON confirmed that notification was warranted but not executed.
Failure to Follow Menu and Serve Correct Portion Sizes
Penalty
Summary
The facility's kitchen staff failed to follow the menu to ensure residents were served the appropriate portion sizes of food during meals. This was evidenced by the kitchen staff using incorrect serving utensils for pureed, mechanically soft, and non-mechanically altered foods. Specifically, on two separate days, the staff used a #12 scoop (1/3 cup) instead of the required 1/2 cup for carrot souffle, mashed potatoes, pureed potato salad, and steamed rice. Additionally, chopped chicken and pureed fried chicken were served in incorrect portions, and bite-sized chicken was not measured but served using tongs. These actions were observed during meal service on 05/28/2024 and 05/29/2024, and the discrepancies were confirmed by the Dietary Manager (S2DM) and the cook (S4COOK) during interviews. The cook admitted to relying on memory for determining serving utensils and was unable to state the correct portion sizes or the capacity of the utensils used. The Dietary Manager acknowledged that the staff should use a chart on the kitchen wall to determine the correct serving utensils but verified that incorrect utensils were used during the observed meals. This deficiency had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 111 residents who consumed meals from the facility's kitchen. The facility's policy on dietary serving sizes was not adhered to, as the staff did not use the dietary menus provided by the food supply company to ensure the appropriate portion sizes were served. The failure to follow the menu and use the correct serving utensils was confirmed through observations, interviews, and menu reviews conducted by the surveyors.
Failure to Monitor Bed Alarm as Ordered
Penalty
Summary
The facility failed to ensure that physician orders and the plan of care were implemented as ordered for monitoring a bed alarm for proper functioning every shift for one resident. The resident, who had severe cognitive impairment due to Alzheimer's disease, Depression, Schizoaffective Disorder, and Insomnia, had a physician's order and a comprehensive care plan that required the bed alarm to be monitored every shift. However, the electronic Treatment Administration Records (eTARs) for March, April, and May 2024 revealed multiple instances where the monitoring was not documented, indicating that the bed alarm was not checked as required. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed that the bed alarm was not functioning properly when tested. The Director of Nursing (DON) also verified that the eTARs contained multiple blanks where staff signatures should have indicated that the bed alarm was monitored. This failure to monitor the bed alarm as ordered led to the deficiency identified by the surveyors.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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