Cornerstone At The Ranch
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Louisiana.
- Location
- 103 West Martial Ave, Lafayette, Louisiana 70506
- CMS Provider Number
- 195565
- Inspections on file
- 29
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cornerstone At The Ranch during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Two residents receiving psychotropic medications did not have their gradual dose reduction (GDR) forms reviewed by a physician as required. One resident with dementia and multiple psychiatric diagnoses had GDR forms for several medications left unaddressed, while another resident on hospice with psychiatric and neurological conditions also had GDR forms for multiple medications that were not reviewed. The administrator confirmed the lack of physician documentation for these GDRs.
Staff did not consistently follow care plans and physician orders for several residents, including failures to document edema severity and fluid intake, apply prescribed medical devices, record vital signs every shift, and update care plans and orders for code status and hospice admission. These deficiencies were confirmed through record reviews, observations, and staff interviews.
The facility did not adequately monitor or audit several open QAPI projects, including those related to GDRs, weekly body audits, and expired medications. Required monitoring and observations were not consistently performed, and the DON confirmed that these deficiencies were not addressed prior to the survey, potentially affecting all residents.
A resident with a documented DNR status on both the admission record and a signed LaPOST form was incorrectly listed as 'Full Code' in the facility's Care Profile Report. The DON confirmed this inconsistency and acknowledged that the Care Profile Report was not updated to match the resident's advance directives.
A resident's MDS assessment was inaccurately coded as a discharge to a short-term general hospital, despite documentation and staff interviews confirming the resident left AMA to her own home and was not transferred to a hospital. Facility records and staff statements verified the error in the MDS coding.
Surveyors observed that expired medications, including Sodium Chloride Tablets, Acetaminophen suppositories, Bisacodyl suppositories, Ferrous Sulfate Elixir, and Vitamin D-3, were not discarded as required and remained stored in two medication rooms. The ADON confirmed these expired drugs should have been removed, but they were still present, contrary to facility policy.
Surveyors observed that garbage and refuse, including used gloves and a garbage bag, were left on the ground and around an open dumpster in the dietary disposal area. The area was not maintained in a sanitary condition as required by facility policy, and staff confirmed that the dumpster should have been kept closed and the area clean.
Surveyors identified unclean kitchen flooring, rodent droppings in a storage area, and improperly labeled and stored food items in a refrigerator used for resident supplements. Additionally, a deep fryer and the floor beneath it were found with significant debris and residue. The dietary manager and kitchen staff confirmed these sanitation lapses during the inspection.
An electrical outlet in the kitchen was found protruding from the wall with a visible hole, and was not properly sealed or secured. This was confirmed by the Assistant Administrator and was not in accordance with facility policy for maintaining a clean and orderly environment. The issue had the potential to affect all residents in the facility.
A resident with multiple health issues experienced frequent diarrhea, but the facility failed to notify the physician as required by policy. Despite the CNA reporting the issue to the LPN, the physician was not informed, and the Nurse Practitioner confirmed the lack of notification. Documentation existed of the episodes, but no action was taken to inform the physician.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including Dementia and HIV. The bowel and bladder charting for the resident showed incorrect documentation of size and consistency, marked with 'Y' instead of the designated letters. Interviews confirmed that CNAs did not document accurately, potentially affecting the entire census of 71 residents.
The facility failed to accurately document edema and behaviors for two residents. One resident had discrepancies in edema and behavior records, despite orders to monitor these conditions. Another resident's edema was inconsistently documented in the MAR and daily assessments, despite receiving a diuretic. These inaccuracies were confirmed by staff and observed during interviews.
The facility failed to maintain a clean and homelike environment for two residents, as their shared room had walls stained with tan, light brown, dark brown, and rust-colored marks. The Housekeeping Supervisor acknowledged the responsibility to clean the walls, which had not been fulfilled.
A resident activated her call light for assistance, but the facility failed to respond promptly. Despite the call light being visible on the hallway sign and electronic board, the LPN on duty did not attend to the resident, instead making overhead announcements for a CNA to respond. The resident, who required assistance for transfers and hygiene, was left waiting, highlighting a deficiency in staffing and response protocol.
A resident with multiple diagnoses and high risk for skin injury experienced inadequate wound care management due to the nursing staff's failure to complete weekly skin assessments, accurately document wound staging, update clinical records, and notify medical staff of wound deterioration. The initial wound assessment was delayed, and subsequent assessments were inconsistent, leading to a deficiency identified by surveyors.
A treatment nurse in an LTC facility failed to follow proper hand hygiene protocols during wound care for a resident with a deep tissue injury. The nurse changed gloves multiple times without sanitizing hands, contrary to the facility's policy. This deficiency was confirmed by both the nurse and the DON/Infection Preventionist.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies. A resident with severe depression had no care plan addressing their condition. Another resident's catheter was not cleaned as ordered, and a diabetic resident lacked a glucose sensor, contrary to their care plan. Communication needs for a resident with dysarthria and feeding assistance for a resident with dementia were also not addressed.
A resident with a suprapubic catheter was observed in the dining room with an uncovered catheter drainage bag, contrary to the facility's dignity policy. The resident, who requires assistance with ADLs due to medical conditions, had approximately 300 cc's of urine visible to others. The DON confirmed the absence of a covering, highlighting a failure to maintain the resident's dignity.
The facility failed to ensure the cleanliness of wheelchairs for two residents, leading to a deficiency in providing a safe, clean, and comfortable environment. Despite a policy requiring regular cleaning, both residents reported their wheelchairs had never been cleaned, and observations confirmed the presence of dust. A CNA acknowledged the oversight, indicating a lapse in adherence to the facility's cleaning schedule.
A facility failed to include pain management in a baseline care plan for a resident admitted with a fracture and other conditions. Despite having a physician's order for Oxycodone, the baseline care plan did not address pain, and the MDS Coordinator confirmed the absence of a pain assessment.
The facility failed to provide proper respiratory care for two residents by not labeling or storing oxygen equipment correctly and administering oxygen without a physician's order. One resident had unlabeled oxygen tubing and a humidifier bottle, while another had oxygen administered without an order and improperly stored oxygen tanks in their room.
A resident with a fractured humerus experienced severe pain and did not receive prescribed Oxycodone due to a lapse in communication and procedure. Despite the resident's complaints and an LPN's attempt to address the issue, the ADON was not informed, and the physician was not contacted for a new prescription, leaving the resident without pain relief for several days.
The facility failed to provide timely responses to call lights for two residents, one with quadriplegia and intact cognition, and another with severe cognitive impairment. Despite digital alerts and announcements, staff did not respond promptly, with one LPN admitting to not answering a call light and a CNA failing to inform a colleague about covering during a break. The Regional Corporate Nurse confirmed staffing issues.
A resident with conditions including End Stage Renal Failure and Heart Failure did not receive prescribed PRN medications for itching, despite having a red rash and reporting the issue to nursing staff. An LPN confirmed the resident's condition but failed to administer the medications, acknowledging the oversight.
The facility failed to remove expired medications from medication room A. During an inspection, a bottle of Vitamin B Complex with Vitamin C and a bottle of Ferrous Gluconate 240 mg were found with expiration dates of May 2024. An LPN confirmed the medications were expired.
A resident with intact cognition had their food preferences disregarded, as mashed potatoes and rice, both listed as dislikes, were served on their meal trays. The Dietary Manager confirmed the error, highlighting a failure to adhere to documented preferences.
A resident with multiple diagnoses, including Anemia and Rheumatoid Arthritis, had incomplete medical records due to a lack of nursing documentation over a month. Despite receiving an antibiotic order, there were no documented signs or symptoms leading to the order, nor was there an ongoing assessment of the resident's swollen right lower extremity. Interviews with an LPN and the DON confirmed the absence of necessary documentation.
A facility failed to maintain an updated hospice care plan for a resident, resulting in an outdated plan on file that did not reflect the resident's current DNR status. The DON was unaware of the missing updated care plan, highlighting a lapse in the facility's process for ensuring current hospice documentation.
The facility failed to maintain functioning call systems for three residents, including one with Parkinson's Disease and another with severe cognitive impairment. Observations revealed that call bells did not alert staff due to battery issues, and maintenance staff did not routinely check the systems, leading to unaddressed calls for assistance.
A facility failed to maintain a safe and sanitary environment for a resident, as evidenced by a window in disrepair. Observations revealed two large cracks on the window pane, covered with tape, indicating inadequate repair. Staff confirmed the window's poor condition, which did not meet the facility's policy for a clean and orderly environment.
The facility failed to ensure a dementia resident received appropriate treatment and services by not revising the care plan to address continued wandering, staff not reporting incidents, and not providing adequate supervision despite complaints. The resident, diagnosed with dementia, frequently wandered into other residents' rooms, causing distress, and interventions were not effectively implemented or reported.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Ensure Physician Review of Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not having gradual dose reduction (GDR) forms reviewed by a physician for two residents. For one resident with diagnoses including dementia, depression, anxiety, restlessness, and agitation, the annual Minimum Data Set (MDS) indicated the use of antipsychotic, antianxiety, and antidepressant medications. Although the MDS documented that a GDR was clinically contraindicated, the facility's GDR binder showed that multiple GDR forms for medications such as Haldol, Klonopin, Remeron, and Zoloft were not addressed by the physician. Another resident, who was on hospice and had diagnoses including depression, unspecified psychosis, anxiety, and senile degeneration of the brain, was also taking antipsychotic, antianxiety, and antidepressant medications. The quarterly MDS for this resident did not document that a GDR was clinically contraindicated. The facility's GDR binder revealed that GDR forms for medications including Seroquel, Celexa, and Lorazepam were not reviewed by the physician. The administrator confirmed that there was no documented evidence that the GDRs for these residents were addressed by the physician as required.
Failure to Follow Care Plans and Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans and physician orders were consistently followed for multiple residents, resulting in several deficiencies. For two residents with orders to monitor and document the severity of edema every shift, staff did not record the required information in the medical record. Additionally, for one of these residents, fluid intake was not documented with every meal as ordered, with staff interviews confirming the lack of documentation and a misunderstanding of responsibility between nurses and CNAs. Another resident with severe cognitive impairment had a physician's order and care plan directive to wear a swath and sling on the left arm when not icing or elevating it. Observations over multiple days showed the resident was not wearing the swath and sling, and a hospice CNA reported never having seen or applied the device. Nursing staff confirmed the order was active and should have been followed. Further deficiencies included the failure to complete and document vital signs every shift for a resident with hemiplegia, hypertension, and dementia, despite a standing physician order. Additionally, a resident admitted to hospice services with a documented DNR status did not have corresponding physician orders or care plan updates reflecting code status or hospice admission. The DON confirmed these omissions in both the physician orders and care plan documentation.
Failure to Monitor and Audit QAPI Projects
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not adequately monitoring open QAPI projects to determine if corrections or revisions were necessary. During a review and interview with the Director of Nursing (DON), it was found that several nursing Quality Assurance (QA) projects had been initiated, but ongoing monitoring and audits were not consistently performed as required. For example, a QA project for Gradual Dose Reductions (GDRs) was opened with the intent to meet with the pharmacy consultant monthly and as needed, but no monitoring or audits were conducted. The DON confirmed that she had not been monitoring or auditing the GDRs project. Another QA project for weekly body audits was also not properly monitored. Although a schedule for daily body audits was placed at each nurses' station and staff were in-serviced, monitoring that began in early June ceased by mid-July due to the absence of the treatment nurse. Similarly, a QA project for expired medications required weekly random observations, but after initial monitoring in June, no further observations were conducted through the end of July. The DON acknowledged awareness of these deficiencies and confirmed that adequate monitoring of the QA projects had not been conducted prior to the survey. These failures had the potential to affect all 73 residents in the facility.
Failure to Accurately Reflect Advance Directives in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record accurately reflected their advance directives. Record review showed that the resident was admitted with a diagnosis including normal pressure hydrocephalus and had a documented Do Not Resuscitate (DNR) status on both the admission record and a signed Louisiana Physician Orders For Scope of Treatment (LaPOST) form. However, the facility's Care Profile Report listed the resident as 'Full Code,' which conflicted with the DNR status documented elsewhere in the record. During an interview, the Director of Nursing confirmed the inconsistency and acknowledged that the Care Profile Report should have been updated to reflect the correct DNR status but was not.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's discharge status. Record review showed that the resident was admitted and later discharged from the facility, with the MDS coded as a discharge to a short-term general hospital. However, review of emergency transfer logs did not show the resident being sent to a hospital, and progress notes indicated the resident left the facility against medical advice (AMA) to go home. Interviews with the Social Services Director, Administrator, and Director of Nursing confirmed that the resident left AMA to her own home and was not transferred to a hospital, and that the MDS was incorrectly coded.
Expired Medications Not Discarded in Medication Rooms
Penalty
Summary
Surveyors found that the facility failed to store drugs and biologicals in accordance with accepted professional principles by not discarding expired medications in two medication rooms. During observations with the Assistant Director of Nursing, expired medications including Sodium Chloride Tablets, Acetaminophen suppositories, and Bisacodyl suppositories were found in Med Room A, while expired Ferrous Sulfate Elixir and Vitamin D-3 were found in Med Room B/C. The Assistant Director of Nursing confirmed that these medications were expired and should have been discarded, but they remained in the medication rooms in violation of the facility's own policy requiring the destruction of discontinued, outdated, or deteriorated drugs or biologicals.
Improper Disposal of Garbage and Refuse in Dietary Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in the dietary garbage disposal area, as observed during a survey. On one occasion, used gloves and other trash items were found on the ground immediately outside the building and along the walkway leading to the garbage dumpster. Two gloves were seen near a large yellow bucket, and three more used gloves were observed in front of the open dumpster. Additionally, a white garbage bag containing refuse was found outside and to the left of the dumpster. The facility's policy requires that waste be properly contained and dumpsters kept closed, with the surrounding area maintained in a sanitary condition. The Dietary Manager confirmed that the dumpster should be kept closed and the area clean at all times. The Administrator stated that the kitchen staff was responsible for maintaining the cleanliness of the area and that the dumpster was not supposed to be left in that condition.
Failure to Maintain Sanitary Kitchen Conditions and Proper Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and did not store food in accordance with professional standards. Observations included unclean flooring, rodent droppings in a kitchen storage area, and opened and unlabeled food items in a refrigerator designated for resident supplements. Specifically, a storage area contained a non-functioning steam table with an open section on the floor, where rodent droppings and traps were found. The refrigerator in this area held three bags of lettuce, two of which were unlabeled and unopened, and one that was opened and undated. The dietary manager confirmed these items were not properly labeled or dated. Further inspection revealed a deep fryer with a thick layer of debris and food residue on both sides, as well as a dark, thick layer of residue on the flooring underneath. The state department Sanitarian's notices from both routine and complaint visits documented violations, including the presence of rodents, unclean floors, and non-food contact surfaces not being cleaned frequently enough. Kitchen staff confirmed that the Sanitarian instructed them to clean the area due to rodent droppings, and the dietary manager acknowledged that the fryer and surrounding floor had not been cleaned as required.
Unsecured Electrical Outlet in Kitchen
Penalty
Summary
Facility staff failed to ensure that an electrical outlet in the kitchen was properly sealed and secured into the wall. During an observation, the outlet box was found protruding from the wall with a visible square hole where it should have been affixed. This condition was confirmed by the Assistant Administrator during an interview, who acknowledged that the outlet was not properly installed. The facility's policy requires a clean, sanitary, and orderly environment, but this standard was not met in this instance. This deficiency had the potential to affect all 79 residents residing in the facility, as the unsafe condition was located in a common area used for food preparation.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition for one of the residents sampled. The facility's policy requires prompt notification of the resident, their attending physician, and representative of changes in the resident's medical or mental condition. However, this policy was not followed for a resident who experienced frequent diarrhea during their stay. The resident, who had diagnoses including Dementia, HIV, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein-Calorie Malnutrition, was admitted to the facility and later discharged without the physician being informed of the diarrhea episodes. Interviews conducted with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care reported the diarrhea episodes to the nurse on duty. Despite this, the Licensed Practical Nurse (LPN) who was aware of the situation did not notify the physician. The Nurse Practitioner confirmed that they had not been informed of the resident's condition. A Corporate Registered Nurse, acting as the Director of Nursing, verified that there was documentation of the diarrhea episodes in the resident's medical record but no evidence of physician notification, which was required by the facility's policy.
Inaccurate Bowel Charting Documentation
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of the three sampled residents. Specifically, the deficiency was identified in the documentation of bowel charting for a resident who was admitted with diagnoses including Dementia, HIV, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein-Calorie Malnutrition. The resident's bowel and bladder charting for October 2024 showed inaccuracies in the documentation of size and consistency, where entries were incorrectly marked with the letter 'Y' instead of the designated letters 'S', 'M', or 'L' for size, and 'S', 'H', or 'W' for consistency. Interviews and record reviews with the Assistant Director of Nursing (S5ADON) and the Administrator (S6ADM) confirmed that the Certified Nursing Assistants (CNAs) did not document the bowel charting accurately. The key provided for documentation was not used correctly, leading to incorrect entries. This failure in documentation had the potential to affect the entire census of 71 residents, as it compromised the communication between the interdisciplinary team regarding the resident's condition and response to care.
Inaccurate Documentation of Edema and Behaviors
Penalty
Summary
The facility failed to maintain accurate medical records for two of the three sampled residents, leading to deficiencies in documentation. Resident #2, who had multiple diagnoses including Diabetes Mellitus Type II, Schizoaffective Disorder, and Congestive Heart Failure, had orders to monitor edema and mood/behaviors every shift. However, discrepancies were found in the documentation of her edema and behaviors. On specific dates in August and September 2024, the MAR indicated no edema was present, contradicting other medical notes that documented the presence of edema. Additionally, despite exhibiting behaviors such as yelling and attempting to throw objects, the MAR inaccurately recorded no behaviors observed on a particular day. Similarly, Resident #3, with diagnoses including Chronic Diastolic Heart Failure and Chronic Kidney Disease, was to have edema monitored before administering a daily diuretic. The MAR documented the presence of edema on several dates in September 2024, yet the daily skilled nursing assessments for those same dates indicated no edema. This inconsistency was confirmed by S3LPN, who acknowledged the inaccuracies in the documentation. Observations on September 24, 2024, confirmed the presence of edema, further highlighting the documentation errors.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents in a shared room. Observations revealed that the walls in the room were stained with tan, light brown, dark brown, and rust-colored marks in a drip-like pattern. These stains were located on the lower portion of the wall to the left of the bathroom door, the wall to the left of one resident's bed, and the front wall of the room. The Housekeeping Supervisor acknowledged that the walls should have been cleaned and confirmed that it was a housekeeping responsibility to maintain cleanliness in the residents' rooms.
Failure to Respond Promptly to Resident's Call Light
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary competencies and skills to ensure resident safety and maintain the highest practicable well-being of each resident. This deficiency was observed when a resident activated her call light at 8:42 a.m., but did not receive assistance until much later. The resident, who required assistance for transfers, walking, grooming, and hygiene, was left waiting despite the call light being activated and visible on both the hallway sign and the electronic board in the nurse's station. The LPN on duty, upon noticing the activated call light at 8:50 a.m., made an overhead announcement for assistance but did not personally attend to the resident. Instead, she waited for a CNA to respond, making a second announcement at 9:00 a.m. The Director of Nursing later stated that the facility's protocol does not include waiting for another staff member to respond after an overhead announcement. This incident highlights a failure in the facility's staffing and response protocol, as the resident's call for assistance was not promptly addressed, leaving her unattended for an extended period.
Deficiency in Wound Care Management Due to Inadequate Nursing Competencies
Penalty
Summary
The facility failed to ensure that the nursing staff demonstrated the necessary competencies and skills to provide safe and effective care for a resident, leading to a deficiency in wound care management. The deficiency involved a failure to complete weekly skin assessments, accurately document the staging of a resident's wound, update the clinical record with the correct wound status, obtain physician orders to continue or discontinue wound care, and notify the physician or Nurse Practitioner of a deteriorating wound. These failures were identified during a review of the facility's policies and the resident's electronic health record (EHR). The resident in question was admitted with multiple diagnoses, including hemiplegia, dysphagia, aphasia, and lack of coordination, and was considered high risk for skin injury. Despite this, the initial wound assessment was not completed when the wound was first identified, and subsequent weekly assessments were not conducted until several months later. The nursing staff inaccurately documented the wound's status and failed to notify the medical team of changes in the wound's condition, including its deterioration to a Stage 3 pressure injury. Interviews with the nursing staff revealed a lack of understanding of what constituted a high-risk resident and inconsistencies in the documentation and notification processes. The Director of Nursing and the responsible nurse confirmed the discrepancies in the wound assessments and acknowledged the failure to notify the medical team promptly. This lack of proper wound care management and communication contributed to the deficiency identified by the surveyors.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections during wound care for a resident. The incident involved a treatment nurse who did not adhere to the facility's hand hygiene policy while providing wound care to a resident with a deep tissue injury on the left ischium. The nurse was observed changing gloves multiple times without performing hand hygiene in between, which is a violation of the facility's hand hygiene policy that requires hand sanitization after removing gloves and before handling clean or soiled dressings. The resident involved had a medical history that included hemiplegia, dysphagia, aphasia, and lack of coordination, and was receiving daily wound care treatment as per physician's orders. During the wound care procedure, the nurse failed to sanitize her hands after removing gloves and before applying a clean dressing, which was confirmed by both the nurse and the Director of Nursing/Infection Preventionist during interviews. This oversight in infection control practices was identified as a deficiency by the surveyors.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to multiple deficiencies. Resident #38, diagnosed with Major Depressive Disorder with Severe Psychotic Symptoms, did not have this condition addressed in their care plan, despite being on antidepressant medication. This oversight was confirmed by the Minimum Data Set Coordinators during a review of the resident's electronic clinical record. Resident #58, who had a suprapubic catheter due to neuromuscular dysfunction of the bladder, was supposed to have the catheter tubing cleaned every shift. However, observations revealed dried, brown sediment on the tubing, indicating that the cleaning was not performed as ordered. This was confirmed by an LPN who acknowledged the unclean state of the catheter tubing. Resident #70, with Type 2 Diabetes Mellitus, was supposed to have a glucose sensor for monitoring blood sugar levels. However, the resident reported not having the sensor since admission, and blood sugars were being checked via finger sticks, which was not documented in the care plan. Additionally, Resident #50's communication difficulties due to severe dysarthria were not addressed in the care plan, and Resident #62, who required assistance with eating, did not have this need documented in their care plan, despite observations and family reports confirming the necessity for assistance.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to uphold a resident's dignity by not providing a covering for a urinary catheter bag. This deficiency was identified during an observation on 07/08/2024, when Resident #70 was seen sitting in a wheelchair in the dining room with an uncovered catheter drainage bag containing approximately 300 cc's of yellow urine, visible to other residents. The facility's policy on dignity, last updated on 06/26/2023, explicitly prohibits demeaning practices and requires staff to assist residents in keeping urinary catheter bags covered. Resident #70 was admitted with diagnoses including acute kidney failure, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive and reflex uropathy. The resident's care plan indicated a need for assistance with activities of daily living due to a left femur fracture and muscle weakness, and noted the presence of a suprapubic catheter related to his medical conditions. The Director of Nursing confirmed the lack of a covering for the catheter bag during the observation.
Failure to Maintain Wheelchair Cleanliness
Penalty
Summary
The facility failed to maintain the cleanliness of wheelchairs for two residents, leading to a deficiency in providing a safe, clean, comfortable, and homelike environment. Resident #30, who has intact cognition and uses a wheelchair, was observed on multiple occasions with a wheelchair that had a layer of dust on the metal parts. Despite being scheduled for cleaning twice a week, there was no documentation of when Resident #30's wheelchair was last cleaned. The resident confirmed that her wheelchair had never been cleaned, and this was corroborated by a CNA who acknowledged the wheelchair's dirty condition. Similarly, Resident #35, who also uses a wheelchair and has a BIMS score indicating some cognitive impairment, was found with a thick layer of dust on his wheelchair. The facility's cleaning schedule indicated that his wheelchair should be cleaned twice a week, but again, there was no documentation of the last cleaning. Resident #35 also stated that his wheelchair had never been cleaned, and the CNA confirmed the observation. These findings highlight the facility's failure to adhere to its own wheelchair cleaning policy, resulting in unclean conditions for the residents.
Failure to Address Pain in Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan addressing pain management for a resident within 48 hours of admission. The resident, who was admitted with diagnoses including hyperlipidemia, diabetes, hypertension, and a fracture of the upper end of the right humerus, had a physician's order for Oxycodone 10 mg to be taken orally every 4 hours as needed for pain. However, a review of the resident's baseline care plan, dated June 26, 2024, showed no evidence that pain was addressed. During an interview on July 10, 2024, the Minimum Data Set Coordinator confirmed that there was no documentation of a pain assessment being initiated for the resident, and pain was not included in the baseline care plan.
Improper Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. Resident #36, who has diagnoses including End Stage Renal Failure and Obstructive Sleep Apnea, had an unlabeled oxygen tubing and humidifier bottle, which were not stored properly. The tubing was observed open to air and wrapped around the oxygen concentrator. A Licensed Practical Nurse confirmed these items should have been labeled and stored in a bag. Resident #66, with diagnoses including Heart Failure and Chronic Kidney Disease, was found to have an unlabeled oxygen tubing and humidifier bottle, with the tubing hanging exposed from the oxygen concentrator. Additionally, there was no physician order for oxygen use for this resident, despite observations of oxygen being administered. Three oxygen tanks were also improperly stored in the resident's room. Both the LPN and the Director of Nursing confirmed the absence of a physician order for oxygen, which should have been obtained.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was experiencing significant pain due to a fracture in the upper end of the right humerus. The resident, who had been admitted with diagnoses including hyperlipidemia, diabetes, hypertension, and a fractured right humerus, reported severe pain and had been requesting pain medication for two days without receiving any. The resident's electronic clinical record showed a physician's order for Oxycodone 10 mg to be administered every four hours as needed for pain. However, the Medication Administration Record indicated that the last dose was given five days prior, and there was no documentation of pain medication being administered on the days the resident reported high pain levels. Interviews with facility staff revealed a breakdown in communication and procedure. An LPN acknowledged the resident's complaints of pain and confirmed that the facility had run out of Oxycodone, requiring a new prescription from the physician. Despite informing the Assistant Director of Nursing (ADON) about the need for a new prescription, the LPN did not receive a response, and the physician was not notified. The ADON confirmed that she was responsible for contacting the physician for new prescriptions but was not informed of the situation, resulting in the resident not receiving pain management for several days.
Delayed Response to Call Lights Due to Staffing Issues
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, as evidenced by delayed responses to call lights for two residents. Resident #58, who was admitted with multiple diagnoses including quadriplegia and had an intact cognitive status, experienced a delay in response to his call light. The surveyor observed dried sediment on the resident's catheter tubing and pressed the call button, which was not answered for ten minutes. The surveyor found an LPN at the nursing station who admitted to not responding to the call light promptly. Resident #61, with severe cognitive impairment, also experienced significant delays in call light response. The resident's responsible party reported that it often took 30 to 45 minutes for staff to respond, particularly on weekends. During the survey, the call light was activated, and despite digital alerts and overhead announcements, staff did not respond promptly. A CNA admitted to not checking the alerts and another CNA failed to inform her colleague about covering her residents during her break. The Regional Corporate Nurse confirmed the facility had staffing issues.
Failure to Administer PRN Medications for Itching
Penalty
Summary
The facility failed to ensure that nursing staff provided appropriate care to meet the needs of a resident, specifically in administering PRN medications for itching. Resident #36, who was admitted with conditions including End Stage Renal Failure, Unspecified Diastolic Heart Failure, and Obstructive Sleep Apnea, had a physician's order for Hydrocortisone cream and Benadryl to be used as needed for itching. Despite these orders, a review of the Medication Administration Record for June and July 2024 showed that the resident did not receive any of the prescribed medications for itching. Observations and interviews revealed that the resident had a red rash on his thighs, lower legs, and abdomen, which he had been scratching until it bled. The resident reported the itching to a nurse on 07/07/2024, but no medication was administered. An LPN confirmed the presence of the rash and acknowledged that she had not administered the PRN medications, despite being aware of the resident's condition and having left a message for hospice regarding the issue.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to ensure that expired medications were not stored in medication room A. During an inspection conducted on July 10, 2024, at 3:40 pm, a bottle of Vitamin B Complex with Vitamin C and a bottle of Ferrous Gluconate 240 mg were found on the shelf with expiration dates of May 2024. An LPN was present during the observation and confirmed that both bottles of medication were expired.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to honor and accommodate the food preferences of a resident, which was identified during an observation and interview process. The resident, who had an intact cognitive status as indicated by a BIMS score of 15, had specific dislikes listed on their Dietary Meal Ticket, including mashed potatoes and rice. Despite this, both items were found on the resident's meal trays during a meal service. The Dietary Manager confirmed that these items should not have been present on the resident's meal trays, indicating a failure to adhere to the resident's documented food preferences.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to maintain complete medical records for a resident, identified as #43, who was admitted with diagnoses including Anemia, Idiopathic Peripheral Autonomic Neuropathy, and Rheumatoid Arthritis. A review of the resident's electronic clinical record revealed a lack of nursing documentation between April 12, 2024, and May 14, 2024. During this period, a new order for the antibiotic Cephalexin was issued, but there was no documentation of the signs and symptoms that led to this order. Furthermore, there was no ongoing assessment documented for the resident's right lower extremity, which was later noted to have redness and swelling. Interviews conducted with the LPN and the Director of Nursing confirmed the absence of documentation regarding the resident's condition and the effectiveness of the antibiotic treatment. The LPN acknowledged that the resident's right lower leg was swollen and that the family had brought this to their attention, leading to an order to send the resident to the hospital to rule out Deep Vein Thrombosis (DVT). The Director of Nursing stated that nurses are expected to document signs, symptoms, and ongoing assessments, which was not done in this case.
Failure to Maintain Updated Hospice Care Plan
Penalty
Summary
The facility failed to ensure that the updated hospice plan of care was on file and available for a resident receiving hospice services. Specifically, the facility's policy required a designated staff member to obtain the most recent hospice plan of care for each resident. However, for one resident, the hospice care plan on file was outdated, dated 01/09/2024, and did not reflect the resident's current code status. The resident's electronic health record indicated a diagnosis of senile degeneration of the brain, and the hospice care plan in the binder stated the resident chose resuscitation if their heart or lungs stopped. A phone interview with the resident's hospice nurse revealed that the resident's code status had changed to Do Not Resuscitate (DNR) and was signed by the physician on 03/26/2024. This updated information was not reflected in the hospice care plan on file at the facility. The Director of Nursing (DON) was unaware that the updated hospice care plan with the resident's new code status was not obtained or on file, indicating a lapse in the facility's process for maintaining current hospice care plans.
Deficiency in Call System Functionality
Penalty
Summary
The facility failed to ensure that the call systems were functioning properly for three residents, leading to deficiencies in resident care. Resident #31, who has Parkinson's Disease and Atrial Fibrillation, was observed with a non-functioning call bell system. Despite pressing the call bell, no alert was displayed on the hall screen, and the CNA confirmed the malfunction. Maintenance staff admitted that they did not routinely check the call bells or their batteries, contributing to the issue. Resident #5, with Schizoaffective Disorder and severe cognitive impairment, demonstrated the use of his call light, but no staff responded within a reasonable time frame. Maintenance personnel later confirmed that the call light required new batteries. Similarly, Resident #66, with Chronic Kidney Disease and Morbid Obesity, experienced a similar issue where the call light was pressed, but no staff responded. Maintenance confirmed the call light was not functioning due to battery issues, and staff were unaware of the resident's call for assistance.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as evidenced by the condition of an exterior window in disrepair for one resident. During an observation on July 8, 2024, two large cracks, each approximately three feet in length, were noted on the left pane of the resident's exterior window. The cracks were covered with seven thick, black pieces of tape, indicating a temporary and inadequate repair. An interview and further observation on July 9, 2024, with staff member S7AIT confirmed the window's poor condition, acknowledging that it should not have been left in such a state. The facility's policy titled 'Quality of Life- Homelike Environment,' updated on March 12, 2024, emphasizes the importance of maintaining a clean, sanitary, and orderly environment to reflect a personalized, homelike setting. However, the condition of the window in the resident's room did not align with these policy standards, highlighting a deficiency in the facility's maintenance and environmental management practices.
Failure to Address Dementia Resident's Wandering Behavior
Penalty
Summary
The facility failed to ensure a dementia resident received appropriate treatment and services to maintain his highest practicable level of well-being. Specifically, the facility did not revise the comprehensive care plan to address the resident's continued wandering, staff failed to report incidents of the resident wandering into other residents' rooms, and adequate supervision was not provided despite complaints. The resident, diagnosed with unspecified dementia and other cognitive impairments, was known to wander into other residents' rooms, causing distress. Interventions such as redirecting the resident and placing a picture of a truck outside his room were implemented but not included in the care plan, and staff did not consistently report these incidents to the Director of Nursing (DON). The DON confirmed that the facility was first made aware of the resident's wandering behavior in December 2023, but no effective interventions were added to the care plan. Despite further complaints and reports of the resident entering other residents' rooms, the facility did not increase supervision or follow up with the affected residents. The staff's failure to report these incidents and the lack of appropriate care plan revisions contributed to the deficiency in providing adequate care for the resident with dementia.
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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