Courtyard Of Natchitoches
Inspection history, citations, penalties and survey trends for this long-term care facility in Natchitoches, Louisiana.
- Location
- 708 Keyser Avenue, Natchitoches, Louisiana 71457
- CMS Provider Number
- 195213
- Inspections on file
- 26
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Courtyard Of Natchitoches during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple chronic conditions, and a care plan noting vaccine refusal due to allergies received a high-dose influenza vaccine without documented prior education or signed consent from the resident or health care proxy, as required by facility policy. An LPN administered the vaccine based on a list of residents reported to have consented, without verifying consent in the record, and the only documented refusal form from the responsible party was signed several days after the vaccine had already been given.
A resident with intact cognition and multiple chronic conditions was assessed and care planned to self-administer only eye drops, with no orders permitting bedside storage of other medications. However, surveyors observed Diclofenac arthritis cream, Nystatin cream, and Hydrocortisone cream left unattended in the resident’s room and bathroom, and the resident reported self-administering these creams after receiving them from a nurse. The ADON confirmed that the resident was authorized only for self-administration of eye drops and that the topical creams should not have been left in the room, demonstrating the facility’s failure to follow its own self-administration assessment and policy.
A resident with quadriplegia, central cord syndrome, edema, and intact cognition, who relied on a wheelchair for mobility and required extensive assistance with ADLs, repeatedly reported that her wheelchair was too small and causing hip discomfort. CNAs confirmed the complaints and notified the administrator, and staff observed that the resident had gained weight and sometimes had edema. Surveyors observed the resident seated with her hips tightly pressed against the wheelchair sides and later noted redness and indentations on both hips after transfer, which an LPN confirmed were from the wheelchair. Therapy staff reported they had not been informed by nursing that the wheelchair was too small, and despite awareness of the issue, no effective action was taken to provide an appropriately sized wheelchair.
A resident's protected health information (PHI) was left visible on an unattended EMR cart, as observed by surveyors. An LPN admitted to leaving the cart unattended without securing the computer screen, and the DON confirmed that staff are required to lock screens when not present. This incident violated the facility's HIPAA privacy policy.
Surveyors found a medication cart left unattended and unlocked in a hallway, with several drawers open and medications accessible. An LPN confirmed the cart should have been locked and secured when not in use, in accordance with facility policy. The DON also stated that medication carts are required to be locked when unattended.
Staff failed to accurately document the administration of medications and completion of ordered care tasks on the MAR for two residents with complex medical needs. Despite performing the required tasks, LPNs did not consistently record times and initials as required by facility policy, resulting in incomplete and inaccurate medical records.
A resident with intact cognition and significant medical needs entrusted a staff member with a large sum of settlement money for safekeeping and distribution to family. The staff member failed to safeguard the funds, claiming they were stolen from her home, did not report the theft, and did not return the money. Facility investigation confirmed the misappropriation of the resident's property by the staff member.
A resident with intact cognition and complex medical needs reported that a staff member misappropriated a significant sum of money. Although the staff member admitted to the misappropriation, the facility did not conduct a thorough investigation, failed to interview all relevant residents, and did not provide comprehensive in-service education to all staff. Additionally, the resident was not consistently monitored for safety or emotional well-being during the investigation, and several staff members lacked awareness of misappropriation as a form of abuse.
Two residents were placed in physical restraints, including a Geri-chair and a pommel cushion, without required physician orders, consents, or risk assessments. Staff interviews confirmed that the facility lacked both the necessary documentation and a policy for restraints or bed rails.
The facility did not obtain physician's orders, informed consent, or conduct risk assessments before installing bed rails for three residents with significant medical and cognitive impairments. Staff confirmed the absence of required documentation and policies related to bed rail use.
A resident with pressure ulcers did not receive the required weekly skin assessments and wound measurements, as confirmed by interviews with the Wound Care Nurse and RN Charge. This failure to document care is contrary to the facility's policies, which mandate weekly documentation to manage pressure ulcers effectively.
A facility failed to ensure consistent documentation of a resident's code status. Despite having a physician's order and signed consent for DNR status, the resident's care plan incorrectly indicated Full code status. Staff were aware of the DNR status through the resident's dashboard and hard chart, but the care plan was not updated accordingly, leading to a discrepancy.
A resident with severe cognitive impairment and osteoporosis experienced a leg injury during repositioning by two CNAs, who failed to report an audible pop immediately. The resident later complained of leg pain, prompting a nurse to investigate and send the resident for an x-ray, which revealed a spiral fracture. The facility's administrator confirmed the CNAs should have reported the incident immediately.
A facility failed to use a mechanical lift for transferring a non-weight bearing resident, as required by the care plan. Two CNAs used a lift pad instead, citing issues with finding a functional lift. The resident, with severe cognitive impairment and osteoporosis, was transferred without the necessary equipment, contrary to facility policy.
The facility failed to maintain wheelchairs in good repair, affecting five residents. Observations showed peeling and cracked armrest cushions, with one resident's family member noting the issue had persisted for months. The DON confirmed the need for replacement during environmental rounds.
The facility failed to meet residents' nutritional needs by not adhering to prescribed portion sizes for pureed meals. Kitchen staff used a 4oz scoop that was not filled to capacity, resulting in residents receiving less than the required portions. This affected multiple residents, including those needing double portions, and was confirmed by staff observations and interviews.
The facility did not provide a Notice of Medicare Non-Coverage (NOMNC) to three residents before discontinuing their Medicare Part A services, despite having benefit days remaining. The social worker acknowledged not issuing the required notice and was unaware of the necessity to do so.
A facility failed to develop a comprehensive Hospice Care Plan for a resident admitted to hospice care, despite the resident's serious health conditions and a physician's order. Interviews confirmed the resident was receiving hospice services, but the care plan did not reflect this, indicating a lapse in care planning.
A resident with a history of dizziness and balance issues fell while trying to get into bed without assistance. The facility failed to update the care plan with new fall prevention strategies after the incident. The MDS coordinator was unaware of the fall due to a lack of communication, resulting in the care plan not being revised.
A resident with a history of osteoporosis and pain did not receive the prescribed Duloxetine dosage due to a failure in entering a physician's order. The resident was supposed to receive 60 mg daily, but the order was not processed, and the resident missed the medication from 09/16/2024 to 09/24/2024. The ADON confirmed the oversight during an interview.
The facility failed to implement a dietitian's recommendations for two residents, leading to deficiencies in maintaining their nutritional status. One resident experienced significant weight loss without receiving recommended dietary supplements, while another resident with mild malnutrition did not receive suggested nutritional supplements or vitamins for wound healing. The ADON confirmed that necessary orders were not entered.
A resident with a history of falls and multiple diagnoses, including dementia and incontinence, experienced a significant delay in receiving assistance after using the call light. Despite being informed that help would arrive soon, the resident waited approximately 35 minutes for assistance to use the restroom. The facility's policy requires call light responses within 15 minutes, but this was not adhered to, indicating a deficiency in staff competency and response time.
A resident with a milk allergy and lactose intolerance was given Ensure, a supplement containing milk protein, three times daily due to weight loss. Despite the care plan requiring nondairy alternatives, staff confirmed the administration of Ensure. The RD admitted to the oversight, assuming the resident only had lactose intolerance.
The facility did not follow professional standards for food service safety by failing to cover, label, and date refrigerated food items after opening. An open block of cheese and a cup of oranges were found uncovered and undated in the refrigerator, confirmed by the kitchen lead. This oversight could impact the 92 residents receiving meals from the kitchen.
Failure to Obtain and Document Consent and Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to follow its policy requiring education and signed consent prior to administering influenza and pneumonia vaccinations. The written policy titled “Pneumonia/Influenza Vaccinations” directed staff to contact the resident and family to explain the importance of vaccinations and to obtain signed consent from the resident and/or family. For one resident, admitted with chronic kidney disease stage 5, end stage renal disease, pneumonia, schizophrenia, and bipolar disorder, the record identified a health care proxy as the responsible party and a care plan focus of refusing vaccines due to allergy to some components, with an intervention to assess for consent or refusal upon admission and periodically with the resident and responsible party. The resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition. Despite these requirements and the resident’s cognitive status and care plan, the physician’s order for a high-dose influenza vaccine was implemented and the vaccine was administered on a documented date and time without any documented evidence of prior education, consent, or refusal from the resident or health care proxy. The eMAR confirmed the vaccine was given, while the medical record lacked a signed consent form or documentation of education about risks and benefits before administration. A subsequent influenza vaccination request and consent form, signed by the responsible party several days after the vaccine was given, documented a refusal of the influenza vaccine on an ongoing basis. Staff interviews confirmed that an LPN administered the vaccine based on a list of residents purported to have consented, without personally verifying a signed consent, and the infection control nurse and ADON acknowledged that consent/refusal and education should have been obtained and documented before the vaccine was administered, but this did not occur for this resident.
Failure to Follow Self-Administration Assessment Limits for Topical Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team assessed and determined clinical appropriateness for self-administration of medications in accordance with its policy for one resident. The facility’s policy required that if a resident desired to self-administer medications, the interdisciplinary team would assess the resident’s cognitive, physical, and visual abilities and document the results on a Self-Administration Assessment form in the medical record. The resident in question had diagnoses including COPD, primary insomnia, depression, and nicotine dependence, and a BIMS score of 15 indicating intact cognition. The resident’s care plan documented a physician’s order for unsupervised self-administration of carboxymethylcellulose eye drops only, and the Self-Administration of Medication assessment form indicated the resident was fully capable to self-administer eye drops, but topical medications (including patches) were not selected as medications the resident was capable of self-administering. There were no physician’s orders allowing the resident to store medications at the bedside. Despite this, surveyor observations and interviews showed that multiple topical medications were present and left unattended in the resident’s room and bathroom, and the resident reported self-administering them. Diclofenac arthritis cream was observed on the bedside table, and later Diclofenac arthritis cream, Nystatin cream, and Hydrocortisone cream were observed on a table next to the resident’s toilet. The resident stated she administered the creams herself and that a nurse had given her the cream in a medicine cup, although she could not recall which nurse. The ADON confirmed during the survey that these topical medications should not have been left unattended in the resident’s bathroom and that, per the self-administration assessment, the resident was only allowed to self-administer eye drops and not topical creams. This discrepancy between the documented assessment/physician orders and the actual practice of allowing the resident to self-administer and keep topical medications in the room led to the cited deficiency.
Failure to Provide Appropriately Sized Wheelchair for Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not providing a wheelchair appropriate for her size. The resident, admitted with diagnoses including edema, unspecified quadriplegia, acute pain, muscle spasm, central cord syndrome of the cervical spinal cord, and seizures, had intact cognition with a BIMS score of 15 and used a wheelchair for mobility. Her MDS and care plan documented limited physical mobility, bilateral upper and lower extremity impairments, and dependence on staff for transfers, toileting, and personal hygiene, as well as risk for pressure ulcers and the need to avoid striking extremities on hard surfaces. During observation, the resident was seen sitting in a wheelchair with no space between her hips and the sides of the chair, and she reported that the wheelchair was too small, rubbed against her hips, and that she had previously informed the administrator of this issue over a month earlier after gaining weight. Multiple CNAs confirmed that the resident had complained that her wheelchair was too small and was hurting her hips, and that they had notified the administrator and shown her that the wheelchair did not fit properly. Another staff member reported noticing that the resident’s wheelchair was too small and that the resident had edema at times and had gained weight. On a subsequent observation, three CNAs were seen transferring the resident from the wheelchair to bed via Hoyer lift, and redness and indentations were observed on both hips where they had been pressed against the sides of the wheelchair; an LPN confirmed these findings. Therapy staff stated that residents are screened every three months and as needed, but nursing had not notified therapy that this resident’s wheelchair was too small. The administrator acknowledged that a requisition for a larger wheelchair had been cancelled and confirmed that no other measures had been implemented to obtain an appropriately sized wheelchair for the resident.
Failure to Protect Resident PHI Due to Unattended EMR Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of medical records for one resident. During an observation on Hall B, an unattended medical cart was found with the electronic medical record (EMR) screen left open, displaying a resident's protected health information (PHI). The cart remained unattended until a staff member, identified as an LPN, returned. Upon interview, the LPN acknowledged leaving the cart unattended with the resident's PHI visible and admitted not ensuring the privacy and confidentiality of the information. The Director of Nursing confirmed that staff are expected to lock computer screens when leaving them unattended to protect resident PHI. This deficiency was identified through observation, interview, and record review, and was found to be in violation of the facility's policy requiring all workforce members to adhere to HIPAA Privacy Standards and prevent unauthorized disclosure of PHI.
Unattended and Unlocked Medication Cart Found During Survey
Penalty
Summary
Surveyors observed that Cart X, containing medications, was left unattended and unlocked in Hall B, with three of its eight drawers open. This occurred during a medication pass and was witnessed at 8:55 a.m. The cart remained unsecured until a staff member, identified as an LPN, returned. Upon interview, the LPN confirmed that the cart was supposed to be locked and all drawers closed when not attended, acknowledging that the medications were not stored in a safe and secure manner. The facility's policy requires all medications to be stored in locked compartments and for medication carts to be locked when unattended, which was not followed in this instance. The Director of Nursing also confirmed that medication carts are to be locked when unattended to ensure security.
Failure to Accurately Document Medication Administration and Care Tasks
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and its own policies. Specifically, staff did not consistently document the administration of medications and completion of ordered care tasks on the Medication Administration Record (MAR) for two residents. The facility's policies require that all medications administered be recorded with time and staff initials on the MAR, and that the electronic MAR (E-MAR) serves as a permanent, legal document within the electronic health record. For one resident with multiple diagnoses including severe cognitive impairment, repeated falls, malnutrition, and dementia, there were multiple instances where staff failed to record the administration of medications such as Levothyroxine, Donepezil, Atorvastatin, Latanoprost, Memantine, and topical creams, as well as the completion of care tasks like applying an overlay on the mattress and ensuring the use of pillow heel boots. These omissions occurred across several dates and shifts, with missing documentation for both day and night shifts. Another resident, with diagnoses including diabetes and hypothyroidism and intact cognition, also had missing documentation for medication administration (Levothyroxine, Novolin R), blood glucose monitoring, and other ordered care tasks over several days. Interviews with administrative and nursing staff confirmed that while medications and care tasks were performed as ordered, the required documentation was not completed on the MARs for the affected residents. Staff acknowledged that the records were not accurate and should have been properly documented according to facility policy.
Staff Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when a staff member, S7 Rehab Tech, misappropriated a resident's funds by agreeing to hold a large sum of money for the resident and subsequently failing to safeguard or return the funds. The resident, who had intact cognition as indicated by a BIMS score of 15 and diagnoses including cervical spine fusion, seizures, quadriplegia, and depression, received a settlement check and entrusted S7 Rehab Tech with approximately $12,000 in cash. The staff member was supposed to distribute portions of the money to the resident's family and hold the remainder for the resident, as per the resident's instructions. After the money was given to S7 Rehab Tech, the staff member reported to the resident that the funds were stolen from her home during a break-in. S7 Rehab Tech did not file a police report regarding the alleged theft and did not return the funds to the resident. The staff member admitted to holding the money and acknowledged that she should not have agreed to the arrangement. The resident attempted to recover the funds and communicate with S7 Rehab Tech, but the staff member avoided contact and blocked the resident's phone number. The facility's investigation, prompted by a rumor and subsequent interviews, confirmed that the staff member had misappropriated the resident's funds. The staff member admitted to the actions during interviews with facility administration and the rehab director. The incident was substantiated as misappropriation of property/funds, as the staff member wrongfully used the resident's money without proper consent or protection, in violation of facility policy and resident rights.
Failure to Thoroughly Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of resident property involving a resident with intact cognition and significant medical conditions, including quadriplegia and depression. The resident reported that a staff member was asked to hold a large sum of money, which was later reported stolen from the staff member's home. The staff member admitted to taking the money, and the incident was substantiated by the facility. Despite the admission, the investigation was not comprehensive. Not all cognitively intact residents were interviewed regarding similar issues, and not all facility and therapy staff received in-service education on misappropriation of resident property or funds. Several staff members, including CNAs and therapy staff, demonstrated a lack of understanding about misappropriation and its classification as a form of resident abuse. Some staff members were unaware of the incident or had not received any related training or education following the event. Additionally, the resident who reported the incident did not receive consistent monitoring or safety checks during the investigation process. The facility's own policy required timely and thorough investigations and monitoring of the resident's emotional well-being during such incidents, but these steps were not fully implemented. The administrator acknowledged that the investigation was limited due to the staff member's admission and confirmed that key investigative and monitoring actions were not completed.
Failure to Obtain Orders, Consents, and Assessments for Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience, as evidenced by the lack of required physician orders, consents, and risk assessments for two residents. One resident, admitted with multiple diagnoses including chronic kidney disease and impaired cognition, was observed using a Geri-chair for mobility without documentation of a physician's order, signed consent, or completed risk assessment. The resident's care plan indicated the use of the Geri-chair, but the necessary regulatory steps were not followed. Another resident, with a history of dementia, falls, and severely impaired cognition, was observed using a pommel cushion in a wheelchair. The medical record did not contain a physician's order, consent, or risk assessment for this device, despite its use being documented in the care plan. Interviews with facility staff, including the DON and Administrator, confirmed that the facility had not obtained the required documentation for these restraints and did not have a policy in place for restraints or bed rails.
Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding the use of bed rails for three residents. Specifically, there was no evidence of physician's orders, informed consent from the residents or their representatives, risk assessments for entrapment, or care plan documentation related to the use of assist rails. Observations confirmed that all three residents were using bed rails, and staff interviews acknowledged that required assessments, consents, and orders had not been obtained. Additionally, the facility did not have a policy in place for the use of bed rails. The residents involved had significant medical histories, including chronic conditions such as chronic kidney disease, heart failure, dementia, and a history of falls. Cognitive assessments indicated that at least two of the residents had moderate to severe cognitive impairment. Despite these factors, the facility did not document any individualized assessment or planning for the use of bed rails, nor did it obtain the necessary authorizations or consents prior to their installation and use.
Failure to Document Weekly Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. The resident, who was admitted with multiple diagnoses including stage 3 pressure ulcer of the right hip and stage 2 pressure ulcer of the sacral region, did not receive the mandated weekly skin assessments and wound measurements on specified dates. The facility's wound care documentation policy requires weekly documentation of all existing and new wounds, including detailed assessments of the wound's status and condition. Interviews with the Wound Care Nurse and the Registered Nurse Charge confirmed the absence of documentation for the required weekly skin evaluations and measurements for the resident on the specified dates. This lack of documentation indicates a failure to adhere to the facility's policies and procedures for managing pressure ulcers, which are crucial for promoting healing and preventing further complications.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's current wishes. The resident, who had multiple diagnoses including cerebral infarction and type II diabetes mellitus, had a physician's order for Do Not Resuscitate (DNR) status created and confirmed on 11/11/2024. The resident had also signed a consent form for DNR status on 10/22/2024, which was confirmed by the physician. However, the resident's care plan, which should have been updated to reflect the DNR status, incorrectly indicated a Full code status as of 10/23/2024. During interviews and record reviews, it was revealed that the facility's staff, including an LPN and the MDS Coordinator, were aware of the DNR status as indicated in the resident's dashboard on Point Click Care (PCC) and the hard chart. Despite this, the care plan was not updated to reflect the DNR status, leading to a discrepancy between the resident's documented wishes and the care plan. The MDS Coordinator confirmed that the care plan should have been updated when the new DNR order was received, but it was not, resulting in the deficiency.
Failure to Report Change in Condition Immediately
Penalty
Summary
The facility failed to ensure immediate reporting of a change in condition for a resident, which is a deficiency in their care protocol. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including a displaced spiral fracture of the left femur, atrial fibrillation, unspecified dementia, and osteoporosis. The resident required substantial assistance with daily activities and was care planned for osteoporosis, with specific interventions for safety and transfer assistance. On the morning of the incident, two CNAs were repositioning the resident when they heard an audible popping sound from the resident's leg. Despite hearing the pop, the CNAs did not report the incident to the nurse immediately, as the resident did not show any immediate signs of pain or distress. The resident was then placed in a wheelchair and taken to the dining room. It was only after the resident complained of leg pain while sitting at the dining table that the CNAs informed the nurse about the earlier popping sound. The nurse, upon being informed, examined the resident and, after consulting with the charge nurse and the resident's doctor, decided to send the resident to the emergency room for further evaluation. An x-ray confirmed a spiral fracture in the resident's left femur. The delay in reporting the initial incident by the CNAs was acknowledged by the facility's administrator as a failure to adhere to the facility's policy on reporting accidents and incidents immediately, regardless of the perceived severity.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to adhere to its policy for transferring non-weight bearing residents, resulting in a deficiency. The policy requires the use of a mechanical lift with two-person assistance for transferring residents who are non-weight bearing. However, on 11/19/2024, two CNAs transferred a resident from bed to wheelchair using a lift pad instead of the mechanical lift, as outlined in the resident's care plan. The CNAs reported that they opted for the lift pad because it was quicker and mechanical lifts were often unavailable due to being hidden or having dead batteries. The resident involved had a history of severe cognitive impairment, osteoporosis, and other medical conditions, necessitating careful handling during transfers. The resident's care plan specifically required the use of a Hoyer lift with two-person assistance for all transfers to ensure safety. Despite this, the CNAs proceeded with the transfer using the lift pad, which was confirmed by the facility's administrator through interviews and camera footage review. This action was contrary to the care plan and facility policy, leading to the deficiency finding.
Wheelchair Armrest Cushions in Disrepair
Penalty
Summary
The facility failed to maintain residents' wheelchairs in good repair, compromising the residents' right to a safe and comfortable environment. Observations revealed that the armrest cushions of wheelchairs for five residents were peeling and in disrepair. Specifically, Resident #19 was observed sitting in a wheelchair with both arm cushions in disrepair. Resident #40's wheelchair arm cushions were also in disrepair, with the resident's son noting that the condition had persisted for 6-8 months. Similar conditions were observed for Residents #47, #49, and #67, with cracked and non-intact surfaces on their wheelchair arm cushions. During environmental rounds with the Director of Nursing (DON), these deficiencies were confirmed, indicating a need for replacement of the damaged equipment.
Failure to Adhere to Prescribed Portion Sizes for Pureed Meals
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the prescribed portion sizes for pureed meals, as observed during a survey. The lunch menu for residents on pureed diets specified serving sizes of 3/4 cup for pureed chicken spaghetti and 1/2 cup for pureed green beans. However, the kitchen staff used a 4oz scoop for all food items, which was not filled to capacity, resulting in residents receiving less than the required portion sizes. This discrepancy was confirmed through observations and interviews with kitchen staff, including the Kitchen Lead and Kitchen Assistant Manager, who acknowledged the failure to serve the correct portion sizes. The deficiency affected multiple residents, including those who required double portions as per their meal cards. Observations revealed that residents often received inadequate amounts of food, as confirmed by CNAs assisting them during meals. The Dietary Manager also confirmed that the staff should have followed the serving sizes indicated on the approved menus. The lack of a menu with serving sizes posted in the kitchen contributed to the staff's inability to serve the correct portions, leading to the nutritional inadequacy of meals provided to residents.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to three residents or their responsible parties before discontinuing Medicare Part A services. This deficiency was identified during a review of the Skilled Nursing Facility (SNF) Beneficiary Review forms for the residents. It was found that the NOMNC, Form CMS-10123, was not provided to the residents prior to their discharge from Medicare Part A services, despite having benefit days remaining. In an interview, the social worker (S4 SW) admitted to not issuing the NOMNC to the residents and was unaware of the requirement to do so.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive Hospice Care Plan for a resident who was admitted to hospice care. The resident, who had multiple serious health conditions including malignant neoplasm, end-stage renal disease, and heart disease, was admitted to hospice on July 22, 2024. Despite the resident's significant health needs and the physician's order to admit the resident to hospice care, the care plan did not include hospice care, which is a critical component of the resident's treatment and support. Interviews with facility staff, including an LPN and MDS coordinators, confirmed that the resident was receiving hospice services, with a hospice nurse visiting weekly and aides visiting twice a week. However, the MDS coordinators acknowledged that the resident's care plan should have included hospice care but did not. This oversight indicates a lapse in ensuring that the resident's care plan was comprehensive and reflective of their current health care needs, as required by regulatory standards.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident, which is a deficiency in care planning. The resident, who had a history of dizziness, chronic obstructive pulmonary disease, chronic kidney disease, and anemia, was at moderate risk for falls due to gait and balance problems. Despite these risks, the care plan was not updated with new interventions after the resident fell while attempting to get into bed without assistance. The fall occurred on September 16, 2024, and was documented in the progress notes, but the care plan remained unchanged. The MDS coordinator responsible for the resident's care plan was unaware of the fall incident, as it was not reported in the morning meeting following the event. This lack of communication resulted in the care plan not being revised to include new fall prevention strategies. The resident acknowledged the fall during an interview, stating that he attempted to get into bed without help, believing he could manage on his own. The oversight in updating the care plan highlights a failure in the facility's process for addressing and preventing falls among residents.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that physician's orders for a resident were followed, leading to a deficiency in meeting professional standards of practice. The resident, who was cognitively intact with a BIMS score of 15, had a medical history that included osteoporosis, an unspecified fracture of the right wrist and hand, anemia, and pain. On 09/20/2024, a physician's order was made to change the resident's Duloxetine dosage to 60 mg daily to help manage back pain and osteoarthritis. However, the order was not entered into the system, and the resident did not receive the prescribed medication. Further review of the resident's Medication Administration Record (MAR) for September 2024 revealed that the resident had not been receiving the previously prescribed 30 mg of Duloxetine daily from 09/16/2024 through 09/24/2024. The resident's care plan included the use of antidepressant medication for pain management, with interventions to ensure the resident was free from discomfort or adverse reactions related to the therapy. During an interview on 09/24/2024, the Assistant Director of Nursing (ADON) confirmed that the order was not entered, and the resident did not receive the medication as prescribed.
Failure to Implement Dietitian's Recommendations for Nutritional Support
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status by not implementing the registered dietitian's recommendations. Resident #11, who had severe cognitive impairment and required assistance with eating, experienced significant weight loss over a six-week period. Despite the dietitian's recommendation to encourage supplements for improved nutrition, there were no physician's orders for dietary supplements, and the Medication Administration Records (MARs) showed no documentation of supplements being provided. The Assistant Director of Nursing (ADON) confirmed that an order for supplements was not entered, which should have been done. Similarly, Resident #195, who had a history of metabolic encephalopathy, vitamin deficiency, and other conditions, was identified as having mild malnutrition with a BMI less than 22. The dietitian recommended supplements between meals and specific vitamins for wound healing. However, there were no physician's orders for these supplements or vitamins, and the MARs did not document their provision. The resident confirmed not receiving any supplements, and the ADON acknowledged that the necessary orders were not entered, which should have been carried out by the floor nurse.
Delayed Call Light Response for Resident with High Fall Risk
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in responding to residents' needs, as evidenced by a delayed call light response for a resident. The resident, who had a history of falls and was at high risk due to confusion and gait/balance problems, required prompt assistance. Despite using the call light to request help to use the restroom, the resident waited approximately 35 minutes before receiving assistance. This delay occurred even after an LPN informed the resident that help would arrive soon and notified another staff member of the resident's need. The resident's clinical record indicated multiple diagnoses, including dementia and frequent urinary and bowel incontinence, necessitating timely assistance. The care plan emphasized the importance of anticipating and meeting the resident's needs promptly, with specific instructions for call light accessibility and response. However, the staff failed to adhere to the facility's policy of responding to call lights within 15 minutes, as confirmed by the Director of Nursing. This incident highlights a deficiency in the facility's ability to provide timely care, potentially compromising the resident's well-being.
Failure to Accommodate Resident's Milk Allergy
Penalty
Summary
The facility failed to honor and accommodate a resident's food allergies and intolerances, specifically by providing a supplement containing milk protein to a resident with a documented milk allergy and lactose intolerance. The resident, who had diagnoses including cerebral palsy and severely impaired cognitive skills, was dependent on staff for all activities of daily living. Despite the resident's care plan indicating a need for nondairy alternatives, the resident was given Ensure, a supplement containing milk protein, three times daily due to weight loss. Interviews with facility staff, including a CNA, LPN, and the Assistant Director of Nursing (ADON), confirmed the administration of Ensure to the resident. The Registered Dietitian (RD) responsible for the resident's dietary plan admitted to recommending Ensure, mistakenly assuming the resident only had lactose intolerance and not a milk allergy. This oversight led to the administration of a product containing milk protein, contrary to the resident's documented allergies and care plan requirements.
Failure to Properly Store and Label Refrigerated Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that refrigerated food items were properly covered, labeled, and dated after opening. During an observation of the kitchen, an open block of cheese and a cup of oranges were found on the refrigerator shelf, both uncovered, exposed to air, and undated. This observation was confirmed by the S7 Kitchen Lead, who acknowledged that all opened food items should be covered and dated, but this protocol was not followed. This deficiency had the potential to affect the 92 residents who received meals served from the kitchen.
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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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