Arbor Lake Skilled Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmerville, Louisiana.
- Location
- 1155 Sterlington Highway, Farmerville, Louisiana 71241
- CMS Provider Number
- 195459
- Inspections on file
- 19
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Arbor Lake Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure residents were free from physical restraints used for convenience, lacking consents and physician orders for lap trays as restraints. Three residents with severe cognitive impairments were observed using gerichairs with lap trays without proper documentation or monitoring for release every two hours.
The facility failed to obtain informed consent for side rail use for two residents. One resident, who is cognitively aware, was observed with bilateral quarter side rails without documented consent or information on risks and benefits. Another resident with Alzheimer's disease was observed with a right quarter side rail, also lacking documented consent and risk-benefit information. Interviews with nursing staff confirmed these deficiencies.
The facility failed to ensure proper documentation of medication administration for several residents, leading to deficiencies in care. Residents with severe cognitive impairments and various medical conditions had multiple instances of undocumented medication administration over two months. This issue was confirmed by the facility's nursing leadership, indicating a systemic problem with medication administration documentation.
A pharmacist failed to identify and report irregularities in medication administration documentation for several residents, including those with severe cognitive impairments and various medical conditions. The oversight involved missing entries in the September 2024 MAR, which were not addressed in the pharmacist's October report. This deficiency was confirmed by the DON and ADON through interviews.
A resident with multiple health conditions was found self-administering unauthorized medications, including Fluticasone nasal spray and an Albuterol inhaler, without proper assessment or documentation. The facility's policy requires evaluation of residents' abilities to self-administer medications and secure storage of such medications, which was not adhered to in this case. An LPN confirmed the resident should not have had these medications at the bedside, indicating a deficiency in medication management.
A facility failed to document the reason for a resident's hospital transfer, violating discharge procedures. The resident had multiple medical conditions, but there was no record in the nurses' notes explaining the transfer. Staff confirmed the lack of documentation and that the family was only notified by phone.
A facility failed to provide a resident-centered activity program for a resident with severe cognitive impairment, despite their expressed preferences and care plan. The resident, with multiple health diagnoses, was observed sitting without engaging in activities, and staff interactions were minimal. Interviews revealed a lack of documentation and facilitation of activities, leading to the deficiency.
A facility failed to provide adequate supervision for a resident with severe cognitive impairment and multiple psychiatric and neurological conditions, who was investigated for smoking. Despite a care plan identifying the resident as at risk for injury related to smoking, the resident was left unsupervised in the smoking area, and staff inaccurately assessed the resident as a safe smoker. The facility's smoking policy requires supervision in designated areas, but observations showed the resident was not properly monitored, leading to a deficiency in ensuring safety.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications by not providing an acceptable diagnosis for Seroquel. Despite recommendations from a Pharmaceutical Consultant, the physician did not address the need for an appropriate diagnosis, which was confirmed by the DON.
Failure to Obtain Consents and Monitor Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, the facility did not obtain restraint consents that included the risks and benefits of restraint use for three residents. Additionally, there were no physician orders for the use of lap trays as restraints for two of these residents, and there was a lack of monitoring for the release of the lap trays for all three residents. Resident #42 was admitted with multiple diagnoses, including major depressive disorder and dementia. The resident's care plan included the use of a gerichair with a lap tray to promote mobility and socialization. However, there was no documented pre-restraining assessment prior to the implementation of the gerichair with a lap tray, and the consent form did not specify the restraint or identify the associated risks and benefits. Furthermore, there was no evidence of monitoring for the release of the lap tray every two hours as required. Similarly, residents #64 and #92 were observed using gerichairs with lap trays without physician orders or documented consents. Both residents had severe cognitive impairments and required assistance with daily activities. The facility failed to document the monitoring of the lap trays' release every two hours, and there was no evidence that the residents or their responsible parties were informed of the potential risks and benefits of using the lap trays as restraints.
Failure to Obtain Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of side rails for two residents, as required by their policy. Resident #22, who is cognitively aware and able to make daily decisions, was observed with bilateral quarter side rails raised on multiple occasions. However, the facility did not document the assistive device in the resident's consent form, nor did they inform the resident or their representative about the potential benefits and risks associated with the side rail use. Interviews with the Assistant Director of Nurses (ADON) and the Director of Nursing (DON) confirmed the absence of consent for the use of side rails for this resident. Similarly, Resident #18, who has a diagnosis of Alzheimer's disease and requires extensive assistance with bed mobility, was observed with a right quarter side rail raised. The facility also failed to document this assistive device in the resident's consent form and did not inform the resident or their representative about the potential benefits and risks of side rail use. An interview with another ADON confirmed that the consent form did not identify the use of the right quarter side rail and that the potential risks and benefits were not included in the consent.
Inadequate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to care for residents' needs, as evidenced by inadequate documentation of medication administration for six residents. The report highlights that there was no documentation of medication administration for various medications prescribed to these residents over September and October 2024. This lack of documentation was confirmed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) during interviews. Resident #68, who has severe cognitive impairment and multiple diagnoses including type 2 diabetes and congestive heart failure, had numerous instances of undocumented medication administration. The September and October 2024 Medication Administration Records (MARs) revealed missing documentation for several medications, including Atorvastatin, Lasix, and Zoloft, among others. Additionally, required assessments such as pain and behavior/mood monitoring were not consistently documented. Similarly, other residents, including those with moderate cognitive impairment and various medical conditions, also experienced lapses in documentation. For instance, Resident #17's MARs showed missing documentation for Macrobid administration, while Resident #83's records lacked documentation for Eliquis administration and bleeding precautions monitoring. These deficiencies were acknowledged by the facility's nursing leadership, indicating a systemic issue with medication administration documentation across the facility.
Pharmacist Fails to Report Medication Documentation Irregularities
Penalty
Summary
The deficiency involves a failure by the pharmacist to identify and report irregularities in medication administration documentation for several residents. The pharmacist did not notify the attending physician, the facility's medical director, or the director of nursing about these irregularities, which included incomplete documentation of medication administration for multiple residents. This oversight was identified during a review of the September 2024 Medication Administration Records (MAR) and confirmed by the Director of Nursing (DON). Resident #68, who has severe cognitive impairment and multiple diagnoses including diabetes and dementia, had numerous instances of undocumented medication administration in September 2024. The pharmacist's October 2024 report failed to address these missing entries. Similarly, Resident #17, with moderate cognitive impairment and a history of urinary tract infections, had missing documentation for the administration of Macrobid, an antibiotic, which was not identified by the pharmacist. Other residents, including those with severe cognitive impairments and various medical conditions, also had significant gaps in their medication administration records. For instance, Resident #50 had multiple medications not documented as administered, and Resident #59 had several instances of undocumented medication administration. The pharmacist's failure to report these irregularities was confirmed through interviews with the DON and Assistant Director of Nursing (ADON), highlighting a systemic issue in the medication review process.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as required by their policy. The policy mandates that staff and practitioners evaluate each resident's mental and physical abilities to determine if self-administration is clinically appropriate. Additionally, the policy requires that self-administered medications be stored securely and that unauthorized medications found at the bedside be reported to the Charge Nurse. However, the facility did not follow these procedures for a resident diagnosed with multiple conditions, including ALS, depression, heart disease, diabetes, hypertension, cerebrovascular disease sequelae, and anxiety disorder. The resident was found to have unauthorized medications, specifically Fluticasone nasal spray and an Albuterol inhaler, at their bedside, which they were self-administering without proper assessment or documentation. These medications were not included in the resident's physician orders, indicating a lack of oversight and adherence to the facility's medication management policy. An LPN later confirmed that the resident should not have had these medications at the bedside and should not have been self-administering them, highlighting a deficiency in the facility's medication administration and monitoring processes.
Failure to Document Hospital Transfer
Penalty
Summary
The facility failed to document the necessity for transferring a resident to the hospital, which is a requirement for proper discharge and transfer procedures. Specifically, there was no documentation in the medical record for a resident who was transferred to the hospital. The facility's policy requires that any changes in a resident's medical or mental condition be recorded in their medical record, but this was not adhered to in the case of the resident in question. The resident had a complex medical history, including conditions such as cerebral infarction, hypertension, and dementia, among others. Despite this, there was no documentation in the nurses' notes explaining why the resident was discharged to the hospital. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed the lack of documentation and that the only communication with the family was a phone call, with no written record of the notification.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the comprehensive assessment, care plan, and preferences of a resident with severe cognitive impairment. The resident, who has diagnoses including hypertensive chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes, expressed a preference for participating in any scheduled activities and indicated happiness when able to attend church. Despite these preferences, observations revealed that the resident spent significant time sitting at a table with staff but without engaging in any activities. Staff interactions were minimal, and the resident was not encouraged or assisted to participate in scheduled activities such as bingo or Bible study. Interviews with staff indicated a lack of documentation regarding specific activities provided to the resident, and the activity notes suggested a goal to offer in-room or daily activities to reduce loneliness or boredom. However, the resident expressed a desire to attend Bible study, which was not facilitated. The lack of engagement and failure to adhere to the resident's care plan and preferences resulted in the deficiency noted by surveyors.
Inadequate Supervision of Resident Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses, who was investigated for smoking. The facility's smoking policy mandates a smoke-free environment and requires supervision in designated smoking areas. However, observations revealed that the resident was left unsupervised in the smoking area on multiple occasions, with staff from various departments lighting cigarettes for the resident without proper monitoring. The resident was known to dig in ashtrays and pick up cigarette butts, indicating a risk for unsafe smoking behavior. The resident's care plan identified a risk for injury related to smoking, with interventions including counseling on smoking hazards and designated areas, as well as observation during smoking. Despite these interventions, the resident was inaccurately assessed as a safe smoker, and the facility failed to provide the necessary supervision. Interviews with staff confirmed that the resident should have been deemed an unsafe smoker and required monitoring while smoking. The lack of accurate assessment and supervision led to the deficiency in ensuring the resident's safety.
Failure to Document Appropriate Diagnosis for 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 provide an acceptable diagnosis for the use of Seroquel for a resident who was admitted with diagnoses including unspecified dementia without behavioral, psychotic, or mood disturbances, anxiety, depression, and other conditions. The resident's October 2024 Physician's Orders included Seroquel with an associated diagnosis of unspecified dementia and anxiety, but lacked a documented acceptable diagnosis for the psychotropic medication. The Pharmaceutical Consultant Report dated 10/10/2024 recommended providing an appropriate diagnosis for the use of Seroquel. However, the physician only addressed the request for a Gradual Dose Reduction (GDR) on 10/30/2024 and did not address the need for an appropriate diagnosis. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the failure to document an acceptable diagnosis for the use of Seroquel.
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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