Allen Oaks Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakdale, Louisiana.
- Location
- 909 East 6th Avenue, Oakdale, Louisiana 71463
- CMS Provider Number
- 195584
- Inspections on file
- 25
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Allen Oaks Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility did not follow the posted menu for residents on a puree diet, as bread and dessert items were not pureed nor were appropriate alternatives consistently provided. The Dietary Manager confirmed that cooks did not puree bread or offer substitutes, resulting in the menu not being fully followed for all residents on puree diets.
Surveyors identified multiple deficiencies in food storage, kitchen sanitation, and staff hygiene, including unlabeled and unsealed food items, improper storage of dry goods, dirty dishware stored incorrectly, and a dietary aide not using a beard restraint. These failures had the potential to affect all residents in the facility.
The facility did not maintain an effective pest control program, as multiple flies were observed in the kitchen, including on food and food prep areas, and in a resident room. The Dietary Manager and administrator both acknowledged the ongoing fly problem, which had the potential to affect 72 residents.
A resident with an indwelling urinary catheter was observed on multiple occasions with their urinary drainage bag visible and without a privacy cover. The resident, who was cognitively intact and had multiple medical conditions, had a physician's order for catheter care. An LPN confirmed that the drainage bag should have been covered but was not, resulting in a failure to maintain the resident's dignity.
A resident with severe cognitive impairment and a history of falls did not have their walker accessible as required by their care plan. Observations showed the resident ambulating without the walker, and staff confirmed the device had not been present for at least a week, contrary to facility policy and the resident's assessed needs.
A resident with significant medical needs did not receive enteral feedings at the rate ordered by the physician. Observation revealed the tube feeding was set at 50 ml/hour instead of the prescribed 40 ml/hour. Facility staff, including an LPN, ADON, and DON, confirmed the feeding should have been administered at the lower rate as per the updated physician order.
A resident with COPD and dependence on supplemental oxygen was observed receiving oxygen at 3.5 L/min via nasal cannula, despite a physician's order for 2 L/min. The resident reported that staff did not check the oxygen flow rate, and observations confirmed the discrepancy on multiple occasions, indicating a failure to follow physician orders and facility policy for respiratory care.
Nursing staff failed to follow required procedures for wasting and documenting controlled substances. In one case, a nurse wasted a Tramadol tablet without a witness signature, and in another, a Hydrocodone/APAP tablet was improperly returned to its blister pack after being opened. The DON confirmed that staff are aware of the correct protocols, but these were not followed.
Expired Hydrocortisone and Clobetasol creams were found available for use in a medication room, with an LPN and the DON confirming they should have been disposed of. Additionally, a narcotic destruction locked box containing controlled substances was not permanently affixed and was stored in a shared office accessible to multiple employees, as confirmed by the ADON.
The facility did not ensure proper infection control practices, including the sanitary storage of clean care items and the implementation of Enhanced Barrier Precautions for a resident with a dialysis catheter. Clean items were stored inappropriately near soiled linen, used care items were returned to clean linen carts, and staff failed to use required PPE, despite active orders and care plan instructions.
A facility failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses, including a history of drug abuse. The care plan lacked necessary interventions beyond addressing synthetic THC gummies found, despite the resident's need for extensive assistance and intact cognition. An LPN confirmed the care plan's inadequacy.
A resident with a history of drug abuse and depression was given THC gummies by the DON without consulting the physician, leading to intoxication and hospitalization. The resident had requested marijuana, and the DON, after consulting with the Administrator, provided THC gummies. The physician was not informed until after the resident's hospitalization.
A resident with a history of drug abuse and major depressive disorder expressed suicidal ideations and was found with THC gummies, which were provided by the DON without physician consultation. The facility failed to follow protocol by not notifying the physician promptly or placing the resident on one-on-one monitoring, leading to a deficiency in care.
A cognitively impaired resident with a history of wandering exited the facility unsupervised on two occasions, despite having a wander alarm and being on an hourly monitoring schedule. The facility failed to post required signage and did not document the hourly monitoring. Video footage showed the resident leaving without staff presence, and staff interviews revealed a lack of awareness and documentation regarding the incidents.
A resident with severe cognitive impairment exited the facility unsupervised on two occasions. The facility failed to complete incident reports, investigate the elopements, or update the resident's care plan with new interventions. The DON did not consider these incidents as elopements since the resident did not leave the facility grounds, and there was no policy for staff training on elopement risks or responses.
A resident with severe cognitive impairment was verbally and mentally abused by a CNA during a night shift. The abuse, captured on video, included derogatory comments and profanity, causing harm to the resident. Another CNA present confirmed the inappropriate behavior, and the facility's administration acknowledged the abuse after reviewing the footage.
A resident with severe cognitive impairment was roughly handled by a CNA, who let the resident fall back onto the mattress while adjusting her gown. The CNA also used her cell phone on speaker during care, ignoring the resident's attempts to communicate. This violated the facility's policy on treating residents with dignity and respect.
A resident with Alzheimer's and other disorders, assessed as high risk for wandering, eloped twice from the facility. Despite these incidents, the care plan was not updated with new interventions. Interviews with the DON and ADM confirmed awareness of the elopements but acknowledged that no additional measures were implemented to prevent further occurrences.
A resident with severe cognitive impairment was improperly handled during transfers and bed mobility in an LTC facility. CNAs failed to follow proper protocols, resulting in rough handling during a transfer to a geri-chair and unsafe repositioning in bed. These actions were captured on video, highlighting deficiencies in care and adherence to the resident's care plan.
A facility failed to maintain proper infection control practices during resident care. A CNA was observed providing perineal care while standing on a mattress and improperly disposing of soiled items. The CNA also stood on a resident's bed to reposition her, contrary to safe and sanitary practices. The resident had severe cognitive impairment and required significant assistance with personal hygiene.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents and did not maintain a water management program to reduce the risk of Legionella. The DON confirmed the absence of EBP policies, and the Administrator acknowledged the lack of a water management plan and failure to check for Legionella.
A facility failed to provide necessary behavioral health care for a resident with a history of substance abuse and related disorders. The resident exhibited threatening behaviors and possessed dangerous items, but the facility did not document these incidents or provide psychiatric services. Staff reported feeling unsafe, and the resident was eventually placed on 1:1 supervision and transferred to a behavioral hospital.
The facility failed to check the placement and gastric residual volume (GRV) for a resident before administering enteral feeding, contrary to its policy. The resident, who had severe cognitive impairment and multiple diagnoses, was reconnected to her tube feeding without the necessary checks, as confirmed by an LPN and the Director of Nursing.
A facility failed to provide proper respiratory care for a resident with severe cognitive impairment and multiple diagnoses, including COPD. The resident's nebulizer mouthpiece was found undated and improperly stored, and an LPN confirmed that the equipment should have been dated and labeled weekly by the weekend ward clerk.
The facility failed to ensure proper communication and coordination with a dialysis facility for a resident requiring dialysis. The nursing staff did not send or receive communication sheets for the resident's dialysis appointments, and the dialysis facility did not complete the necessary documentation.
Failure to Follow Puree Diet Menu and Provide Alternatives
Penalty
Summary
The facility failed to meet the nutritional needs of residents on a puree diet by not following the posted menu and not providing appropriate alternatives for all menu items. Observations and interviews revealed that while the lunch menu included meatloaf, black-eyed peas, cauliflower and cheese, dinner roll, and lemon glazed cake, only the meatloaf, black-eyed peas, and cauliflower and cheese were pureed for residents on a puree diet. The cook confirmed that the glazed cake was not pureed and that pudding was provided as an alternative for all puree diets. Additionally, dinner rolls were not pureed, nor was an alternative provided for bread when it was served. The Dietary Manager confirmed that cooks did not puree bread or provide an alternative for bread for residents on puree diets, and acknowledged that the menu was not followed for these residents. Facility policies require that menus meet the nutritional needs of residents and that if a food group is missing, an alternate means of meeting nutritional needs should be provided. These requirements were not met for the five residents receiving a puree diet, as the menu was not fully followed and appropriate alternatives were not consistently provided.
Deficient Food Storage, Sanitation, and Staff Hygiene in Kitchen
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. Observations revealed that food items in both the refrigerator and freezer, such as a 1-gallon bag of chicken nuggets and a tub of mayonnaise, were left open and undated. Additionally, dry food items like a 50-pound bag of pinto beans and a small bag of powdered creamer were found open, undated, and not stored in sealed containers. A scoop was also found stored inside a flour container, contrary to safe food handling practices. Further deficiencies included improper storage and cleanliness of dishware, with plates stored face up, some visibly dirty, and one plate containing paperclips. Clean dishware was not stored facedown as required. Staff were also observed not following hygiene protocols, as one dietary aide with facial hair was not wearing a beard restraint. These failures had the potential to affect all 72 residents residing in the facility.
Failure to Maintain Effective Pest Control Program Resulting in Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which states that the building should be kept free of insects and rodents. Multiple observations over several days revealed the presence of numerous flies in the kitchen area, including flies landing on food being prepared and on food preparation surfaces. These observations were made in the presence of the Dietary Manager, who confirmed the ongoing fly problem and acknowledged that the kitchen should be free of pests. Additional observations found multiple flies present in a resident room on two separate occasions. The facility administrator also acknowledged the current issue with flies in the building. A total of 72 residents were potentially affected by the facility's failure to control the fly infestation, as the pest issue was observed in both food preparation areas and resident living spaces.
Failure to Provide Privacy Cover for Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided with a privacy cover for the catheter's urinary drainage bag. The resident, who had diagnoses including secondary malignant neoplasm of the liver, hypospadias, neuromuscular dysfunction of the bladder, and was receiving palliative care, was observed on two separate occasions in their room with the catheter drainage bag visible and uncovered. The resident was cognitively intact, as indicated by a BIMS score of 14, and had a physician's order for catheter care every shift. During both morning and afternoon observations, the urinary drainage bag was seen containing urine and lacking a privacy cover. In an interview, an LPN confirmed that the drainage bag should have had a privacy cover but did not at the time of observation. The failure to provide a privacy cover for the urinary drainage bag did not honor the resident's right to dignity and respect, as required by facility policy and regulatory standards.
Failure to Provide Resident with Required Assistive Device
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including dementia, heart failure, and difficulty walking, did not have access to their prescribed assistive device, a walker. The resident's care plan indicated they were a fall risk with a history of two recent falls and required the use of a walker for safe ambulation. Observations on multiple occasions revealed the resident ambulating in their room without supervision or a walker, and the walker was not present in the room during these times. Further review and staff interviews confirmed that the walker had not been seen with the resident for at least a week, and staff were unsure of its location. The facility's policy required that assistive devices be provided, maintained, and accessible to residents based on their care plan and comprehensive assessment. Despite these requirements, the resident was left without the necessary assistive device, resulting in a failure to reasonably accommodate their needs and preferences.
Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical diagnoses, including pneumonitis due to inhalation, COPD with acute exacerbation, heart failure, cerebral infarction, and aphasia, did not receive enteral feedings as ordered by the physician. The resident, who was dependent for all activities of daily living and had a BIMS score of 0, was admitted with a physician's order for Osmolite 1.2 to be administered at 40 ml/hour via pump, with a corresponding care plan intervention. During observation, it was found that the tube feeding was infusing at 50 ml/hour instead of the ordered 40 ml/hour. Interviews with facility staff, including an LPN, the ADON, and the DON, confirmed that the feeding rate should have been 40 ml/hour as per the physician's order, and that the order had been updated during physician rounds. The failure to administer the enteral feeding at the prescribed rate constituted a lack of adherence to professional standards of quality care.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for respiratory care in accordance with professional standards for a resident requiring continuous oxygen therapy. According to the physician's order, the resident was to receive continuous oxygen at 2 liters per minute via nasal cannula due to diagnoses including COPD with acute exacerbation, other lung disorders, dependence on supplemental oxygen, and dyspnea. The resident's care plan also specified continuous oxygen at all times. However, multiple observations revealed that the resident was receiving oxygen at 3.5 liters per minute, which was not in accordance with the physician's order. Additionally, the resident reported that no staff checked the oxygen flow rate to ensure it matched the prescribed amount. The facility's policy required verification of physician orders and ongoing assessment before and during oxygen administration, but there was no evidence that staff were monitoring or adjusting the oxygen flow as ordered. This failure to follow physician orders and facility policy resulted in the resident receiving a higher oxygen flow rate than prescribed.
Failure to Follow Proper Procedures for Wasting and Documenting Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and accurate handling of controlled substances for its residents. Specifically, on one medication cart, a nurse documented the wasting of a Tramadol tablet for a resident but did not obtain the required witness signature, as mandated by facility policy. The policy requires that the destruction of controlled substances be witnessed and documented by at least two staff members. The LPN involved confirmed that the witness signature was missing for the wasted medication. Additionally, another incident involved a resident's Hydrocodone/APAP tablet, which was removed from its blister pack but not administered. Instead of properly wasting the tablet according to protocol, the nurse taped the tablet back into the packaging, which is not permitted by facility policy. The DON confirmed that nurses are aware of the correct procedures, which include never returning a tablet to the packaging after it has been opened and always having two nurses witness and document the destruction of controlled substances. These failures resulted in non-compliance with both facility policy and regulatory requirements for the handling and documentation of controlled substances.
Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
Expired medications were found available for use in one of the facility's medication rooms. Specifically, an opened and used tube of Hydrocortisone cream and a tube of Clobetasol Propionate 0.05% cream, both past their expiration dates, were observed in Med Room B. The LPN present at the time confirmed that these expired creams should have been disposed of but were not, and the Director of Nursing acknowledged that expired medications should not be available for use in the medication room. Additionally, controlled substances awaiting destruction were not stored in accordance with facility policy and regulatory requirements. The narcotic destruction locked box, which contained multiple medication cards and bottles of controlled substances, was found on a shelf in a shared office and was not permanently affixed to any surface. The Assistant Director of Nursing confirmed that the box was not secured as required and that other employees had access to the shared office where the box was stored.
Failure to Maintain Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the storage and handling of resident care items and the implementation of Enhanced Barrier Precautions (EBP). On Hall Z, clean water basins were observed stored unbagged on a shelf in the dirty linen closet, next to overflowing soiled linen, which was confirmed by laundry staff as inappropriate and a risk for cross-contamination. Additionally, opened and used resident care items, such as wipes and denture cups containing baby powder, were found on the clean linen cart instead of being left in residents' rooms as required. Staff interviews confirmed that some employees habitually returned used items to the clean linen cart, and a used bottle of skin and hair cleanser was also found on the cart. The facility also failed to implement EBP for a resident with an indwelling dialysis catheter, despite active physician orders and care plan interventions specifying the need for EBP. Observations revealed no EBP signage or PPE caddy outside the resident's room, and both the resident and staff confirmed that only gloves were used during care, with no gowns applied. Interviews with CNAs and an LPN demonstrated a lack of awareness regarding the resident's EBP status, and facility leadership acknowledged that EBP was not in place as required.
Deficiency in Comprehensive Care Plan Development
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, major depressive disorder, insomnia, and type 2 diabetes mellitus, had a BIMS score indicating intact cognition and required extensive assistance for bed mobility, transfers, and toilet use. Despite having a history of drug abuse noted on admission, the care plan only included an intervention related to synthetic THC gummies found on 08/22/2024, without additional interventions to address the resident's needs. This oversight was confirmed during an interview with an LPN MDS, who acknowledged that the care plan should have included more comprehensive interventions.
Failure to Consult Physician Before Administering THC Gummies
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering THC gummies to a resident without consulting the resident's physician. The resident, who had a history of drug abuse and was diagnosed with major depressive disorder, hemiplegia, hemiparesis, insomnia, and type 2 diabetes mellitus, was found to be lethargic and with slurred speech after consuming the gummies. The resident's care plan noted a history of drug abuse and depression, with interventions in place to monitor mood and behavior. Despite these precautions, the resident was given THC gummies by the Director of Nursing (DON) without prior consultation with the physician. The incident began when the resident expressed feelings of depression and requested marijuana from the DON, who instead offered to procure THC gummies. The DON consulted with the Administrator, who approved the purchase, believing it was legal. The DON subsequently bought a container of 10 THC gummies and gave them to the resident. The resident consumed some of the gummies, leading to a state of intoxication, which was observed by staff who found the resident's room in disarray with food and items scattered on the floor. The physician was not informed of the resident's request for marijuana or the subsequent provision of THC gummies until after the resident was hospitalized for psychiatric evaluation. The physician confirmed that he would not have approved the use of THC gummies and was unaware of the situation until after the resident's hospitalization. Interviews with staff revealed a lack of communication and failure to follow proper protocols, resulting in the resident's adverse reaction and subsequent hospitalization.
Failure to Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder, resulting in a deficiency. The resident, who had a history of drug abuse and was diagnosed with major depressive disorder, expressed suicidal ideations and was found with synthetic THC gummies. Despite these clear signs of distress, the facility staff did not follow the established protocol for handling such situations. The resident's physician was not notified promptly, and the resident was not placed on one-on-one monitoring as required by the facility's policy. The deficiency was further compounded by the actions of the Director of Nursing (DON), who purchased THC gummies for the resident without consulting the physician. This decision was made after the resident requested marijuana, and the DON, after consulting with the Administrator, decided to provide the gummies. This action was taken without considering the potential impact on the resident's mental health condition, which was already compromised. The situation escalated when the resident expressed suicidal thoughts and exhibited erratic behavior, including tearing up her room. Despite these alarming signs, the staff failed to take immediate action, such as notifying the physician or placing the resident under close supervision. It was only after the resident was sent to the hospital for psychiatric evaluation that the full extent of the oversight became apparent, highlighting a significant lapse in the facility's duty to ensure the resident's safety and well-being.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident with a history of wandering, resulting in the resident exiting the building unsupervised on two occasions. The resident, who had severe cognitive impairment and was at high risk for wandering, managed to leave the facility through the front entrance by following visitors out. This occurred despite the resident having a wander/elopement alarm and being on an hourly monitoring schedule, which was not documented as being followed. The resident's medical records indicated a high risk for wandering, with a history of attempting to leave the facility without informing staff. The care plan included interventions such as coded locks on doors, hourly monitoring, and signage to prevent residents from exiting without staff approval. However, observations revealed that the required signage was not posted, and there was no evidence of hourly monitoring being conducted. Interviews with staff confirmed that the resident was able to exit the facility quickly and that no new interventions were implemented after the incidents. The facility's video footage showed the resident leaving the building unsupervised on both occasions, with no staff present in the lobby at the time. Staff interviews revealed a lack of awareness and documentation regarding the resident's monitoring and the incidents were not considered elopements by the facility, as the resident did not leave the facility grounds. This lack of recognition and response to the incidents contributed to the deficiency in providing adequate supervision to prevent accidents.
Failure to Prevent Resident Elopement and Inadequate Incident Reporting
Penalty
Summary
The facility failed to effectively administer its resources to ensure the safety and well-being of a resident with severe cognitive impairment and a history of wandering. This resident exited the building unsupervised on two occasions, following visitors out through the front entrance and into the parking lot. The facility did not have an effective system in place to supervise the resident adequately, which led to these incidents. Additionally, the facility did not complete incident reports or thoroughly investigate the elopements. The resident's care plan was not updated with new interventions to prevent further unsupervised exits. Interviews with the Director of Nursing (DON) revealed that the facility did not consider these incidents as elopements because the resident did not leave the facility grounds. Furthermore, there was no policy in place for training staff on elopement risks or responses, nor were there any in-services conducted following the incidents.
Verbal and Mental Abuse of Resident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member, resulting in actual harm. The incident involved a resident with severe cognitive impairment, diagnosed with Dementia and Major Depressive Disorder, who was verbally abused by a CNA during the night shift. The abuse was captured on video footage, where the CNA made derogatory and demeaning comments to the resident, including calling them a 'meanie' and comparing their behavior to 'loving the Devil.' The resident, who had a history of attending church services and listening to Christian music, was subjected to further verbal abuse when the CNA used profanity and likened the resident's actions to that of an animal. The resident's daughter confirmed that such language would have been deeply upsetting to her mother, who was raised in a religious environment. The facility's policy on abuse and neglect clearly states that all residents should be free from any form of abuse, including verbal and mental abuse, irrespective of their mental or physical condition. The incident was corroborated by another CNA who was present during the abuse. This CNA provided a written statement and a telephone interview, confirming the inappropriate comments made by the offending CNA and the resident's apparent fear. The facility's administration reviewed the video footage and confirmed the occurrence of verbal and mental abuse, acknowledging the failure to protect the resident from such treatment.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by video footage and interviews. A resident with severe cognitive impairment, who required assistance with daily living activities, was subjected to rough handling by a CNA. The CNA was observed roughly turning the resident and letting her fall back onto the mattress while adjusting her gown. This action was contrary to the facility's policy, which emphasizes treating residents with dignity and respect, and assisting them in maintaining their self-esteem and self-worth. Additionally, the same CNA was observed using her cell phone on speaker while providing care to the resident, ignoring the resident's attempts to communicate. The CNA continued her phone conversation, failing to acknowledge the resident, which is a violation of the facility's policy that requires staff to keep residents informed and oriented to their environment. The CNA later confirmed during an interview that she used her cell phone while providing care, acknowledging that it was inappropriate.
Failure to Update Care Plan After Resident Elopements
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as Resident #R7, following two elopement incidents. Resident #R7, who was admitted with diagnoses including Alzheimer's Disease, Schizoaffective Disorder, and Bipolar Disorder, was assessed as being at high risk for wandering. Despite this, the facility did not update the resident's care plan with new interventions after the resident eloped on two separate occasions. The existing care plan included measures such as coded locks, hourly monitoring, and signage for visitors, but these were not revised following the incidents. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that no additional interventions were implemented after the elopements. The DON acknowledged that Resident #R7 had left the facility unsupervised on two occasions, and the ADM confirmed awareness of these events but admitted that the care plan had not been updated to prevent further elopements. This lack of action represents a failure to adequately address the resident's risk of elopement, as no new strategies were put in place to mitigate this risk after the incidents occurred.
Improper Transfer and Bed Mobility Techniques
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident, as evidenced by improper handling during transfers and bed mobility. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, was subjected to rough handling by CNAs during a transfer to a geri-chair. The CNAs did not follow proper transfer protocols, resulting in the resident being abruptly placed in the chair, which was not positioned correctly for a safe transfer. This incident was captured on video by the resident's family, highlighting the improper technique used by the CNAs. In another incident, a CNA was observed standing on the resident's bed to reposition her, which was against the facility's protocol for a two-person assist. The CNA's actions were captured on video, showing her standing on an unstable surface and pulling the resident up in bed, causing the resident to express discomfort. The CNA admitted to rushing the process and not following the correct procedure, which required moving the mattress and lowering the bed for a safer repositioning. These incidents demonstrate a failure to adhere to the resident's care plan and proper transfer techniques, compromising the resident's safety and dignity. The facility's staff did not anticipate and meet the resident's needs as outlined in her care plan, which included ensuring safe and gentle handling during transfers and bed mobility. The improper actions of the CNAs were documented through video evidence and staff interviews, confirming the deficiencies in care provided to the resident.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper perineal care provided to a resident. The staff did not adhere to the facility's policy on perineal care, which requires washing the perineal area from front to back and discarding disposable items into designated containers. Video footage revealed that a CNA provided perineal care while standing on a mattress on the floor next to the resident's bed, and improperly disposed of soiled linens and briefs by placing them on the mattress and floor. Additionally, the CNA was observed standing on the resident's bed to reposition her, which is not a safe or sanitary practice. The resident involved had severe cognitive impairment and required significant assistance with personal hygiene and toileting. The facility's administrator confirmed that the CNA should not have stood on the resident's bed and acknowledged that the CNA was in a rush, which contributed to the improper care provided.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) for residents where indicated. Observations on two separate days revealed the absence of EBP for residents throughout the facility. The Director of Nursing (DON) confirmed that there was no policy or procedure for EBP and that no residents were placed on EBP as indicated. Additionally, the facility did not maintain a water management program to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the water system. The Administrator confirmed that the facility lacked a plan for when control limits are not met and that the maintenance staff had failed to check the water for Legionella.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of opioid abuse, psychoactive substance abuse, and other related disorders. The interdisciplinary team did not thoroughly evaluate the resident's behavioral symptoms or implement a plan of care to address the severity, distress, and potential safety risks. Despite physician orders to document behaviors every shift and provide specific medications, there was no documentation that the resident was assessed by a psychiatric provider or received psychiatric services over a significant period. The resident exhibited concerning behaviors, including possession of a box cutter and a knife, and made threatening comments to staff members. These incidents were reported to the facility's administrator, who did not document the events in the resident's medical records or contact the resident's physician. The administrator believed the situation was resolved without further action, despite the resident's continued inappropriate and threatening behavior towards staff. Interviews with staff members revealed that the resident's behavior made them feel uncomfortable and unsafe. The facility's failure to address these behaviors and provide appropriate psychiatric care resulted in the resident being placed on 1:1 supervision and eventually transferred to a behavioral hospital. The lack of timely and adequate intervention highlights a significant deficiency in the facility's behavioral health care services.
Failure to Check Placement and GRV for Enteral Feeding
Penalty
Summary
The facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not check the placement and gastric residual volume (GRV) for a resident before administering enteral feeding. The facility's policy requires checking the pH of aspirate and measuring GRV with at least a 60 mL syringe to prevent aspiration and assess tolerance of enteral feeding. However, these procedures were not followed for Resident #45, who had severe cognitive impairment and multiple diagnoses, including cerebral infarction, heart failure, epilepsy, dementia, and chronic kidney disease. On the day of the incident, Resident #45 had been out of the facility on pass and returned around 1:20 p.m. The resident's responsible party notified the staff that the resident needed to be reconnected to her tube feeding. An LPN entered the resident's room, cleaned the feeding tube connection, and connected the tubing to the resident's PEG without checking for placement or residual. The LPN confirmed in an interview that she did not perform these checks but acknowledged that she should have. The Director of Nursing also confirmed that the LPN should have checked the placement before initiating the enteral feeding.
Failure to Properly Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, Chronic Obstructive Pulmonary Disease (COPD), Sarcopenia, and Sleep Apnea. The resident had a physician's order for Ipratropium-Albuterol Inhalation Solution to be administered every six hours as needed for shortness of breath and congestion. However, observations revealed that the resident's nebulizer mouthpiece was improperly stored in an undated Ziploc bag on her bedside table, and the mouthpiece itself was also undated. Interviews and further observations confirmed that the nebulizer equipment was not dated or labeled as required. An LPN confirmed the findings and stated that the weekend ward clerk was responsible for dating and labeling the oxygen equipment weekly, but this had not been done. This failure to properly date and label the respiratory equipment represents a deficiency in the facility's respiratory care practices.
Failure to Ensure Proper Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, who had diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Heart Failure, was readmitted with physician's orders to receive dialysis three days per week. However, the facility did not maintain ongoing communication, coordination, and collaboration with the dialysis facility. Specifically, the dialysis communication sheets were not completed by the dialysis facility, and the nursing staff did not send or receive these sheets for the resident's dialysis appointments. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the communication sheets were not being filled out by the dialysis facility, and the nursing staff did not contact the dialysis nurse to communicate the dialysis care received. The dialysis facility's RN confirmed that the nursing facility did not send communication sheets with the resident, which would have been filled out at each dialysis appointment. The DON acknowledged that the communication sheets should have been completed with each dialysis visit but were not.
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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