Colonial Oaks Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Metairie, Louisiana.
- Location
- 4312 Ithaca Street, Metairie, Louisiana 70006
- CMS Provider Number
- 195536
- Inspections on file
- 28
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Colonial Oaks Living Center during CMS and state inspections, most recent first.
Nursing staff failed to document required assistance with bathing, oral care, and eating for a resident with Parkinson's disease and essential tremors who required substantial/maximal help with ADLs per the MDS and care plan. Review of monthly documentation reports over a two-month period showed multiple days and shifts with no recorded evidence that staff provided bathing, oral hygiene, or eating assistance as care-planned. The ADON confirmed that this ADL care should have been documented but was not.
A resident with cognitive and mobility impairments experienced multiple falls due to the facility's failure to implement individualized fall prevention measures. Despite being at high risk for falls, the resident's care plan interventions, such as a visual reminder sign, bed alarm, and fluorescent tape on wheelchair brakes, were not in place. Staff confirmed the absence of these safety measures, leading to repeated unwitnessed falls.
A facility failed to follow a physician's order for daily weight checks for a resident. Despite the order, records showed no evidence of daily weights being taken. Staff interviews confirmed the lack of compliance, and the facility's leadership acknowledged the oversight.
A resident at high risk for skin breakdown did not have a pressure relieving cushion on their wheelchair as ordered by a physician. Despite the care plan and physician's order, observations confirmed the absence of the cushion. Interviews with the resident, an LPN, the DON, and the administrator verified the deficiency, acknowledging the cushion should have been in place.
The facility failed to maintain the required number of CNAs during the day shift on two reviewed days. The facility's assessment indicated a need for 6 to 9 CNAs, but only 2 to 5 were present. Staff interviews confirmed the deficiency, with the CNA Supervisor and DON acknowledging the shortfall in staffing.
The facility failed to properly reconcile controlled drugs on multiple medication carts, with discrepancies in documentation and time sheets. Staff did not consistently initial records to verify reconciliation, leading to a deficiency.
A facility failed to accurately document a resident's electronic Medication Administration Record (eMAR). An LPN recorded that a pressure relieving cushion was in place on a resident's wheelchair, as ordered by a physician. However, the cushion was not present during an observation, and the LPN admitted to not having seen it. The DON and Administrator confirmed the inaccuracy in the eMAR documentation.
A resident's discharge process was mishandled, with the facility failing to ensure the correct discharge location, provide discharge instructions, or offer a choice of home health agencies. The resident was discharged to the wrong address, and necessary documentation was not completed. Interviews revealed that staff did not verify the discharge details or obtain required signatures, leading to a deficient discharge process.
The facility failed to ensure that an enteral feeding bag for a resident was properly labeled with the date and time of initiation and the rate of infusion. This deficiency was observed multiple times over several days and confirmed by the DON and Administrator.
The facility failed to ensure that indwelling urinary catheter drainage bags and tubing did not touch the floor for three residents, increasing the risk of infection. Observations showed that catheter bags and tubing were repeatedly found lying on the floor or touching the floor when hanging from bedrails or wheelchairs. Interviews confirmed that this practice did not meet professional standards.
The facility failed to ensure that a resident's bathroom door could close properly. The resident reported the issue, and subsequent observations and staff interviews confirmed that the door could not be closed completely.
A resident waited over an hour for assistance with a transfer from bed to wheelchair after activating the call light. A CNA turned off the call light but did not provide help, leaving the resident unattended until a physical therapist intervened. Both the CNA Supervisor and DON acknowledged the delay was unacceptable.
The facility failed to ensure expired food items were not available for resident consumption. Observations in the kitchen's dry storage area revealed expired dried cranberries, salad dressing packets, and a container of Cajun Worchester Sauce. Interviews with the Dietary Manager and the Administrator confirmed these items should not have been available.
A CNA failed to perform proper hand hygiene after removing gloves during incontinence care for a resident. The CNA wore three pairs of gloves at once and did not perform hand hygiene after each glove removal, which was confirmed as improper infection control protocol by the DON.
The facility failed to complete and electronically submit resident assessments to CMS in a timely manner for eight residents. The assessments, including Death in Facility, Quarterly, and Discharge Assessments, were either completed or submitted more than 14 days after the ARD or after they were completed. Both the MDS Coordinator and the DON acknowledged the delays.
Failure to Document Assistance With ADLs for Dependent Resident
Penalty
Summary
Facility nursing staff failed to document assistance provided with bathing, oral care, and eating for one resident reviewed for activities of daily living (ADL) care. The resident had Parkinson's disease and essential tremors, required substantial/maximal assistance with bathing, oral hygiene, and eating per the Quarterly MDS dated 12/09/2025, and had a care plan directing staff to assist with these ADLs and to monitor and document the resident's ability to perform them. Review of the resident's December 2025 Documentation Survey Report v2 showed no documented evidence that staff provided bathing assistance on 12/15/2025, 12/22/2025, and 12/29/2025. The same review showed no documented evidence of oral care assistance on multiple day and evening shifts in December, and no documented evidence of eating assistance on multiple day, evening, and night shifts in December. Review of the resident's January 2026 Documentation Survey Report v2 showed continued lack of documentation of ADL assistance. There was no documented evidence that staff provided bathing assistance on 01/12/2026. Additionally, there was no documented evidence of oral care assistance on specified day and evening shifts in January, and no documented evidence of eating assistance on specified day, evening, and night shifts in January. In an interview on 02/25/2026 at 3:16 PM, the Assistant Director of Nursing verified that the ADL documentation for this resident was not completed by staff as having been performed and confirmed that it should have been documented.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement individualized fall prevention interventions for a resident, leading to multiple unwitnessed falls. The resident, who was admitted with cognitive communication deficit, abnormalities of gait and mobility, and generalized muscle weakness, was identified as high risk for falls. Despite this, the facility did not adhere to the care plan interventions, which included placing a visual reminder sign, a bed alarm, and fluorescent tape on the wheelchair brake handles. Observations revealed the absence of these interventions in the resident's environment. Interviews with facility staff, including the LPN and DON, confirmed the lack of implementation of these safety measures. The resident experienced numerous falls over several months, indicating a failure to follow the established fall prevention protocol, as confirmed by the facility's administrator.
Failure to Follow Physician's Orders for Daily Weights
Penalty
Summary
The facility failed to adhere to professional standards of care by not following a physician's order for daily weight checks for a resident. The order, dated November 7, 2024, required daily weights to be obtained, but the facility's records, including the Restorative Aide Log Book and the resident's weight summary report, showed no evidence that these weights were taken as ordered. The weight summary only included entries for three dates, none of which were daily, indicating a lack of compliance with the physician's directive. Interviews with staff, including CNAs and the Assistant Director of Nursing, confirmed that no residents were receiving daily weight checks, and the facility could not provide documentation to show that the order was being followed. The Director of Nursing and the Administrator both acknowledged that the daily weights should have been performed as ordered, but the facility failed to do so, resulting in a deficiency in the quality of care provided to the resident.
Failure to Provide Pressure Relieving Cushion for Resident
Penalty
Summary
The facility failed to adhere to a physician's order for a pressure relieving cushion to be used on a resident's wheelchair, which was crucial for preventing skin breakdown. The resident, identified as being at high risk for skin breakdown, had a physician's order dated July 1, 2024, for a pressure relieving cushion. The care plan, which was reviewed on April 17, 2025, also included an intervention for a pressure reducing device to be placed on the resident's wheelchair. Despite these directives, observations on February 3 and 4, 2025, revealed the resident was sitting in the wheelchair without the required cushion. Interviews conducted with the resident and staff confirmed the absence of the pressure relieving cushion. The resident himself indicated he did not have the cushion while using his wheelchair. An LPN acknowledged the resident's risk for skin breakdown and admitted to not knowing the location of the cushion. The Director of Nursing confirmed the absence of the cushion and acknowledged it should have been in place as ordered. The facility administrator also confirmed that all pressure ulcer prevention measures should have been implemented as per the physician's orders.
Insufficient CNA Staffing During Day Shifts
Penalty
Summary
The facility failed to ensure the required number of Certified Nursing Assistants (CNAs) were present and working during the day shift on two of the three days reviewed. According to the facility's assessment, 6 to 9 CNAs were needed during the day shift to provide competent support and care to the residents. However, on the first day reviewed, only two CNAs were clocked in initially, with the number gradually increasing to five, which was still below the required minimum. On the second day, the number of CNAs present fluctuated between four and five, again failing to meet the minimum staffing requirement. Interviews with staff members, including a CNA/Restorative Aid, the CNA Supervisor, and the Director of Nursing, confirmed that the facility did not have the required number of CNAs working during the day shift. The CNA Supervisor and Director of Nursing both indicated that at least seven CNAs and/or CNA/Restorative Aides should be working during the day shift to meet the residents' needs. The facility's administrator acknowledged the deficiency, agreeing that the required number of CNAs should have been present as per the Facility Assessment.
Failure to Reconcile Controlled Drugs Properly
Penalty
Summary
The facility failed to maintain a proper system for reconciling controlled drugs across multiple medication carts, leading to discrepancies in documentation. Specifically, the report highlights issues with Medication Carts a, b, and d, where the reconciliation of controlled substances was not accurately documented. For Medication Cart a, the time sheets of the involved LPNs showed discrepancies in their clock-in and clock-out times, yet both nurses documented that they reconciled the controlled substances together. Similar issues were found with Medication Cart b, where the time sheets did not align with the documented reconciliation times, indicating that the controlled substances were not properly reconciled between shifts. For Medication Cart d, the report notes that the reconciliation was often conducted by an LPN and the Clinical Care Coordinator when the oncoming nurse was not present, but the Clinical Care Coordinator did not sign the Controlled Drugs-Count Record. Interviews with staff, including the Director of Nursing and the facility Administrator, confirmed that the reconciliation process was not properly followed, as the involved staff members did not consistently initial the records to verify the reconciliation of controlled substances. This lack of proper documentation and adherence to protocol led to the identified deficiency.
Inaccurate eMAR Documentation for Resident's Wheelchair Cushion
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic Medication Administration Record (eMAR) for a resident. Specifically, a Licensed Practical Nurse (LPN) documented that a pressure relieving cushion was in place on a resident's wheelchair, as per the physician's order dated July 1, 2024. However, upon observation on February 5, 2025, the resident was found lying in bed, and no pressure relieving cushion was present on the wheelchair or in the resident's room. The LPN admitted to not having visualized the cushion during her shift and was unaware of its whereabouts. The Director of Nursing (DON) and the facility's Administrator both confirmed that the documentation in the resident's eMAR was inaccurate. The LPN had recorded that the cushion was verified as being in place, despite not having seen it. This discrepancy highlights a failure in maintaining accurate medical records, as required by federal and state regulations, and the facility's own job description for LPNs.
Deficient Discharge Process for Resident
Penalty
Summary
The facility failed to ensure a proper discharge process for a resident, leading to several deficiencies. The resident was admitted to the facility with the goal of returning to the community after completing therapy. However, the discharge location was inaccurately recorded as the address of the resident's responsible party (RP) instead of the resident's actual home address. This error was not identified or corrected before the discharge took place. Additionally, the facility did not provide the resident or the RP with the necessary discharge summary and instructions prior to the discharge. The discharge summary form lacked a signature from the resident or the RP, indicating that they had not received or acknowledged the discharge instructions. Furthermore, there was no documented evidence that the resident or the RP was given a list of home health agencies to choose from, which is a critical part of the discharge planning process. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for the discharge did not review the discharge arrangements with the resident or the RP, nor did they obtain the necessary signatures. The Director of Nursing (DON) and the Social Services Director (SSD) acknowledged the errors, with the SSD admitting to assuming the address on the resident's face sheet was correct without verification. These oversights contributed to the deficient discharge process, failing to meet the resident's needs and goals.
Failure to Properly Label Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure that an enteral feeding bag for a resident was properly labeled with the date and time of initiation and the rate of infusion. This deficiency was observed multiple times over several days. Specifically, on four separate occasions, the enteral feeding bag was found to be missing either the date, time of initiation, or the infusion rate. Interviews with the Director of Nursing and the Administrator confirmed that it is a professional standard of practice to label the enteral feeding bag with this information.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that indwelling urinary catheter drainage bags and catheter tubing did not touch the floor, which is a critical measure to prevent infections. Observations revealed that Resident #7's catheter drainage bag was repeatedly found hanging from the bedrail and lying on the floor on multiple occasions. Similarly, Resident #71's catheter drainage bag was observed hanging from the bottom of the wheelchair with the tubing touching the floor. Resident #341's catheter drainage bag and tubing were also found lying flat on the floor next to the bed and touching the floor when hanging from the wheelchair. Interviews with the Director of Nursing and the Administrator confirmed that the facility's professional standards of practice require that catheter drainage bags and tubing be kept off the floor to reduce the risk of infection. Despite these standards, the facility did not adhere to these practices for the three residents observed, leading to a deficiency in infection control measures for catheter use.
Bathroom Door Closure Issue
Penalty
Summary
The facility failed to ensure that a resident's bathroom door could close properly, which was identified for one of the sampled residents. During an interview, the resident indicated that his bathroom door could not close all the way. Subsequent observations confirmed that the bathroom door was unable to be closed completely. A CNA attempted to close the door and was also unsuccessful. Interviews with the CNA, Housekeeping Supervisor, and Director of Nursing all confirmed that the bathroom door could not close and that it should be able to close properly.
Failure to Provide Timely Transfer Assistance
Penalty
Summary
The facility failed to ensure timely assistance for a resident requiring transfer from bed to wheelchair. On 04/09/2024 at 9:14 a.m., Resident #341 activated the call light for assistance. At 9:15 a.m., the resident indicated needing help with the transfer. By 9:19 a.m., a CNA entered the room, turned off the call light, and informed the resident that another CNA would assist her, but then left without providing help. The resident remained unattended until 10:22 a.m. when a physical therapist assisted her with the transfer. Interviews conducted on 04/11/2024 revealed that both the CNA Supervisor and the Director of Nursing acknowledged that a resident waiting over an hour for assistance was unacceptable. The DON also stated that call lights should not be turned off until the resident's request has been addressed. This incident highlights a significant delay in providing necessary care and a failure to follow proper procedures for responding to call lights.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility failed to ensure expired food items were not available for resident consumption. Observations in the dry storage area of the facility's kitchen revealed a half box of dried cranberries, six packets of Chefs Finest Ranch Salad Dressing, and a 128-ounce container of Cajun Worchester Sauce with 4 ounces remaining, all of which had expired. Interviews with the Dietary Manager and the Administrator confirmed that these expired food items should not have been available for resident consumption.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to perform proper hand hygiene after removing gloves during incontinence care for Resident #7. During an observation, a Certified Nursing Assistant (CNA) was seen providing incontinence care to Resident #7. The CNA used cleansing wipes to clean the resident's genitalia, disposed of the wipes, and then removed her gloves without performing hand hygiene. The CNA was observed wearing three pairs of gloves on each hand and did not perform hand hygiene after removing each pair. She continued to clean the resident's catheter tubing and buttocks, and then put an adult brief on the resident without performing hand hygiene after each glove removal. In an interview, the CNA admitted to not performing hand hygiene after each glove change and explained that she wore three pairs of gloves at once to avoid acquiring new gloves each time they became soiled. The Director of Nursing (DON) confirmed that wearing three pairs of gloves at once was not proper infection control protocol and emphasized that proper hand hygiene should be performed after every glove removal.
Failure to Timely Complete and Submit Resident Assessments
Penalty
Summary
The facility failed to complete and electronically submit resident assessments to CMS in a timely manner for eight residents. The assessments in question included Death in Facility Assessments, Quarterly Assessments, and Discharge Assessments. These assessments were either completed or submitted more than 14 days after the Assessment Reference Date (ARD) or after they were completed. Specific instances included Resident #12's Death in Facility Assessment, Resident #21's Quarterly Assessment, Resident #41's Discharge Assessment, Resident #42's Death in Facility Assessment, Resident #44's Discharge Assessment, Resident #54's Quarterly Assessment, Resident #66's Discharge Assessment, and Resident #70's Quarterly Assessment. Each of these assessments was delayed beyond the required timeframe for completion and/or submission to CMS. In interviews, the MDS Coordinator acknowledged that the assessments were not completed and/or transmitted in a timely manner and confirmed that they should have been. The Director of Nursing also indicated awareness of the late assessments. The report highlights a systemic issue in the timely processing and submission of critical resident assessments, which is essential for maintaining compliance with CMS regulations and ensuring proper resident care documentation.
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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