Ascension Oaks Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gonzales, Louisiana.
- Location
- 711 W. Cornerview Road, Gonzales, Louisiana 70737
- CMS Provider Number
- 195401
- Inspections on file
- 16
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ascension Oaks Nursing & Rehab Center during CMS and state inspections, most recent first.
Staff failed to accurately document the administration or omission of multiple prescribed medications and supplements for two residents in the eMAR, resulting in missing records and signatures for several medications, as confirmed by the DON and facility policy.
The QAPI committee did not provide evidence of ongoing monitoring or evaluation to ensure corrective actions were implemented after identifying the need to monitor coffee temperatures. Despite in-service training and daily audits, coffee was served above the recommended temperature range, and no corrective action or review by the QAPI committee was documented.
A resident with an active diagnosis of bipolar disorder was not referred for a required PASARR Level II evaluation by the facility. Review of records and staff interview confirmed that the necessary referral to the state behavioral health office was not made since the resident's admission.
Surveyors observed that food was served to residents at temperatures below the expected standard, with several residents reporting their meals were cold or lukewarm. Staff left the tray cart door open during meal delivery, and food temperature checks confirmed items were not at the required serving temperature. The dietary manager acknowledged delays in meal service contributed to the issue.
Staff failed to properly seal and label opened frozen food items and did not follow required procedures for sanitizing dishware in the 3 compartment sink, including monitoring water temperatures and soak times as specified by manufacturer instructions.
A wound care nurse failed to perform hand hygiene between glove changes while providing wound care to a resident, despite facility policies requiring handwashing before and after resident contact and during dressing changes. This deficiency was confirmed by interviews with the nurse, the infection preventionist, and the DON.
A resident in a semi-private room was found to be without a required ceiling-suspended privacy curtain around their bed, despite sharing the room with a roommate. Staff and the administrator confirmed the absence of the curtain and acknowledged it should have been in place to ensure privacy.
A resident sustained a serious head injury after falling from a mechanical lift due to staff failing to inspect the sling and locking the lift's brakes during transfer, contrary to the manufacturer's guidelines. The facility also did not follow proper laundering procedures for the lift slings, potentially compromising their integrity.
A facility failed to ensure staff were trained and competent in using a mechanical lift, leading to a resident's fall and serious injury. The CNA did not inspect the lift sling properly and locked the brakes against the manufacturer's guidelines. The CNA Supervisor and other responsible staff were unaware of the correct procedures, and no documented competency evaluation was available.
A resident was injured due to improper use of a mechanical lift in a facility. Staff failed to inspect the lift sling for damage and did not unlock the lift's brakes during transfer, resulting in the resident falling and sustaining a serious injury. Additionally, the facility did not follow manufacturer's guidelines for laundering lift slings, and there was no evidence of staff competency evaluations for using the lift.
The facility's assessment was incomplete, missing critical components such as staff competencies, physical environment and equipment, and cultural factors. The Regional Director of Operations confirmed the oversight during an interview, acknowledging that Section 3, which should have covered these areas, was not completed.
The facility failed to provide required training on resident rights and facility responsibilities to several CNAs, including a supervisor. Personnel records for staff hired between 2014 and 2023 lacked documentation of this training. The administrator confirmed the absence of evidence for the required training.
Two cognitively intact residents were not invited to participate in their care plan meetings, as evidenced by the absence of scheduled times on the facility's list and confirmed by the residents themselves. The facility's social services staff acknowledged the lack of documented evidence of invitations, despite the interdisciplinary team meeting with residents individually before care plan meetings.
The facility did not conduct annual performance evaluations or provide training for several CNAs and their supervisor. Personnel records showed no evidence of evaluations for CNAs hired between 2016 and 2023. Interviews confirmed the absence of evaluations, with the CNA Supervisor and Administrator acknowledging the oversight.
A facility failed to maintain accurate blood glucose records for a resident. The resident had a physician's order for Novolog based on a sliding scale, but the eMAR showed discrepancies, including undocumented blood glucose levels and vague documentation. The Assistant DON acknowledged these inaccuracies and emphasized the need for precise documentation.
The facility failed to provide required QAPI training to several CNAs, including a supervisor, as evidenced by the absence of documentation in their personnel records. The administrator confirmed the lack of training records, highlighting a deficiency in staff training on the QAPI program.
The facility failed to provide documented infection control training for CNAs, including a supervisor, hired between 2014 and 2023. An interview with the administrator confirmed the absence of required training documentation, indicating a systemic issue in the facility's infection prevention and control program.
The facility failed to provide required compliance and ethics training to its CNA staff, including a CNA Supervisor, as evidenced by the absence of documentation in their personnel records. The administrator confirmed the lack of training records for staff hired between 2014 and 2023.
A facility failed to ensure a resident's call light button was within reach, as required by the care plan. The resident, who is bed-bound, had the call light button placed at the base of the bed or at their feet, making it unreachable. CNAs and the Assistant Director of Nursing confirmed that the call light should have been accessible.
A resident's code status was not updated in the EMR to reflect their advance directive, which indicated Do Not Resuscitate (DNR). Despite being notified of the change, the LPN Medicare Nurse Manager delayed updating the EMR, resulting in a discrepancy between the resident's wishes and their documented code status. The facility's administrator confirmed the oversight.
Two residents in an LTC facility received improper catheter care, leading to deficiencies. A resident's catheter bag was found on the floor, which is unsanitary. Another resident, with a history of UTIs, had their catheter area cleaned with contaminated water by a CNA, which was acknowledged as incorrect by the CNA and the Assistant DON.
The facility failed to properly contain soiled linen, as observed in a resident's room where linens were left on the floor, emitting a urine odor. The resident expressed dissatisfaction, and a CNA confirmed the linens should not have been on the floor. The administrator acknowledged the issue but did not elaborate further.
Failure to Accurately Document Medication Administration in eMAR
Penalty
Summary
The facility failed to maintain and accurately document the electronic Medication Administration Record (eMAR) for two residents, as required by professional standards and the facility's own policy. Review of the medical records policy indicated that staff are expected to record all care provided, including medication administration, and to document any adverse reactions or abnormalities. However, for two residents, there was no documented evidence in the eMAR that multiple prescribed medications and supplements were either administered or not administered on several specified dates and times. This included medications for insomnia, constipation, pain, mood disorders, anxiety, nutritional supplementation, and blood thinning. Interviews and record reviews confirmed that the required documentation was missing for these residents, and the Director of Nursing acknowledged that staff should have documented whether medications and supplements were given or not. The absence of documentation included missing signatures and lack of evidence for administration or omission of medications, contrary to facility policy and accepted standards for maintaining resident medical records.
Failure to Monitor and Evaluate Coffee Temperature Compliance
Penalty
Summary
The QAPI committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying the need to monitor coffee temperatures. The facility's QAPI policy required systems to monitor care and services, including the use of performance indicators to track care processes and outcomes. An in-service training instructed staff to serve coffee at temperatures between 120 to 140 degrees Fahrenheit. However, audit documentation showed that on one occasion, coffee was served at 149.1 degrees Fahrenheit, which was outside the specified range, and no corrective action was documented. Interviews with the Dietary Manager and the DON confirmed that while coffee temperatures were being recorded and audit forms were placed in the QAPI binder, there was no staff member assigned to monitor or evaluate the recorded temperatures or the effectiveness of the in-service training. There was no documented evidence that the QAPI committee reviewed or acted upon the audit findings to ensure compliance with the established temperature guidelines.
Failure to Refer Resident with Serious Mental Illness for PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder, a serious mental illness, was referred to the Louisiana Office of Behavioral Health for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. Review of the resident's clinical record showed an active diagnosis of bipolar disorder since admission, but there was no documented evidence that a PASARR Level II referral had been made. The social worker responsible for initiating such referrals confirmed in an interview that the resident had not been referred for the required evaluation since admission.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors found that the facility failed to serve food at an acceptable temperature, as required. Multiple residents residing on Hall a reported that their food was cold or lukewarm. Observations revealed that a staff member transported lunch trays on a tray cart with the door left open, and food on one resident's tray was found to be lukewarm. Temperature checks of the food items showed readings of 103°F for black eyed peas, 107°F for cooked turnip greens, and 99°F for a fried pork fritter, all below the dietary manager's stated expectation of 120°F for served food. The dietary manager acknowledged that lunch trays had exited the kitchen at 11:35AM but had not been served to all residents by 11:51AM, contributing to the food being served at suboptimal temperatures. Multiple residents confirmed through interviews that their lunch was not hot or was served cold.
Deficiencies in Food Storage and Dish Sanitization Procedures
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of frozen food items, as evidenced by an observation of an opened box of okra in the facility's freezer that was not sealed or labeled with an opened date. The facility's policy required that opened boxes of frozen foods be closed, sealed tightly, and dated when opened, but this was not followed. The Dietary Manager confirmed that the bag of okra was not sealed or labeled as required. Additionally, staff did not adhere to the manufacturer's instructions for sanitizing dishware using the 3 compartment sink. The instructions specified that water in the rinse compartment should be at least 110 degrees Fahrenheit, the sanitization compartment at 75 degrees Fahrenheit, and that dishes should be submerged in the sanitization compartment for 45 seconds. However, a cook reported only checking the temperature of the wash compartment and not timing the sanitization soak, and observations confirmed that temperatures and soak times were not properly monitored. The Dietary Manager and Regional Director of Operations provided inconsistent information regarding the required soak time, further indicating a lack of adherence to proper procedures.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During a wound care procedure for a resident, the wound care nurse sanitized her hands and donned a gown and gloves before beginning the dressing change. After removing the resident's right foot dressing and disposing of it in a biohazard bag, the nurse removed her gloves and immediately put on a new pair without performing hand hygiene. This process was repeated after cleaning the wound with normal saline, as the nurse again changed gloves without sanitizing her hands in between. Interviews with the wound care nurse, the infection preventionist, and the director of nursing confirmed that hand hygiene should have been performed between glove changes during the dressing change. The facility's policies on universal precautions and handwashing technique require handwashing before and after each resident contact and during duties such as handling dressings, regardless of glove use. The failure to perform hand hygiene between glove changes was observed and acknowledged by staff.
Missing Privacy Curtain in Semi-Private Room
Penalty
Summary
A deficiency was identified when a resident in a semi-private room was observed on two separate occasions to lack a ceiling-suspended privacy curtain around their bed, as required to ensure privacy. During interviews, a Certified Nursing Assistant confirmed that the resident was sharing the room with a roommate and acknowledged that the privacy curtain was missing and should not have been. The facility administrator also confirmed that a privacy curtain is required for residents in semi-private rooms and acknowledged the absence of the curtain for this resident.
Failure to Follow Lift Procedures Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident during a transfer using a mechanical lift, resulting in a serious accident. The staff did not follow the manufacturer's guidelines for the [NAME]-Lift, which required inspecting the sling for damage and leaving the lift's brakes unlocked during transfers. On the day of the incident, the CNA did not inspect the sling, which was already positioned under the resident, and proceeded with the transfer with the lift's brakes locked. This led to the sling's straps breaking, causing the resident to fall and sustain a left temporoparietal subarachnoid hemorrhage. The resident involved in the incident had been admitted to the facility with diagnoses of Down syndrome and Alzheimer's disease. During the transfer, the resident fell from the lift when the sling's straps broke, resulting in a fall that caused a head injury. The resident was subsequently sent to the hospital, where a CT scan confirmed the presence of a subarachnoid hemorrhage. Interviews with the CNAs involved revealed that they were unaware of the requirement to inspect the sling and to leave the brakes unlocked, which contributed to the accident. Additionally, the facility failed to properly launder the lift slings according to the manufacturer's instructions. The slings were dried in a facility dryer that did not have a delicate cycle, contrary to the guidelines that required either a delicate cycle or air drying. The Housekeeping/Laundry Supervisor was unaware of these guidelines, indicating a lack of communication and training regarding the proper care of the lift slings. This oversight could have contributed to the weakening of the sling, leading to the incident.
Deficient Training and Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that its staff, specifically a Certified Nursing Assistant (CNA), was trained and deemed competent to transfer a resident using a mechanical lift according to the manufacturer's guidelines. This deficiency was highlighted when a resident was transferred using the lift, and the CNA did not inspect the lift sling properly before use. The CNA also locked the brakes of the lift, contrary to the manufacturer's instructions, which required the brakes to remain unlocked to maintain stability during the transfer. During the transfer, the straps of the lift sling broke, causing the resident to fall to the floor. As a result, the resident sustained a left temporoparietal subarachnoid hemorrhage, a serious injury involving bleeding in the brain. The incident was reported, and it was found that the CNA had not been evaluated for competency in using the lift, and the CNA Supervisor was unaware of the correct procedure for using the lift, including the requirement to leave the brakes unlocked. Interviews with staff revealed a lack of proper training and competency evaluation for using the mechanical lift. The CNA Supervisor, along with the Director of Nursing and Assistant Director of Nursing, were responsible for training staff but did not follow the manufacturer's guidelines. The facility was unable to provide documented evidence of the CNA's competency evaluation, and the Administrator acknowledged awareness of the correct procedure but did not offer further explanation for the deficiency.
Deficient Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a serious incident involving a resident. The staff did not follow the facility's policy for transferring a resident using a mechanical lift, known as the [NAME]-Lift. Specifically, the staff did not inspect the entire sling for damage before use and failed to unlock the lift's brakes during the transfer. This oversight resulted in the sling's straps breaking, causing the resident to fall and sustain a left temporoparietal subarachnoid hemorrhage, necessitating emergency medical attention. Additionally, the facility lacked a proper system to ensure the laundering of the [NAME]-Lift slings according to the manufacturer's guidelines. The Housekeeping/Laundry Supervisor was unaware of these guidelines, and the facility's dryer did not have a delicate cycle, which could compromise the integrity of the slings. Furthermore, there was no documented evidence that staff, including the CNA involved, were evaluated and deemed competent in using the [NAME]-Lift, highlighting a significant gap in staff training and competency assurance.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that addressed all necessary components for competent resident care during both routine operations and emergencies. The assessment, dated and reviewed on 06/14/2024, was found lacking in several critical areas, including staff competencies, the physical environment and equipment, ethnic, cultural, or religious factors, and the facility's resources. During an interview on 06/26/2024, the Regional Director of Operations acknowledged that the facility had not completed Section 3 of the assessment, which was supposed to cover these missing components. This oversight resulted in the facility-wide assessment being incomplete and not meeting the required standards.
Lack of Required Training on Resident Rights for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required training on resident rights and facility responsibilities. This deficiency was identified through interviews and record reviews, which revealed that seven CNAs, including a CNA Supervisor, did not have documented evidence of completing the necessary training. The personnel records of these staff members, hired between 2014 and 2023, lacked documentation of the required training on resident rights and facility responsibilities. During an interview, the facility's administrator acknowledged the absence of documented evidence for the required training for the mentioned staff members. This lack of documentation indicates that the facility did not comply with the training requirements necessary to ensure proper care for its residents, as mandated by regulations.
Failure to Invite Cognitively Intact Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, who were cognitively intact, were able to participate in their care plan meetings. Resident #32, with a BIMS score of 15, indicating cognitive intactness, was not invited to care plan meetings on three occasions as evidenced by the absence of a time noted next to her name on the facility's list of care plan meetings. In an interview, Resident #32 confirmed that she had never been invited to a care plan meeting and expressed willingness to attend if invited. Similarly, Resident #46, also with a BIMS score of 15, was not invited to care plan meetings on three separate occasions. The facility's list of care plan meetings showed no time noted next to Resident #46's name, and in an interview, she confirmed not being invited to any care plan meetings. The facility's social services staff indicated that the interdisciplinary team met with residents individually before the care plan meetings and then met without the residents to review the care plans. However, there was no documented evidence that either resident was invited to participate in their care plan meetings.
Failure to Conduct CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance reviews and provide training based on performance evaluation outcomes for several Certified Nursing Assistants (CNAs) and a CNA Supervisor. The personnel records of seven CNAs and their supervisor were reviewed, revealing a lack of documented evidence of yearly performance evaluations or training. The CNAs in question were hired between 2016 and 2023, yet none had received the required evaluations or subsequent training. Interviews conducted with the CNA Supervisor and the facility's Administrator confirmed the absence of performance evaluations for the CNA staff. The CNA Supervisor admitted to not completing evaluations for the CNAs under her supervision. Additionally, the Administrator acknowledged conducting evaluations for certain staff but not for the CNA staff, indicating a systemic oversight in the facility's performance review process for this group of employees.
Inaccurate Blood Glucose Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding blood glucose levels. Resident #32 had a physician's order to receive Novolog, a diabetes medication, based on a sliding scale. However, the electronic Medication Administration Record (eMAR) for June 2024 showed discrepancies. On June 17, 2024, the resident was administered 3 units of Novolog for a blood glucose level of 173, but there was also an instance where no units were administered despite the blood glucose being documented as 'high.' Additionally, there was no documentation of blood glucose levels on June 9, 2024. During an interview, the Assistant Director of Nursing acknowledged the inaccuracies in the eMAR and stated that nurses should document actual blood glucose levels instead of using vague terms like 'high.'
Failure to Train CNAs on QAPI Requirements
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were trained on the requirements for the Quality Assurance Performance Improvement (QAPI) program. This deficiency was identified through interviews and record reviews, which revealed that seven CNAs, including a CNA Supervisor, did not have documented evidence of receiving the required QAPI training. The personnel records of these staff members, hired between 2014 and 2023, lacked documentation of training on the elements and goals of the facility's QAPI program. During an interview, the facility's administrator admitted the inability to produce documented evidence of the required QAPI training for the mentioned staff. This lack of documentation indicates a failure in the facility's responsibility to ensure that all staff are adequately trained in the QAPI program, which is essential for maintaining and improving the quality of care provided to residents.
Inadequate Infection Control Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were adequately trained on an infection control system designed to prevent, identify, report, investigate, and control infections and communicable diseases. This deficiency was identified through interviews and record reviews, which revealed that none of the seven personnel records reviewed contained documented evidence of such training. The CNAs in question, including a CNA Supervisor, were hired between 2014 and 2023, yet there was no documentation to confirm that they had received the necessary infection control training. During an interview, the facility's administrator admitted the inability to produce documented evidence of the required infection control training for the staff members mentioned. This lack of documentation indicates a systemic failure in the facility's infection prevention and control program, as it did not include mandatory training with written standards, policies, and procedures for infection control. The absence of this critical training could potentially compromise the facility's ability to manage infections and communicable diseases effectively.
Lack of Compliance and Ethics Training for CNA Staff
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were trained on the requirements for Compliance and Ethics. This deficiency was identified for seven staff members, including six CNAs and one CNA Supervisor. The personnel records of these staff members, hired between 2014 and 2023, lacked documented evidence of training on compliance and ethics as required by regulations. The absence of such documentation was confirmed through interviews and record reviews. During an interview, the facility's administrator acknowledged the inability to produce documented evidence of the required training for the mentioned staff. This lack of documentation indicates that the facility did not fulfill its obligation to train its staff on compliance and ethics, which is a critical component of maintaining regulatory standards and ensuring ethical practices within the facility.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light button was within reach, as required by the resident's care plan. The care plan for the resident, who is bed-bound, specified that the call light button should be accessible to the resident. However, observations on multiple occasions revealed that the call light button was placed at the base of the bed or at the resident's feet, making it unreachable. Interviews with Certified Nursing Assistants (CNAs) confirmed that the call light button should not have been positioned at the resident's feet and should have been within reach. The Assistant Director of Nursing also acknowledged that the call light button should be accessible to the resident.
Failure to Update Resident's Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was consistent with their wishes, as documented in their advance directive. Resident #86, who was admitted with diagnoses of aphasia and dementia, had an advance directive indicating that Cardiopulmonary Resuscitation (CPR) should not be performed. However, a review of the resident's Electronic Medical Record (EMR) showed that the Advanced Directives tab incorrectly listed the resident as requiring CPR, and the Physician's Orders had an active order to initiate CPR. Interviews revealed that the Licensed Practical Nurse (LPN) Medicare Nurse Manager was notified of the change in the resident's code status to Do Not Resuscitate (DNR) by Social Services but did not update the EMR until a later date. The LPN acknowledged the importance of ensuring that a resident's code status in their EMR matches their advance directive to ensure the resident's wishes are followed. The facility's administrator confirmed that the code status should have been updated promptly.
Improper Catheter Care and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper sanitary care for residents with urinary catheters, leading to deficiencies in the care of two residents. Resident #16 was observed with a catheter bag placed on the floor, which was confirmed by both the Staff Development Nurse and the Infection Preventionist as inappropriate and unsanitary. This improper placement of the catheter bag could potentially lead to contamination and infection. Resident #76, who had a history of urinary tract infections, received improper catheter care from a Certified Nursing Assistant (CNA). The CNA used two wash basins, one with soapy water and one with clean rinsing water, but contaminated the rinsing water by placing used towels into it. The CNA then used the contaminated rinsing water to clean the resident's perineal and catheter area, which was acknowledged as incorrect by both the CNA and the Assistant Director of Nursing. This improper procedure could compromise the resident's health by increasing the risk of infection.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to ensure that soiled linen was bagged or contained in a sanitary manner at the location where it was collected. This deficiency was observed in the case of one resident, where soiled linens were found on the floor of the resident's room, accompanied by a urine odor. During an interview, the resident expressed dissatisfaction with the presence of soiled linen on the floor and indicated a need for someone to remove them. A Certified Nursing Assistant (CNA) confirmed that the soiled linen should not have been on the floor. The facility administrator acknowledged the CNA's response but did not provide further explanation regarding the deficient practice.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
