Colonial Manor Nursing & Rehabilitation Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Rayville, Louisiana.
- Location
- 307 Foster Street, Rayville, Louisiana 71269
- CMS Provider Number
- 195394
- Inspections on file
- 19
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Colonial Manor Nursing & Rehabilitation Home during CMS and state inspections, most recent first.
Surveyors found that kitchen equipment was not maintained in safe and clean condition, including a refrigerator with three torn door seals, a broken toaster, another toaster missing a crumb catcher, and two toasters stored full of bread crumbs. Multiple full-size and half pans were covered in a black hardened substance, two ovens were coated with hardened black residue with one containing several silver pieces of material, and a microwave had dark splattered material on its top and sides. The dietary manager and the administrator both acknowledged that kitchen equipment should be in good repair and clean.
A resident with multiple comorbidities, moderate cognitive impairment, and dependence on staff for ADLs was found to have a large bruise on the right shoulder/armpit area, with no clear cause identified and while receiving Eliquis. Nursing staff documented the bruise, noted the recent use of a sling lift and the resident’s history of easy bruising, and verbally educated CNAs on positioning techniques. The DON and Administrator were aware of the injury and treated it as an injury of unknown origin, but they did not report it to the State Agency within the required 24-hour timeframe, contrary to the facility’s incident/accident and abuse reporting policies.
A resident with multiple comorbidities, moderate cognitive impairment, total dependence for transfers, and on Eliquis was observed with a large bruise on the right shoulder/armpit and could not state how it occurred. Documentation showed the bruise had been present for some time, was first reported by a hospice CNA, and measured 7 cm by 3 cm. Staff referenced recent use of a sling lift and noted the resident bruised easily, but the DON and Administrator acknowledged that no full investigation or incident report was completed for this injury of unknown origin, contrary to facility policies requiring investigation and documentation of such incidents and potential abuse indicators.
A resident with hemiplegia, diabetes, hypertension, late syphilis, and unspecified dementia with behavioral symptoms had a PRN order for Oxazepam 15 mg at night for insomnia written without a discontinue date. Pharmacy consultant review noted that PRN psychotropic medications must be limited to 14 days, with prescriber evaluation, documented rationale, and a specific duration if extended. The physician did not specify a duration for this PRN psychotropic order, and the DON confirmed the absence of a defined time limit, resulting in noncompliance with requirements to prevent unnecessary psychotropic use and chemical restraint.
A resident with a history of falls and other medical conditions fell in the facility, but the physician and family were not notified as required by the facility's fall prevention program. Staff confirmed the resident was assessed and found to have no injuries, but the necessary notifications were not made, as verified by the facility's administrator and DON.
A resident with a history of falls and cognitive impairment was found on the floor by staff, but the LPN did not document a post-fall assessment or complete an incident report as required by the facility's fall prevention policy. Despite the resident showing no immediate signs of injury or pain, the necessary documentation and reporting were not conducted, leading to a deficiency in care.
A resident with cognitive impairments was found with socks on her hands to prevent self-scratching, which she could not remove herself, classifying them as restraints. The facility lacked documentation of a pre-restraint assessment, consent, and monitoring, violating their restraint-free policy.
A facility failed to implement a comprehensive care plan for a resident on anticoagulants. The resident, who was taking Eliquis, was observed with bruising on her hands, which was not documented by nursing staff as required. The care plan included monitoring for bruising, but the MAR entries incorrectly indicated no bruising. The ADON confirmed the oversight.
The facility failed to ensure water temperatures in resident rooms were below 120 degrees, with temperatures ranging from 127.0 to 127.8 degrees confirmed by the Maintenance Supervisor and Assistant Administrator.
A resident with a history of pressure ulcers and at moderate risk was observed multiple times without prescribed heel protectors, despite having a physician's order for them to be worn at all times. Interviews with staff revealed a lack of adherence to the care plan, with an LPN unsure of the resident's compliance and a CNA admitting to not placing the protectors on the resident.
A facility failed to implement its infection control policy for enhanced barrier precautions for a resident with a Foley catheter. There was no signage on the resident's door, and no PPE supplies were available nearby, despite the policy requiring these measures. The Assistant DON confirmed the oversight.
A resident in a long-term care facility, who was cognitively impaired and had multiple medical conditions, was verbally and physically abused by a CNA. The abuse was captured on video, showing the CNA using derogatory language and physically mishandling the resident, causing distress and harm. The incident was reported by the resident's family member, and the facility confirmed the abuse, acknowledging the severe psychosocial harm caused to the resident.
A resident with severe cognitive impairment and mobility issues was denied assistance to the restroom by a CNA, who instructed the resident to use their brief instead. This incident was confirmed by video footage and acknowledged by the facility's administrator as inappropriate.
A resident with severe cognitive impairment was verbally and physically abused by a CNA, as captured on video by the resident's family. The facility's Administrator failed to report the incident to the State Survey Agency within the required timeframe, submitting the report more than 24 hours after being informed of the abuse, which violated state regulations.
Failure to Maintain Kitchen Equipment in Safe and Clean Condition
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain kitchen equipment in safe operating condition and in a clean state. During an initial kitchen tour, they observed three torn door seals on three individual refrigerator doors on one refrigerator, one broken toaster, and another toaster missing a crumb catcher. Two of the three toasters were stored while full of bread crumbs. In addition, four full-size pans and four half pans were covered in a black hardened substance, two ovens were covered with a hardened black substance, one oven contained four silver pieces of material approximately the size of a golf ball, and a microwave had a dark splattered substance on its top and sides. In interviews, the Dietary Manager confirmed that kitchen equipment should be working and clean, and the Administrator confirmed that the equipment in the kitchen should be in good repair and clean.
Failure to Report Injury of Unknown Origin Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency within the required 24-hour timeframe. Facility policies on incidents/accidents and on abuse, neglect, and exploitation require that injuries of unknown origin be treated as reportable events, with written procedures for identifying, investigating, and reporting such occurrences. The abuse policy specifies that all alleged violations, including injuries of unknown origin, must be reported to the Administrator and appropriate state agencies within specified timeframes, including not later than 24 hours if the events do not involve abuse or serious bodily injury. Resident #55, who had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast, was identified as having a large bruise on the right shoulder/armpit area. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and documented dependence on staff for all ADLs, including substantial/maximal assistance with rolling in bed and dependence for transfers. On observation, the resident was unable to state how the bruise occurred, and a CNA reported that the bruise had been present for several weeks without a known cause. The resident was also receiving Eliquis 2.5 mg twice daily. Nursing documentation dated 12/04/2025 showed that the treatment nurse was notified by a hospice CNA of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and could not recall how the bruise was acquired, and the treatment nurse noted that a sling lift had been used earlier in the week and that CNAs were verbally educated on proper lift techniques and positioning. The DON later documented that the lift used did not go under the arms and that the resident had a history of easy bruising and skin tears, and acknowledged that CNAs sometimes assisted the resident by placing a hand under her arm for repositioning. During interviews, the LPN and DON confirmed awareness of the bruise and that it had been reported internally to the DON and Administrator, but the DON and Administrator both confirmed that the injury of unknown origin was not reported to the State Agency as required by facility policy and state law.
Failure to Investigate Injury of Unknown Origin to Resident’s Shoulder/Armpit
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin in accordance with its own incident/accident and abuse policies. The facility’s policies required staff to report, investigate, and document incidents and accidents, including injuries of unknown origin, and to conduct an immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation. These policies also required identification and interviewing of all involved persons and complete documentation of the investigation. Despite these written requirements, the facility did not complete a full investigation when a large bruise of unknown origin was identified on a resident’s right shoulder/armpit area. The resident involved had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast. A quarterly MDS showed moderate cognitive impairment (BIMS score of 8), dependence on staff for all ADLs, substantial/maximal assistance needed for rolling in bed, and total dependence for transfers. The resident was also receiving Eliquis 2.5 mg twice daily. During surveyor observation, the resident was seen sitting up in bed with a large bruise on the right shoulder/armpit and was unable to state how the bruise occurred. Record review showed that on a prior date, a hospice CNA had notified the treatment nurse of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and did not recall how the bruise was acquired. Staff notes referenced use of a sling lift earlier in the week and staff education on proper lift and positioning techniques, and the DON documented that the lift used did not go under the arms and that the resident was an easy bruiser. However, the DON later acknowledged being unsure whether an incident report and investigation were completed, and both the DON and the Administrator confirmed that a full investigation into this injury of unknown origin was not conducted, despite the facility’s policies requiring such an investigation.
Failure to Time-Limit PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from chemical restraints and to limit PRN psychotropic medications to 14 days as required. Record review for Resident #2, who was re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, diabetes, late syphilis, and unspecified dementia with behavioral symptoms, showed a physician’s order dated 10/03/2024 for Oxazepam 15 mg PO PRN every 24 hours at night for insomnia without a discontinue date. The Pharmaceutical Consultant Report dated 10/13/2025 documented that PRN psychotropic medications must be limited to 14 days, with the prescriber required to evaluate the resident before extending the order, document the rationale for any extension, and indicate a specific duration. The report further showed that the physician did not indicate a specific duration for this PRN Oxazepam order, and during interview the DON confirmed that the physician had not specified a duration for the psychotropic PRN order. This failure to include a time-limited duration and required evaluation for the PRN psychotropic medication order for Resident #2 resulted in noncompliance with requirements intended to prevent unnecessary psychotropic use and chemical restraint.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to notify the physician and family after a resident's fall, as required by their fall prevention program. The program mandates that when a resident experiences a fall, the facility must assess the resident, complete an incident report, notify the physician and family, and document all assessments and actions. However, after a resident fell on 02/16/2025, the facility did not fulfill these requirements. Interviews with staff, including CNAs and an LPN, confirmed that although the resident was assessed and found to have no injuries or complaints of pain, the physician and family were not notified of the incident. The resident involved had a medical history that included depression, anxiety, dementia, repeated falls, and a non-displaced fracture of the right clavicle. Despite the resident's fall, there was no documented evidence in the medical record of any notifications made to the family or physician. The facility's administrator and director of nursing confirmed that the LPN should have contacted the physician and family regarding the fall, indicating a lapse in following the established protocol for fall incidents.
Failure to Document Post-Fall Assessment and Incident Report
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as outlined in their fall prevention program policy. Specifically, the nursing staff did not document a post-fall assessment or complete an incident report for a resident who experienced a fall. The facility's policy requires that when a resident falls, an assessment must be conducted, an incident report completed, and the physician and family notified. However, these steps were not followed for the resident in question. The resident involved had a history of depression, anxiety, dementia, repeated falls, and a non-displaced fracture of the right clavicle. On the evening of the incident, the resident was found on the floor by staff, but the LPN who assessed the resident did not document any injuries or pain and failed to complete the necessary incident report or post-fall assessment. Subsequent interviews with staff confirmed these omissions, and the facility's investigation revealed that the required documentation and reporting were not completed as per the facility's policy.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. The resident, who was admitted with diagnoses including cognitive communication deficit, Alzheimer's disease, and generalized anxiety disorder, was observed with socks on her hands. This was done to prevent her from scratching herself, as she was at high risk for skin tears. However, the resident was unable to remove the socks on her own, which classifies them as a physical restraint. The facility's policy mandates that restraints should only be used when medically necessary and with proper documentation, including a pre-restraint assessment and consent. In this case, there was no documented evidence of a pre-restraint assessment, restraint consent, or monitoring for the use of the socks as restraints. Interviews with facility staff confirmed the use of socks as restraints and the lack of necessary documentation and monitoring, indicating a failure to adhere to the facility's restraint-free environment policy.
Failure to Document Bruising in Anticoagulant Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who was on anticoagulant medication. During an observation, the resident was found to have bruising on the back of both hands, which she attributed to taking a blood thinner. The medical record confirmed that the resident was prescribed Eliquis, a blood-thinning medication, at a dosage of 2.5 mg twice daily. The care plan included an intervention to monitor for bruising, and the Medication Administration Record (MAR) required nursing staff to check for bruising each shift. However, the December MAR entries consistently indicated that the resident had no bruising, despite the observed bruising. An interview with the Assistant Director of Nursing confirmed the presence of bruising and the failure of the nursing staff to document it on the MAR.
Excessive Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that the water temperature in resident rooms was below 120 degrees, as required. During an inspection on December 16, 2024, the water temperatures in the rooms of four residents were found to be excessively high, ranging from 127.0 to 127.8 degrees. This was confirmed by the S2Maintenance Supervisor, who acknowledged that the temperatures exceeded the safe limit. The S1Assistant Administrator also confirmed that the water temperatures should not exceed 120 degrees, indicating a lapse in maintaining the required safety standards for resident rooms.
Failure to Provide Ordered Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. The resident, who had a history of a stage 3 pressure ulcer on the left heel and was at moderate risk for pressure ulcers, was observed multiple times without the prescribed heel protectors. Despite having a physician's order for heel protectors to be worn at all times, the resident was seen without them on several occasions, both in the Geri chair and in bed, even after being placed on isolation due to a positive COVID test. Interviews with facility staff revealed a lack of adherence to the care plan. The LPN confirmed the resident's high risk for pressure ulcers and the order for heel protectors, but was unsure if they were being used. A CNA admitted to not placing the heel protectors on the resident, and the Assistant Director of Nursing confirmed that the resident should have had them on as ordered. This indicates a breakdown in communication and responsibility among staff regarding the implementation of the resident's care plan to prevent pressure ulcers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program to prevent the transmission of communicable diseases and infections by not implementing its policy for enhanced barrier precautions for a resident with a Foley catheter. During an observation, it was noted that there was no signage regarding Enhanced Barrier Precautions on the resident's door, and no personal protective equipment (PPE) supplies were located nearby. The facility's policy, dated 11/01/2024, specified that catheters were a qualifying condition for enhanced barrier precautions, requiring clear signage and the availability of gowns and gloves outside the resident's room. An interview with the Assistant Director of Nursing confirmed the facility's failure to implement the policy by not placing the necessary signage and PPE near the resident's room.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively impaired and had multiple medical conditions, including dementia, anxiety, and chronic heart failure. The abuse occurred when the CNA was observed on video surveillance being verbally and physically abusive while providing care to the resident. The resident's family member reviewed the footage and reported the incident to the facility administrators. The video footage revealed that the CNA used derogatory language and physically mishandled the resident. The CNA was seen pushing the resident's wheelchair and making threatening remarks. The resident, who was unable to walk and used a wheelchair, was verbally abused and physically forced into bed, resulting in the resident hitting her head against the wall. The CNA's actions were observed to cause distress to the resident, who responded with upset language. The facility's investigation confirmed the abuse, and the administrators acknowledged that a reasonable person would have been very upset by the treatment the resident received. The incident was reported to have caused severe psychosocial harm to the resident, including feelings of dehumanization and humiliation. The facility's policies on abuse, neglect, and exploitation were reviewed, and it was determined that the CNA's actions violated these policies.
Failure to Assist Resident with Restroom Needs
Penalty
Summary
The facility failed to uphold the resident's right to dignity and self-determination by not assisting a resident with severe cognitive impairment to the restroom upon request. The resident, who was admitted with multiple diagnoses including dementia, chronic heart failure, and mobility issues, required limited physical assistance for daily activities such as bed mobility, transfers, eating, and toilet use. Despite these needs, a Certified Nursing Assistant (CNA) refused to assist the resident to the bathroom, instructing them to use their brief instead. This incident was corroborated by video footage reviewed by the resident's family member and the surveyor, which showed the CNA telling the resident to use their brief or hold it. The facility's administrator confirmed that the CNA's actions were inappropriate and that the resident should have been assisted to the restroom as requested.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal and physical abuse involving a resident to the State Survey Agency within the required timeframe. The incident was reported to the Administrator by the resident's family member, who provided video evidence of the abuse. The video footage showed a Certified Nursing Assistant (CNA) making rude comments and handling the resident roughly during care. Despite being informed of the incident, the Administrator did not report it to the State Survey Agency within the mandated two-hour window. The resident involved in the incident was admitted with multiple diagnoses, including severe cognitive impairment, dementia, and other physical and mental health conditions. The resident required assistance with daily activities and was using a manual wheelchair for mobility. The video evidence captured the CNA verbally abusing the resident and physically forcing the resident into bed, resulting in the resident hitting their head against a wall. The Administrator confirmed the abuse occurred but delayed reporting the incident to the State Survey Agency. The report was submitted more than 24 hours after the incident was discovered, violating the facility's policy and state regulations that require immediate reporting of abuse allegations. This delay in reporting represents a significant deficiency in the facility's adherence to abuse reporting protocols.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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