Avalon Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 4385 Old Sterlington Road, Monroe, Louisiana 71203
- CMS Provider Number
- 195492
- Inspections on file
- 29
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avalon Place during CMS and state inspections, most recent first.
Two residents had inaccurate MDS assessments: one was incorrectly marked as a non-smoker despite documentation and care planning for smoking, and another was documented as not having a colostomy when their care plan included interventions for colostomy care. These inaccuracies were confirmed by facility leadership.
Nursing staff did not properly assess or document care for two residents, including failing to record the rationale for a foot x-ray for one resident and not completing an assessment when another resident reported abdominal pain before hospital transfer. Leadership confirmed the lack of required documentation and assessment by nursing staff.
The facility did not notify the physician or resident representatives when two residents experienced significant changes in condition or were transferred to the hospital. In both cases, documentation confirming required notifications was missing, as verified by staff interviews and record reviews.
A resident with a colostomy did not receive or have documented colostomy care as ordered and per facility policy over several days. Required checks of the stoma site and colostomy bag changes were not documented, and the resident was later hospitalized with complications at the ostomy site, including abnormal bowel color and questionable gangrene.
A resident with dementia and other conditions was involved in an incident where she hit her head on a table. The LPN attempted to notify the resident's physician but was unable to due to outdated contact information, resulting in a failure to communicate the incident. The Interim DON confirmed the LPN should have notified the physician, indicating a deficiency in the notification process.
The facility failed to provide adequate pressure ulcer care for two residents. A resident with moderate cognitive impairment was found with an open pressure ulcer on her heel, without a pressure-relieving device in place, despite previous complaints of pain. Another resident with severe cognitive impairment and a Stage II pressure ulcer on the hip was observed sitting in a geri chair without a pressure-relieving device, risking further skin breakdown.
The facility failed to document and assess incidents involving assistive devices for two residents with severe cognitive impairments. One resident slid under a lap tray and fell, while another broke a lap tray and slid to the floor, resulting in a skin tear. Neither incident was documented in an Incident/Accident Report, nor were the residents assessed for the appropriateness of the assistive devices.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease by not monitoring fluid intake as per physician orders. Despite a 1000 cc fluid restriction, staff interviews revealed that no fluid intake log was maintained, and the ADON confirmed the lack of documentation.
The facility failed to assess the risk of entrapment from bed rails for four residents before installation, despite policy requirements. Observations revealed residents with cognitive impairments and mobility issues had bed rails raised without documented assessments. Interviews confirmed the lack of assessments.
The facility experienced a medication error rate of 10.71%, exceeding the acceptable threshold of 5%. An LPN administered incorrect dosages of Furosemide and Gabapentin to a resident, and another resident received an incorrect dosage of Fludrocortisone. These errors were confirmed by the ADON during an interview.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling medical devices, as required by their policy. Observations showed that these residents did not have EBP signage on their doors, despite having conditions that necessitated such precautions. Interviews confirmed the oversight in communicating and implementing the EBP policy.
The facility failed to notify the appropriate parties of changes in resident conditions. A resident with severe cognitive impairment experienced a fall, but the family was not informed by the LPN. In another case, a resident with moderate cognitive impairment was found with multiple bruises, but the nursing administration was not notified as required by policy.
The facility failed to ensure residents were free from physical restraints used for convenience, as three residents were observed with lap trays without proper documentation or physician orders. Despite severe cognitive impairments, these residents were not monitored for the release of restraints as required by policy, and staff confirmed these deficiencies.
A facility failed to notify a resident and their representative of hospital transfers and did not inform the Ombudsman. The resident was transferred twice without proper notification, as confirmed by the Ombudsman and facility records.
The facility failed to complete quarterly MDS assessments for two residents as required by CMS. One resident's last assessment was in late June, and the other in early June, with no subsequent assessments documented within the required three-month period. The ADON confirmed the oversight.
A facility failed to ensure accurate MDS documentation for a resident's discharge status. The MDS indicated a discharge to the hospital, but nurse's notes and staff interviews confirmed the resident was discharged to home, revealing a documentation inaccuracy.
A facility failed to document the required assessment of a resident's urine character every shift, as outlined in the care plan for a resident with an indwelling urinary catheter. Despite the resident's cognitive intactness and need for substantial assistance, the necessary documentation was absent, which was confirmed by the Assistant Director of Nursing.
A facility failed to maintain a resident's personal hygiene by not keeping their fingernails trimmed. The resident, with severe cognitive impairment and dependent on staff for daily living activities, had long and untrimmed nails despite a care plan for daily nail cleaning. Observations confirmed the deficiency, and the Activity Director addressed the issue after being notified.
A resident with severe cognitive impairment and hand contractures was observed without necessary hand rolls, which are crucial for maintaining range of motion. The LPN was unaware of this oversight, and the resident's care plan lacked documentation addressing the hand contractures, indicating a failure in providing appropriate care.
A facility failed to monitor edema in a resident who was prescribed Lasix, a diuretic, for edema management. The resident had multiple diagnoses, including depression, hypotension, and edema, and required assistance with daily activities. Despite a care plan that included monitoring for hypertension/hypotension and administering medications as ordered, there was no documentation of edema checks. This deficiency was confirmed by the ADON.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of three sampled residents. For one resident with multiple diagnoses including heart disease, dementia, and chronic obstructive pulmonary disease, the MDS assessment inaccurately documented the resident as a non-smoker. However, record reviews and staff interviews confirmed that the resident was identified as a smoker upon admission, had a smoking assessment completed, and had a care plan in place addressing smoking safety, with cigarettes and lighter kept at the nurse's station. Both the administrator and assistant directors of nursing confirmed the omission on the MDS assessment. For another resident with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease, the MDS assessment inaccurately indicated the absence of an ostomy and dependence with toileting hygiene. In contrast, the resident's care plan documented a colostomy and included interventions for colostomy care and monitoring for skin breakdown. The director of nursing confirmed that the MDS assessment was inaccurate regarding the resident's colostomy status.
Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the assessment and documentation of care for two residents. For one resident with a history of cerebral infarction, biliary cirrhosis, heart failure, diabetes, and gout, there was no documented assessment or rationale in the medical record to support the completion of a left foot x-ray. Both the Director of Nursing and the Administrator confirmed that there was no evidence of an assessment or explanation for the x-ray performed. For another resident with diagnoses including Parkinson's Disease, COPD, hypertension, GERD, pain, and edema, nursing staff did not complete or record an assessment when the resident complained of abdominal pain prior to being transferred to a hospital. Interviews revealed that the LPN involved did not recall the resident's code status and believed the decision to transfer was made by hospice staff. Hospital records later showed the resident was diagnosed with a perforated sigmoid colon requiring surgery. The Director of Nursing confirmed there was no documentation to support that a competent assessment was performed by the LPN.
Failure to Notify Physician and Representative of Resident Status Changes and Transfers
Penalty
Summary
The facility failed to notify the physician and/or the resident's representative when there was a significant change in the resident's condition or when a transfer to the hospital occurred. For one resident with multiple chronic conditions, including diabetes, chronic kidney disease, atrial fibrillation, gout, and hypertension, there was no documented evidence that the physician or the resident's representative was notified when the resident was transferred to the emergency room. This was confirmed through record review and staff interview, which verified the absence of documentation regarding the required notifications at the time of transfer. In another case, a resident with diagnoses including Parkinson's disease, COPD, hypertension, GERD, pain, and edema experienced a significant change in condition that led to a hospital transfer and subsequent surgery for a perforated sigmoid colon. The responsible party had voiced concerns about the resident's status, and hospice staff were notified, but there was no documentation that the physician was informed of the change in condition prior to the transfer. Staff interviews confirmed the lack of physician notification and documentation regarding the resident's status change.
Failure to Provide and Document Colostomy Care per Orders and Policy
Penalty
Summary
The facility failed to provide colostomy care in accordance with physician orders, professional standards, and the resident's comprehensive plan of care for one resident. The facility's policy required documentation of colostomy care, including the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, how the resident tolerated the procedure, and notification of the supervisor for refusals or abnormal findings. For the resident in question, who had multiple diagnoses including Parkinson's Disease and a colostomy, the care plan and physician orders specified that the stoma site should be checked every shift for swelling and redness, and the colostomy bag changed as needed every shift. However, a review of the medical record, medication administration record (MAR), and nursing notes revealed no documentation that colostomy care was performed or that the stoma site was checked from June 28 to July 7. During this period, the resident was later transferred to the emergency department, where hospital records noted abnormal bowel color at the ostomy site and questionable gangrene, requiring surgical consultation. The facility's Director of Nursing confirmed the absence of documentation for the required colostomy care during the specified timeframe.
Failure to Notify Physician of Resident Incident
Penalty
Summary
The facility failed to ensure proper notification of a change in a resident's condition, as evidenced by the lack of communication with the resident's physician following an incident. A resident with diagnoses including unspecified dementia, depression, and hypothyroidism was involved in an incident where she hit her head on a table in the day room. The Incident/Accident Reporting Form indicated that the resident was assessed for injuries, and a knot was found on the left side of her head. However, the report inaccurately documented the object as a chair instead of a table. The LPN attempted to notify the resident's physician but was unable to do so because the contact information in the system was outdated, and the phone number was disconnected. Despite efforts to find the correct number, the LPN was unsuccessful, resulting in the physician not being notified of the incident. The Interim Director of Nursing confirmed that the LPN should have notified the physician about the incident, highlighting a deficiency in the facility's notification process.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for two residents. Resident #6, who had a history of pressure ulcers and moderate cognitive impairment, was observed with her feet pressed against the footboard of her bed, complaining of pain. A CNA discovered an open area with drainage on her left heel, indicating a pressure ulcer. Despite previous complaints of foot pain, the LPN had not assessed the resident's feet, and no pressure-relieving device was in place to prevent further skin breakdown. Resident #52, with severe cognitive impairment and dependent on staff for daily living activities, was observed sitting in a geri chair without a pressure-relieving device. The resident had a Stage II facility-acquired pressure ulcer on the right hip. The absence of a pressure-relieving device in the geri chair was confirmed by the ADON, indicating a failure to prevent further skin breakdown.
Failure to Document and Assess Incidents Involving Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate use of assistive devices for two residents, leading to incidents that were not properly documented or assessed. Resident #70, who has severe cognitive impairment and multiple medical conditions, was observed using a geri chair with a lap tray. Despite documented behaviors indicating distress and attempts to remove the lap tray, no Incident/Accident Report was completed when the resident slid under the tray and fell to the floor. Additionally, there was no assessment conducted to determine if the lap tray was an appropriate assistive device for this resident. Similarly, Resident #25, also with severe cognitive impairment and dependent on staff for daily activities, experienced an incident where he broke his lap tray and slid to the floor, resulting in a skin tear. This incident was not documented in an Incident/Accident Report, and the resident's care plan was not updated to reflect the fall. These oversights indicate a failure in the facility's processes for monitoring and documenting incidents involving assistive devices, potentially compromising resident safety.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease, hypertensive heart disease, and unspecified psychosis. The resident was admitted with physician orders for dialysis on Monday, Wednesday, and Friday, along with a 1000 cc fluid restriction. However, there was no documentation in the medical record indicating that the resident's fluid intake was being monitored. Interviews with staff, including a Certified Nurse Aid (CNA) and the Assistant Director of Nursing (ADON), confirmed that the staff were not documenting the resident's fluid intake to ensure compliance with the fluid restriction.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation for four out of five residents reviewed. The facility's policy requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails. However, there was no documented evidence of such assessments for residents #5, #12, #17, and #38. Resident #17, with intact cognition and requiring assistance with activities of daily living, was observed with bed rails raised on both sides of the bed. Despite the facility's policy, there was no documented assessment for the risk of entrapment. Similarly, resident #38, who had moderate cognitive impairment and a history of falling, was observed with bed rails raised, but no assessment for entrapment risk was documented. Resident #12, with moderate cognitive impairment and a history of repeated falls, was observed with bed rails in a locked position, yet there was no documented assessment for entrapment risk. Resident #5, with severe cognitive impairment and requiring substantial assistance, also had bed rails raised without a documented assessment for entrapment risk. Interviews with the Assistant Director of Nursing confirmed the lack of documented assessments for these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.71% error rate during a medication administration observation. Three medication errors were identified out of 28 opportunities. For one resident, the LPN administered incorrect dosages of Furosemide and Gabapentin, providing 20 mg of Furosemide instead of the prescribed 40 mg, and 100 mg of Gabapentin instead of the prescribed 300 mg. Another resident received only one tablet of Fludrocortisone 0.1 mg instead of the prescribed two tablets, totaling 0.2 mg. These errors were confirmed by the Assistant Director of Nursing during an interview, acknowledging the discrepancies in medication administration as observed during the morning medication pass.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy and procedures for three residents who required such precautions due to their medical conditions. The EBP policy, dated April 1, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. This policy applies to residents with indwelling medical devices or those colonized with targeted multidrug-resistant organisms. However, observations revealed that residents with indwelling catheters and dialysis access did not have the required EBP signage posted on their doors, indicating a lapse in communication and implementation of the policy. Resident #18, who had a urinary catheter, did not have an EBP sign posted on her door, despite physician orders for EBP during high-contact care activities. Similarly, Resident #28, who had a dialysis access, also lacked the necessary signage. Resident #35, with an indwelling catheter, was observed multiple times without the EBP sign on his door. Interviews with the Assistant Director of Nursing confirmed these oversights, acknowledging that the facility failed to communicate the need for EBP as per their policy.
Failure to Notify of Changes in Resident Conditions
Penalty
Summary
The facility failed to ensure proper notification of changes in resident conditions, as evidenced by two separate incidents involving residents. In the first case, a resident with severe cognitive impairment, as indicated by a BIMS score of 5, experienced a fall. Despite the facility's policy requiring prompt notification of the resident's representative, the attending physician, and the resident themselves, the family of the resident was not informed of the fall by the LPN responsible. This oversight was confirmed through interviews with the LPN and the Assistant Director of Nursing. In the second incident, another resident with moderately impaired cognitive skills, as indicated by a BIMS score of 9, was found to have multiple bruises on her body. The staff failed to notify the nursing administration upon discovering these injuries, which were of unknown origin. The bruises were observed during an inspection by the Assistant Directors of Nursing, who confirmed they were unaware of the injuries prior to the inspection. The facility's policy mandates that staff notify the administration of any injuries of unknown origin, which was not adhered to in this case.
Failure to Monitor and Document Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, three residents were observed using lap trays as restraints without proper documentation or physician orders. The facility's policy requires that restraints only be used with a physician's order and informed consent, and that residents be monitored and the restraints released regularly. However, the facility did not adhere to these requirements for the residents in question. Resident #70, who has severe cognitive impairment and requires assistance with activities of daily living, was observed multiple times sitting in a geri chair with a lap tray. Despite the use of the lap tray being documented as a physical restraint for trunk control, there was no physician's order for its use, nor was there documentation of monitoring the release of the lap tray every two hours as required. The Assistant Director of Nursing confirmed these deficiencies during an interview. Similarly, Resident #52, who also has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed with a lap tray in place without documentation of monitoring for its release. The resident's hands were contracted, indicating an inability to remove the tray independently. Resident #25, with severe cognitive impairment and multiple diagnoses, was also observed with a lap tray without a physician's order or documentation of monitoring. Interviews with staff confirmed these lapses in compliance with the facility's restraint policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to a resident and the resident's representative regarding the transfer or discharge to a hospital, as well as the reasons for the move, in writing. Additionally, the facility did not send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman. This deficiency was identified for a resident who was transferred to the hospital on two separate occasions. A review of the Emergency Transfer Logs for June and July 2024 revealed that there was no documented evidence of the Ombudsman being notified of the resident's transfers on the specified dates. During a telephone interview, the local Ombudsman confirmed that she had not been notified of these transfers. The facility administrators were informed of these findings.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to conduct quarterly assessments for two residents, as required by the Centers for Medicare and Medicaid Services (CMS). Resident #25 was admitted on an unspecified date, and their last documented Quarterly Minimum Data Set (MDS) Assessment had an Assessment Reference Date (ARD) of 06/25/2024. However, there was no subsequent Quarterly MDS Assessment recorded for this resident. Similarly, Resident #27, also admitted on an unspecified date, had their last Quarterly MDS Assessment with an ARD of 06/04/2024, but no further assessment was documented within the required three-month period. An interview with the Assistant Director of Nursing (ADON) confirmed that the Quarterly MDS Assessments for both residents were not completed within the mandated timeframe. This oversight indicates a failure to adhere to the regulatory requirement of updating each resident's assessment at least once every three months.
Inaccurate MDS Documentation of Resident Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for one of the residents selected for closed record reviews. Specifically, the discharge MDS assessment for a resident indicated that the resident was discharged to the hospital, while a review of the nurse's notes and interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed that the resident was actually discharged to home. This discrepancy highlights an inaccuracy in the documentation of the resident's discharge status.
Failure to Document Urine Assessment for Resident with Catheter
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with an indwelling urinary catheter. The care plan required documentation of the character of the resident's urine, including color, clarity, and odor, every shift. However, a review of the resident's medical records, including the Medication Administration Record (MAR) for September and October 2024, revealed no documented evidence of staff assessing these aspects of the resident's urine as required. The resident, who was cognitively intact and required substantial assistance with activities of daily living, had diagnoses including urinary retention and chronic urinary tract infection. Despite the care plan's directive to assess the urine's character every shift, observations confirmed the presence of the indwelling catheter, but the necessary documentation was missing. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the failure to document the required assessments.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the facility did not keep the resident's fingernails trimmed. The resident, who was admitted with diagnoses including dementia, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect, had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene. Despite a care plan that included daily nail cleaning, there was no documented evidence of nail care being provided during the 30-day look-back period. Observations on October 14, 2024, revealed the resident sitting in a geri chair with long and untrimmed fingernails. Later that day, the Activity Director trimmed the resident's fingernails after being notified of their condition. The Activity Director confirmed that the resident's nails needed trimming. The facility's failure to document and provide regular nail care for the resident was noted during the survey, and the Corporate Administrator and Administrator were informed of these findings.
Failure to Provide Hand Rolls for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically in addressing hand contractures. Resident #52, who was admitted with diagnoses including dementia, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect, was observed without hand rolls in place, which are necessary to prevent further decrease in range of motion. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene. Despite these needs, there was no documented evidence in the plan of care to address the resident's hand contractures. During an observation, it was noted that the resident was sitting in a geri chair with both hands contracted and closed, without any hand rolls present. When notified, the LPN was unaware of the absence of hand rolls and confirmed that they were supposed to be in place at all times. This oversight indicates a failure in the facility's responsibility to ensure that the resident received the necessary treatment and services to maintain or improve range of motion, as there was no plan of care addressing this specific need.
Failure to Monitor Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring edema for a resident who was prescribed a diuretic. The medical record review for the resident revealed an admission with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness, and anemia. The resident's annual Minimum Data Set (MDS) assessment indicated intact cognition for daily decision-making, and the resident required assistance with activities of daily living. The care plan noted a potential for hypertension/hypotension related to medication use, with interventions to monitor blood pressure, administer medications as ordered, and obtain labs and diagnostic tests as ordered. However, despite a physician's order for Lasix, a diuretic, to be administered every other day for edema, there was no documented evidence of edema checks being performed. This was confirmed in an interview with the Assistant Director of Nursing.
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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