Covenant Home
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 5919 Magazine Street, New Orleans, Louisiana 70115
- CMS Provider Number
- 195614
- Inspections on file
- 17
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Covenant Home during CMS and state inspections, most recent first.
A resident did not receive prescribed Klonopin for several days due to the medication not being available from the pharmacy, as confirmed by nursing notes and staff interviews. Additionally, the facility failed to maintain accurate and complete controlled substance records on two medication carts, with missing documentation, incomplete shift change reconciliations, and absent nurse signatures, as verified by staff and administrative interviews.
A bottle of expired atorvastatin 20 mg was found on a medication cart and remained available for a resident's use, despite facility policy requiring removal of outdated medications. Both an LPN and the DON confirmed the expired medication should not have been accessible.
Surveyors found that food items, including bacon and various cheeses, were improperly stored and left unlabeled and undated in the kitchen refrigerator. Prepared sandwiches were left unrefrigerated for several hours, resulting in unsafe temperatures. Additionally, raw chicken was thawed incorrectly in a sanitization sink with standing water. Staff interviews confirmed these practices did not meet professional standards for food safety.
The facility did not post required signage informing staff of their rights against retaliation for reporting suspected crimes, as confirmed by observations and interviews with multiple staff members including an LPN, DON, and RN. The administrator was unable to provide evidence that such signage had ever been displayed.
A resident with a history of skin tears, muscle weakness, vision problems, and on anticoagulant therapy experienced multiple skin tear injuries. Facility records and staff interviews confirmed that no care plan was developed or implemented to address prevention of further skin tears, despite the resident's ongoing risk and repeated incidents.
A resident with a UTI did not receive a scheduled dose of prescribed antibiotic because staff failed to administer the medication from the Emergency Drug Kit, despite its availability. Nursing staff and the DON confirmed the medication should have been given as ordered, but it was missed due to lack of awareness and follow-through.
A resident with Parkinson's disease and anxiety did not have the administration of their prescribed Sinemet medication accurately documented in the eMAR on two occasions. An LPN confirmed administering the medication but failed to record it as required by facility policy, and the administrator acknowledged the documentation lapse.
A registered nurse/treatment nurse used the same multi-dose wound cleanser bottle to spray directly onto the wounds of two residents without disinfecting the bottle or using protective measures between uses. The bottle was placed back on the treatment cart and into a drawer after each use, contrary to CDC infection control guidelines, and this practice was confirmed by both the nurse and the DON.
A resident who sustained a head laceration did not receive the required neurological assessments or documentation during several shifts, as mandated by facility policy. Staff and leadership confirmed the assessments were neither completed nor recorded as required.
The facility did not ensure the required number of CNAs were present and working during both the day and evening shifts, as outlined in its own facility assessment. Staffing records and interviews confirmed that at times, only 3 or 4 CNAs were on duty, which was below the minimum needed to meet resident care needs according to staff and leadership.
A resident with severe cognitive impairment and physical disabilities was physically abused by another resident during an activity session in the dining room. The attack, which involved punching and scratching, resulted in a superficial injury. Staff members, including an LPN and the Resident Activity Director, witnessed the incident and confirmed it as physical abuse, indicating a failure to protect the resident.
A resident with severe cognitive impairment was involved in a physical altercation with another resident, resulting in minor injuries. Despite the incident being witnessed and considered abuse by staff, the Administrator did not report it to authorities, citing the resident's dementia and lack of serious harm. This action violated the facility's policy requiring immediate reporting of such incidents.
A resident, who was cognitively intact and had a diagnosis of aphasia, was subjected to verbal and mental abuse by a CNA. The abuse involved the CNA yelling derogatory language at the resident, which was witnessed by another resident. The facility's investigation confirmed the abuse, leading to the termination of the CNA.
The facility failed to ensure proper food storage, labeling, and cleanliness in the kitchen area. Observations revealed undated and improperly stored food items, expired food, and cleanliness issues with ceiling fans and a mop bucket. The Dietary Supervisor confirmed these deficiencies.
The facility failed to dispose of garbage and refuse properly. An observation revealed a large crack in the dumpster lid, which had been present for approximately three months according to the Dietary Supervisor.
A resident with intact cognition was found with six disposable medicine cups containing Tums on her bedside table without an assessment for self-administration or a physician's order. The DON confirmed that the resident had not been assessed for self-administration, contrary to the facility's policy.
The facility failed to allow residents unrestricted visitation, requiring family members to make appointments and limiting visiting hours from 10:00 a.m. to 8:00 p.m. This practice led to complaints from residents and their families, who faced difficulties scheduling visits and expressed concerns over the restricted visitation policy.
Medication Availability and Controlled Substance Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident with multiple diagnoses, including dementia, unspecified psychosis, Parkinson's disease, and anxiety. The resident had a physician's order for Klonopin 0.5 mg to be administered twice daily, but the medication was not available from the pharmacy for several consecutive days. Nursing administration notes and interviews with nursing staff confirmed that the medication was not received and, therefore, not administered as ordered on multiple occasions. Additionally, the facility did not maintain accurate or complete records for controlled substances on two medication carts. Review of controlled substance count sheets for two residents revealed missing information, such as the date and time medications were received, inaccurate distribution amounts, incomplete on-hand amounts, and missing nurse signatures. There was also a lack of documented evidence for the receipt and disposition of controlled medications for these residents. Further review of the controlled drug inventory forms for both medication carts showed multiple instances where required shift change reconciliations were not completed or lacked the necessary signatures from both oncoming and off-going nurses. Interviews with nursing staff and the administrator confirmed that the controlled substance reconciliations were incomplete or inaccurate, and that the forms should have been properly completed and verified.
Expired Medication Found Accessible on Medication Cart
Penalty
Summary
A deficiency occurred when a bottle of atorvastatin 20 mg, prescribed for a resident to be taken daily, was found on Medication Cart b with a discard by date that had already passed. The expired medication was still available for use, contrary to the facility's Storage of Medications policy, which requires that no discontinued, outdated, or deteriorated medications be used and that such medications be recycled or destroyed. This was confirmed through observation of the medication cart, review of the resident's physician orders, and interviews with both the LPN and the Director of Nursing, who acknowledged that the expired medication should not have been accessible for resident use. The incident involved a resident with an active order for atorvastatin, and the expired medication was found during a review of the medication cart, with staff confirming the oversight.
Improper Food Storage, Labeling, and Thawing Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and preparation practices. In the kitchen refrigerator, an opened box of uncooked bacon was stored above containers of orange juice, and several opened food items—including shredded cheddar cheese, American cheese, liquid eggs, sour cream, and Italian dressing—were found without labels or dates. Additional unlabeled and undated items, such as crab cakes, peas, and cooked meat, were also present. Individually wrapped sandwiches prepared the previous evening were left unrefrigerated from early morning, resulting in internal temperatures of 74°F and 71.5°F for turkey/mayonnaise and ham/mayonnaise sandwiches, respectively. Staff interviews confirmed that all food items should be labeled and dated, and that meat should not be stored above other foods. The dietary manager also acknowledged that the sandwiches should have remained refrigerated and that bacon should be stored on the bottom shelf. Further deficiencies were identified in the facility's food thawing procedures. Five bags of raw chicken, each with holes allowing water to enter, were found submerged in standing water in the facility's sanitization sink, with no running water present. The dietary manager confirmed that this was not the correct method for defrosting chicken and that it should have been thawed in the refrigerator instead. These observations and staff interviews demonstrate failures to store, label, and thaw food in accordance with professional standards and facility policy.
Failure to Post Employee Rights Against Retaliation for Reporting Crimes
Penalty
Summary
The facility failed to ensure that a notice of employees' rights against retaliation for reporting crimes against residents was posted in a conspicuous location, as required by the United States Social Security Act Title XI, Part A, Section 1150B(d)(3). Observations conducted in the employee common areas revealed that there was no signage related to employees' rights against retaliation for reporting suspected crimes. This was confirmed during multiple interviews with facility staff, including an LPN, the DON, and a Registered Nurse/Treatment Nurse, all of whom indicated that they had not seen such signage posted in the facility. Further, the facility administrator confirmed that there was no evidence to show that the required sign had ever been posted in a conspicuous location. The absence of this signage means that staff were not provided with the mandated information regarding their rights and the process for filing complaints if they experienced retaliation for reporting suspected crimes against residents. No information about specific residents or their medical conditions was included in the report.
Failure to Develop Care Plan for Skin Tear Prevention
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan to address the prevention of skin tear injuries for a resident with multiple risk factors. The resident was admitted with diagnoses including a laceration to the left forearm, muscle weakness, lack of coordination, vision problems, and vascular dementia. The resident was also prescribed Plavix, a medication that increases the risk of bleeding. Despite these risk factors, the facility's records showed multiple incidents of skin tear injuries over several months. Review of the resident's care plan revealed no documented interventions or strategies to prevent further skin tear injuries. Interviews with facility staff confirmed that no care plan addressing these risks was developed or implemented, and no explanation was provided for this omission. The lack of a care plan occurred despite repeated incidents and the resident's ongoing vulnerability to injury.
Missed Administration of Prescribed Antibiotic for UTI
Penalty
Summary
A resident diagnosed with a urinary tract infection (UTI) was prescribed Sulfamethoxazole/Trimethoprim 800/160 mg to be administered orally twice daily for seven days, starting on 05/14/2025 at 8:00AM. Review of the electronic Medication Administration Record (eMAR) showed that the resident did not receive the scheduled morning dose as ordered. The medication was available in the facility's Emergency Drug Kit at the time the dose was due. Interviews with nursing staff and the Director of Nursing confirmed that the medication should have been administered from the Emergency Drug Kit if it was not available from the pharmacy. However, the staff did not administer the medication as ordered, and one nurse indicated a lack of knowledge regarding the contents of the Emergency Drug Kit. The administrator was unable to provide an explanation for the missed dose despite the medication's availability.
Failure to Accurately Document Medication Administration in eMAR
Penalty
Summary
A deficiency occurred when the facility failed to ensure accurate documentation of medication administration in the electronic Medication Administration Record (eMAR) for a resident diagnosed with Parkinson's disease and anxiety. The resident had a physician's order for Sinemet 25-100 mg to be administered orally three times daily. Review of the eMAR for May 2025 showed that the administration of Sinemet at 10:00 PM was not documented on two specific dates. During interviews, the LPN responsible confirmed that the medication was administered on those dates but was not documented in the eMAR as required by facility policy. The administrator also acknowledged that the medication administration was not properly documented.
Improper Handling of Multi-Dose Wound Cleanser During Wound Care
Penalty
Summary
The facility failed to follow infection control guidelines regarding the use of a multi-dose bottle of wound cleanser during wound care for two residents. Observations showed that a registered nurse/treatment nurse used the same bottle of wound cleanser to spray directly onto the wounds of two different residents, holding the bottle close to each wound. After each use, the nurse placed the bottle back onto the treatment cart and into a drawer without disinfecting it or placing it in a protective container to prevent cross-contamination. Interviews confirmed that the same bottle was used for both residents without any sanitization between uses. The nurse acknowledged this practice, and the director of nursing indicated that the wound cleanser should not have been used in this manner. The report references CDC guidelines, which state that multi-dose wound care products should be dedicated to individual residents or handled in a way that prevents cross-contamination, which was not followed in these instances.
Failure to Complete and Document Post-Head Injury Neurological Assessments
Penalty
Summary
The facility failed to ensure that post head injury neurological assessments were completed and documented as required for one resident. According to the facility's policies, neurological observations should be performed every hour for four hours, every four hours for twenty hours, and every shift for forty-eight hours following a head injury. The policies also require that these assessments be documented by the nurse on duty and reviewed by the Director of Nursing for accuracy and content. However, review of the resident's medical record and incident reports revealed that there was no documented evidence that neurological assessments were performed or recorded during several required shifts after the resident was found with a laceration to the back of the head from an unknown origin. Interviews with facility staff, including the Registered Nurse Supervisor/Wound Care Nurse, the DON, and the Administrator, confirmed that the neurological assessments should have been completed and documented according to policy, but the facility could not provide any documentation for the specified shifts. The lack of documentation and completion of required neurological assessments constituted a failure to follow established protocols for monitoring residents after a head injury.
Failure to Maintain Required CNA Staffing Levels
Penalty
Summary
The facility failed to provide the required number of Certified Nursing Assistants (CNAs) per its own facility assessment on one of two days reviewed. According to the facility's assessment, 5 to 6 CNAs were needed on the day shift and 5 to 6 on the evening shift to meet the needs of an average census of 64 residents. However, on the day in question, only 4 CNAs were scheduled for the day shift and 5 for the evening shift. Time sheet reviews further revealed that during certain periods of the day and evening shifts, there were only 3 or 4 CNAs present, which was below the facility's identified minimum staffing requirements. Interviews with staff, including CNAs, the scheduler, and the Director of Nursing, confirmed that 5 to 6 CNAs were needed on the day shift to adequately meet resident needs, and that having fewer than this number made it difficult to provide appropriate care. The administrator also confirmed that more than 4 CNAs should have been working during the day and evening shifts to meet resident needs. There was no documented evidence that additional CNAs were present during the times when staffing was below the required level.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #3, who has severe cognitive impairment and is dependent on staff for activities of daily living due to diagnoses of sequelae of Poliomyelitis and hemiplegia, was physically attacked by Resident #2. The altercation occurred in the dining room during an activity group session, where Resident #2 approached and punched Resident #3 in the face, causing a scratch on the chin with a small amount of bleeding. This incident was witnessed by staff members, including a Licensed Practical Nurse and the Resident Activity Director, who confirmed the occurrence of physical abuse. The facility's policy on identifying types of abuse defines physical abuse as actions such as hitting and slapping, which aligns with the actions taken by Resident #2 against Resident #3. Interviews with staff, including the Director of Nursing and the Administrator, corroborated that the altercation was considered physical abuse. Despite the presence of staff, the attack could not be prevented, highlighting a failure in protecting Resident #3, who was unable to defend herself due to her medical condition.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident abuse within the required timeframe to the Health Standards Section (HSS). The incident involved Resident #2, who has a diagnosis of unspecified dementia with mood disturbance and severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. On the morning of 11/04/2024, Resident #2 was involved in an altercation with Resident #3 in the dining room during an activity group session. Witnesses, including a Licensed Practical Nurse (LPN) and the Resident Activity Director, observed Resident #2 approach and physically assault Resident #3 by punching and scratching their face, resulting in a small amount of bleeding. Despite the incident being witnessed and considered physical abuse by several staff members, including the Resident Activity Director and the Director of Nursing, the Administrator did not report the incident to the appropriate authorities. The Administrator believed that due to Resident #2's dementia diagnosis and the lack of serious bodily harm, the incident did not constitute abuse. This decision was contrary to the facility's policy, which mandates reporting all alleged and validated violations to the governing state agency.
Resident Subjected to Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13, and had adequate hearing and vision. The resident was admitted with a diagnosis of aphasia. The abuse was substantiated through interviews and record reviews, revealing that the CNA yelled at the resident, using derogatory language. This incident was witnessed by another resident, who confirmed hearing the CNA yell at the resident multiple times. The facility's policy on abuse defines verbal abuse as language that includes disparaging and derogatory terms, and mental abuse as actions such as humiliation and harassment. The facility's investigation confirmed the abuse, and the CNA involved was terminated. The incident was reported in the Statewide Incident Management System, and the facility substantiated the verbal and mental abuse through their investigation, which included reports from other residents who also experienced verbal abuse from the same CNA.
Deficiencies in Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and cleanliness in the kitchen area. Observations revealed multiple instances of opened and undated food items in the walk-in cooler, including chicken breast chunks, fig preserve, cubed cheese, celery stalks, sliced ham, and sliced turkey. Additionally, a 10-pound roll of ground beef was found directly on the freezer floor due to a slanted bottom shelf. Expired food items, such as cinnamon rolls and Hershey's syrup, were also found in the walk-in freezer and cooler, respectively. The Dietary Supervisor confirmed these findings and acknowledged that food should be dated, labeled, and not stored on the floor or left open to air. Further observations identified cleanliness issues in the kitchen area, including two ceiling fans with a buildup of an unidentified gray substance and a yellow mop bucket with a buildup of an unidentified black substance. The ceiling fans, which were used during the day and blew over food preparation areas, were confirmed to be in need of cleaning. The Dietary Supervisor also confirmed that the yellow mop bucket, used daily to mop the kitchen area, should have been replaced due to its condition.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly. An observation on 05/19/2024 at 9:10 a.m. revealed that the dumpster had a large crack in the lid. During an interview at the same time, the Dietary Supervisor confirmed the findings and indicated that the dumpster lid had been cracked for approximately three months.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, specifically for Resident #32. The facility's policy requires a self-medication consent and release form, a self-medication assessment by the Director of Nursing (DON), and an order from the resident's physician to keep medication in the room. However, Resident #32, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15, was found with six disposable medicine cups containing different colored tablets on her bedside table. The resident identified these tablets as Tums, which she kept in her dresser drawer and bedside table without an order or assessment for self-administration. Observations over two days confirmed the presence of these medicine cups. Interviews with a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) revealed that the resident's granddaughter brought the tablets, and the LPN was unaware that the resident was self-administering Tums. The DON confirmed that Resident #32 had not been assessed for self-administration of medications and should not have had medications at the bedside. This oversight indicates a failure to follow the facility's policy on self-administration of medications.
Failure to Allow Unrestricted Visitation
Penalty
Summary
The facility failed to allow residents unrestricted visitation, as evidenced by the posted visitation hours and the requirement for family members to make appointments. Observations and interviews revealed that residents and their families were restricted to visiting hours from 10:00 a.m. to 8:00 p.m., and appointments had to be scheduled in advance. This practice was confirmed through interviews with staff, residents, and family members, who expressed frustration and concern over the limited and scheduled visitation times. For instance, Resident #30's family had to make an appointment to visit her in the lobby, and Resident #15's daughter faced difficulties scheduling visits due to the online system being fully booked for her preferred times. Additionally, the facility's visitation policy, updated in March 2024, aimed to maintain security, dignity, and the rights of all residents but inadvertently restricted visitation. The policy required visits to be scheduled to avoid interfering with resident care activities such as bath time, therapy, and meals. However, this led to complaints from family members and residents, as noted in a confidential interview, where it was mentioned that families and residents were reluctant to voice their concerns due to fear of retaliation. The administrator confirmed that the decision to set visiting hours and require appointments was made to avoid interference with resident care, but this practice ultimately limited residents' rights to receive visitors at their convenience.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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