Belle Grande Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 172 Versailles Blvd, Alexandria, Louisiana 71303
- CMS Provider Number
- 195420
- Inspections on file
- 24
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Belle Grande Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities who required a two-person assist and a specific sling size for transfers fell from a mechanical lift when staff used the wrong size sling and failed to attach the sling loops correctly. This resulted in the resident sustaining a femur fracture and subarachnoid hemorrhage.
A resident with multiple medical conditions and total dependence for toileting did not receive incontinence care for approximately eight hours, despite physician orders and a care plan requiring checks and care at least every two hours. Facility records and interviews confirmed that two CNAs failed to provide the necessary care during their shifts, and the DON verified the lapse in required services.
The facility was found to have improperly stored food items in the walk-in freezer/cooler, including corn dogs, biscuits, squash, and breadsticks, which were open to air and undated. This was against the facility's policy requiring all frozen foods to be tightly wrapped or packaged. S4 DM confirmed that staff should label, date, and store opened food items properly, which was not done in this instance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds, as there was no signage or PPE outside their rooms. Additionally, an LPN did not follow proper hand hygiene protocols during wound care, using the same gloves for different wounds. These deficiencies indicate a lack of adherence to infection control policies.
A facility failed to transmit a resident's MDS Assessment within the required 14 days. The resident, with conditions including Cerebral Infarction and Hemiplegia, had a completed Quarterly MDS Assessment that was not transmitted until over a month later. An LPN/MDS Nurse acknowledged forgetting to notify the ADON to close and transmit the assessment, resulting in the delay.
A resident with dementia and an above-the-knee amputation did not receive necessary grooming assistance, specifically shaving, despite requiring substantial help with ADLs. The resident was observed with long facial hair, and staff interviews confirmed the oversight, with CNAs responsible for ADL care and nurses for monitoring.
Failure to Follow Lift Transfer Protocols Results in Resident Fall and Serious Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure proper practices were followed during a mechanical lift transfer, resulting in a resident falling from the lift. The resident, who had multiple diagnoses including schizoaffective disorder, bipolar disorder, diabetes mellitus, muscle wasting with atrophy, and Parkinson's disease, was dependent on staff for transfers and required a two-person assist with a specific size and color of sling as indicated on her care plan and wall care sheet. Despite these clear instructions, staff used a sling that was the wrong size and did not attach the sling loops correctly to the lift, with one strap being hooked in a different loop position than the others. On the day of the incident, two CNAs were responsible for transferring the resident using the mechanical lift. The sling used was a large, blue-trimmed pad instead of the required medium, red-trimmed pad. The top right strap of the sling was attached to a higher notch, while the other three straps were attached to the lowest level, closest to the pad. Staff involved in the transfer admitted to not checking the care sheet for the correct sling size and instead used the sling that was already in the room. Both CNAs had previously received training and check-offs on proper lift use, sling size selection, and correct attachment procedures, but failed to follow these protocols during the transfer. As a result of these failures, the resident fell from the lift, sustaining a complete displacement fracture of the proximal left femur and a subarachnoid hemorrhage. The incident was witnessed by other staff, and immediate first aid was provided before the resident was sent to the hospital. The facility's investigation confirmed that the wrong sling size was used and the sling was not properly attached, directly leading to the resident's fall and injuries.
Removal Plan
- The administrative team in-serviced all CNAs and nurses on proper lift technique and correct sling use.
- The administrative nursing team checked-off all CNAs and nurses on the lift and slings, using return demonstration technique.
- All lifts were inspected by the assistant administrators to ensure they were in safe working order.
- S3 CNA and S4 CNA received individual counseling and in-service. Skills check-off was completed, with follow-up questions, to ensure complete understanding.
- S3 CNA and S4 CNA were to ensure a nurse was present during any transfer of a resident with a lift. The nurse completed a check-off sheet, documenting use of the correct sling size and correct connection of the sling to the lift.
- S2 ADON ensured all residents requiring use of the Vander-Lift had the correct sling size indicated on the care sheet in their room. The size/color of sling to be used was added to each order for the Vander-Lift.
- The housekeeping supervisor checked all the slings in the building, ensuring they were not frayed or torn, and were in good working condition.
- The medical equipment company inspected all lifts in the facility to ensure they were in safe use.
- S1 ADM provided an in-service to all Laundry staff regarding proper laundering of lift slings.
- The Assistant Administrator ensured all resident rooms provided enough space for safe transfer with a lift.
- The DON or designee will monitor a random sample of residents being transferred with a lift to ensure the correct procedure was followed. This monitor will be completed 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed.
- The DON or designee will monitor, ensuring any lift sling in a resident's room was the correct size for the resident. This monitor will be completed on a random sample of residents with lift orders 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed.
- Administration was responsible for oversight of all the implemented actions, which would be reviewed during the weekly Quality Meeting for 6 weeks.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including traumatic subdural hemorrhage, muscle wasting, overactive bladder, and lack of coordination, did not receive required incontinence care. The resident was fully dependent on staff for toileting hygiene and was always incontinent of urine, as documented in the Minimum Data Set (MDS) and care plan. Physician orders and the care plan specified that incontinence care was to be provided at least every two hours and as needed, with a two-person assist, to maintain skin cleanliness and dryness. On the date in question, the resident did not receive incontinence care from 10:40 a.m. until 6:44 p.m., a period of approximately eight hours. Facility records and interviews confirmed that two CNAs failed to provide the required care during their respective shifts. The Director of Nursing verified that the resident should have received incontinence care at least every two hours, but this did not occur during the specified timeframe.
Improper Food Storage in Freezer
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in its food service operations, as observed during a survey. Specifically, the walk-in freezer/cooler contained several food items that were improperly stored. These items included a box of corn dogs, a bag of biscuits, a bag of squash, and a bag of breadsticks, all of which were open to the air and undated. According to the facility's policy on freezer storage, all frozen foods should be tightly wrapped or packaged to prevent freezer burn. During an interview, S4 DM confirmed that staff are expected to label, date, and properly store opened food items, acknowledging that the observed items did not meet these standards.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of communication and implementation of Enhanced Barrier Precautions (EBP) for residents with specific wound care needs. Observations revealed that there was no EBP signage or personal protective equipment (PPE) available outside the rooms of four residents who required such precautions due to their chronic wounds. The Infection Preventionist admitted to being unaware of the necessity for EBP in cases involving pressure ulcers, venous stasis ulcers, or diabetic foot ulcers, indicating a gap in the facility's adherence to its own policies. Additionally, the facility did not ensure proper hand hygiene during wound care procedures, as observed in the care of a resident with multiple wounds. The LPN responsible for the resident's wound care failed to change gloves or sanitize hands between handling different wounds, despite the facility's policy requiring such actions. This lapse in protocol was confirmed by the LPN, who acknowledged the mistake during an interview. The deficiencies highlight a significant oversight in both the communication of necessary precautions and the execution of proper infection control practices during wound care. These failures were observed during a survey, which included interviews and record reviews, and were directly linked to the facility's inability to provide a safe and sanitary environment for its residents.
Delayed Transmission of MDS Assessment
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) Assessment within the required 14 days of completion for a resident. The resident, who was admitted with diagnoses including Cerebral Infarction, Essential Hypertension, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side, had a Quarterly MDS Assessment with an Assessment Reference Date (ARD) of June 26, 2024. Although the assessment was completed, it was not transmitted until July 31, 2024, exceeding the 14-day requirement. During an interview, the LPN/MDS Nurse admitted to forgetting to notify the Assistant Director of Nursing (ADON) to close and transmit the assessment, confirming the delay in transmission.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide necessary grooming services to a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had a history of dementia and an above-the-knee amputation, required substantial assistance with personal hygiene, including shaving. Despite the resident's request for a shave and the facility's policy to assist with grooming, the resident was observed multiple times with facial hair approximately half an inch long, indicating that the grooming assistance was not provided. Interviews with staff revealed that the responsibility for providing and documenting ADL care, including grooming, fell to the CNAs, while nurses were responsible for monitoring these tasks. However, the resident did not receive the necessary grooming care, as confirmed by both the resident and the Director of Nursing (DON). The resident expressed a desire to be shaved, and the DON acknowledged the oversight, confirming the resident's facial hair had not been attended to as required.
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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