Chateau De Notre Dame Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 2832 Burdette Street, New Orleans, Louisiana 70125
- CMS Provider Number
- 195589
- Inspections on file
- 34
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Chateau De Notre Dame Community Care Center during CMS and state inspections, most recent first.
A resident's Quarterly MDS assessment did not accurately reflect the administration of a diuretic and an antidepressant, as documented in the eMAR. The MDS failed to indicate the use of these medications, and staff interviews confirmed the assessment was not completed correctly.
A resident receiving continuous enteral nutrition and scheduled free water flushes did not have the required infusion rate labeled on their feeding and flush bags, as observed on multiple occasions. Facility policy and physician orders required this labeling, and staff confirmed the omission during interviews.
A resident with COPD and lung cancer did not receive oxygen at the physician-ordered rate of 4 lpm via nasal cannula, as observations showed administration at lower rates on multiple occasions. Both an LPN and the DON confirmed the oxygen was not set as ordered.
A resident with PTSD, anxiety, and depression did not have a care plan that addressed the source of trauma, monitoring for PTSD symptoms, identification of triggers, or interventions to prevent further trauma. Despite recommendations for a crisis/safety intervention plan, the clinical record and care plan lacked necessary assessments and documentation, as confirmed by both the LPN and DON.
A certified nursing assistant/transport driver failed to secure the front straps of a resident's wheelchair during van transport, resulting in the wheelchair tipping over and the resident sustaining a head injury. The resident, who had multiple medical conditions and was on blood thinners, required emergency evaluation and missed a scheduled dialysis treatment.
A CNA did not engage a resident's wheelchair brakes before securing the chair in a transport van, contrary to facility policy and training. The administrator also failed to verify brake engagement or use the required checklist during monitoring. Staff and manufacturer interviews confirmed that engaging wheelchair brakes is a necessary step in the securement process.
A facility failed to provide a resident with a 30-day written notice before discharge and did not include required contact information for Louisiana's Mental Health Advocacy Service in the discharge notice. The resident, who had major depressive disorder and bipolar disorder, was discharged without documented evidence of the cited reasons for discharge, such as smoking. The administrator confirmed the omission of necessary advocacy contact details.
A resident with severe cognitive impairment and mental health diagnoses expressed passive suicidal ideation during a shower transport. Two CNAs present did not report the statement to the nurse on duty, contrary to facility policy. The resident was later found with a bag strap around his neck, highlighting a failure to provide necessary behavioral health care.
A resident, who was cognitively intact and had a care plan requiring the call bell to be within reach, was found to have the call bell placed out of reach on multiple occasions. Despite the resident's inability to reach the call bell, staff members believed the resident was capable of using it.
A facility failed to involve a resident's family in care planning meetings, contrary to its policy. The resident's family was initially involved but was not invited to subsequent meetings. The Social Services Director admitted to not scheduling care plan conferences since June 2023, and the administrator confirmed that these meetings had not been held for long-term residents since that time.
A resident with Cerebral Palsy and bilateral hand contractures did not receive the recommended Occupational Therapy evaluation for splint fitting, as observed during a survey. Despite a rehabilitation screen suggesting the need for splints to prevent further decline, the resident was found without splints, and staff confirmed the evaluation had not been completed.
A facility failed to monitor a resident for targeted behaviors related to psychoactive medications, as required by their policy. The eMAR showed no documentation of monitoring for antidepressant and antianxiety medications. Interviews revealed that staff did not routinely chart assessments for targeted behaviors, only documenting if behaviors were observed. The DON admitted to this oversight, and the Administrator was unaware of the issue.
The facility failed to ensure adequate supervision and functioning of the WanderGuard system for residents at risk of wandering. A resident assessed as high risk for wandering exited the facility unsupervised, and the WanderGuard system did not alert staff. The system was not tested properly at ankle level or from multiple angles, contributing to the failure to prevent elopement.
The facility failed to ensure proper supervision and functioning of the WanderGuard system for a high-risk resident, who was able to exit the facility and was unsupervised for approximately 13.45 hours. The system was not tested at ankle level or from multiple angles, contributing to the deficiency.
Inaccurate MDS Assessment of Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) assessment accurately reflected the medications administered during the required lookback period. Review of the electronic medication administration record (eMAR) showed that the resident received Lasix, a diuretic, and Trazodone, an antidepressant, during the assessment period. However, the corresponding MDS assessment did not indicate the use of either a diuretic or an antidepressant in the relevant sections, and instead marked 'none of the above.' Interviews with the Clinical Care Coordinator, Director of Nursing, and Administrator confirmed that the MDS was not completed accurately as required, and the medication use should have been documented in the assessment.
Failure to Label Enteral Feeding and Free Water Flush Bags with Infusion Rate
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia and gastrostomy status, who was receiving continuous enteral nutrition and scheduled free water flushes, did not have the required labeling on their enteral feeding and free water flush bags. The facility's policy required that these bags be labeled with specific information, including the infusion rate, to ensure proper administration according to physician orders. However, multiple observations over several days revealed that both the enteral feeding bag and the free water flush bag lacked the necessary labeling of the infusion rate. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the bags should have been labeled with the infusion rate as per facility policy and physician orders. The failure to label the bags was consistently observed and acknowledged by staff, indicating noncompliance with established procedures for enteral feeding management.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
Facility staff failed to follow a physician's order for oxygen administration for Resident #52, who had a history of chronic obstructive pulmonary disease (COPD) and lung cancer and was assessed as having intact cognition. The physician's order specified that oxygen should be administered at 4 liters per minute (lpm) via nasal cannula every shift, with removal only for bathing and daily care. However, observations on two separate occasions revealed that the resident was receiving oxygen at lower rates—3.4 lpm and 3 lpm, respectively. Both the Clinical Care Coordinator/LPN and the Director of Nursing confirmed that the oxygen was not administered at the prescribed rate, acknowledging that it should have been set at 4 lpm as ordered.
Failure to Develop and Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a resident-specific plan of care for a resident diagnosed with post-traumatic stress disorder (PTSD), anxiety, and depression. Review of the resident's Minimum Data Set indicated intact cognition, and the resident's medical history included PTSD. However, there was no documented evidence in the physician's orders or psychiatric progress notes that the facility assessed the source of the resident's trauma, monitored for signs and symptoms of PTSD, identified triggers, or implemented interventions to avoid further trauma. The PASRR Level II Summary recommended a crisis/safety intervention plan, but this was not reflected in the resident's care plan. Interviews with the Clinical Care Coordinator/LPN and the Director of Nursing confirmed that the resident's clinical record and care plan did not address the PTSD diagnosis, including the necessary assessments and interventions. The lack of documentation and individualized planning for the resident's behavioral and emotional needs constituted a failure to provide trauma-informed and culturally competent care as required.
Failure to Properly Secure Wheelchair During Resident Transport
Penalty
Summary
A deficiency occurred when a certified nursing assistant/transport driver failed to properly secure the front straps of a resident's wheelchair during transport in the facility's van. As a result, the wheelchair tipped over backwards when the van accelerated after a stop, causing the resident to fall and strike the back of his head. The facility's policy required that wheelchairs be properly secured with securement equipment, and staff interviews confirmed that the wheelchair was not secured according to these guidelines. The resident involved had significant medical conditions, including end stage renal disease, peripheral vascular disease, cognitive communication deficit, and a right above knee amputation. He was also prescribed blood thinning medications, which increased his risk for serious injury following a head trauma. Due to the incident, the resident was transported to a local emergency department for evaluation of a head injury and was unable to receive his scheduled dialysis treatment.
Failure to Ensure CNA Competency in Wheelchair Securement Procedures
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow the facility's established procedure for securing a resident's wheelchair in a transport vehicle. During the loading of a resident into the facility van, the CNA attached the front Q'Straint securement straps to the wheelchair without first engaging the wheelchair brakes, as required by the facility's competency checklist and the Q'Straint user instructions. The CNA then exited the vehicle and prepared to close the van door without ensuring the wheelchair brakes were engaged. The CNA had previously completed the required training on the securement procedure. Additionally, the facility administrator monitored the securement process but did not use the facility's competency checklist or verify that the wheelchair brakes were engaged. Multiple staff interviews confirmed that engaging the wheelchair brakes is a required step in the securement process. The Q'Straint representative also confirmed that the brakes should be engaged before applying the securement system. The administrator acknowledged not checking the status of the wheelchair brakes during monitoring and could not explain why the checklist was not followed.
Failure to Provide Proper Discharge Notice and Required Advocacy Information
Penalty
Summary
The facility failed to provide a resident with a 30-day written notice before a facility-initiated discharge, as required by regulations. The resident was readmitted to the facility from an inpatient psychiatric hospital and was discharged four days later. The discharge notification was given on the same day as the discharge, citing the facility's inability to meet the resident's needs and the resident's continued smoking as reasons. However, there was no documented evidence of the resident smoking or possessing smoking paraphernalia after returning from the psychiatric hospital. The resident was under one-on-one monitoring during this period, and the administrator could not provide evidence to dispute the deficiency. Additionally, the facility failed to include the required contact information for Louisiana's Mental Health Advocacy Service in the resident's discharge notice. The resident had diagnoses of major depressive disorder and bipolar disorder, which necessitated the inclusion of this information. The administrator confirmed that the discharge notice did not contain the necessary contact details, further contributing to the deficiency.
Failure to Address Passive Suicidal Ideation in Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care for a resident who displayed passive suicidal ideation. The resident, who had severe cognitive impairment and diagnoses of dementia, depression, and schizophrenia, made a statement indicating passive suicidal ideation while being transported to the shower room. The statement was made in the presence of two CNAs, who did not report the incident to the nurse on duty as required by the facility's policy. The CNAs proceeded to give the resident a shower and returned him to his room without further assessment or intervention. Later, one of the CNAs found the resident with a promotional bag strap around his neck and then brought him to the nurse on duty. Interviews with facility staff, including the administrator and a psychiatric mental health nurse practitioner, confirmed that the CNAs should have reported the resident's statement immediately and remained with the resident to ensure his safety. The failure to follow the facility's policy on addressing suicide threats resulted in a deficiency in providing necessary behavioral health care to the resident.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. Resident #64, who was cognitively intact with a Brief Interview for Mental Status score of 13, had a care plan that included an intervention to have the call bell within reach due to potential respiratory distress, self-care deficit, and risk for falls. However, observations on multiple occasions revealed that the call bell was either on the nightstand or in the top drawer of the nightstand, making it inaccessible to the resident. Interviews with the resident confirmed that he could not reach the call bell, while staff members, including an LPN and a CNA, indicated that the resident was capable of using the call bell, despite its inaccessibility.
Failure to Involve Resident's Family in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was invited to participate in care planning meetings. This deficiency was identified for one resident who was investigated for participation in care planning. The facility's policy, dated September 2013, encourages the involvement of residents, their families, and legal representatives in the development and revision of care plans. However, it was found that the facility did not adhere to this policy, as evidenced by the lack of invitations extended to the resident's family for care plan conferences. Interviews conducted during the investigation revealed that the resident's family member had participated in quarterly care plan conferences when the resident was first admitted but had not been invited to subsequent meetings. The Social Services Director admitted to not contacting families to schedule care plan conferences since June 2023, and stated that a conference was only held if a family member attended. The facility's administrator acknowledged that care plan conferences had not been completed for long-term residents since June 2023, despite the expectation to schedule them for each quarterly assessment.
Failure to Provide Recommended Occupational Therapy Evaluation
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with limited range of motion, as identified in a therapy screening. Resident #44, diagnosed with Cerebral Palsy, had functional limitations in the range of motion of both upper extremities and contractures of the bilateral upper extremities. A rehabilitation screen conducted on 09/01/2023 recommended an evaluation by Occupational Therapy for splint fitting to prevent further decline. However, an observation on 06/11/2024 revealed that Resident #44, while in her wheelchair, did not have splints on her hands despite having bilateral hand contractures. Interviews with an LPN and the Rehab Director confirmed that the Occupational Therapy evaluation for splints had not been completed, despite the earlier recommendation.
Failure to Monitor Targeted Behaviors for Psychoactive Medications
Penalty
Summary
The facility failed to monitor a resident for targeted behaviors related to the use of psychoactive medications, resulting in a deficiency. The facility's policy required the interdisciplinary team to monitor for side effects and complications of psychoactive medications. However, a review of the resident's Electronic Medication Administration Record (eMAR) showed no documentation of monitoring for targeted behaviors associated with administered antidepressant and antianxiety medications prior to a specified date. Interviews with facility staff, including the Clinical Coordinator and Director of Nursing, revealed that the nursing staff did not routinely chart assessments and monitoring of targeted behaviors for residents receiving psychoactive medications. The Director of Nursing admitted that the staff only documented progress notes if targeted behaviors were observed, and the Administrator was unaware of the lack of monitoring for the resident in question.
Failure to Ensure Adequate Supervision and Functioning of WanderGuard System
Penalty
Summary
The facility failed to ensure adequate supervision and functioning of the WanderGuard system for residents at risk of wandering and elopement. Resident #1, who was assessed as being at high risk for wandering, was able to exit the facility unsupervised through Door A. The WanderGuard system did not alert staff, and Resident #1 was missing for approximately 13.45 hours before being located by an LPN on a street near the facility and returned to the facility. The WanderGuard system was not tested properly at ankle level or from multiple angles, which contributed to the failure to prevent Resident #1's elopement. Additionally, the facility did not ensure that the WanderGuard system was functioning correctly for other residents at high risk for wandering. Residents #2, #3, #4, and #5, all assessed as high risk for wandering, had WanderGuard bracelets placed on their ankles or wrists. However, the system was not tested adequately to ensure it would alert staff if these residents attempted to exit the facility. Observations revealed that the WanderGuard system on Door A did not lock the doors or sound an alarm when approached from certain angles or at ankle height. Interviews with staff indicated that the WanderGuard system was only tested at waist level and not from multiple angles. The facility's Plant Manager confirmed that the system was not set to its maximum range to allow residents to use the facility's elevator. This lack of proper testing and system configuration contributed to the failure to prevent residents from exiting the facility unsupervised, posing a significant risk to their safety.
Failure to Ensure Proper Supervision and Functioning of WanderGuard System
Penalty
Summary
The facility failed to ensure proper supervision and functioning of the WanderGuard system for a resident assessed as being at high risk for wandering and elopement. Resident #1, who had a WanderGuard transmitter on his right ankle, was able to exit the facility through Door A and was unsupervised for approximately 13.45 hours. The resident was eventually found walking on a street near the facility by an LPN and was returned to the facility. This incident created an Immediate Jeopardy situation, highlighting the failure in monitoring and testing the WanderGuard system effectively. Interviews revealed that the Plant Manager tested the WanderGuard system at waist level rather than ankle level, and the Corporate Administrator confirmed that the system's range was not set as wide as it could have been. Additionally, the facility did not test the WanderGuard system from multiple angles, which contributed to the failure in preventing the resident's elopement. There was no documented evidence that the WanderGuard system was tested with a transmitter bracelet at ankle height or from different angles, leading to the deficiency.
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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