Calcasieu Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Charles, Louisiana.
- Location
- 4190 Gerstner Memorial Drive, Lake Charles, Louisiana 70607
- CMS Provider Number
- 195644
- Inspections on file
- 14
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Calcasieu Community Care Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective antibiotic stewardship program, lacking proper surveillance, tracking, and trending of antibiotic use. The Infection Preventionist confirmed the absence of a certified Infection Control Preventionist since April, and the previous DON lacked certification. Multiple infections were reported, with insufficient documentation for residents on antibiotics. The facility did not provide evidence of an effective program by the survey exit.
The facility did not ensure that the designated Infection Preventionist had completed specialized training in infection prevention and control, as required by their policy. The Assistant Director of Nursing, who held the role, lacked documented evidence of such training. The Director of Nursing confirmed the absence of a certified Infection Preventionist since April, obtaining her certification only when surveyors were present. This deficiency potentially affected 115 residents.
The facility failed to maintain nutritional standards for residents on pureed diets, leading to significant weight loss in four residents. Kitchen staff did not use recommended liquid additives, using water instead, which did not meet nutritional requirements. Residents experienced severe weight loss, with low meal intake percentages and missing menu items. The registered dietitian had previously in-serviced staff on proper preparation, but oversight was lacking.
The facility failed to adhere to pureed diet guidelines, affecting eight residents. Kitchen staff used water instead of broth or milk to puree foods and omitted pureed bread from a meal. The dietary manager confirmed the error, and the registered dietician had previously trained staff on proper procedures.
The facility failed to implement and maintain an effective QAPI program, lacking evidence of measuring success, data collection, and staff in-services. This deficiency, confirmed by the DON, potentially affected 115 residents.
A facility failed to assess a resident's ability to self-administer medication, as required by their policy. The resident, with conditions including COPD and Mild Cognitive Impairment, had a nasal spray and inhaler at their bedside, which they used without documented assessment. An LPN confirmed the lack of assessment, highlighting a potential risk to other residents.
A facility failed to complete and submit a Minimum Data Set (MDS) assessment in a timely manner for a resident who was readmitted after a hospital discharge. The resident's medical record lacked evidence of a reentry assessment being opened, completed, or transmitted, which was confirmed by the Clinical Coordinator.
A resident with Cerebrovascular Disease and Unspecified Dementia was not accurately coded in the MDS for hospice care and significant weight changes. Despite having a physician's order for hospice care and experiencing a 7.4% weight gain in the last 30 days, the MDS assessment did not reflect these conditions. The Clinical Coordinator confirmed the omissions during a review.
A facility failed to refer a resident with newly diagnosed mental disorders for a Level II PASARR evaluation, as required by policy. The resident, initially admitted with Major Depressive Disorder and PTSD, was later diagnosed with Schizophrenia, Bipolar Disorder, and Anxiety Disorder. Despite these new diagnoses, no Level II PASARR was submitted, which was confirmed by the Social Services Director.
The facility failed to ensure accurate PASARR screenings for two residents with mental disorders. One resident with Bipolar Disorder and another with Obsessive-Compulsive Disorder had screenings that did not reflect their diagnoses. The Social Services Director admitted to not updating the screenings and could not locate the necessary documentation for one resident.
A facility failed to properly label an enteral feeding administration set for a resident, as required by policy. During an observation, it was found that the set lacked the resident's name, date, time of initiation, and the initials of the person who initiated the feeding. An LPN confirmed the labeling omission. The resident had a history of cerebral infarction, dysphasia, and aphasia, with specific physician's orders for enteral feeding. This deficiency potentially affected four residents receiving enteral feedings.
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in infection control practices. A resident's nebulizer tubing and mouthpiece were left exposed to air, and another resident's oxygen nasal cannula was found on the floor. Both instances were confirmed by LPNs to be against the facility's infection prevention policy.
The facility did not follow professional standards for food service safety by failing to label opened refrigerated food items with the date they were opened. During an observation, a gallon of ranch dressing and a bag of sliced cucumbers were found opened and undated in the kitchen refrigerator. The Dietary Manager confirmed the oversight, which could potentially impact the 115 residents consuming food from the kitchen.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage II Pressure Ulcer, as required by their infection control policy. Despite the policy's mandate for gown and glove use during wound care, there was no signage or PPE available near the resident's room. Two wound care nurses confirmed their lack of awareness regarding the EBP requirement for residents with pressure ulcers, highlighting a lapse in policy adherence.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of surveillance, tracking, and trending of antibiotic use. The policy titled 'Antibiotic Stewardship' was not effectively implemented, as it required the Infection Preventionist (IP) or designee to review all clinical infections treated with antibiotics and document them on a surveillance tracking form. However, the facility did not provide evidence of such documentation or an effective program in place. The Infection Preventionist confirmed that the facility had not had a certified Infection Control Preventionist since April 2024, and the previous Director of Nursing (DON) who was handling infection control did not have the necessary certification. The report highlighted that there were multiple infections reported from July to October 2024, with several infections remaining open and unresolved. During the review period from September to October 2024, five residents were on antibiotics, but documentation was insufficient, with only one progress note for two residents receiving antibiotics. The facility's DON, who was also the Infection Preventionist, acknowledged the absence of an effective antibiotic stewardship program and confirmed that floor nurses were responsible for daily documentation, which was not adequately performed. The facility did not provide evidence of an antibiotic stewardship program by the time of the survey exit.
Infection Preventionist Lacked Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed specialized training in infection prevention and control. The facility's policy required that the Infection Preventionist have professional training in a related field and obtain specialized ICP training beyond initial professional training. However, a review of the facility's infection control records revealed no documented evidence that the Assistant Director of Nursing, who was the designated Infection Preventionist, had completed such specialized training. During an interview, the Director of Nursing confirmed that the facility had not had an Infection Preventionist with a certification since April 2024. She also stated that she obtained her certification on October 8, 2024, when the surveyors were present at the facility. This deficiency had the potential to affect a census of 115 residents.
Failure to Maintain Nutritional Standards for Residents on Pureed Diets
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for residents on mechanically altered therapeutic diets, leading to significant weight loss in four residents. The deficiency was identified through observations, interviews, and record reviews, revealing that the kitchen staff did not consistently use the recommended liquid additives when preparing pureed foods. Instead of using broth or milk as specified in the facility's Pureed Foods Guideline, water was used, which is not recommended. This failure to adhere to the guidelines resulted in meals not meeting the nutritional requirements as planned by the registered dietitian. Resident #52 experienced a severe weight loss of 9.17% in three months and 17.86% in less than six months. The resident's care plan indicated a focus on nutritional problems, with interventions to provide and serve the diet as ordered. However, meal intake records showed low consumption percentages, with many meals consumed at 0-25%. Resident #88 also suffered a severe weight loss of 12.13% in one month and 22.76% in six months, with observations confirming the absence of pureed bread on the meal tray, which was part of the planned menu. Resident #93 had a weight loss of 7.63% in three months, with a care plan focusing on returning to baseline weight. The resident was observed refusing meals, indicating a potential issue with meal acceptance. Resident #106 experienced a weight loss of 10.40% in less than three months, with fluctuating meal intake and reliance on PEG feedings for nutrition. The registered dietitian confirmed that she had previously in-serviced the kitchen staff on proper pureed diet preparation but did not observe the preparation process during her rounds. The dietary manager was responsible for overseeing the kitchen staff, but the deficiency in following the guidelines persisted.
Failure to Follow Pureed Diet Guidelines
Penalty
Summary
The facility failed to ensure that recipes for pureed foods and menus were followed for residents receiving pureed diets. This deficiency affected eight residents who were prescribed pureed diets. During an observation, it was noted that the kitchen staff, S7KS, used water instead of the recommended liquids such as broth or milk to puree chicken and potato salad. Additionally, the pureed diet tray prepared for a resident lacked pureed bread or a substitute, deviating from the facility's lunch menu which included chicken thighs with barbecue sauce, baked beans, Texas toast, and vanilla dessert. The dietary manager, S5DM, confirmed that water should not have been used as a liquid for pureeing foods and that the bread should have been pureed as part of the meal. The registered dietician, S8RD, who conducts monthly kitchen inspections, was informed of the improper use of water and confirmed that she had previously trained the kitchen staff on the correct preparation of pureed diets. Despite this training, the guidelines were not followed, leading to the deficiency in meal preparation for residents on pureed diets.
Deficiency in QAPI Program Implementation
Penalty
Summary
The facility failed to effectively implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's undated QAPI policy and an interview with the Director of Nursing (S2DON). The facility did not provide documented evidence of measuring or tracking the success of actions implemented, nor did it show evidence of data collection and analysis. Additionally, there was no documentation of in-services conducted with clinical and non-clinical support staff. The Director of Nursing confirmed the absence of documentation related to data collection, analysis, monitoring, performance tracking, and staff in-services. This lack of evidence had the potential to affect the care of 115 residents.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess whether it was clinically appropriate for a resident to self-administer medication, which is a requirement according to their policy. The policy mandates that an interdisciplinary team must evaluate each resident's cognitive and physical abilities to determine the safety and appropriateness of self-administering medications. However, for one resident with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Mild Cognitive Impairment, there was no documented evidence of such an assessment in the resident's electronic medical record. During an observation and interview, it was found that the resident had a prescription nasal spray and inhaler on their bedside table, which they confirmed they used to self-administer medication. A Licensed Practical Nurse (LPN) also confirmed the presence of these medications at the bedside and acknowledged that there was no assessment documented for the resident's ability to self-administer medication. This oversight in following the facility's policy had the potential to affect a significant number of residents.
Failure to Complete and Submit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was completed and submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for a resident who was readmitted. The deficiency was identified during a review of the medical record of a resident who had been discharged to the hospital and subsequently readmitted. The resident's medical record showed no documented evidence that a reentry assessment was opened, completed, or transmitted after the readmission. This oversight was confirmed during an interview with the Clinical Coordinator, who acknowledged that the reentry assessment had not been initiated or submitted as required.
Inaccurate MDS Coding for Hospice Care and Weight Changes
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically in the areas of weight gain and hospice care. The resident, who was admitted with diagnoses including Cerebrovascular Disease and Unspecified Dementia, had a physician's order for hospice care and a care plan indicating end-stage cardiovascular disease. Despite these details, the resident's MDS assessment did not reflect the hospice care status, as Section O, which pertains to special treatments and programs, was not coded for hospice care. Additionally, the resident experienced a significant weight change, with a 7.4% weight gain in the last 30 days and an 18.4% weight loss in the last 90 days. However, the MDS assessment failed to capture this information, as Sections K0300 and K0310, which address weight loss and gain, were not assessed and were left with a dash, indicating they were not evaluated. The Clinical Coordinator confirmed these omissions during a record review and interview, acknowledging that the MDS should have been coded to reflect the resident's weight gain and hospice care status.
Failure to Refer for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with newly diagnosed mental disorders to the appropriate state-designated authority for a Level II PASARR evaluation. The deficiency was identified during a review of the facility's policy and the resident's electronic health record (EHR). The policy stated that any resident with newly evident or possible serious mental disorder (MD) or intellectual disability (ID) must be referred for a Level II PASARR evaluation. However, the facility did not adhere to this policy for one resident who was diagnosed with Schizophrenia, Bipolar Disorder, and Anxiety Disorder on 08/16/2024. The resident in question was initially admitted with diagnoses including Major Depressive Disorder and Post-Traumatic Stress Disorder. Despite the new diagnoses of Schizophrenia, Bipolar Disorder, and Anxiety Disorder, there was no evidence that a Level II PASARR had been submitted after these diagnoses. The Social Services Director confirmed that the resident's PASARR from 2020 indicated a Level II was not required and acknowledged the oversight in not submitting a new Level II evaluation after the new diagnoses.
Inaccurate PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that residents with mental disorders or intellectual disabilities had accurately completed PASARR Level I and/or Level II screenings. Specifically, two residents, identified as #11 and #49, were found to have discrepancies in their PASARR screenings. Resident #11 was admitted with a diagnosis of Bipolar Disorder, but the Level I PASARR screening did not indicate this mental illness. Similarly, Resident #49, who was admitted with a diagnosis of Obsessive-Compulsive Disorder, also had a Level I PASARR screening that failed to reflect this condition. The screenings were not updated to include these qualifying diagnoses. During a concurrent records review and interview, the Social Services Director (S4SSD) acknowledged responsibility for completing and reviewing PASARRs upon resident admission. However, she admitted that she did not resubmit the PASARR screenings to reflect the qualifying diagnoses for both residents. Additionally, the Level I PASARR screening form for Resident #49 could not be located in the electronic medical record, and S4SSD was unable to confirm if the qualifying diagnosis had been accurately indicated. This oversight resulted in the facility's non-compliance with PASARR requirements for these residents.
Failure to Label Enteral Feeding Administration Set
Penalty
Summary
The facility failed to ensure proper labeling of a resident's enteral feeding administration set, which is a requirement according to their policy. During an observation, it was noted that the administration set for a resident receiving tube feeding did not have the resident's name, date, time of initiation, or the initials of the person who initiated the feeding. This observation was confirmed by an LPN present at the time, who acknowledged that the set should have been labeled with this information. The resident involved had a medical history including cerebral infarction, dysphasia, and aphasia, and had specific physician's orders for enteral feeding that were not properly documented on the feeding set. This deficiency had the potential to affect a total of four residents receiving enteral feedings in the facility.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in infection control practices. Resident #10, who was admitted with diagnoses including Osteoporosis and Major Depressive Disorder, had a physician's order for Ipratropium-Albuterol Inhalation solution to be administered three times a day for pneumonia. During an observation, it was noted that Resident #10's nebulizer tubing and mouthpiece were left on top of a drawer unit, exposed to air, and not stored in a plastic bag as required by the facility's infection prevention policy. This was confirmed by an LPN who acknowledged that the equipment should have been stored in a bag when not in use. Similarly, Resident #96, who was admitted with Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Chronic Cough, had an order for oxygen to be applied as needed for dyspnea. An observation revealed that the resident's oxygen nasal cannula was found on the floor, which was confirmed by another LPN to be inappropriate as it should have been stored in a bag. These findings indicate a failure to adhere to the facility's policy on the proper storage of respiratory equipment, potentially compromising infection control measures.
Failure to Label Opened Refrigerated Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling refrigerated food items with the date they were opened. During an observation and interview with the Dietary Manager, it was noted that a gallon of ranch dressing and a zip-locked bag of sliced cucumbers in the kitchen's free-standing refrigerator were opened and used without being labeled with the date of opening. The Dietary Manager confirmed these findings and acknowledged that the opened food items should have been labeled with the date they were opened, but they were not. This oversight had the potential to affect the 115 residents who consumed food prepared in the kitchen.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage II Pressure Ulcer, as required by their infection prevention and control policy. The policy, revised in April 2024, mandates the use of gown and gloves during high-contact resident care activities, such as wound care, to prevent the spread of multi-drug resistant organisms. Despite this, there was no signage indicating the need for EBP on or near the resident's room, nor was there any personal protective equipment (PPE) available in the immediate area. During an observation and interview with two wound care nurses, it was confirmed that they were unaware of the requirement for EBP for residents with pressure ulcers. The resident in question had a pressure ulcer on her left gluteus, which required daily wound care. The absence of EBP signage and PPE availability indicates a lapse in adherence to the facility's infection control policy, potentially compromising the safety and care of the resident.
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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