Chateau Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenner, Louisiana.
- Location
- 716 Village Road, Kenner, Louisiana 70065
- CMS Provider Number
- 195184
- Inspections on file
- 42
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Chateau Living Center during CMS and state inspections, most recent first.
A resident’s right to privacy during perineal care was not maintained when two CNAs provided care without closing the privacy curtain or room door, leaving the resident’s buttocks exposed to a roommate and to another resident who entered the room. Facility policy required that the door and privacy curtain be closed during perineal care, and both a CNA and the DON later confirmed that the door and/or curtain should have been closed.
A resident with urinary incontinence was left in soiled clothing for over 40 minutes after staff were made aware of her need for assistance. Despite the resident's repeated requests and visible distress, both an LPN and a CNA Supervisor failed to provide timely incontinence care, which was only given after a CNA intervened. Facility policy required residents to be changed within 15 to 20 minutes after an incontinence episode, but this standard was not met.
A resident with a history of chronic pain and a previous fall was unable to receive prescribed Hydrocodone-Acetaminophen for pain relief because the medication was not reordered in time and was unavailable when requested. Staff confirmed the medication was out of stock and not administered as ordered.
A resident with a urinary catheter was observed with her drainage bag visible while using a wheelchair, despite having previously requested a privacy cover. An LPN and the Assistant Director of Nursing both confirmed awareness of the request and the need for a privacy cover, but the resident had not received one, resulting in a failure to maintain the resident's dignity and privacy.
Surveyors found that two medication carts contained insulin pens that were either expired or lacked an opened date, making it impossible to determine if they were safe for use. An LPN confirmed the expired status of one pen, while another LPN acknowledged that an unlabeled pen should have been discarded.
A medication cup with two unidentified pills was found on a resident's bedside table after the resident declined to take her sleeping pills when offered by a nurse. Facility policy prohibits leaving medications unattended with residents, and the ADON confirmed this practice was not followed.
Several residents reported that their meals were consistently served cold, and surveyors observed that food trays were transported on top of insulated carts rather than inside them. Temperature checks confirmed that food items were served below acceptable hot food standards, and both staff and surveyors found the food to be cold.
Two residents were left without a working call bell in their bathroom and bathing area for several days, requiring them to wait for staff rounds to receive assistance. Staff were aware of the malfunction but did not notify the administrator, resulting in a prolonged lack of access to the call system.
The facility failed to ensure a clean and odor-free environment, with strong urine odors in two halls and trash on a resident's floor. A resident's room contained debris, and their wedge pillow was damaged. The administrator acknowledged these issues.
A resident with multiple stage 3 pressure injuries did not receive proper wound care when a CNA removed dressings and failed to notify the nurse, leaving wounds exposed. Additionally, a heel protector was incorrectly applied to the right heel instead of the left, as ordered. The resident's medical conditions increased the risk of pressure ulcer development, highlighting the importance of following care protocols.
A resident with peripheral vascular disease did not receive necessary toenail care in a timely manner. Despite the resident's request for toenail care upon admission, observations showed the toenails were long, thick, and curled. Interviews with the ADON and an LPN confirmed the need for trimming, but the resident was not scheduled for a podiatry appointment, and there was no evidence of a prior podiatry consult.
The facility failed to ensure CNAs demonstrated competencies in hand hygiene, EBP, and proper showering, and an LPN demonstrated competency in applying a heel protector. Two residents were affected: one with stage three pressure injuries and an indwelling urinary catheter, where CNAs did not adhere to EBP, and another requiring substantial assistance, where a CNA failed to wash the resident's buttocks and did not perform hand hygiene during incontinence care.
A long-term care facility failed to maintain an effective infection prevention and control program for two residents. One resident, with multiple medical conditions, did not receive proper Enhanced Barrier Precautions (EBP) as CNAs failed to wear gowns, perform hand hygiene, or change gloves during care. Another resident received incontinence care without proper hand hygiene or glove changes. The facility's Administrator and DON confirmed these lapses in infection control protocols.
A resident with moderate cognitive impairment and incontinence issues did not receive adequate personal hygiene care during a bathing session. The CNA failed to wash the resident's buttocks, leaving them uncleaned. The CNA acknowledged the oversight, and the facility administrator confirmed that the resident's buttocks should have been washed.
A resident with a WanderGuard transmitter exited a facility through an unalarmed door, resulting in a head injury. Staff used a secondary reset code to disable door alarms, contrary to policy, compromising resident safety. The deficiency led to Immediate Jeopardy due to the risk of harm to residents at risk for elopement.
A CNA failed to recognize a resident at risk for elopement, despite facility policy requiring staff to be trained on elopement prevention. The CNA, assigned to a room with two at-risk residents, only identified one as at risk. The Director of Nursing confirmed that staff should use binders at nursing stations to identify such residents, but the CNA was unaware of this resource.
A facility failed to ensure privacy for a resident during PEG tube care. An LPN performed the procedure without closing the door, leaving the resident's abdomen exposed and visible from the hallway. The resident had a diagnosis of mild intellectual disability. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that the door should have been closed to maintain privacy.
A facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) during PEG tube care for a resident. Despite a policy requiring gown use for high-contact activities, an LPN was observed performing PEG tube care without a gown. The resident had a gastrostomy and physician orders for EBP, which mandated gown and glove use. Interviews confirmed the lapse in protocol adherence.
The facility failed to ensure a safe environment as water leaked from Shower Room A into the hallway due to an uneven floor. Observations confirmed the presence of water pooling in the hallway, and staff interviews verified the issue. The Administrator was aware of the incident.
The facility failed to complete required Braden skin assessments for a resident upon re-admission and inaccurately documented another resident's pressure ulcer status. Additionally, the facility did not implement necessary pressure ulcer prevention and treatment interventions for a resident, as staff failed to turn the resident every two hours and use heel protectors as per the care plan.
A facility failed to accurately revise a care plan for a resident's skin condition. The resident had a care plan for impaired skin integrity, but it was inaccurately updated to reflect a stage III pressure ulcer later than documented in nursing notes. This discrepancy was confirmed by a corporate nurse.
A facility failed to properly store discontinued and expired medications, as a blister packet of Norco 5-325 mg tablets was found in a medication cart despite being discontinued and expired. Staff, including an LPN, ADON, DON, and the Administrator, confirmed the oversight, acknowledging that the medication should have been removed according to facility policy.
Two residents with moderately impaired cognition were found with medications on their bedside tables without being assessed or care planned for self-administration, as required by the facility's policy. Interviews with staff confirmed the lack of assessment and care planning for these residents.
A resident's wheelchair was found in poor condition, with a blackish-brownish substance on the brake levers, a missing right arm pad, and a torn left arm pad with exposed foam. Facility staff confirmed the issues, and the DON indicated the need for replacement.
A resident admitted for rehabilitation and receiving IV medications through a PICC line reported that the site was not cleaned or bandage changed during their stay. Facility records lacked documentation of PICC site care, and staff interviews confirmed the absence of documentation and inability to recall if care was provided.
A facility failed to accurately complete a Level I PASARR for a resident with Major Depressive Disorder and Bipolar Disorder. The resident's mental illnesses were not documented, and a Level II PASARR referral was not initiated, despite the resident's diagnoses and history of mental health treatment. Interviews revealed staff were unaware of the need for a Level II referral, and the administrator confirmed the oversight.
The facility did not maintain food on the steam table at the required temperature of at least 135°F. During an observation, various foods were held on the steam table for lunch, and the temperature of pureed sweet potatoes was found to be 130°F. Interviews with staff confirmed that the steam table should maintain food at a temperature no lower than 135°F.
A facility failed to transmit a resident's discharge assessment data within the required timeframe, resulting in a deficiency. The assessment was completed and signed by the DON, but an error in the MDS caused a delay in transmission. The MDS Nurse indicated that the error in entering the Unit Certification or Licensure Designation led to the late submission.
A facility failed to ensure a resident's MDS assessment accurately reflected their skin condition. The resident had a stage III pressure ulcer documented in nursing notes, but the MDS inaccurately indicated no unhealed pressure ulcers. This discrepancy was confirmed by a corporate nurse.
Failure to Maintain Resident Privacy During Perineal Care
Penalty
Summary
The facility failed to maintain a resident’s privacy during perineal care, contrary to its Perineal Care Policy and Procedure dated 11/17/2015, which required that the resident’s door and privacy curtain be closed during such care. On 02/09/2026 at 12:28 PM, two CNAs (S2CNA and S3CNA) provided perineal care to Resident #1 without closing the privacy curtain, resulting in the resident’s buttocks being exposed to the roommate. During the same episode of care, a random resident walked into the room, and Resident #1’s buttocks remained exposed because the door and privacy curtain were not closed. In a subsequent interview at 2:10 PM, S2CNA acknowledged that she did not close the door or privacy curtain while performing perineal care and stated that she should have done so. In a separate interview at 2:12 PM, the Director of Nursing (S1) indicated that both CNAs should have closed the resident’s door and/or privacy curtain while performing the perineal care.
Delay in Providing Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely assistance with activities of daily living (ADL) for a resident who required help with toileting and hygiene due to urinary incontinence. The resident, who had diagnoses including overactive bladder and unspecified urinary incontinence, was observed crying in her wheelchair in the hallway after experiencing an episode of incontinence. Despite informing staff members, including an LPN and a CNA Supervisor, of her situation and visibly displaying distress, the resident did not receive prompt incontinence care. The LPN stated she would find a CNA to assist, and the CNA Supervisor acknowledged the resident's statement about being wet but did not provide immediate help, instead only showing the resident where her clothes were located. The resident continued to seek assistance, wheeling herself through the hallway and expressing her need for clean clothes and incontinence care. It was not until approximately 42 minutes after the initial observation that a CNA provided the necessary care. Interviews with staff confirmed that facility policy required residents to be changed within 15 to 20 minutes after a known episode of incontinence. The delay in providing care was contrary to this policy, and staff acknowledged the expectation for timely assistance following incontinence episodes.
Failure to Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's prescribed pain medication, Hydrocodone-Acetaminophen 10-325 mg, was available for administration as ordered by the physician. Review of the medication records showed that the resident had zero tablets available after receiving the last dose on 08/29/2025 at 8:43 PM. The resident reported experiencing pain related to a previous fall and chronic pain during the night and morning following the last available dose, and stated that she requested her pain medication but was informed by nursing staff that it was not available because it had not been reordered. Staff interviews confirmed that the medication was not available when requested, and the LPN on duty was unable to administer the prescribed pain medication due to the lack of supply. The Staff Development/Charge Nurse/Infection Preventionist acknowledged that medications with active orders should be available for administration, and the Director of Nursing indicated that medications should be ordered from the pharmacy before running out. The deficiency was identified for one of three residents reviewed for medication administration.
Failure to Provide Privacy Cover for Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed ambulating in her wheelchair with her catheter drainage bag attached under the seat, and the contents of the bag, including yellow urine, were visible. The resident called out to an LPN and requested a privacy cover for her catheter drainage bag, stating that she had made the same request the previous week but had not received one. The LPN acknowledged the prior request and confirmed that the resident should have a privacy cover. The Assistant Director of Nursing also confirmed that the resident should have a privacy cover for her catheter drainage bag. These observations and interviews demonstrate that the facility failed to provide the requested privacy cover, compromising the resident's dignity and right to privacy.
Expired and Unlabeled Insulin Pens Found on Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use on two medication carts. During observation, an insulin pen prescribed for one resident was found in a medication cart with an opened date that indicated it was expired, as it had been opened more than 28 days prior. The LPN present confirmed that the insulin pen was expired and still available for use. Additionally, another insulin pen for a different resident was found in a separate medication cart without any label indicating the date it was opened. The LPN interviewed stated that without the opened date, it was not possible to determine if the medication was expired, and acknowledged that the pen should have been discarded. These findings were based on direct observation, staff interviews, and review of relevant medication storage guidelines.
Medications Left Unattended at Bedside
Penalty
Summary
A deficiency was identified when a medication cup containing two unidentified white, round pills was observed on a resident's bedside table. The resident stated that these were her sleeping pills, which had been given to her by a nurse the previous night, but she chose not to take them and left them on the table. Facility policy specifies that nurses should not leave residents with medications in a medication cup. The Assistant Director of Nursing confirmed that medications should not have been left unattended at the resident's bedside.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified that the facility failed to serve food at an acceptable temperature to residents. Multiple residents reported that their food was consistently cold when served, both in their rooms and in common areas. Observations confirmed that food trays were placed on top of insulated tray carts rather than inside them during transport, which compromised the ability of the carts to maintain food temperature. On two separate occasions, surveyors collected trays that had been transported in this manner and found the food to be lukewarm or at room temperature. Temperature checks conducted by the dietary technician and surveyor revealed that food items such as pork, lima beans, and cabbage were served at temperatures ranging from 78 to 91 degrees Fahrenheit, which is below the standard for hot food service. Both the surveyor and the dietary technician confirmed through sampling that the food was cold. Interviews with staff and residents consistently indicated awareness of the issue, with staff acknowledging that the food temperatures were not acceptable.
Nonfunctional Call Bell System Leaves Residents Without Means to Request Assistance
Penalty
Summary
A deficiency was identified when it was observed that the call bell system in the bathroom and bathing area for two residents was not functional. The call light above their room door remained illuminated, indicating a malfunction. Staff interviews confirmed that the call bell had been broken since a specific date and that the issue persisted over the weekend. Both residents reported that they were unable to use the call bell to request assistance and had to wait for staff to enter their room during routine rounds. Further interviews revealed that staff were aware of the malfunction but did not notify the facility administrator. The administrator confirmed that he was not informed about the broken call bell and could not provide evidence to dispute the deficiency. The lack of a working call system left the residents without a means to call for help in their bathroom and bathing areas for several days.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations. On March 11, 2025, strong unpleasant odors of urine were detected throughout Hall A, and a combination of trash and urine odors were present in Hall B. Additionally, a resident's room was found to have debris, including a container, napkins, mints, two plastic bags, and chipped paint on the floor near the bed. Furthermore, the resident's wedge pillow, used for repositioning, was damaged with pieces of foam missing. In an interview conducted on March 13, 2025, the facility's administrator acknowledged the presence of trash on the resident's floor and confirmed that such conditions were unacceptable.
Failure in Wound Care and Heel Protector Application
Penalty
Summary
The facility failed to ensure proper wound care and prevention of pressure ulcers for a resident with multiple stage 3 pressure injuries. A Certified Nursing Assistant (CNA) removed the resident's wound dressings during incontinence care but did not notify the nurse, leaving the wounds exposed. The resident's electronic medical record indicated orders for specific wound care, including cleansing and dressing changes every hour as needed for soilage and dislodgement. However, the CNA's failure to communicate the removal of dressings resulted in the resident's wounds being left uncovered and exposed to potential contamination. Additionally, the facility did not ensure the correct application of a heel protector as ordered by the physician. The resident was observed without a heel protector on the left heel, as required, and instead had it incorrectly placed on the right heel. This oversight was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the error. The resident's medical history included conditions such as morbid obesity, muscle weakness, and reduced mobility, which increased the risk of pressure ulcer development, making adherence to care protocols critical.
Failure to Provide Toenail Care for Resident with Peripheral Vascular Disease
Penalty
Summary
The facility failed to ensure that a resident diagnosed with peripheral vascular disease received appropriate foot care, specifically toenail trimming. The resident was admitted with a condition that required careful management of blood flow to the limbs. An observation revealed that the resident's left great toe toenail was unusually long, thick, and curled backward. The resident had requested toenail care upon admission, but interviews with the Assistant Director of Nursing (ADON) and an LPN confirmed that the resident's toenails were long and thick and needed trimming. The ADON admitted that the resident was not scheduled for a podiatry appointment or consult. There was no documented evidence that the resident had seen a podiatrist prior to the survey entrance date.
Deficiencies in CNA and LPN Competencies
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) demonstrated competencies in hand hygiene, use of Enhanced Barrier Precautions (EBP), and proper showering techniques, as well as a Licensed Practical Nurse (LPN) demonstrating competency in applying a heel protector. This deficiency was observed in two residents. For Resident #1, who had multiple medical conditions including stage three pressure injuries and an indwelling urinary catheter, CNAs did not adhere to EBP by failing to wear gowns and perform hand hygiene before and after providing incontinence care. Additionally, the LPN incorrectly applied a heel protector to the wrong heel, contrary to the physician's orders. For Resident #2, who required substantial assistance with activities of daily living due to moderately impaired cognition, a CNA failed to wash the resident's buttocks during a shower. Furthermore, another CNA did not perform hand hygiene before and after providing incontinence care, and did not change gloves after removing a soiled brief. These actions were contrary to the facility's protocols and the expectations for maintaining hygiene and infection control.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents, leading to deficiencies in care. Resident #1, who had multiple medical conditions including stage three pressure injuries and an indwelling urinary catheter, required Enhanced Barrier Precautions (EBP) to prevent the spread of Multi Drug Resistant Organisms (MDRO). However, observations revealed that Certified Nursing Assistants (CNAs) did not adhere to these precautions. They failed to wear gowns, perform hand hygiene, or change gloves while providing incontinence care, and they improperly handled Resident #1's BIPAP/CPAP mask, which was left uncovered in an open drawer. Resident #2, who had moderate cognitive impairment and was incontinent of bladder and bowel, also received inadequate care. A CNA was observed performing incontinence care without performing hand hygiene before or after the procedure, and without changing gloves. This lack of adherence to infection control protocols was confirmed by the CNA during an interview. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed that the CNAs did not follow the facility's policies and procedures for infection control. The Administrator and DON acknowledged that staff should have performed hand hygiene and worn gowns when required, particularly for residents on EBP. The improper storage of medical equipment and failure to follow hygiene protocols contributed to the facility's deficiency in maintaining an effective infection prevention and control program.
Deficiency in Personal Hygiene Care for a Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident with moderate cognitive impairment and incontinence issues. The resident, who required substantial assistance with bathing and personal hygiene, was observed during a bathing session where the Certified Nursing Assistant (CNA) did not wash the resident's buttocks. The CNA transferred the resident to a shower chair, rinsed the front of the resident's body, and encouraged the resident to wash his own genital area. However, the CNA did not ensure that the resident's buttocks were washed, leaving them dry and uncleaned. During an interview, the CNA acknowledged that the resident's buttocks had not been washed. The facility administrator also confirmed that the resident's buttocks should have been washed during the bathing process. This oversight in personal hygiene care was identified during a survey, highlighting a deficiency in the facility's provision of activities of daily living (ADL) care for the resident.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, leading to an Immediate Jeopardy situation. A resident, who was ordered a WanderGuard transmitter due to being at risk for elopement, managed to exit the facility through an unalarmed door. The resident was found 0.4 miles away with a head injury, which resulted in a right temporal bone fracture and a right subdural hematoma. This incident highlighted the facility's failure to maintain effective elopement prevention measures. Further investigation revealed that staff members were using a secondary reset code to disable door alarms, allowing residents with WanderGuard transmitters to exit the facility without triggering an alert. This practice was contrary to the facility's policy, which required that door alarms remain active unless under direct supervision. Interviews with staff confirmed that multiple employees were using this code, which bypassed the WanderGuard system's security features, compromising resident safety. The facility's policy required staff to be trained on preventing and responding to elopement, including understanding risk factors and interventions. However, the use of the secondary reset code by unauthorized staff members indicated a lack of adherence to these protocols. The deficiency had the potential to cause more than minimal harm to residents identified as being at risk for elopement, as evidenced by the incident involving the resident who sustained serious injuries after eloping.
CNA Lacks Competency in Elopement Risk Procedure
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S7CNA, was competent in the procedure for managing residents at risk for elopement. The facility's policy, effective since July 31, 2019, mandates that all staff be trained on preventing elopement, including understanding risk factors and interventions. However, during an interview, S7CNA denied receiving training on residents at risk for elopement since December 23, 2024, despite having signed an in-service acknowledgment on December 26, 2024. S7CNA was unaware that Resident #R4, in her assigned room, was at risk for elopement, although the facility's Elopement Binder, located at the nursing station, listed both Resident #R4 and Resident #R7 as requiring WanderGuard transmitters due to their elopement risk. The Director of Nursing (DON), identified as S2DON, confirmed that nursing staff should be knowledgeable about which residents are at risk for elopement and that the facility's process involves checking binders at the nursing stations for this information. S2DON acknowledged that S7CNA should have been aware of the elopement binder as a resource. The deficiency was identified during a review of the facility's CNA staffing schedule and census, which showed that S7CNA was assigned to the room where both at-risk residents resided, yet she failed to recognize Resident #R4 as an elopement risk.
Failure to Ensure Privacy During PEG Tube Care
Penalty
Summary
The facility failed to ensure privacy for a resident during Percutaneous Endoscopic Gastrostomy (PEG) tube feeding care. The facility's policy required staff to pull a privacy screen and drape the resident during such care. However, an LPN entered the resident's room and performed PEG tube care without closing the door, leaving the resident's abdomen exposed and visible from the hallway. This incident involved a resident with a diagnosis of mild intellectual disability. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that the door should have been closed to maintain the resident's privacy.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to ensure that staff adhered to the Enhanced Barrier Precautions (EBP) policy during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The facility's policy, dated April 1, 2024, required staff to wear a gown when performing high-contact activities, such as feeding device care, for residents with indwelling medical devices. Despite this policy, an LPN was observed performing PEG tube care for a resident without wearing a gown, which included air bolus placement check, residual check, and free water flush. The resident involved had a diagnosis of age-related cognitive decline, moderate protein-calorie malnutrition, and a gastrostomy. The resident's physician orders from August 2024 specified the use of EBP, requiring staff to wear a gown and gloves during high-contact care activities. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that a gown should have been worn during the PEG tube care for the resident on EBP, indicating a lapse in following the established infection prevention and control protocols.
Water Leakage from Shower Room A into Hallway
Penalty
Summary
The facility failed to maintain a safe and clean environment as evidenced by water leaking from Shower Room A into the hallway. Observations on August 27, 2024, at various times revealed a pool of water present in the hallway outside Shower Room A's doorway. Interviews with staff, including the Staff Developer, Maintenance personnel, and the Assistant Director of Nursing, confirmed the presence of water in the hallway and identified the cause as an uneven floor in Shower Room A. The uneven floor allowed water to pool in low areas and drain into the hallway. The Administrator acknowledged awareness of the incident.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its policy of completing a Braden skin risk assessment upon re-admission for a resident who had multiple hospital stays. Despite the policy requiring assessments upon re-admission, the assessments were not completed on two separate occasions. This oversight was confirmed by both the Assistant Director of Nursing and the Corporate Nurse, who acknowledged that the assessments should have been conducted. Additionally, the facility did not accurately document the status of a resident's pressure ulcer. The resident had a stage III pressure ulcer to the sacral area, but the wound was inconsistently documented as an irritation/excoriation in the Wound Assessment Reports. This inconsistency in documentation was acknowledged by the Corporate Nurse, who confirmed that the wound should have been documented as a new pressure ulcer when its status changed. Furthermore, the facility failed to implement pressure ulcer prevention and treatment interventions for another resident. Despite the care plan indicating the need to turn the resident every two hours and use heel protectors, observations revealed that these interventions were not consistently carried out. Staff interviews confirmed the lack of adherence to the care plan, with staff unaware of the need for heel protectors and failing to turn the resident as required.
Inaccurate Care Plan Revision for Pressure Ulcer
Penalty
Summary
The facility failed to accurately revise a care plan addressing a resident's skin condition. Resident #62 had a care plan developed for impaired skin integrity due to irritation/excoriation in the sacral area on 06/16/2024. However, the care plan was inaccurately revised on 07/15/2024 to indicate a stage III pressure ulcer, despite nursing notes from 07/02/2024 already documenting the presence of a stage III pressure ulcer with slough in the same area. This discrepancy was confirmed by S2Corporate Nurse, who acknowledged that the care plan did not accurately reflect the resident's skin condition.
Expired and Discontinued Medication Found in Use
Penalty
Summary
The facility failed to ensure that discontinued and expired medications were properly stored and not available for resident use. During an observation of medication carts, it was found that a blister packet of Norco 5-325 mg tablets, which had been discontinued for a resident, was still present in Med Cart a. The medication had expired on 06/06/2024, yet five tablets remained available for use. This was in violation of the facility's policy on the disposal and destruction of medications, which requires that discontinued controlled medications be removed from the medication cart and stored securely until destroyed. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, confirmed the presence of the expired and discontinued Norco tablets in Med Cart a. Each staff member acknowledged that the medication should not have been available for use and should have been removed following the discontinuation order. The oversight was identified as a failure to adhere to the facility's established procedures for handling discontinued and expired medications.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for self-administration of medications, as required by their policy. Resident #122, with a Brief Interview for Mental Status score indicating moderately impaired cognition, was observed with a bottle of Nystatin Topical Powder on the bedside table. There was no documented evidence that Resident #122 was assessed or care planned for self-administration of medication. Interviews with the LPN, ADON, and DON confirmed that Resident #122 was not assessed for self-administration and should not have had medications at the bedside. Similarly, Resident #189, also with a moderately impaired cognition score, was observed with multiple bottles of Nystatin Topical Powder and a tube of Ammonium Lactate 12% lotion on the bedside table. The facility did not have documented evidence of an assessment or care plan for Resident #189 to self-administer medication. Interviews with the LPN, ADON, and DON confirmed that Resident #189 was not assessed for self-administration and should not have had medications at the bedside.
Deficiency in Wheelchair Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain a resident's wheelchair in good repair and sanitary condition, impacting one of the three residents reviewed for environmental conditions. Observations over three consecutive days revealed that the resident's wheelchair had a blackish-brownish substance covering both brake levers, a missing right arm pad, and a torn left arm pad with exposed foam. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the poor condition of the wheelchair, with the Director indicating that the wheelchair should be replaced.
Failure to Document and Provide PICC Site Care
Penalty
Summary
The facility failed to provide proper site care for a peripherally inserted central catheter (PICC) for a resident receiving intravenous medications. The resident, admitted for rehabilitation following knee surgery, reported that the PICC site was not cleaned or the bandage changed during their stay from early April to early May 2024. Record reviews revealed no documented evidence of PICC site care during this period. Interviews with the Director of Nursing and treatment nurses confirmed the absence of documentation and inability to recall if the care was performed. The administrator also acknowledged the lack of documentation for the PICC site care during the resident's stay.
Failure to Complete Accurate PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with Major Depressive Disorder and Bipolar Disorder. The resident, who was admitted with these diagnoses, was taking antidepressants daily and had a history of mental health treatment. Despite these indicators, the Level I PASARR documentation did not reflect the resident's mental illnesses, and it was neither signed nor dated by a physician. Furthermore, the facility did not initiate a referral for a Level II PASARR evaluation, which is required for residents with such diagnoses. Interviews with facility staff revealed a lack of awareness and follow-through regarding the PASARR process. The social services staff member admitted uncertainty about whether a Level II PASARR was completed and acknowledged that a referral should have been made based on the resident's mental health diagnoses and assessments. The facility administrator confirmed the inaccuracies in the Level I PASARR and the omission of a necessary Level II referral, highlighting a significant oversight in the facility's compliance with PASARR requirements.
Failure to Maintain Proper Food Temperature
Penalty
Summary
The facility failed to maintain food on the steam table at the required temperature of at least 135 degrees Fahrenheit, as per the Centers for Medicare and Medicaid Services guidelines. During an observation, it was noted that various foods, including hamburger, rice, mashed potatoes, and pureed meat, were being held on the steam table for lunch. The temperature of the pureed sweet potatoes was checked by a cook and found to be 130 degrees Fahrenheit, which is below the required temperature. Interviews with the cook and the dietary supervisor confirmed that the steam table should maintain food at a temperature no lower than 135 degrees Fahrenheit. The administrator also acknowledged that the food temperature should be at least 135 degrees Fahrenheit.
Late Transmission of Resident Assessment Data
Penalty
Summary
The facility failed to transmit a resident's assessment data within the required timeframe, resulting in a deficiency. Specifically, the discharge assessment for Resident #105 was completed on February 21, 2024, but was not transmitted by the required date of March 6, 2024, as mandated by the Centers for Medicare and Medicaid Services (CMS). The assessment was signed by the Director of Nursing on February 23, 2024. However, a review conducted on July 23, 2024, revealed that the assessment had not been transmitted within the 14-day window. The facility's Final Validation Report on July 24, 2024, confirmed that the Minimum Data Set (MDS) for Resident #105 was accepted with an error message indicating late submission. During an interview on July 24, 2024, the MDS Nurse explained that an error in entering the Unit Certification or Licensure Designation in Section A0410 of the MDS caused the delay in transmission. This error led to the discharge MDS being submitted late, beyond the required deadline.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's skin condition. Specifically, Resident #62 had a stage III pressure ulcer with slough to the sacral area as documented in the wound assessment nursing notes dated 07/02/2024. However, the MDS with an Assessment Reference Date (ARD) of 07/07/2024 inaccurately indicated that Resident #62 had no unhealed pressure ulcers. This discrepancy was confirmed during an interview with the S2Corporate Nurse, who acknowledged that the MDS did not accurately reflect the resident's skin condition at the time of the assessment.
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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