Colfax Nursing And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Colfax, Louisiana.
- Location
- 366 Webb Smith Drive, Colfax, Louisiana 71417
- CMS Provider Number
- 195430
- Inspections on file
- 24
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Colfax Nursing And Rehab, Llc during CMS and state inspections, most recent first.
Fifteen resident rooms were found to have hot water temperatures exceeding 120°F, with some readings as high as 140°F. The maintenance supervisor was measuring water temperatures incorrectly, leading to inaccurate logs and unrecognized hazards. No residents or staff reported injuries or complaints, but the facility failed to ensure a safe environment by not properly monitoring and controlling water temperatures.
Residents were restricted to accessing the outdoor patio only during scheduled smoking breaks, despite requests to go outside at other times for fresh air or relaxation. Multiple residents, including those with intact cognition, reported being denied access outside of these times, and staff confirmed that supervision was required and rarely available. This practice was inconsistent with the facility's stated policy on resident rights to dignity and self-determination.
A strong urine odor was observed throughout the facility, with multiple residents and staff confirming persistent unpleasant smells and poor cleanliness. Housekeeping staff noted limited coverage after certain hours, and an LPN reported that soiled diapers were left in room trash cans overnight by agency staff. These actions and inactions resulted in the facility not maintaining a clean, comfortable, and homelike environment as required by policy.
A resident with cognitive impairments physically abused another resident due to agitation over a perceived odor. The incident resulted in a cut on the victim's lip. Staff failed to report the aggressor's behavior to nursing staff, violating the facility's abuse prevention policy.
A resident with moderate cognitive impairment was sexually abused by a roommate with intact cognition and a history of inappropriate behavior. The incident was reported two days later, and the facility moved the victim to a different hall. The facility's abuse prevention policy was not effectively implemented, leading to this deficiency.
A facility failed to implement a care plan for a resident with Major Depressive Disorder and did not document food intake or notify the physician and family of another resident's significant weight loss. The DON confirmed these deficiencies, highlighting a lack of person-centered care planning and communication.
The facility did not adhere to the menu for a lunch meal, failing to serve the specified 2 ounces of roasted turkey gravy with the meal. Observations and interviews with dietary staff confirmed the absence of gravy on the serving line, resulting in a failure to meet the nutritional needs of residents.
The facility failed to prepare pureed foods according to standardized recipes, affecting eight residents on pureed diets. A dietary staff member did not measure ingredients or use the recipe, and the dietary manager confirmed the recipes were not followed due to being misplaced. A registered dietitian highlighted the necessity of following recipes to ensure adequate caloric intake.
The facility failed to maintain professional standards for food service safety, with unmonitored refrigerator and freezer temperatures, undated food items, and unsanitary kitchen equipment. Observations included unclean microwaves and ice machines, and a lack of sanitizer checks in the 3-compartment sink, confirmed by dietary staff.
The facility failed to serve residents sitting at the same dining table simultaneously, leading to delays of 9 and 19 minutes for some residents. This practice was confirmed by the DON, who acknowledged that residents should have been served together.
The facility failed to maintain a clean and homelike environment, with observations revealing unsanitary conditions in resident rooms and common areas. Residents reported infrequent cleaning due to understaffing, and maintenance issues such as water-stained ceiling tiles and improperly fitted air conditioning units were noted. Shower rooms were found with soap scum and urine stains, and the DON confirmed inadequate cleaning practices.
The facility failed to provide necessary ADL assistance to several residents, including bathing, nail care, and shaving. Observations revealed residents with unmet hygiene needs, such as long, dirty fingernails and infrequent bathing. Interviews confirmed the lack of documentation and assistance, despite the facility's policy requiring such care.
The facility failed to serve meals at regular times as per residents' needs and preferences, with breakfast and lunch consistently delayed. Observations and interviews revealed that meals were served late due to staffing shortages in the kitchen, affecting all residents in the dining room. A resident reported receiving dinner at 6:00 p.m. instead of 4:00 p.m., and lunch around 2:00 p.m. instead of 11:30 a.m. The Dietary Manager acknowledged the lack of a staffing schedule and uncertainty about adequate staffing levels.
The facility failed to maintain an effective pest control program, leading to a significant fly infestation affecting residents and the dining area. Despite having a pest control service contract, there were lapses in addressing reported fly issues, and recommended measures were not implemented.
The facility failed to inform two residents of potential charges for services not covered by Medicare, as required by policy. The ABN notices sent to the residents' representatives lacked estimated costs, which was confirmed by facility staff responsible for issuing these notices.
A facility failed to complete a timely quarterly MDS assessment for a resident with multiple diagnoses, including dementia and chronic kidney disease. The last assessment was completed several months ago, and the corporate nurse confirmed the delay, citing the absence of an MDS nurse.
The facility failed to follow physician orders for a dermatology referral for a resident with facial cysts and did not report abnormal lab results or recollect a urine sample for another resident with a history of UTIs. The responsible staff did not notify the provider or perform necessary follow-ups, leading to lapses in care.
A resident with a history of dementia and coronary artery disease was observed using oxygen therapy without a physician's order, contrary to the facility's policy. The resident's care plan included oxygen administration, but no order was found in the medical records. An LPN confirmed the need for oxygen but acknowledged the lack of an order.
The facility did not include the Medical Director in a required QAA committee meeting. The sign-in sheet for the meeting showed the Medical Director was absent, and the Corporate Nurse confirmed this, stating that the Medical Director reviews the meeting information later.
The facility failed to secure handrails in Hall Y, as observed between rooms L and M. The Maintenance Supervisor confirmed the handrails were not properly affixed, potentially affecting 24 residents.
Failure to Maintain Safe Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident environments were free from accident hazards by not maintaining hot water temperatures at or below 120 degrees Fahrenheit in 15 out of 28 resident rooms. Observations revealed that water temperatures in these rooms ranged from 122.0 to 140.0 degrees Fahrenheit, exceeding the facility's policy and the recommended safety threshold to prevent scalding. The deficiency was identified during a survey when a maintenance supervisor was observed measuring water temperatures incorrectly, using the middle of the thermometer instead of the tip, which led to inaccurate documentation of water temperatures in the facility's logs. The logs for several months did not reflect any temperatures above 120 degrees Fahrenheit, despite actual measurements showing otherwise. Interviews with the maintenance supervisor, DON, and administrator confirmed that the method used for measuring water temperatures was incorrect and that the temperatures in the affected rooms were indeed above the safe limit. However, there were no reported incidents, injuries, or complaints from residents or staff regarding excessively hot water. The deficiency was based on the failure to accurately monitor and control water temperatures as required by facility policy, resulting in a hazardous environment for residents.
Failure to Honor Resident Rights to Outdoor Access and Dignity
Penalty
Summary
The facility failed to honor residents' rights to dignity and self-determination by restricting access to the outdoor patio area to only three scheduled times per day, which coincided with smoking breaks. Multiple residents, including those with both moderate cognitive impairment and intact cognition, reported that they were not allowed to go outside except during these designated times. Residents stated they had requested to go outside for fresh air or relaxation at other times but were told by staff that it was not permitted or that staff would get in trouble for allowing it. Staff interviews confirmed that residents were only allowed outside during smoking times unless a staff member was available, which rarely occurred due to workload. The facility's policy stated that residents have the right to independent personal decisions and to be treated with respect and dignity, but this was not reflected in practice. Resident council minutes also documented that residents had expressed a desire for more frequent access to the patio for non-smoking purposes. Despite administrative claims that nothing was preventing residents from going outside if staff were available, both staff and residents consistently reported that access was limited and requests outside of scheduled times were routinely denied. The restriction applied regardless of residents' cognitive status, and some residents described feeling confined as a result. The deficiency was identified through interviews, record reviews, and review of facility policy and resident council minutes.
Failure to Maintain Sanitary and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable homelike environment for all residents by not ensuring the facility was free of odor, specifically a strong urine smell. Upon entrance, a strong urine odor was noted throughout the facility, and this was corroborated by multiple observations and interviews. Resident council minutes documented complaints about unpleasant hallway odors, with staff responses attributing the smell to residents who change themselves and leave soiled items in their rooms. Observations included a persistent strong odor in specific halls and resident rooms, with one room also having a sticky floor. Residents interviewed described poor cleanliness, infrequent mopping, and dissatisfaction with the facility's sanitation. Housekeeping staff confirmed the presence of a strong urine odor and noted that there is no housekeeping coverage after 3:00 p.m., which may contribute to lingering odors from items like linen barrels not being sent to laundry. An LPN also reported a strong urine odor in the morning and indicated that agency staff had left soiled diapers in room trash cans overnight. These findings collectively demonstrate a failure to provide a clean, odor-free, and comfortable environment as required by facility policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved Resident #4, who was physically abused by Resident #5. Resident #5 became agitated due to a perceived odor in the room and began stripping the linen off Resident #4's bed. Despite Resident #4's protests, the situation escalated into a physical altercation in the hallway, where Resident #5 hit Resident #4, resulting in a small cut on Resident #4's lip. Resident #4 has a medical history that includes paraplegia, schizophrenia, schizoaffective disorder, bipolar disorder, and a history of traumatic brain injury. The resident requires assistance with daily activities and is always incontinent of bladder and bowel. Resident #5, who has diagnoses including epilepsy, dementia, schizoaffective disorder, and profound intellectual disabilities, also requires supervision for personal care activities. Both residents have moderate cognitive impairments as indicated by their BIMS scores. The facility's staff, specifically S3 CNA and S4 CNA, failed to report Resident #5's aggressive behavior and increased agitation to the nursing staff. Despite witnessing the initial signs of agitation and the subsequent altercation, the CNAs did not take appropriate action to prevent the escalation. The facility's policy on abuse prevention was not effectively implemented, as the staff did not follow the protocol for reporting and responding to aggressive behaviors, leading to the incident of resident-to-resident abuse.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident #33, who has moderate cognitive impairment, reported an incident where his roommate, Resident #75, attempted to pull down his pants and made inappropriate sexual comments. This incident occurred while Resident #33 was asleep, and he reported it to the Day Program staff two days later. Resident #75, who has intact cognition and a history of socially inappropriate behavior due to Schizoaffective Disorder, admitted to touching Resident #33 but claimed it was a joke. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the occurrence of this incident. The report indicates that Resident #33 was moved to a different hall after the facility was notified, but the initial failure to prevent the abuse constitutes a deficiency. The administrator confirmed the incident and noted that Resident #75 had not shown inappropriate sexual behavior since the event.
Failure to Implement Care Plans for Depression and Weight Loss
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident #59, who was diagnosed with Major Depressive Disorder among other conditions. Despite receiving antidepressant and antianxiety medications, the resident's care plan did not address their depression and anxiety. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging that the resident should have been care planned for these conditions. Additionally, the facility did not adequately monitor and document the food intake of Resident #26, who experienced significant weight loss. The resident's care plan included interventions for altered nutrition due to various health issues, but staff failed to record food intake and notify the resident's physician and family of the weight loss since September 2023. The DON confirmed the lack of documentation and communication regarding the resident's nutritional status and weight changes.
Failure to Serve Menu-Specified Gravy
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not following the established menu for a lunch meal on 06/02/2024. The menu specified that 2 ounces of roasted turkey gravy should accompany the oven-roasted turkey breast, au gratin potatoes, and green peas. However, observations during the food serving process revealed that the roasted turkey gravy was not served to the residents. This was confirmed through interviews with the dietary staff, including S6 Dietary Cook and S5 Dietary Manager, who acknowledged that the gravy was not present on the serving line and was not included on the trays prepared for the residents.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to the approved recipe, which is necessary to conserve nutritional value for eight residents on pureed diets. During an interview, a dietary staff member admitted to not measuring the amount of turkey added to a pureed dish and not using the standardized recipe. The dietary manager confirmed that the recipes for pureed meals were not followed because they could not be located, although they should have been. Additionally, a registered dietitian emphasized the importance of following recipes to ensure residents receive adequate caloric intake.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and sanitation. Observations revealed that the refrigerator and freezer temperature logs were not checked or documented from May 31 to June 2, 2024. Additionally, bags of breadsticks in the walk-in freezer were found open and undated, which was confirmed by a dietary staff member. The 3-compartment sink, essential for maintaining sanitation, was found with water in all compartments and cooking utensils on the sanitizer side shelf, with the staff admitting to not checking the sanitizer level due to time constraints. Further observations highlighted cleanliness issues within the kitchen. The microwave was noted to have multiple food particle splatters inside, and the ice machine had a dark brown/black substance on its inner surface, which was dripping onto the ice below. The ice scoop was stored in a holder with a similar dark substance at the bottom. These observations were confirmed by the dietary staff member present, indicating a failure to maintain clean and sanitary kitchen equipment.
Failure to Serve Residents Simultaneously at Mealtime
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime by not ensuring that residents sitting at the same dining room table were served their meals together. On two separate occasions, observations revealed that one resident at a table was served their meal while the other resident at the same table had to wait for a significant amount of time before being served. Specifically, on one occasion, a resident was served 19 minutes after their tablemate, and on another occasion, a resident was served 9 minutes later than their tablemate. This practice was confirmed by the Director of Nursing (DON), who acknowledged that residents sitting together should have been served simultaneously.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by multiple observations of unsanitary conditions in resident rooms and common areas. Observations revealed significant cleanliness issues, including food debris, sticky floors, and strong urine odors in resident rooms and hallways. Interviews with residents and staff confirmed that housekeeping services were insufficient, with reports of rooms not being cleaned regularly due to understaffing. The housekeeping department was noted to be operating with reduced hours and insufficient staff, making it challenging to maintain cleanliness standards. Further observations highlighted maintenance issues in several rooms, including loose, cracked, and water-stained ceiling tiles, improperly fitted air conditioning units, and stained privacy curtains. Residents expressed dissatisfaction with their living conditions, noting the inability to open blinds for natural light and the presence of flies and gnats. Maintenance staff confirmed these findings, indicating a lack of timely repairs and upkeep in the facility. The facility's shower rooms were also found to be in poor condition, with water-stained and loose ceiling tiles, soap scum, and urine stains on shower chairs. The DON confirmed that the whirlpools and shower chairs had not been cleaned or disinfected after use, as required. These observations and interviews collectively demonstrate a failure to provide a safe, clean, and homelike environment for residents, as mandated by the facility's policies and regulations.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform Activities of Daily Living (ADLs) independently, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in five out of seven residents reviewed for ADLs. The facility's policy required appropriate care and services for residents unable to carry out ADLs independently, including hygiene support such as bathing, dressing, grooming, and oral care. However, observations and interviews revealed that residents were not receiving these services as required. Resident #66, who had severe cognitive impairment and required assistance with personal hygiene, was observed with long, jagged, and dirty fingernails. Despite expressing a desire to have his nails cleaned and cut, this was not done. Similarly, Resident #6, who was dependent on staff for bathing, reported only receiving baths once a week instead of the scheduled three times per week. The CNA responsible for Resident #6 confirmed the lack of documentation for bathing and stated that the computer system did not allow her to document when a resident received a bath. Resident #12, who required setup assistance for bathing, also reported only receiving a bath once a week. Resident #87, who required substantial assistance with personal hygiene, expressed frustration over being left in a dirty diaper and only receiving a bath once a week. Additionally, Resident #10, who could not shave himself due to hand issues, was observed with long facial hair and stated that he believed the facility lacked razors. The DON confirmed that the facility had the necessary equipment and that Resident #10 should have been shaved during his bath but was not.
Meal Service Timing Deficiency Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that meals were served at regular times in accordance with residents' needs and preferences, as observed during multiple meal services. The facility's policy stated that meals should be served at scheduled times, with breakfast at 6:30 a.m., lunch at 11:30 a.m., and dinner at 4:30 p.m. However, observations revealed that meals were consistently served late, with breakfast starting at 8:00 a.m. and lunch being served as late as 12:20 p.m. and 1:20 p.m. on different days. Interviews with residents and staff confirmed these delays, with one resident reporting receiving dinner at 6:00 p.m. instead of the scheduled 4:00 p.m., and lunch around 2:00 p.m. instead of 11:30 a.m. The delays in meal service were attributed to staffing shortages in the kitchen, as noted by a dietary staff member who mentioned being short-handed for several weeks. The Dietary Manager, who was recently hired, acknowledged the lack of a staffing schedule for June 2024 and was uncertain if the staffing levels were adequate to serve meals on time. During a Resident Council meeting, residents expressed concerns about receiving meals 1 to 2 hours late, indicating that the issue was widespread and affected multiple residents. This deficiency in meal service timing had the potential to impact all residents who were served meals in the dining room.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies throughout the building, particularly affecting residents in Hall X and the dining area. Observations revealed multiple flies in several residents' rooms, with residents expressing ongoing issues with flies and dissatisfaction with the facility's efforts to address the problem. The presence of flies was also noted in the dining area, where residents were observed swatting flies away while eating, further indicating the extent of the issue. Interviews with staff and review of the facility's pest control logs revealed that although the facility had a pest control service contract, there were lapses in addressing reported fly sightings. The pest control service was contracted to perform monthly services and additional treatments as needed, but the logs showed no follow-up for reported fly issues in October and November 2023, and no entries for June 2024. The pest control worker confirmed monthly treatments and had recommended additional measures like air curtains and fly lights, which the facility had not implemented. The administrator acknowledged the problem and the lack of action on the recommendations.
Failure to Inform Residents of Potential Charges
Penalty
Summary
The facility failed to inform residents of the charges for services they may be responsible for paying, specifically for two residents out of a sample of three. The facility's policy requires that if the director of admissions or benefits coordinator believes that Medicare will not cover certain skilled services, the resident or their representative must be notified in writing about the potential non-coverage and their financial liability. However, the review of the Advanced Beneficiary Notices (ABN) for two residents revealed that the estimated cost sections were left blank, failing to inform the residents or their representatives of the potential charges. Interviews with facility staff confirmed the oversight. S10 Clerical, responsible for sending the ABN notices, acknowledged that the estimated cost sections were not completed for the two residents. S11 Office Manager, the supervisor of S10 Clerical, also confirmed the omission, stating that the estimated costs should have been included in the notices. This failure to provide complete information on the ABN notices led to the deficiency identified by the surveyors.
Failure to Complete Timely Quarterly Assessment
Penalty
Summary
The facility failed to ensure that a quarterly assessment was completed in a timely manner for one resident. The resident, who was admitted with diagnoses including hyperlipidemia, seizures, schizoaffective disorder, dementia, and chronic kidney disease, had their last quarterly MDS assessment completed on January 24, 2024. Since then, no further quarterly assessments were accepted. During an interview, the corporate nurse acknowledged the absence of an MDS nurse at the facility and confirmed that the resident's quarterly MDS assessment was not submitted on time.
Failure to Follow Physician Orders and Report Abnormal Lab Results
Penalty
Summary
The facility failed to follow physician's orders for a dermatology referral for Resident #30, who had been trying to get three cysts removed from his face for about six months. Despite the resident's intact cognition and repeated complaints to the Nurse Practitioner and a doctor, no appointment was made. The Nurse Practitioner had documented the need for a dermatology evaluation in a progress note, but the clerk responsible for scheduling the appointment was not informed, resulting in no referral being made. For Resident #23, the facility did not report abnormal lab results to the provider or recollect a urine sample as recommended. The resident, who had a history of urinary tract infections and was dependent on staff for personal care, had abnormal urine analysis results indicating probable contamination. The staff failed to notify the provider of these results and did not perform a recollection of the urine sample, as recommended by the lab report. The Director of Nursing confirmed that the staff did not sign off on the lab report or notify the medical provider, which was a deviation from the expected protocol. Interviews with the Director of Nursing and the Nurse Practitioner revealed that the staff did not follow the proper procedures for handling abnormal lab results. The Nurse Practitioner stated that she would not have treated the resident with antibiotics due to chronic colonization and lack of symptoms, but expected a recollection of the urine sample. The failure to notify the provider and recollect the sample was attributed to the staff not reviewing the lab results, leading to a lapse in care for Resident #23.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident, identified as Resident #87, who was receiving oxygen therapy without a physician's order. The facility's policy on oxygen administration requires a physician's order for the procedure, but a review of Resident #87's medical records revealed no such order was present. Despite this, observations on two separate occasions showed Resident #87 using oxygen at 2L/min via nasal cannula, and the resident confirmed frequent use of oxygen, particularly while sleeping. Resident #87 had a history of Unspecified Dementia, Major Depressive Disorder, Alzheimer's Disease, and Coronary Artery Disease, with a moderate cognitive impairment indicated by a BIMS score of 10. The resident's care plan included administering oxygen as ordered and monitoring oxygen saturation, yet no order for oxygen administration was found in the resident's June 2024 orders. An LPN confirmed the resident required oxygen but acknowledged the absence of a physician's order for the therapy.
Medical Director Absence in QAA Meeting
Penalty
Summary
The facility failed to include the Medical Director or his designee in the Quality Assessment and Assurance (QAA) committee's quarterly meeting, as required by regulations. The facility had a total census of 84 residents at the time. A review of the sign-in sheet for the QAA meeting held on March 29, 2024, showed that the Medical Director was not present. During an interview on June 4, 2024, the Corporate Nurse confirmed that the Medical Director did not sign the attendance sheet for the meeting. The Corporate Nurse stated that when the Medical Director does not attend a meeting, he reviews the information at a later time.
Loose Handrails in Hallway
Penalty
Summary
The facility failed to ensure that handrails in the hallways were securely affixed to the walls, specifically in Hall Y. During an observation, it was noted that the handrails between rooms L and M on Hall Y were loose. This observation was confirmed by the Maintenance Supervisor, who acknowledged that the handrails were not secured properly to provide safety. This deficiency had the potential to affect 24 residents residing on Hall Y.
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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