Bayou Vista Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bunkie, Louisiana.
- Location
- 323 Evergreen Hwy, Bunkie, Louisiana 71322
- CMS Provider Number
- 195603
- Inspections on file
- 22
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bayou Vista Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility did not submit complete and accurate direct care staffing data to CMS for an entire quarter, including missing RN hours and documentation of 24-hour licensed nursing coverage, as confirmed by the administrator responsible for PBJ submissions.
The facility did not inform residents of potential financial liability by failing to document estimated costs for non-covered services on required ABN forms. Staff responsible for presenting and completing these forms confirmed that the cost estimate section was left blank for several residents, contrary to facility policy.
A resident with a PEG tube and complex medical needs did not have their tube feeding and flush intake documented each shift as required by the care plan. Both an LPN and the DON confirmed that this documentation was not completed on multiple occasions, despite clear care plan directives.
Two residents did not receive respiratory care in accordance with professional standards. One resident's suction equipment was not labeled or dated as required, and another resident received oxygen at a higher flow rate than ordered by the physician. These deficiencies were confirmed through observations and staff interviews.
A CNA in a LTC facility verbally and mentally abused two residents, one with severe cognitive impairment and another with moderate impairment. The CNA taunted one resident by threatening to withhold a drink and dismissed the other's request for assistance with back pain. The incident was witnessed by the ADON and confirmed by video footage, leading to the CNA's termination.
A resident at high risk for falls was injured due to the facility's failure to ensure fall prevention measures were in place and functioning. The resident's fall mat was not in place, the call light was out of reach, and the bed alarm was not working properly due to a weak battery. A housekeeper moved the fall mat and did not return it, assuming a CNA would do so. The LPN checked the equipment earlier than documented, and there was no system for checking bed alarm batteries. The CNA was terminated for not replacing the fall mat.
The facility failed to submit accurate payroll information for direct care staffing, resulting in a one-star staffing rating, low weekend staffing, no RN coverage for 8 consecutive hours per day, and no licensed nursing coverage 24 hours/day. The Administrator and MDS Nurse did not check the final file validation report after 24 hours, leading to the rejection of the files due to an invalid file extension.
The facility failed to change enteral feeding tubing and supplies every 24 hours as required, as observed in a resident receiving Jevity 1.5 at 40ml per hour. The feeding setup had been in use for over 24 hours, contrary to the facility's policy and manufacturer guidelines, as confirmed by the S3 MDS Nurse.
Failure to Submit Required Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2025 revealed that the facility did not submit RN hours for any day during the 92-day quarter and failed to document licensed nursing coverage for 24 hours each day throughout the same period. These omissions resulted in triggers for a One Star Staffing Rating, excessively low weekend staffing, no RN hours, and lack of 24-hour licensed nursing coverage. During an interview, the administrator responsible for PBJ submissions confirmed that the required staffing information was not accurately submitted for the quarter.
Failure to Provide Estimated Costs on ABN Forms
Penalty
Summary
The facility failed to inform residents of the charges for services for which they may be responsible, specifically in cases where Advanced Beneficiary Notices of Non-Coverage (ABN) were issued. Record review showed that for three sampled residents who received ABNs, the section of the ABN form (CMS-10055) requiring an estimated cost per day, item, or service for continuing daily skilled nursing care was left blank. This omission was identified during a review of the facility's ABN policy, which requires a good faith effort to provide a reasonable cost estimate or to indicate if no estimate is available. Interviews with facility staff confirmed the deficiency. The administrator was unaware of why the estimated cost section was not completed, and the accounts manager, who was responsible for presenting and documenting the ABN forms, acknowledged that she failed to document the estimated costs on the forms. The accounts manager confirmed that the estimated cost should have been included on the ABN forms for the affected residents but was not.
Failure to Document Tube Feeding and Flush Intake as Care-Planned
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident with multiple complex medical conditions, including dysphagia following cerebral infarction, dementia, protein-calorie malnutrition, and a PEG tube for nutrition. The resident was care-planned to receive Jevity 1.2 cal at 50mL/hr with a 25mL/hr flush, and the care plan required monitoring and documentation of intake and output every shift. Despite these documented interventions, review of the resident's records revealed that intake of tube feeding and flushes was not documented each shift on multiple dates. Interviews with both an LPN and the Director of Nursing confirmed that the intake of tube feeding and flushes had not been documented as required by the care plan. The lack of documentation was observed on several specific dates, indicating a failure to follow the established care plan for monitoring and recording the resident's nutritional and fluid intake as ordered by the physician and outlined in the care plan.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident with a history of shortness of breath, acute respiratory failure, dysphagia, cerebral infarction, and dementia, surveyors observed that suction equipment, including a canister, tubing, and Yankauer suction tip, was available at the bedside but was not labeled or dated as required by facility policy. This lack of labeling was confirmed over two consecutive days, and staff interviews verified that the equipment should have been labeled with the date it was opened and changed every seven days. For another resident with diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and schizoaffective disorder, the oxygen concentrator was observed to be set at 3.5 liters per minute, despite a physician's order for 2 liters per minute via nasal cannula. Multiple observations over two days confirmed the oxygen was consistently set above the ordered rate. Staff later verified the discrepancy between the physician's order and the actual oxygen flow rate being administered.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect two residents from mental and verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a CNA speaking to two residents in a rude and aggressive manner. One resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was spoken to in a way that made her cry. The CNA taunted her by threatening to withhold a diet coke if she moved a pillow. The other resident, who had moderately impaired cognition, was also spoken to rudely, which upset him. The incident was captured on video footage, showing the CNA interacting with the residents in a dining area. The CNA was observed repositioning a pillow for one resident and using it as leverage to deny her a drink. The CNA also dismissed the second resident's complaint of back pain and request to go to bed, stating he would have to wait for someone else. This behavior was witnessed by the Assistant Director of Nursing (ADON), who intervened after hearing the second resident's protest. The facility's Administrator reviewed the video footage and confirmed the CNA's aggressive and antagonizing behavior towards the residents. The CNA's actions were deemed abusive, as they involved taunting and depriving the residents of care in a manner that was not respectful or considerate of their needs and conditions.
Failure to Ensure Fall Prevention Measures Resulted in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident's fall prevention measures were in place and functioning properly, leading to an accident. A resident, who was at high risk for falls due to conditions such as hemiplegia, dementia, and anxiety disorder, was found on the floor with injuries including a subdural hematoma, a left eye laceration, and skin tears. At the time of the fall, the resident's fall mat was not in place, the call light was not within reach, and the bed alarm was not functioning properly due to a weak battery. The incident occurred when a housekeeper moved the fall mat to clean the room and did not return it to its proper place. The housekeeper assumed that a CNA would replace the mat, but this did not happen. Additionally, the LPN responsible for the resident had checked the bed alarm, call light, and fall mat earlier in the day and noted them as being in place and functioning, but the bed alarm's battery was weak, making it ineffective at the time of the fall. Interviews with staff revealed that there was a lack of clear responsibility for ensuring the fall prevention equipment was in place and functioning. The LPN admitted to checking the equipment earlier than documented, and the DON confirmed that there was no prior system for checking bed alarm batteries. The CNA involved was terminated for failing to replace the fall mat, which was a violation of the facility's policy.
Failure to Submit Accurate Payroll Information for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit payroll information for direct care staffing as required. The review of the facility's PBJ (Payroll Based Journal) staffing Data Report for FY Quarter 1 2024 revealed several triggers, including a one-star staffing rating, low weekend staffing, no RN coverage for 8 consecutive hours per day, and no licensed nursing coverage 24 hours/day. The facility's CMS Payroll Based Journal submission report indicated that the submission had been received but needed to be checked for errors within 24 hours. However, the final file validation report showed that the number of files processed was 4, the number of files accepted was 0, and the number of files rejected was 4 due to an invalid file extension (.xml). The facility did not correct and resubmit the files as required. An interview with the Administrator revealed that both he and the MDS Nurse were responsible for submitting the PBJ information. The Administrator confirmed that neither he nor the MDS Nurse checked the final file validation report after 24 hours to ensure the facility staffing information had been submitted and accepted as required. This oversight led to the failure in submitting accurate and complete payroll information for direct care staffing, resulting in the identified deficiencies.
Failure to Change Enteral Feeding Supplies as Per Guidelines
Penalty
Summary
The facility failed to ensure that enteral feeding tubing and supplies were changed at least every 24 hours in accordance with manufacturer guidelines. This deficiency was observed in the case of a resident who was receiving tube feeding of Jevity 1.5 at 40ml per hour. The resident's tube feeding bag and flush bag were labeled with a date and time indicating they had been in use for over 24 hours, contrary to the facility's policy and manufacturer guidelines. During an observation, the resident was noted to be receiving tube feeding with bags labeled from the previous day. The S3 MDS Nurse confirmed that the tube feeding setup had been hanging longer than 24 hours and acknowledged that it should have been changed. The resident's clinical record included diagnoses such as Hemiplegia, Hemiparesis, Dementia, Dysphagia, and Chronic Obstructive Pulmonary Disease, highlighting the need for strict adherence to enteral feeding protocols to prevent complications.
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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