Center Point Health Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 8225 Summa Avenue, Baton Rouge, Louisiana 70809
- CMS Provider Number
- 195483
- Inspections on file
- 44
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Center Point Health Care And Rehab during CMS and state inspections, most recent first.
Surveyors identified a 60% medication error rate during a med pass when an LPN failed to administer a prescribed Hydralazine dose because the drug was not available or ordered from the pharmacy, and multiple residents received extensive morning medication regimens well beyond the facility’s allowed 1‑hour window before and after scheduled times. Staff, including LPNs and the administrator, confirmed that morning medications were expected to be given within a defined time frame and that doses given after that window were considered late, resulting in numerous counted errors across several residents.
Surveyors found that the facility failed to ensure an ordered antihypertensive medication was available and administered as prescribed. A resident with essential HTN had a standing order for Hydralazine 10 mg PO BID, but during a medication pass an LPN did not have the drug on the cart or in storage, and confirmed it was not in the facility. Record review showed the last dose was given the prior evening and that the next scheduled morning dose was not documented as administered. The LPN acknowledged the medication had not been reordered in advance as required by facility policy, and the administrator confirmed that medications ordered by physicians are expected to be available at all times and refilled before running out.
A resident with a history of alcohol abuse was discharged to a rehab center without a documented discharge plan, interdisciplinary team involvement, or a comprehensive discharge summary. Staff interviews confirmed that required assessments, documentation of the resident's intent, and post-discharge planning were not completed, in violation of facility policy.
Two residents were transferred to hospitals or rehabilitation facilities without receiving the required written notice specifying the duration of the bed-hold policy at the time of transfer. Record reviews and staff interviews confirmed that neither the residents nor their responsible parties received or signed the necessary documentation, despite facility policy requiring this notification during such events.
The facility failed to develop a comprehensive assessment addressing staff training and competency in non-pharmacological interventions for residents with Schizophrenia, PTSD, and SUD. Personnel files of four staff members lacked evidence of such training or competency evaluations. The facility administrator confirmed these deficiencies.
A facility failed to ensure the accuracy of an MDS Assessment for a resident with Schizoaffective Disorder and PTSD. The resident's diagnoses were not recorded in the MDS, and the most recent Gradual Dose Reduction (GDR) attempt and physician's response were also omitted. Staff confirmed these inaccuracies during interviews.
A facility failed to create a comprehensive care plan for a resident with Schizoaffective Disorder and PTSD, as required by their policy. The oversight was confirmed by staff, including the MDS Coordinator and DON, who acknowledged the care plan did not reflect the resident's needs. This deficiency had the potential to impact the entire resident census.
A facility failed to update a resident's diet order in the electronic medical record, despite a change from a mechanical soft diet with honey thickened liquids to a regular texture with thin liquids. Staff interviews confirmed the discrepancy, as the nurse who signed the diet requisition form did not update the electronic record, leading to inaccurate documentation.
The facility did not post required nurse staffing data, including resident census and hours worked by RNs, LPNs, and CNAs, at multiple nursing stations. Staff responsible for posting the data were unaware of the requirements, leading to incomplete information being displayed.
The facility failed to coordinate PASARR Level II assessments and care plans for two residents. One resident's PASARR Level II was not resubmitted after expiration, and another resident's care plan was not updated with Level II recommendations due to communication breakdown among staff.
A resident with multiple medical conditions, including pressure ulcers and dysphagia, experienced significant weight loss due to the facility's failure to provide a prescribed Boost supplement with meals. Despite physician orders and dietician recommendations, the supplement was not included on meal trays or communicated to nursing staff, resulting in continued weight loss.
A resident with chronic pain did not receive prescribed narcotic pain medication due to the facility running out, and the administration was not documented on the MAR. Staff interviews revealed lapses in reordering medication and documentation, violating facility policies.
The facility failed to serve meals at regular times for residents on Hall B, with lunch scheduled for 12:30 p.m. but often served as late as 2:00 p.m. Observations and interviews confirmed the delay, including a resident council meeting where residents reported late lunch service. Staff acknowledged the issue, confirming that the late service was unacceptable and contrary to the facility's policy.
The facility failed to maintain sanitary conditions in the kitchen, affecting food storage, preparation, and distribution for 141 residents. Staff did not adhere to attire policies, with one member not wearing a facial hair restraint and another without a hairnet. Observations revealed unsanitary conditions, including outdated food, unsealed items, and insect activity. Staff confirmed these issues, acknowledging the need for proper food safety and hygiene practices.
The facility failed to maintain an effective pest control program, leading to the presence of roaches, flies, and gnats throughout the premises. Observations revealed live pests in various rooms and common areas, with residents confirming frequent sightings. The pest control company was unable to complete scheduled treatment due to the facility's lack of preparation and staffing issues.
The facility did not complete and transmit a Discharge MDS assessment for a resident as required by policy. The assessment should have been completed within 14 days of discharge and transmitted to the CMS system. Staff confirmed the oversight during interviews.
The facility failed to maintain a Level 1 PASRR form for a resident with cognitive impairment and did not conduct a Level II PASRR for another resident with Bipolar Disorder. Staff relied on external screenings, leading to oversight in necessary evaluations.
A resident with multiple diagnoses, including diabetes and dementia, had a physician's order for weekly nurses' notes, which were not documented despite being acknowledged by nursing staff. Interviews with LPNs and the DON confirmed the lack of documentation, highlighting a deficiency in meeting professional standards of care.
A resident's medications were found unsecured on top of a refrigerator in her room, contrary to the facility's policy requiring drugs to be stored in locked compartments. The resident, who was cognitively intact, had medications including Oscal Vit D, Diltiazem, and Tylenol, which were part of her active physician's orders. An LPN and the ADON confirmed that medications should not be left unsecured.
A resident with severe cognitive impairment had a DNR status in their advance directive, but the facility's EHR incorrectly listed them as full code. Staff interviews confirmed the inconsistency between the hard copy chart and the EHR, and the DON acknowledged the mismatch.
A facility failed to coordinate hospice care services effectively, resulting in missing documentation for a resident's hospice care. The facility's policy required maintaining specific hospice care information, but the resident's records lacked a plan of care, physician certification, and other necessary documents. Interviews with the DON and hospice nurse confirmed these omissions.
A facility failed to adhere to its infection control policy when two staff members did not wear the required PPE during peg tube care for a resident on Enhanced Barrier Precautions. Despite clear signage and policy guidelines, the staff acknowledged their oversight, and the DON confirmed the necessity of PPE in such cases.
A resident with a PEG tube was not consistently receiving her tube feedings as ordered due to her wheelchair not accommodating the feeding apparatus. Staff frequently disconnected her feeding to allow her mobility around the facility, despite her care plan requiring continuous feeding for 20 hours a day. The facility's administration acknowledged the resident's right to mobility while receiving her prescribed nutrition.
A resident with a PEG tube was not consistently receiving her prescribed enteral feedings as ordered by the physician. Despite being NPO and requiring continuous feeding from 6:00 p.m. to 2:00 p.m., observations and staff interviews revealed that the feedings were not always administered, and there was no documentation of refusals. The resident, who liked to move around the facility, confirmed that staff sometimes did not reconnect her feedings, and the ADON acknowledged the lack of proper documentation.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications by prescribing Escitalopram Oxalate and Lorazepam with a diagnosis of Dementia, which is not an acceptable diagnosis for these medications. Interviews with staff confirmed the inappropriate diagnosis, highlighting a deficiency in the facility's adherence to its policy on psychotropic drug use.
A resident with muscle wasting and type 2 diabetes did not receive the prescribed double portions of protein and vegetables, as confirmed by an observation of their lunch tray. Despite the facility's policy requiring adherence to physician's dietary orders, the resident was served single portions, which was acknowledged by a staff member.
High Medication Error Rate Due to Omitted and Late Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying a 60% error rate during a medication administration observation involving five residents and 65 opportunities, resulting in 39 errors. The facility’s medication administration policy, revised 04/2022, required staff to compare medications with the MAR for correct resident, medication, dose, route, and time, and to administer medications within 60 minutes before or after the scheduled time unless otherwise ordered. For one resident, Hydralazine 10 mg ordered twice daily at 8:00 a.m. and 5:00 p.m. was not administered because the medication was not available in the facility and had not been ordered from the pharmacy, as confirmed by the LPN at the time of observation. For other residents, surveyors observed multiple medications being administered outside the facility’s required time frame. One resident with multiple scheduled morning medications, including Arginaid, Acetaminophen ER, Vitamin C, a multivitamin with minerals, Ferrous Gluconate, Vitamin B12, Ipratropium-Albuterol, Spironolactone, Metoprolol Succinate ER, Jardiance, and Furosemide, received these medications at 10:47 a.m., which the LPN confirmed was late given that morning medications were to be administered between 8:00 a.m. and 10:00 a.m. Additional residents with extensive 8:00 a.m. medication regimens, including antihypertensives, antiplatelets, antidepressants, vitamins, and other chronic medications, were observed receiving their morning doses after 10:00 a.m. The LPNs and the administrator confirmed that nurses were expected to administer medications within one hour before and one hour after the scheduled time, and that medications given at or after 10:00 a.m. were considered late, establishing that these administrations constituted medication errors contributing to the elevated error rate.
Failure to Maintain Availability of Ordered Antihypertensive Medication
Penalty
Summary
Surveyors identified that the facility failed to ensure prescribed medications were available for administration, as required by its own "Medication Reordering" policy. That policy stated that acquisition of medications should be completed in a timely manner to ensure timely administration, and that nurses must monitor remaining supply and reorder medications early enough to prevent omissions. During a medication pass observation and interview on 02/18/2026 at 9:36 a.m., an LPN did not have Hydralazine HCL 10 mg on the medication cart or in the medication storage room for a resident. The LPN confirmed that the medication was not available anywhere in the facility at that time. Record review showed the resident had been admitted with diagnoses including essential hypertension and had a current physician order for Hydralazine HCL 10 mg by mouth twice daily, with a start date of 01/06/2025. The Medication Administration Record indicated the last dose of Hydralazine 10 mg was given on 02/17/2026 at 5:00 p.m., and there was no documented evidence that the 8:00 a.m. dose on 02/18/2026 was administered. The LPN confirmed the medication had not been reordered from the pharmacy as of 02/18/2026, despite the ability of any nurse administering medications to reorder it up to seven days in advance to prevent running out. In a subsequent interview, the administrator confirmed that medications ordered by the physician should always be available for administration and that nurses were expected to request refills before supplies were exhausted.
Failure to Develop and Document Effective Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was reviewed for discharge. Specifically, the facility did not identify the resident's discharge needs or develop a discharge plan tailored to those needs. There was no evidence that the interdisciplinary team was involved in an ongoing process to create or update the discharge plan, nor was there documentation that the resident had been asked about their interest in returning to the community. Additionally, the resident's medical record lacked a comprehensive discharge summary, including a post-discharge plan of care, arrangements for follow-up care, and documentation of where the resident planned to reside after discharge. The resident in question had a history of alcohol abuse and had resided at the facility for several years. He was cognitively intact, as indicated by a BIMS score of 15, and expressed interest in going to rehab, with the expectation of returning to the facility after treatment. However, staff interviews revealed conflicting understandings of the resident's discharge intentions, with some staff expecting the rehab center to assist with permanent placement after the treatment program. There was no documentation in the clinical record reflecting the resident's intent to discharge, involvement in discharge planning, or a completed discharge summary. Interviews with facility staff, including the administrator, social worker, nurse practitioner, and director of nursing, confirmed the absence of required documentation and processes. The staff acknowledged that the resident's intent to discharge, assessment of self-care capability, discharge order, and summary were not present in the medical record. The facility's own policy required these elements, but they were not followed in this case, resulting in a deficiency related to discharge planning and documentation.
Failure to Provide Written Bed-Hold Policy Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice specifying the duration of the bed-hold policy to residents or their responsible parties at the time of transfer to a hospital or rehabilitation facility for two out of three sampled residents. According to the facility's own policy, written information regarding bed-hold practices must be given both at admission and at the time of transfer for hospitalization or therapeutic leave. However, record reviews and interviews confirmed that there was no documented evidence that such notice was provided to the affected residents or their representatives during their transfers. One resident, admitted with conditions including unsteadiness, morbid obesity, and a need for assistance with personal care, was transferred to a rehabilitation hospital and confirmed in an interview that no written bed-hold information was provided or signed prior to transfer. Another resident, admitted with a displaced bimalleolar fracture and gait abnormalities, was transferred to a local hospital for surgery, and again, no documentation or confirmation of written bed-hold notice was found. Facility staff, including the DON and administrator, acknowledged the absence of required documentation for both residents at the time of their transfers.
Deficiency in Staff Training and Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to develop a comprehensive facility assessment that addressed staff training for skills and non-pharmacological interventions, as well as the process to evaluate the competency of skill sets necessary to meet the mental and psychosocial health needs of residents diagnosed with Schizophrenia Disorder, Post Traumatic Stress Disorder (PTSD), and Substance Use Disorder (SUD). The facility's assessment did not outline the process for staff training and ensuring competency in non-pharmacological interventions for these conditions. Additionally, there was no documented evidence of training materials or competency evaluation materials for non-pharmacological interventions related to these mental health diagnoses. The personnel files of four staff members, including two LPNs, one RN, and one MSW, lacked documented evidence of training for non-pharmacological interventions for Schizophrenia and SUD or competency evaluations to ensure the necessary skill sets to meet the mental and psychosocial health needs of the resident population. An interview with the facility administrator confirmed these deficiencies, acknowledging the absence of a process to ensure staff competency in non-pharmacological interventions for residents with Schizophrenia, PTSD, and SUD.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessments for a resident, which was identified during a review of the resident's clinical records and interviews with facility staff. The resident, who was admitted to the facility, had active diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD) as documented in a Psychiatry Progress Note. However, the MDS Assessment for this resident did not reflect these diagnoses, as the relevant sections for Schizophrenia and PTSD were left unchecked. Additionally, the facility did not accurately document the resident's most recent Gradual Dose Reduction (GDR) attempt and the physician's response. The resident's GDR, performed earlier, indicated that the medications Seroquel and Vistaril were reviewed, and the physician deemed a dose reduction inappropriate due to the resident's condition. However, the MDS Assessment failed to record the GDR attempt, the date of the last attempted GDR, and the physician's documentation of the GDR being clinically contraindicated. Interviews with the MDS Coordinator, Director of Nursing, and Administrator confirmed these omissions, acknowledging that the MDS Assessments should accurately reflect the resident's status.
Failure to Develop Comprehensive Care Plan for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to develop a trauma-informed, comprehensive person-centered care plan for a resident diagnosed with Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD). This deficiency was identified during a review of the resident's clinical records, which revealed the absence of a care plan addressing these specific diagnoses. The facility's policy mandates that care plans be reviewed and revised upon a resident's status change, yet this was not adhered to in the case of the resident in question. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the oversight. Both staff members acknowledged that the resident's care plan did not accurately reflect their current medical and psychosocial needs, as required by the facility's policy. This lapse in care planning had the potential to affect the facility's entire resident census of 147 individuals.
Failure to Update Resident's Diet Order in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for a resident who was reviewed for therapeutic diets. The resident, who was admitted to the facility with diagnoses including Unspecified Cerebral Infarction and Pneumonitis Due To Inhalation of Food and Vomit, had a diet order that was not updated in the electronic medical record. Initially, the resident was prescribed a mechanical soft diet with honey thickened liquids, but on a later date, the diet was upgraded to a regular texture with thin liquids as per pharyngogram results. Despite this change, the electronic medical record did not reflect the updated diet order. Interviews with facility staff, including the Registered Dietitian (RD), Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed that the electronic record should have been updated to reflect the current diet order. The RD and ADON reviewed the resident's physician orders, handwritten diet order, diet requisition form, and meal tickets, all of which indicated the updated diet. However, the nurse who signed the diet requisition form failed to update the electronic record, resulting in a discrepancy between the resident's actual diet and the documented orders.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis, which included the total resident census number and the total number and actual hours worked for both licensed and unlicensed nursing staff. This deficiency was observed at multiple nursing stations (J, K, and L) on the same day. The nurse staffing data sheets at these stations did not include the required information for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The absence of this information was confirmed through observations and interviews with staff members responsible for posting the data. Interviews with various staff members, including Assistant Directors of Nursing (ADONs) and a Certified Nurse Aide (CNA), revealed a lack of awareness regarding the requirement to include specific staffing information on the posted sheets. Each staff member confirmed that the necessary data, such as the resident census and the total and actual hours worked by nursing staff, was missing from the sheets they were responsible for posting. The Director of Nursing (DON) also confirmed the omission of this critical information and was unaware that it should have been included.
Failure to Coordinate PASARR Level II Assessments and Care Plans
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) Level II for two residents. For one resident, the facility did not refer for a Level II resident review after the expiration of a six-month temporary effective period. The resident was admitted with diagnoses including unspecified dementia, psychotic disturbance, and other mental health conditions. Despite the expiration of the PASARR Level II, no resubmission was made, and no recommendations were documented. Interviews with staff confirmed the oversight, with the PASARR not being resubmitted due to a misunderstanding that it was only necessary if private pay ended or a significant change occurred. For another resident, the facility failed to incorporate PASARR Level II recommendations into the resident's care plan. This resident was admitted with conditions such as cerebral infarction sequelae and severe major depressive disorder with psychotic symptoms. Although approved for Level II services, the care plan was not updated to reflect this. Staff interviews revealed a communication breakdown, where the staff responsible for PASARRs did not notify the MDS nurses, who were responsible for updating care plans, resulting in the omission of necessary care plan updates.
Failure to Provide Nutritional Supplements Leads to Resident Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss. The resident, who was moderately cognitively impaired and had multiple medical conditions including pressure ulcers and dysphagia, experienced a weight drop from 204 pounds in April to 170 pounds by mid-June. Despite a physician's order for a Boost supplement with meals to address the weight loss, the supplement was not provided. Observations and interviews revealed that the Boost supplement was not included on the resident's meal trays or meal tickets, and the order was not properly communicated to the nursing staff. Interviews with various staff members, including CNAs, LPNs, the dietician, and the ADON, confirmed that the Boost supplement was not administered as ordered. The dietician had recommended the supplement due to the resident's weight loss and wounds, but the order was not entered into the Medication Administration Record (MAR), leading to a lack of awareness and action by the nursing staff. The oversight in providing the necessary nutritional supplement contributed to the resident's continued weight loss, as confirmed by the staff involved.
Deficiency in Pain Management and Documentation
Penalty
Summary
The facility failed to ensure that physician-ordered narcotic pain medication was available for administration to a resident, leading to a deficiency in pain management. The resident, who had a history of bilateral below-knee amputations and chronic pain, was prescribed Oxycodone-Acetaminophen to manage phantom pain. However, the facility ran out of the medication, and the resident was left without it for a whole day, despite requesting it every eight hours. Interviews with staff confirmed that the medication was not reordered in a timely manner, resulting in the resident experiencing unmanaged pain. Additionally, the facility did not document the administration of as-needed narcotic pain medication on the Medication Administration Record (MAR) for the same resident. The resident's Individual Narcotic Record showed that the medication was administered on several occasions, but these administrations were not recorded on the MAR. The LPN responsible for administering the medication admitted to sometimes forgetting to document it on the MAR, which is a violation of the facility's Controlled Substance Administration & Accountability policy. The facility's policies require a systematic approach to ensure medications are reordered when low and that all controlled substances are accurately documented. However, the failure to notify the nurse practitioner in time to reorder the medication and the lack of documentation on the MAR contributed to the deficiency. Interviews with staff, including the Assistant Director of Nursing, confirmed these lapses in protocol, which resulted in the resident not receiving their prescribed pain management medication as needed.
Late Meal Service on Hall B
Penalty
Summary
The facility failed to serve meals at regular times comparable to normal community meal times for residents on Hall B. According to the facility's policy, residents should receive at least three meals daily without extensive time lapses between meals, with lunch scheduled for 12:30 p.m. However, observations and interviews revealed that meals were often served late. Resident #132 reported receiving lunch as late as 2:00 p.m., and on the day of observation, his lunch tray was not delivered until 2:05 p.m. This delay was confirmed by multiple observations and interviews, including a resident council meeting where another resident from Hall B also reported receiving lunch at 2:00 p.m. Interviews with staff, including S6DM and S1ADM, confirmed that lunch for Hall B should be served at 12:30 p.m. and acknowledged that the 2:00 p.m. lunch service was unacceptable. S1ADM admitted there had been past complaints about meal service times, although he was unaware of recent issues until informed of the specific incident involving Resident #132. The facility's failure to adhere to scheduled meal times resulted in a deficiency in meeting the nutritional needs and preferences of the residents on Hall B.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the storage, preparation, and distribution of food for 141 residents. Observations revealed that staff members did not adhere to the facility's policy on attire, as one staff member with facial hair was not wearing a restraint, and another was not wearing a hairnet. These lapses in personal hygiene standards were confirmed by the staff during interviews. The kitchen inspection uncovered multiple issues with food storage and cleanliness. In the refrigerator, there were dented milk cartons, an unlabeled sandwich, unsealed bags of grapes and lettuce, and outdated containers of peaches and pudding. The dry goods storage area was disorganized, with loose packets of sugar and sweetener on the floor, and a scoop left in a bulk container of rice. Additionally, the drink dispensing table and food preparation areas were found to be unsanitary, with loose drink spouts, a lidless trash barrel, and evidence of insect activity. Interviews with staff confirmed these findings, acknowledging that food should be sealed, labeled, and dated, and that equipment should be properly maintained. The presence of a roach and the condition of the food preparation tables, which were cluttered with crumbs and debris, further highlighted the lack of adherence to sanitary protocols. The facility's administrator was informed of these deficiencies and confirmed the expectations for food safety and staff attire.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of various pests, including roaches, flies, and gnats, throughout the premises. Observations made over several days revealed live roaches in multiple rooms, including bathrooms and hallways, as well as flies and gnats swarming around residents and in common areas. Interviews with residents confirmed frequent sightings of these pests, with some residents noting that staff were aware of the issue and had attempted to spray for bugs. The pest control company representative stated that the facility was scheduled for an annual treatment, which was not completed due to the facility's lack of preparation. The facility administrator acknowledged the seasonal nature of pest issues and cited insufficient staffing as a reason for not being able to remove residents from their rooms for treatment. This deficiency had the potential to affect all 142 residents residing in the facility.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of a Discharge Minimum Data Set (MDS) assessment for a resident. According to the facility's policy, a Discharge Assessment must be completed within 14 days of the discharge date and transmitted to the designated CMS system within 14 days of completion. However, the clinical record review revealed that a resident, who was admitted and later discharged from the facility, did not have an electronically transmitted discharge MDS assessment. Interviews with the staff responsible for MDS assessments confirmed that the Discharge MDS Assessment was not completed as required.
Failure in PASRR Documentation and Evaluation
Penalty
Summary
The facility failed to maintain a record of the Level 1 Pre-admission Screening and Resident Review (PASRR) form for Resident #37, who was admitted with diagnoses including Other Sequelae of Cerebral Infarction, Unspecified Mood Affective Disorder, and Recurrent Severe Major Depressive Disorder with Psychotic Symptoms. Despite being assessed as moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 11, there was no documentation of the Level 1 PASRR form in the resident's file. Interviews with staff members confirmed the absence of this crucial documentation. Additionally, the facility did not conduct an accurate Pre-admission Screening for Resident #46, who was admitted with diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. The resident was assessed as cognitively intact with a BIMS score of 14, yet was not considered for a Level II PASRR despite having a serious mental illness diagnosis. The resident's care plan and medical records indicated active treatment for Bipolar Disorder, but no Level II PASRR evaluation was completed. Interviews with staff revealed a reliance on the initial screening process conducted by external personnel, leading to an oversight in the required Level II PASRR evaluation. The staff responsible for PASRR evaluations and MDS coordination assumed that the initial Level I screenings were completed accurately by external sources, resulting in a lack of verification and follow-up for necessary Level II evaluations. This assumption led to the failure in ensuring proper documentation and evaluation for residents with mental disorders, as evidenced by the cases of Residents #37 and #46.
Failure to Document Weekly Nurses' Notes
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality, specifically in the documentation of weekly nurses' notes for a resident. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Essential Primary Hypertension, and Vascular Dementia, had a physician's order for weekly nurses' notes to be documented every Friday during the 2:00-10:00 p.m. shift. However, a review of the resident's Treatment Administration Record (TAR) for May and June 2024 showed checkmarks indicating acknowledgment of the task, but no corresponding nurses' notes were documented on the specified dates. Interviews with the nursing staff, including two LPNs and the Assistant Director of Nursing (ADON), confirmed that the checkmarks on the TAR indicated acknowledgment of the task, but the actual documentation of the nurses' notes was not completed. The Director of Nursing (DON) also confirmed the lack of documentation and stated that the expectation was for nursing staff to document at least weekly on a resident, which was not done for this resident. This oversight in documentation was identified as a deficiency in meeting professional standards of quality care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by their policy and professional principles. During an observation, it was noted that a resident had three loose pills on top of her bedroom refrigerator, which were identified as Oscal Vit D, Diltiazem, and Tylenol. These medications were not under the direct observation of nursing staff, nor were they stored in a locked compartment, which is a violation of the facility's medication storage policy. The resident involved was cognitively intact, as indicated by a BIMS score of 14, and had been admitted with diagnoses including age-related cognitive decline, shortness of breath, hypertension, atrial fibrillation, and heart failure. The medications found were part of her active physician's orders. The LPN confirmed that the medications should not have been left unsecured, and the Assistant Director of Nursing also confirmed that medications should not be left at the bedside.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. This deficiency was identified during a review of the medical records for a resident with severe cognitive impairment, who had an advance directive indicating a Do Not Resuscitate (DNR) status. However, discrepancies were found between the resident's hard copy chart and the electronic medical record (EHR), with the EHR indicating a full code status instead of DNR. Interviews with staff, including LPNs and the Director of Nursing (DON), confirmed the inconsistency between the hard copy chart and the EHR. The hospice nurse also confirmed that the resident was a DNR as per the new advance directive signed by the resident's personal health care representative and the hospice physician. Despite this, the facility's EHR continued to reflect a full code status. The DON acknowledged that both the EHR and the hard chart should have matched the resident's DNR status, but they did not. This inconsistency in the resident's code status documentation led to the deficiency identified by the surveyors.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to coordinate hospice care services effectively, resulting in a deficiency related to the management of hospice care documentation for a resident. The facility's agreement with a local hospice company and its internal policy required the designated interdisciplinary team member to obtain and maintain specific hospice care information, including the most recent hospice plan of care, physician certification and recertification of terminal illness, hospice medication information, and physician orders. However, upon review, it was found that the hospice medical records for a resident admitted to hospice services did not contain the necessary documentation, such as the plan of care, physician certification/recertification, current/standing orders, or hospice care team assessments. Interviews conducted with the Director of Nursing (DON) and the hospice nurse confirmed the absence of required documentation in the resident's hospice binder. The DON acknowledged the responsibility for ensuring that each hospice resident's binder was up to date in collaboration with the hospice care team. Despite this responsibility, the necessary hospice documentation was missing from the resident's records, indicating a lapse in the facility's coordination and management of hospice care services.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members during the care of a resident. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, mandates the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms. However, during an observation, it was noted that two staff members, S13TN and S16CNA, did not wear the required PPE while providing peg tube care and repositioning a resident who was on Enhanced Barrier Precautions. The resident in question was admitted with diagnoses including Malignant Neoplasm of the Larynx and Gastrostomy Status, necessitating the use of a peg tube. Despite a sign on the resident's door indicating the need for Enhanced Barrier Precautions, both staff members failed to don the appropriate PPE. Interviews with the staff confirmed their awareness of the resident's precautionary status and their acknowledgment of the oversight. The Director of Nursing also verified the requirement for PPE use in such situations and confirmed the lapse in protocol adherence by the staff.
Failure to Accommodate Tube Feeding Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident requiring tube feeding management. The resident, who has a PEG tube due to conditions such as cerebral infarction, muscle wasting, atrophy, dysphagia, and gastrostomy status, was observed on multiple occasions without her tube feeding connected as per the physician's orders. The resident's care plan indicated she was at risk for inadequate nutrition and aspiration, and her feeding schedule was clearly outlined to run from 6:00 p.m. to 2:00 p.m. the following day, with a four-hour break. However, observations and interviews revealed that the resident's tube feeding was not consistently administered during the scheduled times. Interviews with staff, including LPNs and CNAs, confirmed that the resident often requested her tube feeding to be disconnected so she could propel herself around the facility in her wheelchair. The staff acknowledged that the resident's wheelchair did not accommodate her PEG tube feedings, which led to her being disconnected from the feeding when she was out of bed. Despite the resident's cognitive impairment, she was described as compliant with her care and did not refuse feedings. The staff's actions of disconnecting the tube feeding were based on the resident's desire for mobility and freedom within the facility. The facility's administration, including the ADON and DON, confirmed that the resident should have been able to move freely while still receiving her tube feedings as ordered. The medical provider also confirmed the resident's feeding schedule and her preference for mobility. The deficiency arose from the facility's failure to ensure the resident's wheelchair accommodated her tube feeding, resulting in her not receiving the prescribed nutrition during the times she was mobile, which was not in accordance with her care plan and physician's orders.
Failure to Administer PEG Tube Feedings as Ordered
Penalty
Summary
The facility failed to ensure that a resident received enteral feedings as ordered by the physician. Resident #19, who was admitted with diagnoses including Cerebral Infarction, Muscle Wasting and Atrophy, Dysphagia, and Gastrostomy Status, was observed not receiving her prescribed PEG tube feedings. Her care plan indicated she was NPO and required tube feeding to prevent aspiration due to dysphagia. The physician's orders specified continuous feeding from 6:00 p.m. to 2:00 p.m. the following day, with a four-hour break. However, observations and interviews revealed that the resident's feedings were not consistently administered as scheduled, with no documentation of refusals or held feedings. Interviews with staff, including LPNs and CNAs, confirmed that Resident #19's feedings were sometimes not connected as ordered. The resident herself stated that staff occasionally failed to reconnect her tube feedings. Staff members noted that the resident liked to propel herself around the facility and would request disconnection of her feeding tube, but there was no indication that she refused feedings. The Assistant Director of Nursing confirmed that the feedings should have been administered as ordered and acknowledged the lack of documentation when feedings were not given as prescribed.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not have an acceptable diagnosis for the use of antidepressant and anti-anxiety medications for one of the residents reviewed. The facility's policy on the use of psychotropic drugs states that such medications should only be administered to treat a specific condition that is diagnosed and documented in the clinical record. However, the resident in question was prescribed Escitalopram Oxalate and Lorazepam with a diagnosis of Dementia, which is not an acceptable diagnosis for these medications. Interviews with facility staff, including a Nurse Practitioner, an LPN, and the Director of Nursing, confirmed that the resident's medications were ordered with a diagnosis of Dementia. All staff members acknowledged that Dementia was not an appropriate diagnosis for the prescribed psychotropic medications. The failure to ensure an appropriate diagnosis for the use of these medications constitutes a deficiency in the facility's adherence to its policy and regulatory requirements.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident received a therapeutic diet as ordered by the physician. The resident, who was admitted with diagnoses including muscle wasting, atrophy, and type 2 diabetes mellitus, had a physician's order for double portions of protein and vegetables with all meals. However, during an interview, the resident reported frequently not receiving the ordered double portions. This was confirmed through an observation of the resident's lunch tray, which contained single portions of red beans and rice, sausage, and greens, instead of the prescribed double portions. The facility's policy, last approved in May 2023, mandates that dietary and nursing staff provide therapeutic diets in the appropriate form and nutritive content as prescribed by a physician. Despite this policy, the resident's lunch meal ticket indicated that double portions were required, yet the resident was served single portions. An interview with a staff member present during the observation confirmed that the resident was not served the correct portions, highlighting a failure in adhering to the prescribed dietary orders.
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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