Camelot Leisure Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Ferriday, Louisiana.
- Location
- 6818 Highway 84 West, Ferriday, Louisiana 71334
- CMS Provider Number
- 195516
- Inspections on file
- 22
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Camelot Leisure Living during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including ileostomy status and dementia, experienced repeated issues with a leaking ileostomy bag and inadequate care, as reported by the responsible party to the DON on several occasions. Despite these complaints, the facility did not initiate a formal grievance, document an investigation, or provide a resolution, contrary to its grievance policy. Staff confirmed that concerns were communicated to nursing leadership but not processed as grievances.
A resident with significant cognitive and physical impairments, including dysphagia and altered consciousness, did not have their required feeding assistance needs reflected in their care plan. Staff confirmed the omission after a family member reported a meal tray was left unattended in the resident's room, and review of records showed the care plan lacked documentation of the necessary feeding support.
A resident with an ileostomy did not receive timely and appropriate care as required by facility policy and professional standards. The resident was found with feces on her skin due to a leaking appliance, and staff delayed changing the ileostomy bag despite repeated notifications and complaints from the responsible party. Communication lapses among nursing staff contributed to the delay in care.
The facility failed to maintain a sanitary kitchen, leading to potential foodborne illness risks for all residents. Staff used inappropriate chemicals for dishwashing, and food items were improperly labeled and stored. The walk-in freezer had excessive frost, and the kitchen was unclean. Staff did not wear proper hair restraints or practice effective hand hygiene. Temperature logs were missing, indicating inadequate monitoring of food safety.
The facility failed to effectively manage its dietary department, leading to improper dishwashing practices and inadequate staff training. A dietary staff member used bleach for dishwashing, and others lacked training on food preparation and safety standards. The absence of a dietary manager and insufficient oversight by the administrator contributed to these deficiencies.
The facility failed to adhere to professional standards for respiratory care for three residents. One resident's nebulizer mask was left uncovered, another received oxygen therapy without a required humidifier, and a third had unlabeled and improperly stored oxygen equipment. Staff confirmed these lapses, which were against facility policy.
The facility failed to properly label and store medications, including an unlabeled insulin vial and expired ophthalmic solutions. The emergency kit's tag number did not match the log, and narcotic records showed discrepancies in counts and documentation. Additionally, a discontinued Lorazepam was not removed from the cart as required by policy.
The facility failed to provide sufficient support personnel for food and nutrition services, resulting in consistently late meal service. Observations and interviews revealed that lunch was often served significantly past the scheduled times, affecting residents, including one with Type 2 Diabetes Mellitus and another with Protein Calorie Malnutrition.
The facility failed to ensure pureed foods were prepared according to standardized recipes, affecting 11 residents on pureed diets. Observations showed dietary staff did not measure ingredients or follow recipes, preparing meals by sight without proper training. The acting dietary manager confirmed that recipes should be followed, highlighting a deficiency in meal preparation.
The facility failed to maintain an effective infection prevention and control program. Staff did not decontaminate blood pressure cuffs between residents and neglected hand hygiene. Enhanced Barrier Precautions were not used for a resident on dialysis, and oxygen tubing was improperly stored on the floor. These actions were confirmed by staff interviews and observations.
The facility failed to treat two residents with dignity. A resident was not served his meal on time, despite being seated with others who were already eating. Another resident, who requires assistance with personal hygiene, was not shaved despite her requests, leaving her with unwanted facial hair. These actions contradict the facility's policy on resident dignity and grooming preferences.
A resident with a history of heart failure and other conditions experienced a syncope episode, becoming unresponsive. Despite this significant change, the charge nurse did not notify the physician, believing the resident was at baseline. The facility's policy to notify the physician of such changes was not followed.
The facility failed to secure and maintain the confidentiality of medical records when a computer screen displaying resident information was left open and unattended on a medication cart. An LPN confirmed the screen should have been closed, and further interviews with the ADONs corroborated that such screens should not be visible when staff is not present.
A facility failed to complete a Discharge MDS assessment for a resident upon discharge. The ADON, responsible for MDS assessments, confirmed the oversight and later submitted the assessment, but it was completed late, more than 14 days after the ARD.
A facility failed to complete a significant change MDS assessment within the required timeframe for a resident admitted to hospice. The resident, with diagnoses including Parkinson's Disease and Depression, was admitted to hospice services, marking a significant change in condition. However, the MDS assessment was not completed within 14 days, as confirmed by the ADON.
A resident with contractures and impaired mobility developed a wound due to the facility's failure to revise the care plan to include pressure-relieving devices. Despite being at risk for pressure injuries, the care plan lacked interventions like a hand roll, leading to a skin tear from the contracted hand. Observations confirmed the absence of preventative measures, and the wound was attributed to the fingernail pressing into the palm.
A resident with moderate cognitive impairment and mobility issues fell in the facility's parking lot due to a known hazard of cracked and uneven concrete. The resident, who required assistance for walking, was being taken to a doctor's appointment when the incident occurred, resulting in knee injuries and a hospital evaluation. The hazard had been previously reported, but remained unaddressed until after the incident.
The facility did not post the required daily nurse staffing information, including the resident census and actual hours worked by RNs, LPNs, and CNAs. Observations showed that the posted forms only listed the total number of scheduled staff, lacking details on staffing hours. The DON confirmed that while the facility tracked this information, it was not displayed as required.
The facility failed to properly dispose of garbage, affecting all 64 residents. Observations revealed open dumpster lids and doors, with one lid broken, and litter scattered around the area. The Maintenance Supervisor confirmed the issues, and the Administrator was unaware of the broken lid.
A facility failed to report a sexual abuse allegation involving a cognitively intact resident to the State Survey Agency within the required timeframe. Additionally, a resident with severe cognitive impairment and multiple diagnoses was found with fractures of unknown origin, which were not reported as required. The facility's administrator confirmed these reporting failures.
A facility failed to investigate an allegation of sexual abuse involving a resident with intact cognition and a history of mental health issues. Despite a complaint made by the resident's family to law enforcement, the facility did not conduct an investigation, contrary to its policy requiring prompt reporting and thorough investigation of such allegations.
A resident with intact cognition and multiple diagnoses fell from a wheelchair, resulting in a nosebleed and hospital transfer. The facility failed to update the care plan with fall interventions, as confirmed by the DON.
Failure to Promptly Address and Resolve Grievance Regarding Ileostomy Care
Penalty
Summary
The facility failed to ensure prompt resolution of a grievance related to improper ileostomy care for one resident. The resident, who had diagnoses including Type 2 Diabetes Mellitus, moderate protein-calorie malnutrition, gastrostomy and ileostomy status, and dementia, required partial to moderate assistance with activities of daily living. The resident's care plan included specific interventions for ileostomy care, such as scheduled appliance changes. The resident's responsible party reported to the DON on multiple occasions that the resident's ileostomy bag was leaking, resulting in feces on the resident and towels being used to catch the leakage. Despite these complaints, the responsible party stated that the issue persisted and was not resolved as assured by the DON. Review of facility records showed that no formal grievance was initiated for this resident, and the grievance log did not contain any entries related to the reported concerns. Documentation from the facility's Hand in Hand Program indicated that concerns about the timeliness of colostomy bag changes were noted and that nursing leadership was notified, but there was no follow-up or resolution documented. Interviews with staff confirmed that complaints from the responsible party were communicated to nursing leadership but were not processed as formal grievances, and no investigation or resolution was documented as required by facility policy.
Failure to Develop Person-Centered Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop a person-centered care plan addressing feeding assistance for one resident. According to facility policy, a comprehensive care plan with measurable objectives and timetables should be developed and implemented for each resident, including support for activities of daily living such as dining. Review of the resident's medical record showed diagnoses including dysphagia, senile degeneration of the brain, anorexia, moderate protein calorie malnutrition, and sequelae of intracerebral hemorrhage. The resident was rarely or never understood, had an altered level of consciousness, and required moderate assistance with eating, as well as being dependent for personal hygiene, mobility, and transfers. A grievance filed by the resident's family member reported that a lunch tray was left on the bedside table and had tumbled onto the resident's bed, with no aide present in the room. Investigation confirmed the tray was left in the room over the resident. Review of the resident's care plan revealed it did not reflect the required level of feeding assistance. During interviews, staff confirmed that the resident required staff assistance to be fed and acknowledged that this need was not included in the care plan, despite it being necessary.
Failure to Provide Timely Ileostomy Care
Penalty
Summary
A deficiency occurred when a resident requiring ileostomy care did not receive services consistent with professional standards of practice. The facility's policy required ileostomy appliance changes every Tuesday and Thursday, and as needed for dislodgement, with documentation of care provided. The resident, who had diagnoses including Type 2 Diabetes Mellitus, moderate protein-calorie malnutrition, gastrostomy and ileostomy status, and dementia, was dependent on staff for personal hygiene and toileting. The care plan and medication administration record specified frequent attention to the ileostomy, including burping or emptying the appliance up to six times daily as needed. Despite these requirements, the resident was observed with loose feces on her skin due to leakage from the ileostomy bag, and a towel had been placed around the appliance to catch the feces. The resident's responsible party reported multiple complaints to the DON about the resident being left with feces on her and waiting long periods for ileostomy care. On the day of observation, a CNA reported the need for an appliance change to the treatment nurse, who indicated a delay. The treatment nurse did not provide care, and the LPN who eventually changed the appliance did so several hours later, after being informed late. Interviews confirmed a lack of timely communication and response among staff, resulting in the resident not receiving prompt and appropriate ileostomy care.
Deficient Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which led to the potential for foodborne illnesses affecting all 64 residents. Observations revealed that staff did not use approved chemicals or sanitizers during dishwashing, as evidenced by S3 Dietary using a Clorox/Bleach solution to clean a blender used for meal preparation. This practice was contrary to the facility's policy, which required the use of a three-compartment sink for cleaning and sanitizing utensils and dishes. Additionally, food items in refrigerators and pantries were not labeled or dated, and expired foods were available for use. The facility's walk-in freezer was found to be in poor condition, with excessive frost build-up preventing the door from closing properly. This resulted in food items being covered with frost and stored directly on the floor, contrary to professional standards for food storage. The kitchen was also observed to be unclean, with grease stains, food particles, and dust accumulation on various surfaces, including the floors, shelving, and equipment. Staff were not wearing appropriate hair restraints, and there was a lack of effective hand hygiene and glove usage during food preparation activities. Temperature monitoring was inadequate, with missing logs for both food and refrigerator temperatures on multiple dates. This failure to monitor and document temperatures could compromise food safety. Interviews with staff confirmed these deficiencies, with some staff unaware of the requirement to wear beard nets or practice proper hand hygiene. The facility's Registered Dietitian also expressed concerns about the use of bleach for dishwashing and the persistent frost build-up in the walk-in freezer, indicating ongoing issues with compliance to food safety standards.
Removal Plan
- The administrator called the dietary consultant to in-service and train the dietary staff to ensure regulatory compliance.
- The administrator removed all bleach from dietary, and the facility.
- The administrator verbally in-serviced dietary staff present that bleach is not used to sanitize equipment, pots & pans, and cutlery.
- The 3 compartment sink was explained and how to check the proper level of sanitizer.
- The administrator called the dietary consultant to in-service and train dietary staff on sanitary conditions in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance.
- The administrator called off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer.
- All dietary staff have been in-serviced.
- Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at in-services for all dietary staff.
- The kitchen will be audited randomly to ensure there is no bleach in the kitchen, the audits will be done to monitor the kitchen that no bleach is present.
- This monitoring will be included in the current QAPI being done in the kitchen and reported in the QA meeting.
- The Administrator and Maintenance Supervisor will complete the random audits and audits.
- Any dietary staff not following policies and procedures given in-services will be given written warnings up to and including termination.
Deficient Dietary Practices Due to Lack of Training
Penalty
Summary
The facility failed to administer its resources effectively, impacting the dietary department's adherence to professional standards for food services. This deficiency was observed when a dietary staff member used a Clorox/Bleach solution for dishwashing a blender used in pureed meal preparation, which was not in compliance with proper sanitation practices. The staff member admitted to using this method regularly to save time, indicating a lack of proper training and oversight. Further observations revealed that the dietary staff lacked proper training and competency checks. One staff member was seen preparing pureed meals by free-pouring an unmeasured amount of powdered thickener, admitting that she had not been taught otherwise. Another staff member was observed without a beard net, stating he was unaware of the requirement and had not received any training since his hire. Interviews with staff revealed a lack of guidance and support from the administration, with some staff members feeling uncomfortable seeking help due to perceived inattention from supervisors. The facility's documentation showed no records of training or competency evaluations for dietary staff, including the administrator and maintenance supervisor who were overseeing the kitchen in the absence of a dietary manager. The administrator acknowledged the absence of a dietary manager since July 2024 and admitted to being responsible for the kitchen's daily operations, yet there was no evidence of effective management or training being provided to the dietary staff.
Removal Plan
- The training of new dietary staff will be done on hire, and continuing education will be provided at monthly in-services for all dietary staff to improve the knowledge, and basic skills of the dietary staff to ensure regulatory compliance.
- The training and continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant.
- The administrator verbally in-serviced dietary staff present not to use bleach to sanitize equipment and instructed staff how to use the 3 compartment sink and check for the proper amount of sanitizer.
- The administrator called the dietary consultant to in-service and train dietary staff on sanitation in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance.
- The administrator called off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer.
- All dietary staff have been in-serviced.
- Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff.
- The training of each new hire in dietary will be monitored using a check list to orient them to the kitchen and dietary policies and procedures, and all dietary staff will receive monthly in-servicing training.
- The administrator will monitor the training of new dietary staff and the monthly in-services, both will be ongoing.
- The dietary consultant will monitor the administrator to ensure new hire training and monthly in-servicing is taking place during their monthly visit.
- This monitoring will be included in the current QAPI being done in the kitchen and reported in the QA meeting.
Deficiency in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents, as observed during a survey. For one resident with Chronic Obstructive Pulmonary Disease (COPD) and other conditions, a nebulizer mask was found uncovered on top of the refrigerator, contrary to the facility's policy that requires such equipment to be stored properly in a zip lock bag when not in use. The resident confirmed the use of the nebulizer mask for breathing treatments, and an LPN acknowledged that the mask should not have been left uncovered. Another resident, who had diagnoses including dementia and acute respiratory failure, was observed receiving oxygen therapy without a humidifier bottle attached, despite having orders for continuous oxygen at 3 liters per minute, which requires humidification according to the facility's policy. The oxygen tubing was also undated, and the resident confirmed wearing oxygen at all times. An LPN was unsure if the resident required humidified oxygen, and the Director of Nursing (DON) later confirmed that the resident should have had a humidifier bottle attached. A third resident with severe persistent asthma and other conditions was found with oxygen tubing on the floor and a nebulizer mask placed directly on a dresser, both unlabeled and unbagged. An LPN confirmed that the equipment should have been stored and labeled correctly. The DON reiterated that the facility's policy requires weekly changes and proper labeling and storage of oxygen and nebulizer equipment, which was not adhered to in these cases.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as evidenced by several deficiencies. An opened vial of Lantus insulin was found in the medication refrigerator without a label indicating the date it was opened, contrary to the facility's policy that requires insulin vials to be labeled and discarded 28 days after opening. Additionally, the emergency medication kit's tag number did not match the log, and the log lacked documentation of medication strength, quantity, and physician's name. A loose, unidentified pill was also found in a medication cart, which should not have been there. Further deficiencies were noted in the handling of expired medications. Several ophthalmic solutions were found in a medication cart with open dates exceeding the 28-day discard period, and one bottle lacked an open date entirely. The facility's policy requires medications to be labeled with open dates and discarded appropriately, which was not followed. Additionally, discrepancies were found in the narcotic records, with incorrect counts and missing documentation of administered doses. For instance, the narcotic record for a resident showed two different records with a total of 26 tablets, while only 13 were present. The facility also failed to manage discontinued medications properly. A blister pack of Lorazepam, which had been discontinued for a resident, was still present in the medication cart. The facility's policy requires discontinued controlled substances to be removed and returned to the pharmacy, which was not done. The Director of Nursing confirmed that the discontinued medication should have been removed but was not, indicating a lapse in following the facility's procedures for handling controlled substances.
Late Meal Service Due to Insufficient Support Personnel
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition services, resulting in meals being served late. Observations on multiple occasions revealed that lunch service began significantly past the posted meal times, with one instance showing a delay of 1 hour and 5 minutes. Interviews with residents and staff confirmed that late meal service was a regular occurrence, with lunch often served between 1:00 p.m. and 1:30 p.m., despite the scheduled time being 11:30 a.m. for the dining room and 12:00 p.m. for hall trays. Resident #32, who has intact cognition and multiple health conditions including Type 2 Diabetes Mellitus and Heart Failure, reported that lunch was consistently served late. Similarly, Resident #26, who suffers from Protein Calorie Malnutrition and is on a mechanically altered diet, experienced delays in receiving meals, with lunch sometimes served as late as 2:00 p.m. Observations confirmed that Resident #26's lunch tray was delivered at 1:04 p.m., further illustrating the facility's failure to adhere to scheduled meal times.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods that conserved nutritional value for 11 residents who were ordered and served pureed diets. Observations revealed that the dietary staff did not follow standardized recipes when preparing pureed meals. Specifically, the dietary staff member, identified as S3 Dietary [NAME], was observed preparing pureed rice, spinach, and beef patties without measuring ingredients or referring to the approved recipes. The staff member admitted to preparing the meals by sight and confirmed that she had not been trained to refer to recipes when preparing meals. The facility's policy required the use of standardized recipes to ensure the nutritional value of meals, but this was not adhered to during the preparation of pureed foods. The acting dietary manager, S4 Maintenance Supervisor, confirmed that dietary cooks were expected to follow recipes when preparing meals. The failure to follow standardized recipes and the lack of training for dietary staff contributed to the deficiency in meal preparation for residents on pureed diets.
Infection Control and Equipment Decontamination Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Staff did not decontaminate reusable medical equipment, such as blood pressure cuffs, between resident uses. Observations revealed that an LPN used a wrist and arm blood pressure cuff on multiple residents without decontaminating them between uses. Additionally, the same LPN did not wash hands or use hand sanitizer before or after direct contact with residents. Interviews with the LPN and Assistant Directors of Nursing confirmed these practices were not in compliance with the facility's policies. Enhanced Barrier Precautions (EBP) were not utilized for a resident undergoing dialysis, despite physician orders indicating the need for such precautions. Observations over two days showed no EBP signage or equipment outside the resident's room. An interview with the Assistant Director of Nursing confirmed that EBP should have been in place for residents receiving dialysis, but they were not maintained. Another deficiency involved improper storage of oxygen equipment. A resident's oxygen tubing was observed directly on the floor, contrary to the facility's policy requiring tubing to be stored in labeled bags. An LPN confirmed the improper storage, and the Director of Nursing acknowledged that all oxygen tubing should be labeled and stored correctly when not in use.
Failure to Uphold Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, impacting two residents. Resident #32 was not served his meal at the same time as other residents seated at his table. Despite being seated in the dining room since 11:50 a.m., Resident #32 did not receive his lunch tray until 12:14 p.m., after repeated requests from the CNA and intervention by the ADON. This delay in service was confirmed by the ADON, who acknowledged that all residents seated together should be served simultaneously. Resident #19, who has intact cognition and requires assistance with personal hygiene, was observed with long facial hair on her chin and neck, which she expressed a desire to have shaved. Despite her requests, staff did not shave her, citing fear of cutting her. This was confirmed by an LPN who acknowledged the need for shaving but had not addressed it. These incidents demonstrate a failure to uphold the residents' dignity and personal grooming preferences as outlined in the facility's policy.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to consult with a resident's physician following a significant change in the resident's physical status. The incident involved a resident with a medical history that included heart failure, coronary angioplasty implant and graft, essential hypertension, type 2 diabetes mellitus, and dementia. On the day of the incident, the resident experienced a syncope episode, becoming unresponsive after twitching. Despite the change in condition, the charge nurse decided not to notify the physician, believing the resident was at his baseline and did not require hospital evaluation. Interviews with staff revealed that the charge nurse and LPN were aware of the resident's unresponsiveness but did not contact the physician. The charge nurse performed a sternal rub, which elicited a response from the resident, and concluded that the resident did not need further medical evaluation. The Director of Nursing was not informed of the incident, and the physician could not recall being notified. The facility's policy requires notifying the physician of significant changes in a resident's condition, which was not followed in this case.
Failure to Secure and Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the security and confidentiality of medical records, as observed on 02/19/2025. A computer screen on Cart A in Hall A was left open and visible, displaying resident information, without any staff present. This was confirmed by a surveyor who remained with the cart until a staff member, identified as S7LPN, returned. During an interview, S7LPN acknowledged that the computer screen should have been closed when she was away from the medication cart. Further interviews with S6ADON and S5ADON confirmed that computer screens with resident information should not be visible when staff is not present, as per the facility's policy on electronic medical records dated 12/23/2024.
Failure to Timely Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) assessment for a resident upon their discharge. The resident was admitted and later discharged, but a review of their MDS record showed no Discharge MDS assessment was completed. During an interview, the Assistant Director of Nursing (ADON) confirmed that she was responsible for completing MDS assessments and acknowledged that she did not complete the Discharge MDS assessment for the resident at the time of discharge, although it was required. Later, the ADON submitted the Discharge MDS assessment, but it was completed late, more than 14 days after the Assessment Reference Date (ARD).
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 calendar days after determining there was a significant change in a resident's status. Resident #7, who was admitted to the facility with diagnoses including Parkinson's Disease, Unspecified Psychosis, and Depression, was admitted to hospice services on 02/03/2025. Despite this significant change in condition, there was no evidence that a significant change MDS had been completed or was in progress following the resident's admission to hospice. An interview with the Assistant Director of Nursing (ADON) confirmed that the significant change MDS had not been completed for Resident #7, although it should have been done within the required timeframe.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to revise the care plan interventions to prevent the development of a wound for Resident #43, who was at risk for impaired skin integrity due to contractures and impaired mobility. Despite being identified as at risk for pressure injuries, Resident #43's care plan did not include the use of a hand roll or other pressure-relieving device for the contracted right hand. Observations revealed a contracted right hand without a hand roll, and subsequent examinations showed a purple discoloration and an open wound with reddish-pink drainage on the palm where the 5th digit pressed into it. The facility's staff confirmed that Resident #43 was not care-planned for a hand roll, and attempts to use one in the past were unsuccessful due to the tight clenching of the hand. The deficiency was further highlighted by the lack of documentation of current skin impairment in Resident #43's progress notes, despite the presence of a wound. The wound was attributed to a skin tear caused by the fingernail pressing into the palm due to the contracted hand. A physician's order was eventually made to address the wound, but the initial failure to implement appropriate preventative measures in the care plan led to the development of the wound. The facility's policy required ongoing assessments and revisions of care plans as residents' conditions changed, which was not adequately followed in this case.
Resident Falls Due to Unrepaired Parking Lot Hazard
Penalty
Summary
The facility failed to maintain a safe environment for its residents, resulting in an accident involving a resident with moderate cognitive impairment and mobility issues. The resident, who had a history of chronic systolic heart failure, pain, cognitive communication deficit, lack of coordination, and muscle weakness, was being assisted to a scheduled doctor's appointment. Despite requiring supervision and assistance for walking, the resident was ambulating with a walker in the facility's parking lot when they encountered a cracked and uneven concrete surface filled with rainwater. This hazard caused the resident to fall, resulting in redness and pain in the knees, necessitating a hospital evaluation. Interviews and observations revealed that the cracked concrete in the parking lot had been a known issue, with previous incidents reported. The Director of Nursing confirmed the unsafe condition of the parking lot, and the Maintenance Supervisor acknowledged that all employees were responsible for ensuring the safety of the parking lot. Despite these acknowledgments, the hazard remained unaddressed until after the incident, highlighting a lapse in the facility's duty to provide a hazard-free environment for its residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the resident census and the total number and actual hours worked by RNs, LPNs, and CNAs responsible for resident care per shift. Observations on two consecutive days revealed that the Daily Nursing Census forms posted near the nurse's station did not include the required information on daily staffing hours. Instead, the forms only listed the total number of nurses and CNAs scheduled for each shift. An interview with the Director of Nursing (DON) confirmed that while the facility maintained records of the required and provided daily nursing hours, this information was not posted as required.
Improper Garbage Disposal and Maintenance Issues
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which had the potential to affect all 64 residents. During an observation of the facility's dumpster area, it was found that both dumpsters had their top lids and side doors open. One of the dumpsters had a broken lid that could not close properly. Additionally, there was litter, including used gloves, paper products, and metal pieces from a mechanical lift, scattered around the dumpster area. The Maintenance Supervisor confirmed these findings and acknowledged that the dumpster lids and doors should remain closed and the area should be kept clean. The Administrator was unaware of the broken lid and confirmed that dumpsters should remain closed when not in use.
Failure to Report Abuse and Injury in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Survey Agency within the required timeframe. A resident with intact cognition was admitted with various diagnoses, including anxiety and depression. A deputy from the sheriff's office visited the facility to inquire about the resident, revealing that the family had made a complaint regarding sexual abuse. The facility's administrator confirmed that the allegation was not reported as required, despite being informed by the sheriff's department about the complaint. Additionally, the facility did not report a fracture of unknown origin for another resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease and osteoporosis. The resident required extensive assistance with mobility and was found with bruising and edema on the left foot. X-rays revealed fractures in the tibia and fibula, and the resident was transferred to the hospital. The facility's administrator confirmed that this incident was not reported to the State Survey Agency, as required by regulations.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident. The facility's policy mandates that all reports of abuse, neglect, exploitation, and other related incidents must be promptly reported to relevant agencies and thoroughly investigated by facility management. However, in this case, there was no evidence of an investigation into the alleged sexual abuse of a resident, despite a complaint being made by the resident's family to the sheriff's office. The resident involved had a medical history that included pain, anxiety disorder, depression, bipolar disorder, and was receiving aftercare following surgery. The resident's cognitive function was intact, as indicated by a BIMS score of 13. Despite the family’s complaint and the involvement of law enforcement, the facility did not initiate an investigation into the allegation, which was confirmed by the facility's administrator during an interview.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to develop a comprehensive care plan with appropriate interventions following a fall incident involving a resident. The resident, who was admitted with diagnoses including pain, anxiety disorder, depression, bipolar disorder, and was receiving surgical aftercare, had a BIMS score indicating intact cognition. The resident required limited assistance with bed mobility and eating, and extensive assistance with transfers and toilet use. On a specific date, the resident fell face first out of a wheelchair in the dayroom, resulting in a nosebleed and subsequent hospital transfer. Despite this incident, the resident's care plan lacked any interventions for the fall, which was confirmed by the Director of Nursing during an interview.
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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