Belle Maison Nursing & Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hammond, Louisiana.
- Location
- 15704 Medical Arts Plaza, Hammond, Louisiana 70403
- CMS Provider Number
- 195523
- Inspections on file
- 19
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Belle Maison Nursing & Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with significant neurological and physical impairments, including dysphagia and muscle weakness, was entirely dependent on staff for feeding, yet the care plan lacked documented interventions for feeding assistance. Multiple staff members, including CNAs, LPNs, and an occupational therapist, confirmed the resident's total dependence, and the care plan coordinator acknowledged the omission.
The facility did not ensure accurate and complete medical documentation for two residents. One resident's required oxygen saturation checks were not consistently recorded, and there was no documentation of refusals when checks were missed. For another resident who died while on hospice, the death note lacked essential details such as notifications and body release information, contrary to facility policy.
During catheter and incontinence care for a resident, two CNAs failed to change gloves and perform hand hygiene after contact with contaminated areas and before handling clean items and linens. Both staff members acknowledged the lapse, and the DON confirmed that facility policy requires glove changes and hand hygiene when moving from dirty to clean tasks.
A facility failed to accurately assess a resident's status by not coding Generalized Edema as an active diagnosis in the resident's MDS, despite the resident being prescribed Furosemide for this condition. Staff interviews confirmed the oversight and uncertainty regarding the coding requirements.
The facility failed to store and label food items properly, affecting 108 residents. Observations revealed several open and unlabeled food items in the kitchen and walk-in cooler, including seasonings, beans, flour, panko crumbs, rice, tea bags, slaw dressing, mayonnaise, and salad dressing. An interview confirmed that these items should have been sealed and labeled with an open date.
The facility failed to ensure accurate MDS assessments for four residents, resulting in incorrect coding for PASRR, anxiety, hospice, and discharge status. A resident with a serious mental illness was not coded for PASRR, another with anxiety was not coded for the condition, a third resident in hospice care was not coded as such, and a fourth resident was incorrectly coded as discharged to a hospital instead of home. These errors were confirmed by the staff responsible for MDS assessments and the Director of Nursing.
The facility failed to limit PRN orders for psychotropic medications to 14 days for two residents. One resident was prescribed Vistaril for anxiety without a stop date, and another was prescribed Diazepam and Xanax without specified durations. The DON confirmed these orders exceeded the 14-day limit without end dates.
A resident with severe cognitive impairment and a history of falls was observed without the prescribed wheelchair cushion, leading to a fall. Facility staff confirmed the care plan intervention was not implemented, resulting in the resident's fall.
A resident with a history of falls and Alzheimer's disease experienced a fall, but the facility failed to update the care plan with new interventions. Staff responsible for care plan updates acknowledged the oversight, confirming no revisions were made after the incident.
A facility failed to provide a diabetic resident with necessary snacks, juice, or supplements during dialysis treatments, leading to the resident feeling tired and weak. Despite the resident's complaints, the facility did not verify with the dialysis center whether COVID-19 restrictions on food had been lifted, resulting in a lack of communication and appropriate care.
The facility did not post nurse staffing data, including resident census and staff hours, in a location accessible to residents and visitors. Observations and staff interviews confirmed the absence of this information, with an LPN, ADON, and DON acknowledging the deficiency.
Failure to Develop Comprehensive Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that addressed the specific feeding assistance needs for one of three residents reviewed. The resident in question was admitted with multiple diagnoses, including sequelae of cerebral infarction, dysphagia, need for assistance with personal care, tremors, neuropathy, and muscle weakness. Despite these conditions, a review of the resident's most recent care plan revealed no documented interventions for feeding assistance. Direct observation showed that the resident was entirely dependent on staff for feeding, with staff members providing all food and hydration without the resident's participation. Multiple interviews with CNAs, LPNs, and an occupational therapist confirmed that the resident required total assistance with feeding at all meals. The staff responsible for the resident's care plan acknowledged that feeding assistance interventions were not included and confirmed that they should have been. The Director of Nursing also confirmed that residents needing feeding assistance should have individualized interventions documented in their care plans to ensure proper care and support.
Failure to Maintain Accurate Medical Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete documentation for two residents. For one resident with dementia, physician orders required routine oxygen saturation checks every shift, with instructions to notify the physician if levels fell below 90%. However, the Medication Administration Record (MAR) showed multiple shifts where oxygen saturation was not documented. Additionally, there were no nursing notes indicating the resident's refusal of oxygen checks on those dates, despite staff stating that refusals sometimes occurred. The Director of Nursing confirmed the absence of both oxygen saturation documentation and notes regarding refusals for the specified dates. For another resident who expired while on hospice care, the nurse's note simply stated the resident had expired, without including required details such as the date and time of death, pertinent details of the event, notifications to the physician and family, or information about the release of the body. The Director of Nursing confirmed that the death note was incomplete and did not meet the facility's policy requirements for documentation following a resident's death.
Failure to Follow Infection Control Practices During Catheter and Incontinence Care
Penalty
Summary
Staff failed to maintain appropriate infection control practices during and after incontinence and catheter care for a resident. During an observed catheter care procedure, two CNAs donned clean gloves and cleaned the resident's catheter tubing. Without changing gloves or performing hand hygiene, one CNA picked up clean soapy washcloths, performed perineal care, disposed of the washcloths, and touched the resident and various items in the immediate environment. The second CNA used a wet wipe to clean the resident's buttocks and removed a dirty brief, then, without changing gloves, both CNAs touched clean briefs, draw sheets, the resident's gown, multiple pillows, sheets, and the call light. Only after completing these tasks did both CNAs remove their gloves and perform hand hygiene. Interviews with both CNAs confirmed that they did not change gloves or perform hand hygiene after touching the resident's dirty catheter and before moving to clean areas or items, acknowledging that they should have done so. The Director of Nursing also stated that staff are expected to change gloves and perform hand hygiene when transitioning from dirty to clean areas during catheter care. The facility's policy on hand hygiene emphasizes the importance of changing gloves and performing hand hygiene at appropriate times to prevent infection, which was not followed in this instance.
Inaccurate Assessment of Resident's Diagnosis
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically regarding the diagnosis of Generalized Edema. The resident, who was admitted with a diagnosis of Generalized Edema, was prescribed Furosemide 20 mg daily to manage this condition. However, during a review of the resident's Quarterly MDS with an Assessment Reference Date (ARD) of 09/07/2024, it was found that Generalized Edema was not coded as an active diagnosis. Interviews with staff members confirmed the oversight, with one staff member acknowledging the omission and another expressing uncertainty about the coding requirements for the diagnosis.
Failure to Store and Label Food Properly
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 108 residents who received meals prepared by the kitchen. During an observation of the kitchen meal prep area, several food items were found to be open and unlabeled, including a 28-ounce container of lemon pepper seasonings, a 25-pound bag of lima beans, a 25-pound bag of flour, a 25-pound bag of panko crumbs, a 5-pound bag of white rice, and a 6-pound box of tea bags. Additionally, in the walk-in cooler, a 1-gallon container of slaw dressing, a 1-gallon container of mayonnaise, and a 1-gallon container of salad dressing were also found to be open and unlabeled. An interview with S5DM confirmed that all opened food items should be sealed and labeled with an open date, which was not done in this case. S5DM further confirmed that the rice, flour, lima beans, panko crumbs, and tea bags should have been stored in sealed containers, which they were not.
Inaccurate MDS Assessments for Four Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for four residents, leading to deficiencies in coding for PASRR, anxiety, hospice, and discharge status. Resident #38, who had a serious mental illness, was not correctly coded in the MDS for PASRR, as sections A1500, A1510A, and A1510B were left blank despite a Level II PASRR indicating a serious mental illness. Resident #45, diagnosed with an anxiety disorder, was not coded for anxiety in the MDS, which was confirmed by the staff responsible for MDS assessments. Resident #62, who had been admitted to hospice, was not coded for hospice in the MDS, despite physician orders confirming hospice admission. Lastly, Resident #119 was incorrectly coded as being discharged to a hospital, while nurse's notes indicated discharge to home. The Director of Nursing confirmed these coding errors upon review, acknowledging that the MDS assessments should have been coded correctly for all four residents.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days and included a specified duration for two residents. Resident #9 was prescribed Vistaril 50 mg to be taken every 8 hours as needed for anxiety, starting on September 22, 2023. However, the medication order did not include a stop date or duration, and it was confirmed by the Director of Nursing (S2DON) that the PRN order was in place for longer than 14 days without an end date. Similarly, Resident #27 was prescribed Diazepam 5 mg to be taken every 6 hours as needed, starting on March 26, 2024, and Xanax 0.25 mg to be taken every 6 hours as needed, starting on July 4, 2024. Both medications lacked a stop date or duration in the physician's orders and the Medication Administration Record (MAR). The S2DON confirmed that the PRN orders for these medications were also in place for longer than 14 days without an end date or duration documented.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as a high fall risk. The resident, who has severe cognitive impairment and a history of repeated falls, was observed without the prescribed wheelchair cushion intended to improve positioning and reduce fall risk. This observation was made when the resident fell out of the wheelchair at the nurse's station, indicating that the intervention was not in place as required by the care plan. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the care plan intervention to replace the wheelchair cushion was not implemented. The staff acknowledged that the cushion should have been present in the resident's wheelchair according to the care plan, but it was not, leading to the resident's fall. This oversight highlights a failure in ensuring that care plan interventions are consistently followed to meet the resident's needs.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised following a fall incident. Resident #108, who has a history of repeated falls, difficulty in walking, reduced mobility, cognitive communication deficit, and Alzheimer's disease, experienced a fall on 07/07/2024. The resident was found on the floor by a CNA during rounds, with a skin tear on the back of the right hand. Despite this incident, the resident's care plan was not updated to include new fall interventions after the fall on 07/07/2024. Interviews with facility staff revealed that the responsibility for updating care plans after incidents lies with S7IP, who acknowledged awareness of the fall but confirmed that no revisions were made to the care plan. S2DON also confirmed that the care plan should have been updated with new interventions after each fall, but no changes had been made since 06/17/2024. This oversight resulted in a deficiency in the facility's care planning process for the resident.
Failure to Provide Nutritional Support During Dialysis
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease and Type II Diabetes Mellitus, who required dialysis services. The resident, who was sent to dialysis three times a week, reported feeling tired and weak after treatments due to not receiving any snacks, juice, or supplements during the lengthy sessions. Despite the resident's complaints to the nursing and administrative staff, the facility did not provide the necessary nutritional support during dialysis. Interviews with facility staff revealed a lack of communication with the dialysis center regarding the current policy on food restrictions. The LPN responsible for communication with the dialysis centers admitted to not verifying whether the COVID-19 restrictions on bringing food had been lifted, which they had. The Director of Nursing also confirmed the oversight and acknowledged that the resident was not sent with the necessary nutritional items, as they were under the impression that food was still not allowed at the dialysis center.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data, including resident census and the total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficiency was observed on 07/08/2024 at 11:00 a.m., when no nursing staffing data was found posted in a visible area within the facility. Interviews conducted with staff members, including an LPN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed the absence of posted nursing data. The LPN was unaware of any such data being posted, while both the ADON and DON acknowledged that no nursing staff data was accessible to residents and visitors.
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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