Carroll Health And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Grove, Louisiana.
- Location
- 307 N Castleman St, Oak Grove, Louisiana 71263
- CMS Provider Number
- 195423
- Inspections on file
- 26
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 23 (2 serious)
Citation history
Health deficiencies cited at Carroll Health And Rehab Llc during CMS and state inspections, most recent first.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
A resident with severe cognitive impairment and a history of elopement exited the facility through a window and was found by police on a highway after staff failed to implement or communicate an elopement risk care plan. Additionally, three residents were found with loose, improperly secured bedrails, with staff confirming the need for repairs and lack of adherence to safety policies.
The facility did not ensure adequate nursing staff coverage on numerous weekends and specific dates, as confirmed by staffing records and the DON. This resulted in insufficient staff with appropriate competencies and skill sets to meet resident needs.
A resident who was cognitively intact did not receive their most recent quarterly financial statement as required by facility policy. The BOM stated that statements are mailed, but the resident reported not receiving it, and the SSD could not confirm delivery. An anonymous source also indicated that residents were not receiving their statements.
Surveyors found that multiple residents with complex medical needs were using wheelchairs with cracked, torn armrests and seats, as well as wheels with significant dirt and grime. These deficiencies were observed over several days and confirmed by the DON and Director of Maintenance, indicating a failure to maintain mobility equipment in safe and clean condition.
Surveyors identified a medication error rate of 19.35%, well above the acceptable 5% threshold, due to late administration of multiple medications to one resident and a missed dose of Thiamine Hydrochloride for another. LPNs either administered medications significantly past the scheduled time or failed to give a prescribed dose, with errors confirmed by both nursing staff and the DON.
The facility did not conduct or document a facility-wide assessment to determine necessary resources for competent care during daily operations and emergencies. The last assessment was completed over a year ago, as confirmed by the DON, a corporate RN, and a manager.
Surveyors found that the facility failed to obtain physician orders, conduct entrapment risk assessments, and update care plans for four residents using bedrails. Despite residents having various medical conditions and cognitive statuses, bedrails were observed in use without the required documentation or assessment, as confirmed by the DON.
Two residents with intact cognition were prescribed as-needed Klonopin for longer than 14 days without a specified stop date, despite pharmacist requests for clarification. The DON confirmed that the physician did not address the recommendations, resulting in continued use of psychotropic medications beyond the recommended duration.
A resident with a history of traumatic subdural hemorrhage, seizures, and encephalopathy was prescribed Valproic Acid with a physician order for monthly Depakote level monitoring. The facility did not obtain or document any Depakote lab results, and the DON confirmed that these labs were not drawn as required.
Surveyors found that an ice scoop used for serving ice to residents was stored inside an ice chest containing ice for resident use, a practice confirmed by the dietary supervisor and later reported to the DON. This action did not meet professional standards for food service safety.
The facility did not complete four quarterly Quality Assessment and Assurance (QAA) committee meetings with all required members present within the past year, as confirmed by record review and staff interviews.
A resident with an unstageable pressure ulcer did not have Enhanced Barrier Precautions (EBP) signage posted in their room as required by physician order and facility policy. The DON confirmed the absence of the necessary signage, indicating a lapse in the infection prevention and control program.
The facility did not provide at least 12 hours of required annual in-service training to several CNAs, as confirmed by record review and interview with the DON. Personnel files lacked documentation of the mandated training, including education in dementia care and abuse prevention.
The facility did not develop or implement care plans for two residents with severe cognitive impairment and elopement risk, nor for a resident with paraplegia and bilateral hand contractures. Staff confirmed the absence of these care plans, despite documented needs and assessments indicating the necessity for individualized interventions.
A resident with multiple risk factors for pressure ulcers, including immobility and a history of skin impairment, was observed multiple times without a pressure-reducing cushion in the wheelchair as required by the care plan. The DON confirmed the absence of the cushion, despite its documented necessity for pressure ulcer prevention.
Staff did not follow catheter care protocols for a resident with multiple health conditions, as the catheter bag and tubing were repeatedly observed lying on the floor and improperly stored, contrary to facility policy. Both an LPN and the DON confirmed these practices were not appropriate.
Four residents with open wounds and active infections continued to receive whirlpool baths, while staff failed to clean the whirlpool according to manufacturer guidelines. The whirlpool's disinfectant jets were not functioning, the disinfectant reservoir was empty, and cleaning procedures did not include all required steps, leading to inadequate infection control. Staff interviews confirmed a lack of knowledge and oversight regarding proper cleaning protocols.
A Wound Care Nurse in an LTC facility failed to maintain proper infection control during a wound care procedure. The nurse contaminated a jar of Silvadene Cream by using a bare hand to scoop the cream with a medication cup, which was not resident-specific. Additionally, a bottle of Dermal Wound Cleanser was placed on an unsanitized table and returned to the wound care cart without being sanitized, risking cross-contamination.
A resident with multiple health conditions suffered a burn injury after spilling hot noodles on his leg. The night LPN assessed the blisters but failed to notify the physician, only informing the oncoming nurse. The injury was later addressed by an RN who contacted the physician for treatment. This delay in communication was identified as a deficiency.
A resident with severe cognitive impairment and nicotine dependence was observed smoking unsupervised in the designated smoking area. Despite the care plan requiring supervision, the resident was left alone and discarded a lit cigarette butt onto the concrete instead of using the fire safety ashtray, indicating a lapse in supervision and adherence to safety protocols.
A facility failed to conduct quarterly Safe Smoking Evaluations for a resident with chronic schizophrenia, despite policy requirements. The resident was cognitively intact, but documentation was incomplete, with an incorrect date on one evaluation and no evidence of quarterly assessments. The deficiency was confirmed by facility staff.
The facility exhibited multiple environmental deficiencies, including water-stained and sagging ceiling tiles in the kitchen, dirty hallway floors, and inappropriate use of a box fan in the whirlpool room. Outside, various discarded items were found, and the laundry room had rotten wood and a wet floor with a black substance. These issues were confirmed by staff and had the potential to affect 51 residents.
The facility failed to ensure nursing staff demonstrated necessary competencies, as evidenced by missing documentation for wound care, tracheostomy care, and medication administration for four residents. A resident with paraplegia and a stage 3 wound lacked documented dressing changes, while another with a stage 4 pressure ulcer had missing dressing change records. A resident with multiple diagnoses had undocumented wound care, and a resident with a tracheostomy had missing records for tracheostomy care and medication administration. Interviews confirmed these documentation lapses.
A facility failed to report and investigate an incident where a resident was found with illegal drugs. The resident, who was cognitively intact and used a wheelchair, was acting unusually and admitted to smoking marijuana. Staff found marijuana in his belongings and disposed of it without completing an Accident and Incident Report or conducting a thorough investigation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. Despite the resident's medical conditions and physician's orders for wound care, observations revealed the absence of an EBP sign on the resident's door. Interviews confirmed the oversight, highlighting a lapse in following infection control procedures.
The facility failed to conduct weekly skin assessments for residents with pressure ulcers, as required by their policy. A resident with a stage 3 pressure ulcer, another with a stage 2 ulcer, and a third with a stage 4 ulcer did not have documented weekly assessments. Interviews with the Interim DON and an RN confirmed the lack of assessments, acknowledging the oversight.
A resident in an LTC facility was subjected to verbal and mental abuse by another resident, who used racial slurs and derogatory comments about the victim's medical condition. Despite staff intervention, the aggressive behavior continued, causing distress to the victim. The facility failed to protect the resident from abuse, violating their rights.
A resident in an LTC facility experienced verbal and mental abuse from another resident, involving racial slurs and threats. Despite the facility's policy requiring immediate reporting, the incidents were not promptly reported to the Administrator or the State Survey Agency. Staff members witnessed the abuse but failed to notify the appropriate authorities within the required timeframe.
The facility was cited for non-compliance with laws and regulations due to the S1Administrator's response time being over one hour. The S1Administrator lived 1.5 hours away from the facility, as confirmed by her employee file and interviews, leading to a response time that did not meet the required standards.
The facility experienced a shortage of essential care supplies, such as wipes and toilet paper, affecting resident care. Several residents reported the lack of supplies, and staff confirmed the issue was due to a recent change in medical supply vendors, causing delivery delays. The shortage impacted the facility's ability to meet the needs of all residents.
The facility failed to maintain a clean and safe environment, affecting all residents. Observations revealed a black substance in toilets, foul odors, and dirt and grime in rooms and hallways. Interviews confirmed inadequate cleaning practices, with the administrator acknowledging the need for thorough cleaning.
A resident reported a $100 theft from his wallet, which he discovered after seeing a staff member exit his room. The facility administrator was informed four days later but failed to report the incident to the state agency and law enforcement within the required 24-hour period, violating federal reporting requirements.
A resident reported a $100 bill missing from his wallet after seeing the Housekeeping/Laundry Supervisor exit his room. The facility delayed investigating the allegation, failing to suspend the staff member or promptly review video footage. The administrator admitted to being busy, which contributed to the delay. Video evidence later contradicted the staff member's denial of entering the room, leading to her termination for dishonesty. The facility's inaction resulted in a deficiency in handling the situation according to their policy.
The facility failed to maintain proper hygiene and grooming for residents unable to perform activities of daily living. A resident with severe cognitive impairment was observed with food debris on clothing and unclean fingernails, while two other residents had long, dirty fingernails despite care plans requiring weekly nail care. Staff did not provide necessary assistance, as confirmed by an RN.
The facility failed to ensure that CNAs demonstrated competency in necessary skills and techniques to care for residents, as identified through assessments and care plans. A review of personnel records for five CNAs revealed no documented evidence of skills checks or competency evaluations, despite their hire dates ranging from 2021 to 2024. An interview with the Regional HR confirmed the absence of such documentation.
Two residents experienced medication administration errors, resulting in a 12.12% error rate. An LPN failed to administer Losartan and Carboxymethyl Cellulose Sodium to one resident, while another resident received Vitamin D3 daily instead of weekly and Seroquel in the morning instead of at bedtime. These errors were confirmed by an RN.
The facility failed to defrost chicken breasts properly, as observed during a kitchen visit. The chicken was submerged in water without running cold water and placed directly in the sink, contrary to the facility's policy. This practice could potentially affect 44 residents receiving meals from the kitchen, as confirmed by the Dietary Manager.
The facility did not have documented evidence of conducting a QAA meeting for the first quarter of 2024, as required. This was confirmed by the administrator during an interview, indicating a failure to meet the quarterly meeting requirement.
The facility failed to implement Enhanced Barrier Precautions for residents with wounds and colostomies, as required by their policy. Despite having conditions that necessitated such precautions, no residents were on enhanced barrier precautions. Interviews with staff confirmed this oversight, indicating a lapse in following infection control protocols.
The facility did not designate a qualified individual as the Infection Preventionist responsible for the infection prevention and control program. A review of records showed no evidence of a designated staff member, and the administrator confirmed this absence.
The facility failed to maintain an effective pest control program, resulting in a persistent fly infestation affecting all residents. Observations revealed flies in hallways and rooms, including a room with a urine smell and flies on a breakfast tray. Residents confirmed the issue, using fly swatters in their rooms. The facility's pest control policy was not effectively implemented, as confirmed by the administrator.
The facility failed to provide required in-service training for five nurse aides, lacking documentation for dementia management and resident abuse prevention training. Additionally, two aides did not complete the mandated 12 hours of annual training. These deficiencies were confirmed through personnel record reviews and an HR interview.
The facility failed to complete and transmit discharge MDS assessments within 14 days for three residents. A review of medical records showed that a resident was admitted and discharged without a timely assessment. Another resident was readmitted and discharged, and a third resident was admitted and discharged, all without the required timely assessments. The MDS Coordinator confirmed these assessments were not performed and transmitted on time.
The facility failed to provide proper respiratory care for two residents. One resident received oxygen therapy at a higher rate than prescribed, and another had a nebulizer mask and tubing improperly stored. These actions were inconsistent with professional standards and the facility's policies.
The facility failed to conduct State Adverse Actions checks for CNAs upon hire and monthly thereafter, affecting five CNAs. Additionally, the CNA registry was not verified upon hire for one CNA. This oversight was confirmed by the Regional HR representative, indicating a lapse in compliance with state regulations.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Prevent Elopement and Maintain Safe Bedrail Conditions
Penalty
Summary
The facility failed to have an adequate system in place to ensure residents at risk for elopement were properly supervised, resulting in an Immediate Jeopardy situation for one resident. This resident, who had vascular dementia, hemiplegia, cerebrovascular accident, heart failure, and mild cognitive impairment, was assessed as being at risk for elopement upon admission. Despite this, there was no documented evidence of a care plan addressing elopement risk, and staff were not adequately informed of the resident's risk status. The resident exited the building through a window and was found by police pacing on a highway nearly a mile from the facility, before being returned without injury. Staff interviews revealed that CNAs were unaware of the resident's elopement risk and did not notify nursing staff when the resident was missing, assuming he was elsewhere. The DON confirmed that only the day shift nurse was informed of the risk, and no comprehensive communication or care plan was in place for the resident's elopement risk prior to the incident. Additionally, the facility failed to ensure that the environment was free from accident hazards by not properly securing bedrails for three residents. Observations over several days showed that quarter or half bedrails on the beds of these residents were loose and not properly attached. Both the DON and the Director of Maintenance confirmed the bedrails were not secured and required repair. The facility's policy required correct installation and maintenance of bedrails, including following manufacturer instructions and regular inspections, but these procedures were not followed for the affected residents. The deficiencies were identified through observations, record reviews, and staff interviews. The lack of proper communication, documentation, and adherence to facility policies contributed to the failure to prevent elopement and to maintain a safe environment regarding bedrail use. The issues were confirmed by multiple staff members, including the DON, CNAs, and the Director of Maintenance, who acknowledged the lapses in supervision, communication, and equipment maintenance.
Removal Plan
- DON or Designee will screen all new admits or readmits for potential wandering and/or elopement, including history and current cognitive status and continue with ongoing elopement risk assessments.
- Hourly observations for Resident #73 was initiated.
- Hourly observations for all high risk for elopement residents were initiated.
- Ensured all high risk for elopement residents had on orange wristbands.
- Maintenance Director secured all windows.
- DON or Designee will be responsible for updating the elopement binders for all high-risk new admissions and readmissions for elopement. To be placed at each nurses station with face sheets continuously.
- Elopement policy updated to include: any elopement risk resident will wear an orange wrist band as an identifier.
- Charge nurses will meet with all staff (CNAs, nurses, any other direct/indirect care staff) at beginning of each shift to communicate high risk elopement residents.
- DON and ADON inserviced nurses to complete hourly observations of high risk elopement residents and document on monitoring tool – completed inservice.
- DON inserviced MDS nurse to update care plan to reflect elopement risk residents.
- Inservice was completed by DON and ADON to all staff on elopement risk and orange wristbands.
- Education also added to the new hire orientation process.
- DON or Designee will observe and document high risk elopement residents’ behaviors for initial period in facility after new admission or readmission.
- Inserviced staff began using the hourly observations monitoring tool for Resident #73.
- DON or Designee will monitor the completion of the hourly observations of high risk residents and the documentation on monitoring tool is complete.
- Inserviced staff began using the hourly observations monitoring tool for all high risk elopement residents.
- Maintenance Director will monitor windows to random rooms. All findings will be reported to Quality Assurance (QA) committee.
- Hourly monitor tool binder on high risk elopement residents to be completed for the initial period after new admission or readmission.
- DON or Designee will monitor orange wristbands to ensure it is intact and to be changed as needed if soiled or dislodged on high risk residents.
- DON or Designee will complete elopement drills. All findings will be reported to the QA committee.
Failure to Maintain Sufficient Nursing Staff on Multiple Dates
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents. Payroll-Based Journal (PB&J) Staffing Reports and personnel staffing patterns revealed that the facility had excessively low weekend staffing during the second quarter of Fiscal Year 2025, specifically from January through March. Additionally, there were multiple specific dates in January, February, March, and June 2025 where staffing was found to be insufficient. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not meet the required staffing hours on the identified dates. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Resident with Quarterly Financial Statements
Penalty
Summary
The facility failed to ensure that a resident's individual financial records were made available through quarterly statements as required by policy. Review of the facility's Resident Funds policy indicated that each resident should have access to their financial records via quarterly statements. For one resident, who was found to be cognitively intact with a Brief Interview of Mental Status score of 14, interviews and record reviews revealed that the resident had not received the most recent quarterly statement. The Business Office Manager confirmed that statements are mailed, but the resident reported not receiving it, and the Social Services Director could not recall if the statements were delivered. An anonymous source also stated that residents were not receiving their quarterly statements.
Failure to Maintain Wheelchairs in Good Repair and Cleanliness
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents who used wheelchairs. Observations over multiple days revealed that the wheelchairs of four residents had cracked, torn, or otherwise damaged armrest padding and seats, and in some cases, a build-up of dirt and grime on the wheels. These deficiencies were confirmed by both the Director of Nursing and the Director of Maintenance during joint inspections. The affected residents had significant medical histories, including acquired limb absence, diabetes, epilepsy, Alzheimer’s disease, schizophrenia, major depressive disorder, paraplegia, bipolar disorder, anxiety disorder, alcohol abuse, hypertension, cerebrovascular disease, aphasia, and seizure disorders. All required wheelchairs for ambulation and varying levels of assistance with activities of daily living. The observations specifically noted that the damaged and unclean wheelchairs were in use by the residents in hallways and their rooms, and that the issues persisted over several days. The facility staff acknowledged the need for repair and cleaning of the wheelchairs during the survey. The report documents that the facility did not ensure that residents’ wheelchairs were maintained in good repair, directly impacting the environment provided to these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 19.35% error rate during the observed medication administration pass. Out of 31 opportunities, there were 6 medication errors involving two residents. For one resident, a LPN administered five prescribed medications, including Norvasc, Colace, Ferrous Sulfate, Levaquin, and Xarelto, significantly later than the scheduled time. The medications were due at 9:00 a.m. but were not given until 10:40 a.m., exceeding the facility's policy of administering medications within one hour of the prescribed time frame. Both the LPN and the DON confirmed the late administration during interviews. Another resident did not receive a scheduled dose of Thiamine Hydrochloride 100 mg at the prescribed 9:00 a.m. time. The LPN responsible for this medication pass failed to administer the medication, initially believing it was unavailable. However, upon further review, the medication was found on the LPN's medication cart, and the LPN acknowledged being unaware of its presence during the morning pass. These actions and inactions directly contributed to the elevated medication error rate identified during the survey.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review showed that the last facility assessment was completed on 06/25/2024. During an interview, the DON, a corporate RN, and a manager confirmed that no subsequent facility assessment had been performed or documented since that date. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Assess, Document, and Care Plan Bedrail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bedrails for four residents. Specifically, the facility did not obtain physician orders for the use of bedrails, did not assess residents for the risk of entrapment prior to installing bedrails, and did not update care plans to reflect the use of bedrails. These deficiencies were identified through observations, interviews, and record reviews. For each of the four residents reviewed, there was no documentation of a physician's order authorizing the use of bedrails, no entrapment risk assessment completed before installation, and no care plan developed to address the use of bedrails. The residents involved had varying medical histories, including chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, acute kidney failure, cirrhosis of the liver, paraplegia, bipolar disorder, diabetes mellitus, morbid obesity, and muscle weakness. Cognitive assessments indicated that most residents had no or only moderate cognitive impairment, and none had upper or lower extremity impairments that would have necessitated bedrail use without proper assessment. Observations on multiple dates confirmed that the residents were in bed with bedrails in place, despite the lack of required documentation and assessments. Interviews with the DON confirmed the absence of physician orders, entrapment risk assessments, and care plans for all four residents using bedrails.
Failure to Ensure Timely Review and Limitation of Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that residents were free from chemical restraints and that psychotropic medications were not used for purposes of discipline or convenience, but only as required to treat medical symptoms. Specifically, two residents with intact cognitive function were prescribed Klonopin, a psychotropic medication, on an as-needed basis for periods exceeding 14 days. In both cases, the pharmacist requested that the prescribing physician provide a specific duration and stop date for the medication, but these requests were not addressed by the physician. For one resident with diagnoses including COPD, peripheral vascular disease, hypertension, major depressive disorder, and dementia without behavioral disturbance, the as-needed Klonopin order remained active beyond 14 days without a stop date. Similarly, another resident with diagnoses of edema, heart failure, depressive disorder, and anxiety had an as-needed Klonopin order for alcoholism that also lacked a specified duration or stop date, despite the pharmacist's recommendation. The DON confirmed in both cases that the orders were not updated as requested and remained in place for longer than 14 days.
Failure to Monitor Lab Results for Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring required laboratory results for an anti-seizure medication. A review of the resident's care plan indicated that lab and diagnostic work should be obtained as ordered and results reported to the physician. The resident had active physician orders for Valproic Acid to be administered daily and a standing order for monthly Depakote (Valproic Acid) level testing. However, there was no documentation of any Depakote lab results in the resident's chart, and the Director of Nursing confirmed that these levels were not drawn during the resident's stay. This lack of monitoring occurred despite the resident's diagnoses, which included traumatic subdural hemorrhage, seizures, altered mental status, and encephalopathy.
Improper Storage of Ice Scoop in Ice Chest
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, on two separate occasions, an ice scoop used for serving ice to residents was found stored inside an ice chest that contained ice intended for resident use. This practice was confirmed by the dietary supervisor during the observation. The DON was later informed of the dietary staff's method of storing the ice scoop in the ice chest containing resident ice. No information regarding the medical history or condition of any specific residents was provided in the report.
Failure to Hold Quarterly QAA Committee Meetings with Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly with all required members present. Record review showed that QAA committee meetings with the required staff were documented on three occasions within the past year. During interviews, both a corporate RN and the Director of Nursing confirmed that four quarterly QAA committee meetings with all required staff present had not been completed in the past year.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) as ordered for a resident with a pressure ulcer. Specifically, observations on multiple dates revealed that there was no EBP signage posted in the resident's room, despite a physician's order for EBP and the facility's policy requiring the use of gown and gloves during high-contact care activities for residents with wounds or indwelling medical devices. The resident involved had an unstageable pressure ulcer of the left heel and was cognitively intact according to a recent assessment. The Director of Nursing confirmed that EBP signage should have been posted but was not present at the time of observation.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to provide the required annual in-service training of at least 12 hours to ensure the continued competence of Certified Nursing Assistants (CNAs). Record reviews for three CNAs showed no documented evidence of completion of the mandated annual training hours. Specifically, personnel files for CNAs hired on 07/02/2021, 04/19/2023, and 05/30/2012 lacked documentation of 12 hours of annual in-service education. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the required training had not been provided to these staff members. The deficiency was identified through both record review and staff interview, with no evidence found in the personnel files to support that the CNAs had received the necessary annual training, including education in dementia care and abuse prevention.
Failure to Develop and Implement Comprehensive Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with identified risks and needs. Specifically, two residents with severe cognitive impairment and documented risk for elopement did not have care plans addressing their elopement risk upon admission, as confirmed by both record review and interviews with the Director of Nursing. Additionally, a resident with paraplegia and bilateral hand contractures did not have an active care plan to address her contractures, despite observations of her condition and her reports of inconsistent interventions such as the use of wash cloths and braces. Interviews with facility staff, including the Director of Nursing and Therapy Director, confirmed the absence of required care plans for these residents. The lack of documented, measurable objectives and timeframes to address the residents' medical, nursing, and psychosocial needs was evident in the records and through staff acknowledgment, indicating a failure to meet regulatory requirements for comprehensive care planning based on the residents' assessments.
Failure to Provide Pressure-Relieving Device for At-Risk Resident
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for one resident. According to the facility's policy, nursing staff are required to assess and document significant risk factors for pressure ulcers and implement appropriate interventions. A review of the resident's records showed that the individual was at risk for developing pressure ulcers, as indicated by a Braden Score of 18, and had a care plan intervention to place a cushion on the seat of his wheelchair. The resident had multiple diagnoses, including dementia, epilepsy, abnormal posture, melanoma of the scalp, and age-related disability, and used a wheelchair for ambulation. Despite the care plan intervention, observations on multiple occasions revealed that the resident's wheelchair did not have a pressure-reducing device in the seat. The wheelchair was observed at the bedside without a cushion, and Velcro was present where a cushion should have been attached. The DON confirmed that the resident previously had a cushion in the chair and acknowledged that it was needed but not present during the observations. This failure to ensure the presence of a pressure-relieving device in the wheelchair constituted a deficiency in pressure ulcer prevention care.
Failure to Maintain Proper Catheter Care Practices
Penalty
Summary
Facility staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, as required by the facility's Urinary Catheter Care Policy. The policy specifies that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated urinary tract infections. Observations on multiple occasions revealed that the resident's catheter bag was lying on the floor inside a plastic bag, and the catheter tubing was also found directly on the floor. Interviews with an LPN and the DON confirmed that the catheter bag and tubing should not have been on the floor or stored in a trash bag. The resident involved had diagnoses including diabetes mellitus, heart disease, urinary retention, and dementia, with moderate cognitive impairment noted on assessment.
Failure to Maintain Sanitary Whirlpool Practices for Residents with Open Wounds
Penalty
Summary
The facility failed to maintain a sanitary environment and prevent the transmission of communicable diseases and infections for four residents who were reviewed for infection control. Certified Nursing Assistant (CNA) staff did not clean the whirlpool according to the manufacturer's guidelines, and the facility's policy and procedure for whirlpool cleaning did not align with these guidelines. Observations revealed that the whirlpool's disinfectant jets were not functioning, the disinfectant reservoir was empty, and the cleaning process did not include the use of a brush or proper attention to the swivel lift chair. The CNA responsible for cleaning the whirlpool was unaware of the location of the disinfectant reservoir and did not report the malfunction to her supervisor. All four residents involved had open wounds and were receiving antibiotics for wound infections. These residents continued to receive whirlpool baths three times a week despite their open wounds and ongoing infections. Medical records and interviews confirmed that each resident had a documented wound infection, with cultures showing the presence of various pathogens, including MRSA, Pseudomonas aeruginosa, and Vancomycin-resistant Enterococcus. The residents' wounds were actively being treated with antibiotics as ordered by their physicians. Interviews with facility staff, including the CNA, the wound care LPN/infection preventionist, the maintenance supervisor, and the Director of Nursing (DON), confirmed that the whirlpool was not being cleaned per manufacturer guidelines and that the facility's policy did not require such cleaning. The maintenance supervisor had not been checking the disinfectant reservoir, and the DON had not monitored the cleaning process since assuming her role. The DON acknowledged that residents with open wounds should not have been using the whirlpool and that the current cleaning procedures were inadequate to prevent the spread of infections.
Infection Control Breach During Wound Care Procedure
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the Wound Care Nurse (WCN) during a wound care procedure for a resident. The WCN contaminated a jar of Silvadene Cream 1% by using a bare hand to retrieve a medication cup from the wound care cart and then dipping the cup into the cream. This action resulted in both the inside and outside of the medication cup coming into direct contact with the topical cream. The cream was not specific to the resident but was available for any resident who might require it, increasing the risk of cross-contamination. Additionally, the WCN placed a bottle of Dermal Wound Cleanser (DWC) on the resident's over-the-bed table without sanitizing the table beforehand. After completing the wound care procedure, the WCN returned the bottle of DWC to the wound care cart without sanitizing it, placing it next to other wound care supplies. These actions were confirmed by the WCN, who acknowledged not using proper infection control techniques. The facility's administrator was notified of these findings.
Failure to Notify Physician of Resident's Burn Injury
Penalty
Summary
The facility failed to immediately consult a resident's physician when there was a change in the resident's condition, specifically when blisters were observed on the resident's skin. The incident involved a resident who was readmitted to the facility with multiple diagnoses, including Type 1 diabetes and hypertensive chronic kidney disease. On the night of the incident, the resident accidentally spilled hot noodles on his right thigh, resulting in blisters. The night nurse, an LPN, assessed the resident and observed the blisters but did not notify the physician. Instead, she informed the oncoming nurse during the morning report. Later that morning, another nurse, an RN, was informed by the resident about the burn and assessed the injury after the resident returned from dialysis. The RN observed a large blister, some of which had burst, and subsequently contacted the physician to receive an order for Silvadene cream to treat the burn. The delay in notifying the physician about the resident's condition change was identified as a deficiency in the facility's practice.
Resident Smoking Unsupervised Leads to Safety Hazard
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who was diagnosed with dementia and nicotine dependence, was observed smoking unsupervised in the designated smoking area. Despite the care plan indicating the need for supervision while smoking, the resident was left alone and subsequently tossed a lit cigarette butt onto the concrete instead of using the fire safety ashtray provided. This incident highlights a lapse in supervision and adherence to the care plan designed to prevent accidents.
Failure to Conduct Quarterly Safe Smoking Evaluations
Penalty
Summary
The facility failed to adhere to its smoking policy by not ensuring that a Safe Smoking Evaluation was completed quarterly for a resident. The policy mandates that residents who smoke should be assessed on admission, quarterly, and when there is a significant change in their ability to handle smoking products. However, the medical record of a resident admitted to the facility showed incomplete documentation regarding their smoking status. Initially, a Safe Smoking Evaluation sheet was found with the words 'non-smoker' handwritten, but it lacked any further information or a date. A subsequent evaluation sheet dated incorrectly as 01/09/2024, later corrected to 01/09/2025, indicated the resident was a safe smoker, yet there was no evidence of quarterly evaluations being conducted. The resident in question had a diagnosis of chronic schizophrenia and was assessed as cognitively intact with a Brief Interview for Mental Status score of 15, indicating sound daily decision-making skills. Despite this, the facility did not maintain consistent documentation of the resident's smoking evaluations as required by their policy. The deficiency was confirmed during an interview with the facility's social services staff and the administrator, who acknowledged the absence of documented quarterly evaluations for the resident.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and staff, as evidenced by multiple environmental concerns both inside and outside the building. Observations revealed that the kitchen ceiling had acoustic suspended tiles with old water stains, sagging tiles, and two holes. The Dietary Manager confirmed these issues. Additionally, the hallway floors throughout the facility were observed to have a buildup of dirt and grime, which was acknowledged by the Administrator. In the whirlpool room, a window was found open with a box fan placed in it, but the screen was not attached, which was confirmed as inappropriate by the Administrator. Further environmental issues were noted outside the facility, where various discarded items such as mop buckets, barrels, an old mattress, a bed frame, pieces of sheet rock, a shower chair, a Christmas tree, a broken glass picture frame, and rusted pipes were observed on the ground. Inside the laundry room, rotten wood was found behind the clean sink and eye wash station, and the floor was wet with a black substance present. These conditions were confirmed by the Laundry Worker. The Administrator was informed of these environmental issues, which had the potential to affect the 51 residents residing in the building.
Deficiencies in Nursing Staff Competency and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to care for residents' needs, as evidenced by the lack of documentation for wound care, tracheostomy care, and medication administration for four residents. For one resident with paraplegia and a stage 3 wound, the facility did not document daily dressing changes on multiple occasions as ordered by the physician. Similarly, another resident with a stage 4 pressure ulcer did not have documented evidence of dressing changes on specified days, despite physician orders. Another resident with multiple diagnoses, including type 2 diabetes and end-stage renal disease, had an order for wound care that was not documented six times in November. There was no documentation of the resident refusing care, indicating a failure in recording the necessary wound care procedures. Additionally, a resident with chronic respiratory failure and a tracheostomy had multiple instances of undocumented tracheostomy care, suctioning, and medication administration over two months, despite specific physician orders and care plan interventions. Interviews with the Director of Nursing and a Registered Nurse confirmed the lack of documentation for the required care and treatments for these residents. This lack of documentation suggests that the facility did not ensure that nursing staff were competent in performing and recording essential care tasks, leading to deficiencies in the care provided to these residents.
Failure to Investigate and Report Incident Involving Illegal Drugs
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, the facility did not complete an Accident and Incident Report or conduct a thorough investigation after a resident was found with illegal drugs. The resident, who was cognitively intact and used a wheelchair for locomotion, was discovered in the smoking area acting unusually, with dilated eyes and a strong marijuana odor. The resident admitted to smoking marijuana and taking a pill, leading to his transfer to the emergency department for evaluation. The facility's staff, including an LPN and an RN, found marijuana in the resident's belongings and disposed of it by flushing it down the toilet, as directed by the Administrator. However, the facility did not follow its policy to document and investigate the incident thoroughly. The Administrator confirmed that no Accident and Incident Report was completed, and no investigation was conducted to determine how the resident obtained the marijuana. Interviews with staff and the resident revealed inconsistencies in the handling and reporting of the incident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident who required such precautions. The policy, dated April 1, 2024, outlines the use of gown and glove during high-contact care activities for residents colonized or infected with multidrug-resistant organisms (MDROs) or those at increased risk of MDRO acquisition. Resident #2, who was admitted with multiple diagnoses including severe sepsis and abscess of the vulva, required substantial assistance with daily activities and had a physician's order for wound care. Despite these conditions, observations on November 4 and November 6, 2024, revealed the absence of an EBP sign on the resident's door. Interviews conducted on November 12, 2024, with the infection preventionist and the Director of Nursing confirmed the oversight. The infection preventionist stated that he is responsible for posting EBP signs and notifying staff verbally about residents on EBP. However, it was confirmed that the necessary signage was not posted for resident #2, indicating a lapse in following the facility's infection control procedures.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that residents with wounds or a history of wounds received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not perform weekly skin assessments for three residents, all of whom had significant medical conditions including pressure ulcers. The facility's policy required weekly skin evaluations and documentation of any skin abnormalities, but these assessments were not conducted for the residents in question. Resident #1 had multiple diagnoses, including a stage 3 pressure ulcer and paraplegia, yet no weekly skin assessments were documented. Similarly, Resident #2, with a stage 2 pressure ulcer, and Resident #3, with a stage 4 pressure ulcer, also lacked documented weekly skin assessments. Interviews with the Interim Director of Nursing/Wound Care Nurse and a Registered Nurse confirmed the absence of these assessments, acknowledging that the facility had not been completing them as required.
Verbal and Mental Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by another resident, which is a violation of the residents' rights to be free from abuse. The incident involved a resident who was cognitively intact and required assistance with daily activities due to multiple medical conditions, including diabetes, renal disease, and depression. This resident was subjected to verbal abuse by another resident who had a history of being verbally aggressive towards others. The first incident occurred when the aggressive resident entered a dining area where the victim was using a gaming monitor with headphones. The aggressive resident played loud music and, upon being asked to lower the volume, began cursing and using racial slurs against the victim. Despite intervention by an LPN, the aggressive resident continued to verbally threaten the victim. The second incident involved the aggressive resident making derogatory comments about the victim's incontinence while waiting for assistance from a CNA. These incidents were reported to staff, including the social worker and the administrator, who confirmed the verbal and mental abuse. Interviews with staff and the victim revealed that the aggressive resident's behavior made the victim uncomfortable and angry. The facility's failure to prevent these incidents and protect the victim from abuse highlights a deficiency in adhering to their abuse prevention policy. The aggressive resident was eventually discharged from the facility, but the incidents had already caused distress to the victim.
Failure to Report Verbal and Mental Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that an alleged violation involving verbal and mental abuse was reported immediately to the Administrator and Director of Nursing, as well as to the State Survey Agency within the required timeframe. The incident involved resident #4, who was cognitively intact and required assistance with daily activities, and resident #1, who verbally abused and threatened resident #4 on multiple occasions. Despite the facility's policy requiring immediate reporting of such incidents, the abuse was not reported promptly. On 08/25/2024, resident #4 reported an incident where resident #1 played loud music and verbally abused him with racial slurs and threats. This incident was witnessed by S9LPN and S10LPN, who intervened but failed to report the incident to the Administrator. Additionally, another incident occurred over the weekend of 09/07/2024 or 09/08/2024, where resident #1 harassed resident #4 with derogatory comments about his condition. This incident was reported to S5Social Worker on 09/10/2024, who then informed the Administrator. Interviews with staff confirmed that the incidents were not reported to the Administrator or the State Survey Agency as required by the facility's abuse prevention policy. The Administrator and Director of Nursing were not informed of the incidents in a timely manner, leading to a failure in reporting the abuse to the appropriate authorities within the mandated timeframe.
Administrator's Response Time Exceeds Compliance Standards
Penalty
Summary
The facility was found to be non-compliant with applicable Federal, State, and Local laws, regulations, and codes due to the response time of the S1Administrator. During an interview, the S1Administrator disclosed that she resided 1.5 hours away from the facility. This was corroborated by a review of her employee file, which confirmed her residence was at least a 1.5-hour drive from the facility. In a subsequent interview, the S1Administrator confirmed that her response time from her residence to the facility exceeded one hour.
Supply Shortages Affect Resident Care
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of its residents, as evidenced by a shortage of essential care supplies such as wipes, toilet paper, and briefs. This deficiency was identified through record reviews and interviews with residents and staff. Resident #17, with no cognitive impairment, reported that the facility sometimes runs out of wipes. Similarly, Resident #26, also with no cognitive impairment, mentioned a lack of wipes for care. Resident #29, who has moderately impaired cognition, was observed to have no toilet paper or paper towels in his bathroom over several days, despite requesting them. During a Resident Council meeting, additional residents voiced complaints about the lack of toilet paper and wipes. Interviews with facility staff, including CNAs and the Assistant Director of Nursing (ADON), revealed that the facility had been experiencing a shortage of supplies, particularly wipes and briefs, due to a recent change in medical supply vendors. This change caused delays in the delivery of necessary items, leading to a limited supply available for resident care. The ADON confirmed the shortage and acknowledged the impact on resident care. The facility's administrator was informed of these concerns, highlighting the potential impact on all 44 residents residing in the facility.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Observations over several days revealed a persistent black substance in the toilets of several residents' bathrooms, including those of residents #17, #23, #26, #11, #8, #49, and #27. Additionally, foul odors were noted in the bathrooms of residents #23 and #29, with resident #29's room also having a noticeable urine odor. The cleanliness issues extended beyond individual rooms, with dirt, grime, and spills observed on doors, floors, and baseboards in various rooms and hallways, affecting all nine sampled residents and potentially impacting all 44 residents in the facility. Interviews with residents and staff further confirmed the facility's inadequate cleaning practices. Resident #15 reported that his room was not being cleaned properly, and an interview with the facility's administrator, S1Administrator, acknowledged the need for a thorough cleaning of the facility. The observations and interviews collectively highlight a significant deficiency in maintaining a clean and safe environment, which is a fundamental right of the residents.
Failure to Timely Report Suspected Theft
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. This deficiency was identified during a review of a case involving a resident who reported a theft of a $100 bill from his wallet. The resident, who was cognitively intact, had left his wallet in his room and later discovered the money missing after seeing a staff member exit his room. The resident reported the incident to the facility's administrator and Director of Nursing four days after the alleged theft occurred. The administrator acknowledged receiving the report from the resident but did not notify the state agency and local law enforcement within the required 24-hour timeframe. The report to the state agency was made eight days after the incident, and no report was made to law enforcement. This failure to report in a timely manner is a violation of the facility's abuse prevention policy and the federal requirement to report suspected misappropriation of resident property promptly.
Failure to Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure a timely and thorough investigation of an alleged misappropriation of resident property, specifically involving a $100 bill reported missing by a resident. The resident, who was cognitively intact, reported the incident to the facility's administrator, stating that he had left his wallet containing $1,000 in his room and later found $100 missing after seeing the Housekeeping/Laundry Supervisor exit his room. Despite the resident's report, the facility did not immediately suspend the staff member involved or promptly investigate the allegation. The facility's administrator delayed obtaining staff witness statements and reviewing video surveillance footage, which showed the Housekeeping/Laundry Supervisor entering and exiting the resident's room. The administrator admitted to being busy due to the resignation of the Director of Nursing and Assistant Director of Nursing, which contributed to the delay in the investigation. The facility's policy required immediate suspension of any employee accused of misappropriation pending investigation, which was not followed in this case. The investigation was further hampered by the Housekeeping/Laundry Supervisor's false statement denying entry into the resident's room, which was contradicted by video evidence. The administrator acknowledged the failure to suspend the staff member and the delay in reviewing surveillance footage, which ultimately led to the decision to terminate the Housekeeping/Laundry Supervisor for dishonesty during the investigation. The facility's inaction and delayed response to the resident's allegation resulted in a deficiency in handling the situation according to their abuse prevention policy.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #6, who had severe cognitive impairment and required substantial assistance with personal hygiene, was observed multiple times with food debris on his clothing and long, dirty fingernails. Despite the presence of staff, no assistance was provided to clean the resident or maintain his hygiene, as confirmed by a registered nurse. Similarly, residents #17 and #23, who required assistance with personal hygiene, were observed with long, unclean fingernails. Resident #17, who had no cognitive impairment, and resident #23, who had moderate cognitive impairment, both had care plans indicating the need for weekly nail care. However, observations revealed that their fingernails were long and dirty, and this was confirmed by a registered nurse. These findings indicate a failure by the facility to adhere to the care plans and physician orders for maintaining the residents' personal hygiene.
Lack of Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This deficiency was identified through a review of personnel records for five CNAs (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA), which revealed a lack of documented evidence of skills checks or competency evaluations. The hire dates for these CNAs ranged from 2021 to 2024, yet none had documented competency evaluations in their records. An interview with the Regional Human Resources representative confirmed the absence of documentation for competency evaluations and skills checks for the CNAs in question. This lack of documentation indicates that the facility did not ensure that these CNAs were adequately assessed for their ability to meet the care needs of residents, as required by the facility's standards and regulations.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 12.12% due to four errors out of 33 opportunities. For Resident #41, the Licensed Practical Nurse (LPN) did not administer the prescribed high blood pressure medication, Losartan 25 mg, at the scheduled time of 9:00 a.m. Additionally, the eye medication Carboxymethyl Cellulose Sodium was not administered because it was unavailable. These omissions were confirmed by a Registered Nurse (RN) during interviews. For Resident #13, the LPN administered Vitamin D3 50,000 IU daily instead of the prescribed weekly dosage, as indicated in the physician orders. Furthermore, the antipsychotic medication Seroquel 25 mg, which was ordered for bedtime, was incorrectly administered during the morning medication pass. These errors were also confirmed by the RN during interviews, highlighting a significant deviation from the prescribed medication regimen.
Improper Food Defrosting in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by improperly defrosting chicken breasts. During a follow-up visit to the kitchen, it was observed that a large amount of chicken breasts were submerged in water in the kitchen sink without running cold water, contrary to the facility's policy for safely thawing food. The policy specifies that food should be thawed in cold water with running tap water to prevent bacterial growth, and the food should be kept in its original container or a plastic bag to protect the kitchen sink and counter from germs. However, the chicken breasts were placed directly in the sink without any container. An interview with the Dietary Manager confirmed that the staff did not defrost the chicken breasts properly according to the facility's policy. This deficient practice had the potential to affect 44 residents who received meals served from the kitchen.
Lack of Quarterly QAA Meeting Documentation
Penalty
Summary
The facility failed to have documented evidence of conducting a Quality Assessment and Assurance (QAA) meeting at least quarterly for the year 2024. A review of the QAA binder revealed no documentation of a QAA meeting for the first quarter of 2024 to address facility issues. This was confirmed during an interview with the administrator, who acknowledged the absence of documented evidence for the required meeting.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions Policy for five residents who were reviewed for such precautions. According to the policy, Enhanced Barrier Precautions are necessary for residents with infections or colonization with CDC-targeted Multi Drug-Resistant Organisms (MDRO) when contact precautions do not apply, or for residents with wounds and/or indwelling medical devices that cannot be covered or contained. The policy specifies that gown and glove use is required during high-contact resident care activities for those known to be colonized with MDRO or at increased risk of MDRO acquisition. Despite this, observations and interviews revealed that no residents were on enhanced barrier precautions at the time of the survey. The report specifically identified five residents who should have been on enhanced barrier precautions due to their medical conditions. These residents had wounds and, in some cases, colostomies, which according to the facility's policy, warranted the use of enhanced barrier precautions. Interviews with the Director of Nursing and the Administrator confirmed that there were no residents on isolation, and further confirmation from the Clinic Operations Consultant indicated that these residents should have been on enhanced barrier precautions. This oversight highlights a failure to adhere to the facility's own infection prevention and control protocols.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist responsible for the infection prevention and control program. A review of the facility's Infection Control Records showed no documented evidence of a designated staff member for this role. During an interview, the administrator confirmed the absence of a designated Infection Preventionist.
Persistent Fly Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent issue with flies affecting all 44 residents. Observations revealed flies in the hallways and rooms of several residents, including those of residents #11, #27, #29, and #49. Resident #29's room was noted to have a urine smell and multiple flies, with flies observed on his breakfast tray. Interviews with residents #11 and #49 confirmed the presence of flies, with both residents using fly swatters in their rooms. The Resident Council meeting further highlighted complaints from multiple residents about the fly issue throughout the building. The facility's Pest Control Policy, dated May 2008, states that an ongoing pest control program should ensure the building is free of insects and rodents. However, interviews with the S1Administrator confirmed the ongoing problem with flies. The deficiency affected all sampled residents and had the potential to impact all residents in the facility, indicating a significant lapse in maintaining a pest-free environment as per the facility's policy.
Deficiency in Nurse Aide Training
Penalty
Summary
The facility failed to provide necessary in-service training for nurse aides, resulting in a deficiency. Specifically, five nurse aides (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) did not receive required training in key areas. S20CNA, S21CNA, S22CNA, and S23CNA lacked training in resident abuse prevention, while S20CNA, S23CNA, and S24CNA did not receive dementia management training. Additionally, S21CNA and S24CNA, who had been employed for over a year, did not complete the mandated 12 hours of annual in-service training. These deficiencies were confirmed through personnel record reviews and an interview with S3Regional Human Resources, who acknowledged the absence of documentation for the required training.
Failure to Timely Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments within 14 days after residents were discharged, as required. This deficiency was identified for three residents during a review of their medical records. Resident #10 was admitted and later discharged without a timely discharge MDS assessment. Similarly, resident #31 was readmitted and then discharged, and resident #40 was admitted and discharged, both without the required timely assessments. An interview with the MDS Coordinator confirmed that the discharge MDS assessments for these residents were not performed and transmitted in a timely manner.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the comprehensive person-centered care plan for two residents. Resident #20, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and vascular dementia, was observed receiving oxygen therapy at 5.5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing, who noted that the oxygen flow had been increased during a recent respiratory exacerbation but should have been adjusted back to the prescribed rate. The resident was unable to adjust the oxygen flow independently, leading to the continued administration of an incorrect oxygen rate. Resident #34, diagnosed with chronic systolic congestive heart failure, was found to have a nebulizer mask and tubing that were not stored in a plastic bag when not in use, as required by the facility's policy. The nebulizer equipment was observed uncovered and undated in the resident's room, despite the policy stating that it should be replaced weekly and stored properly. The Director of Nursing confirmed the oversight, acknowledging that the nebulizer mask and tubing should have been stored in a labeled plastic bag when not in use.
Failure to Conduct Required Checks for CNAs
Penalty
Summary
The facility failed to ensure that the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNAs) both initially upon hire and monthly thereafter. This deficiency was identified for five CNAs, specifically S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA. Additionally, the facility did not verify the CNA registry upon hire for S20CNA. The personnel files reviewed showed no documented evidence of these checks being conducted, which is a requirement for maintaining compliance with state regulations. The personnel files revealed various hire dates for the CNAs, ranging from 2021 to 2024, yet none had the required State Adverse Actions checks documented. An interview with the Regional Human Resources representative confirmed the absence of documentation for these checks. This oversight indicates a systemic failure in the facility's hiring and monitoring processes for CNAs, potentially compromising the quality of care provided to residents.
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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