Alpine Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ruston, Louisiana.
- Location
- 2401 North Service Road, Ruston, Louisiana 71270
- CMS Provider Number
- 195538
- Inspections on file
- 23
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Alpine Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified that the facility did not consistently provide the minimum required nursing staffing hours on certain weekends, based on review of PBJ staffing data and weekend staffing pattern forms for a fiscal quarter. On two separate weekend days, the total nursing hours actually provided fell below the calculated minimum required hours. In a subsequent interview, the administrator confirmed that the facility failed to meet the minimum staffing requirements on those days.
Nursing staff failed to follow medication administration and documentation requirements for two residents. For one resident with intact cognition and multiple medical conditions, an LPN left a cup containing four oral medications unattended at the bedside and did not remain with the resident to ensure the medications were taken, contrary to facility policy. For another resident with rhabdomyolysis, acute pulmonary edema, CKD, heart failure, and atrial flutter, physician orders for IV Lasix twice daily over several days were not documented as administered on multiple ordered times, and the DON and corporate nurse confirmed the absence of documentation. These issues reflect a lack of required competencies and adherence to medication administration procedures by licensed nursing staff.
Surveyors found that staff failed to follow Enhanced Barrier Precautions and infection control practices during catheter care and bathing for a dependent resident with an indwelling urinary catheter, PEG tube, and pressure ulcer, including not wearing gowns and reusing the same washcloth on genital, perineal, and leg areas, including over an open blister. In addition, a resident with respiratory and neurologic conditions had a nebulizer mask and Yankauer suction device left uncovered instead of stored in bags as required by facility policy, and another resident with chronic pulmonary disease had oxygen tubing left on the floor and not bagged when oxygen was not in use.
A resident with multiple chronic conditions and a cognitively intact BIMS score was self-administering a prescribed nasal spray that was kept on a dresser in the room, rather than secured as required by facility policy. The resident stated that staff provided new bottles as needed and that she administered the medication herself. Review of records and staff interviews showed there was no provider order for self-administration and no completed self-administration assessment or consent, despite facility policy requiring an interdisciplinary evaluation, documentation, and secure storage before allowing self-administration of medications.
A resident with a pressure ulcer did not receive a timely wound assessment by an RN upon discovery of skin breakdown. The resident, who was alert and oriented, reported a sacrum wound, but the initial assessment was conducted by an LPN/Wound Care Nurse. The first RN assessment occurred days later, leading to a deficiency in accurate assessment procedures.
The facility failed to display 'Oxygen in Use' signage outside the rooms of three residents receiving continuous oxygen therapy, as required by their policy. This deficiency was confirmed by the DON during observations.
The facility failed to assess entrapment risks before installing side rails for several residents, including those with severe cognitive impairments and mobility issues. Observations revealed side rails in use without prior assessments or physician orders, and interviews confirmed the absence of necessary documentation.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings at least quarterly, as required. Records showed meetings on specific dates, but there was no meeting between two of these dates, indicating a lapse. An interview with the administrator confirmed the absence of a meeting during this period.
A pharmacist failed to identify and report a medication irregularity for a resident prescribed Quetiapine Fumarate without an appropriate diagnosis. The facility's policy requires communication of medication issues to prescribers and leadership, but the pharmacist did not document or notify the necessary parties about the irregularity, as confirmed by the DON.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications. The resident, with multiple diagnoses including adjustment disorder with depressed mood and vascular dementia, was prescribed Quetiapine Fumarate without an appropriate diagnosis. The DON confirmed the lack of a suitable diagnosis for this antipsychotic medication.
Failure to Meet Minimum Weekend Nursing Staffing Requirements
Penalty
Summary
The facility failed to ensure sufficient nursing staff on all days to meet residents’ needs and to provide at least the minimum required staffing hours on certain weekends. Review of the facility’s PBJ Staffing Data Report for Fiscal Year Quarter 4 2025 (July 1 to September 30) showed that excessively low weekend staffing was triggered. Further review of the Staffing Pattern Forms for weekends in that quarter revealed that on 07/06/2025 the facility provided 255.70 nursing hours when 260.85 hours were required, and on 08/24/2025 the facility provided 271.20 nursing hours when 282 hours were required. In an interview on 01/12/2026 at 3:45 p.m., the administrator confirmed the facility did not provide the minimum required staffing hours on those two dates. No specific resident medical histories or conditions were described in the report, and the deficiency was based on documented staffing hours and administrative confirmation of failure to meet minimum staffing requirements on the identified weekends.
Failure to Ensure Competent Medication Administration and Documentation
Penalty
Summary
The deficiency involves failures in nursing staff competency related to medication administration for two residents. Facility policy for administering oral medications, revised April 2019, requires staff to remain with the resident until all medications have been taken. For one resident, admitted on 06/03/2022 with diagnoses including hemiplegia, muscle wasting, obesity, muscle weakness, pain, debility, and hypokalemia, a quarterly MDS showed intact cognition for daily decision making. On 01/11/2026 at 10:25 a.m., this resident was observed lying in bed with a medication cup containing four pills left unattended on the over-bed table; the resident stated these were his morning medications that he had not taken. At 10:30 a.m., the medications were still at the bedside when observed with the LPN responsible, who acknowledged the medications should not have been left at the bedside and that she should have stayed with the resident until the medications were swallowed. The DON later confirmed the nurse should not have left the medications unattended and should have remained until they were taken. For a second resident, admitted on 12/19/2025 with diagnoses of rhabdomyolysis, acute pulmonary edema, chronic kidney disease, heart failure, and atrial flutter, a physician order dated 12/31/2025 directed Lasix 10 mg/ml, 4 ml IV twice daily for edema for three days, with one dose to be given that day and then twice daily for three days. Review of the January 2026 MAR showed no documented evidence that Lasix was administered as ordered on 01/01/2026 at 8:00 p.m., 01/02/2026 at 8:00 a.m., and 01/03/2026 at 8:00 p.m. In an interview on 01/13/2026 at 4:45 p.m., the DON and Corporate Nurse confirmed there was no documentation of Lasix administration for those ordered times. These findings demonstrate failures to ensure licensed nurses had and applied the necessary competencies and skills to administer and document medications according to physician orders and facility policy.
Failure to Follow Enhanced Barrier Precautions and Sanitary Storage of Respiratory Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP), during urinary catheter care and bathing. One resident with metabolic encephalopathy, mild protein calorie malnutrition, a stage 3 sacral pressure ulcer, dementia, chronic kidney disease, benign prostatic hyperplasia with urinary retention, and an indwelling urinary catheter and PEG tube had an EBP sign posted on the room door. During observation of a bed bath and catheter care, two CNAs entered the room and provided care without donning gowns, despite facility guidance that gowns and gloves are to be used for high-contact care activities such as bathing and device care for residents with indwelling devices and wounds. One CNA performed catheter care and a bed bath without a gown, and the other washed the resident’s face without a gown. During the same bathing episode, the CNA providing catheter care used improper bathing technique that did not follow infection control practices. After placing soap into a washbasin, the CNA cleaned the resident’s penis with a washcloth and then placed the washcloth back into the soapy water. The CNA then retrieved the same washcloth and used it to wipe the resident’s buttocks, legs, and over an open blister on the leg, repeatedly returning the washcloth to the same basin of soapy water. The CNA continued to wash the resident’s lower legs with the same washcloth that had already been used on the genital and perineal areas and over the open blister. In a subsequent interview, the CNA acknowledged not using a gown and confirmed using the same washcloth after cleaning the resident’s penis. The facility also failed to store respiratory equipment in a sanitary manner for two additional residents. For one resident with a history including cerebrovascular accident, dysphagia, acute respiratory failure, protein calorie malnutrition, hypertension, and muscle wasting, a nebulizer mask was observed lying uncovered on a bedside table, and a Yankauer oral suction instrument was observed sitting uncovered on the suction machine, contrary to facility policy requiring such items to be stored in bags. For another resident with interstitial pulmonary disease, pulmonary fibrosis, chronic pulmonary edema, and mild intermittent asthma, an oxygen concentrator with humidifying water was present in the room, and the oxygen tubing attached to the concentrator was observed not stored in a bag and lying on the floor on multiple observations when the resident was not using oxygen. The DON later confirmed that the oxygen tubing should have been stored in a bag and was not stored correctly.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring assessment and authorization before allowing residents to self-administer medications. The facility’s Self-Administration of Medications policy states that residents have the right to self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, based on an assessment of the resident’s mental and physical abilities, including understanding of labels, purpose, dosage, timing, administration, and recognition of risks. The policy further requires completion of a Self Administration of Medications assessment form and a signed consent form, and specifies that medications for self-administration must be stored in a locked cabinet in the resident’s room, not accessible to other residents, with the resident responsible for reporting each dose used to nursing staff. Resident #1 was admitted with diagnoses including encephalopathy (unspecified), Parkinsonism (unspecified), essential tremor, COPD (unspecified), and shortness of breath, and had a BIMS score of 12 indicating cognitive intactness. Physician’s orders included Flonase (fluticasone propionate nasal spray) to be administered as one inhalation in both nostrils twice daily. On multiple observations over two days, surveyors noted a bottle of fluticasone on top of a dresser at the foot of the resident’s bed, rather than secured in a locked cabinet. The resident reported that she self-administered the fluticasone and that staff brought her a new bottle when needed. The DON confirmed the presence of the fluticasone bottle in the room, and the corporate RN confirmed that there was no physician order for self-administration and no completed self-administration assessment for this resident, despite the resident self-administering the medication and keeping it at bedside.
Failure to Conduct Timely RN Wound Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment was completed for a resident with a pressure ulcer. The deficiency was identified when a resident, who was alert and oriented, reported having a wound on the sacrum area. The resident was admitted with several diagnoses, including idiopathic pulmonary fibrosis and mild protein malnutrition. Despite the presence of a wound, a body assessment completed earlier did not record any skin issues. A nurse's note indicated that skin breakdown was reported and assessed by an LPN/Wound Care Nurse, who obtained new physician orders for preventive measures. However, the initial wound assessment was not completed by a registered nurse when the skin breakdown was first identified. The first wound assessment by an RN was conducted several days later, as confirmed by the Director of Nurses. This delay in assessment by a registered nurse upon the initial discovery of the skin breakdown constitutes the deficiency noted in the report.
Failure to Display Oxygen Use Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care by not displaying signage indicating oxygen use outside the rooms of three residents. The facility's Oxygen Administration policy, revised in October 2010, requires an 'Oxygen in Use' sign to be placed outside the resident's room. However, observations revealed that residents who were receiving continuous oxygen therapy did not have the required signage on their doors. This deficiency was noted for three residents, each with various medical conditions requiring oxygen therapy. Resident #29, with severe cognitive impairment and multiple diagnoses including heart failure and dementia, was observed receiving oxygen therapy without the necessary signage. Similarly, resident #316, who was alert and oriented, was also receiving oxygen therapy without the required sign. Resident #104, with a history of hypertension and atrial fibrillation, was observed on multiple occasions with oxygen in use but without the appropriate signage. The Director of Nursing confirmed the absence of the required signage for these residents.
Failure to Assess Entrapment Risks Before Side Rail Installation
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from side rails before their installation. This deficiency was observed in five residents who were reviewed for side rail use. The facility did not complete the required Side Rail Utilization Assessment and obtain consent for side rails prior to their implementation for these residents. Resident #40, who had severe cognitive impairment and required extensive assistance with daily activities, was observed with side rails in the raised position without a prior assessment for entrapment risks. Similarly, resident #55, who had no cognitive impairment but required assistance with mobility, also had side rails installed without an entrapment risk assessment. Both residents' medical records lacked physician orders for side rails, and interviews with the Director of Nursing confirmed the absence of necessary assessments. Resident #50, who was severely cognitively impaired and dependent on staff for all activities, had side rails installed without an entrapment risk assessment, despite having a care plan that included side rails for mobility. Resident #22, with severe cognitive impairment, had side rails installed without prior assessment or consent, which was only completed after the fact. Resident #104, also severely cognitively impaired, had side rails installed without an entrapment risk assessment. Interviews confirmed the lack of documentation for assessing entrapment risks before side rail installation for these residents.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly, as required. A review of records showed that the QAA meetings were held on 10/18/2023, 04/09/2024, 07/10/2024, and 10/30/2024. However, there was no record of a meeting between 10/18/2023 and 04/09/2024, indicating a lapse in the quarterly meeting schedule. An interview with the administrator on 12/04/2024 confirmed the absence of a quarterly meeting in January 2024, further substantiating the failure to adhere to the required meeting frequency.
Pharmacist Fails to Report Medication Irregularity
Penalty
Summary
The pharmacist at the facility failed to identify and report medication irregularities for a resident who was prescribed Quetiapine Fumarate without an appropriate diagnosis. The facility's policy requires the consultant pharmacist to communicate potential or actual problems related to medications to prescribers and facility leadership. However, during the monthly drug regimen review, the pharmacist did not document any irregularity regarding the use of Quetiapine Fumarate for the resident, who had multiple diagnoses including type 2 diabetes mellitus, spinal stenosis, and vascular dementia. An interview with the Director of Nursing confirmed that the pharmacist did not notify the facility, the DON, or the attending physician about the lack of an appropriate diagnosis for the antipsychotic medication prescribed to the resident. This oversight was identified during a review of the resident's electronic health records, which showed an order for Quetiapine Fumarate for mood related to adjustment disorder with depressed mood, but no corresponding diagnosis to justify its use.
Inappropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not have an appropriate diagnosis documented in the medical record for the use of Quetiapine Fumarate, an antipsychotic medication, for a resident. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, adjustment disorder with depressed mood, vascular dementia, and major depressive disorder, had an order for Quetiapine Fumarate to be administered twice daily for mood related to adjustment disorder with depressed mood. During an interview, the Director of Nursing confirmed that the resident did not have an appropriate diagnosis for the use of this antipsychotic medication.
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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