Cypress At Lake Providence
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Providence, Louisiana.
- Location
- 5976 Us-65 North, Lake Providence, Louisiana 71254
- CMS Provider Number
- 195585
- Inspections on file
- 26
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cypress At Lake Providence during CMS and state inspections, most recent first.
Two residents with multiple chronic conditions, including schizoaffective disorder, legal blindness, paraplegia, heart failure, and multiple myeloma, were found in rooms that were not kept clean or in good repair. Surveyors observed dirt and grime on bed frames, bed rails, over-bed table frames, and furniture surfaces, as well as a missing nightstand drawer and a white powdery substance on an air conditioner vent for one resident. For the other resident, surveyors noted dirty and stained floors and furniture, along with an over-bed table with broken and missing veneer exposing particle board. These conditions were confirmed during observations with the facility Administrator.
The facility did not obtain or document informed consent for the use of psychotropic medications for five residents with various psychiatric and medical conditions. Despite some residents being cognitively intact and capable of providing consent, staff confirmed that no consents were present in the medical records for medications such as antipsychotics, antidepressants, and antianxiety agents.
The facility did not post the results of three recent surveys, making only the previous annual survey results accessible to residents. This was confirmed by the administrator, who acknowledged that the more recent survey outcomes, which included deficiencies, were not available for resident review.
Several residents did not have accurate MDS assessments, with omissions including unreported pressure ulcers, falls, and wounds. Required quarterly risk assessments for skin and falls were not completed as scheduled. Staff interviews and record reviews confirmed that these inaccuracies and missed assessments did not reflect the residents' true clinical status.
Several residents with significant medical and cognitive needs did not receive adequate assistance with bathing and personal hygiene, including nail and facial hair care. Observations and interviews revealed that residents had long, dirty fingernails or lengthy facial hair, and documentation showed that scheduled baths were frequently missed without record of refusals or alternative care. Nursing staff and the DON confirmed these deficiencies during the survey.
The facility did not implement or update appropriate interventions after falls for two residents—one with severe cognitive impairment and another with intact cognition but at risk for falls. In both cases, falls were not consistently addressed in the care plans, and new interventions were not documented or attempted after each incident, as confirmed by the DON.
The facility did not assess three residents for bed rail entrapment risk, failed to obtain informed consent or physician orders, and did not update care plans to reflect bed rail use. Observations confirmed bed rails were in use without required documentation or assessments, as verified by the Regional Director of Clinical.
Nursing staff did not follow physician orders to notify the physician when a resident with diabetes had multiple blood glucose readings above 401, as required. Documentation was lacking for these events, and the DON confirmed that notifications were not recorded.
A physician did not provide an adequate clinical rationale when declining a pharmacist's recommendation for a gradual dose reduction of antipsychotic and antidepressant medications for a resident, responding only with 'severity.' Additionally, the facility's pharmacist failed to identify and report irregularities related to necessary lab monitoring for two residents prescribed Levothyroxine and Atorvastatin Calcium, as confirmed by the DON and Regional Director of Clinical.
Surveyors observed flies throughout the facility on multiple days, with several residents reporting and being seen swatting flies away from their food in their rooms. The administrator confirmed the ongoing presence of flies in resident rooms and hallways.
The facility did not provide or document required dementia care, abuse prevention, and skills training for several CNAs, as confirmed by the DON during review of personnel records.
A resident with intact cognition was moved to a different room following a conflict with a roommate, but neither the resident nor her responsible party received the required written notice explaining the reason for the move. The DON confirmed that only verbal notification was provided, contrary to facility policy.
A resident was discharged from Medicare Part A skilled services by the facility before exhausting their benefit days, but was not given the required CMS-10055 and CMS-10123 notices. Documentation of these notices was not found, and the Clinical Reimbursement Specialist confirmed they could not locate the completed forms.
Surveyors found that multiple residents' rooms had unclean air/heating units with visible grime and dust, dead insects on bathroom walls, heavy lint on ceiling vents, and improperly positioned toilet lids. Facility leadership confirmed these environmental deficiencies during observations and interviews.
A resident with severe cognitive impairment and multiple medical conditions was prescribed antipsychotic and antianxiety medications, but staff failed to document monitoring for side effects and behaviors as required by the care plan. Review of medication records and staff interviews confirmed the absence of this monitoring over several weeks.
Surveyors found that the facility did not follow care plans for two residents: one was not provided with a smoking apron while smoking despite supervision, and another did not have a fall mat placed at the bedside as required, even after experiencing previous falls. Staff confirmed these lapses and that care plans were not individualized to resident needs.
Surveyors found that three residents requiring respiratory care did not receive services consistent with professional standards, as nebulizer mouthpieces were not stored in bags when not in use and required oxygen use/no smoking signage was not posted outside a resident's room. The DON confirmed these practices did not meet facility policy.
Two residents did not receive their prescribed medications because the facility did not have Vitamin D-2 and Farxiga available for administration. During medication pass observations, an LPN and the DON confirmed that these medications were not present on the medication cart or in the medication room, despite active physician orders.
A resident with significant medical conditions, including heart failure and chronic kidney disease, was prescribed a daily diuretic. Facility records showed no documented monitoring for edema on multiple occasions over two months. Facility leadership confirmed that edema monitoring should have been performed and documented while the resident was on the diuretic.
Two residents did not receive their prescribed daily medications because the medications were not available on the medication cart or in the facility at the time of administration. An LPN confirmed the omissions, resulting in a medication error rate of 7 percent, which exceeds the acceptable threshold.
Two residents were found with medications left unsecured at their bedsides, including one who self-administered a nasal spray without an active order and another with night medications left from the previous night. An LPN and the DON confirmed these findings, indicating a failure to store drugs and biologicals in locked compartments as required.
The facility did not conduct or document quarterly QAA meetings with the required committee members, as confirmed by record review and administrator interview.
A resident with cerebral infarction and dysphasia, who required medications to be crushed and flushed via tube feeding, had a used syringe improperly stored with liquid remaining in the tip and the plunger still inserted. The DON confirmed the syringe should have been rinsed and disassembled before storage.
Surveyors found that daily nurse staffing data was not posted in a prominent or accessible location on two consecutive days. The DON confirmed the omission, which had the potential to affect all 68 residents, as required staffing information was not available to residents or visitors.
The facility did not report two separate incidents—one involving a resident with a head laceration of unknown origin and another involving verbal abuse by a CNA—within the required 2-hour timeframe to the administrator and State Survey Agency. In both cases, delays in reporting were confirmed through interviews and record reviews, despite facility policy and regulatory requirements.
A CNA verbally abused a resident with cognitive and behavioral disorders by raising his voice and using inappropriate language after the resident grabbed his wrist during care. The incident was overheard by an agency LPN, reported to the DON, and confirmed as verbal abuse per facility policy.
A resident with significant pain-related diagnoses did not receive prescribed Oxycodone-Acetaminophen for several days because the medication was not available. Despite the care plan requiring timely pain management, staff were unable to provide the ordered medication, leading to the resident experiencing unrelieved pain and distress. Alternative pain relief was offered but refused, and non-pharmacological interventions were ineffective. The absence of the medication and the resulting lack of appropriate pain management were confirmed by staff and documentation.
A resident with moderate cognitive impairment was sexually abused twice by another resident after the facility failed to provide required 1:1 supervision. Despite policy requiring continuous monitoring following the first incident, the accused resident was left unsupervised and entered the victim's room again, resulting in a second allegation of abuse. Staff interviews and video evidence confirmed the lack of supervision.
A facility failed to provide required 1:1 supervision for a resident after an initial allegation of sexual abuse, resulting in a second incident where the same resident entered another's room and inappropriate contact was again alleged. Despite staff instructions, the assigned CNA did not maintain continuous observation, and video evidence confirmed the lack of supervision. Both residents involved had moderate cognitive impairment and complex medical histories.
The facility failed to report an abuse incident within the required timeframe. Two residents were involved in an altercation where one hit the other with a walker. Despite no injuries being found, the incident was not reported to the state agency until the next day, violating the facility's policy of reporting within two hours.
A cognitively impaired resident was physically abused by a CNA, who punched the resident multiple times after the resident grabbed the CNA's necklace. The incident was observed by two other CNAs, and the resident sustained bruising and scratches. The facility's investigation confirmed the abuse, and the CNA was arrested.
The facility failed to maintain an effective pest control program, resulting in multiple flies throughout the facility, including on residents' beds and dressings. The Regional Director of Clinical confirmed the facility's failure to ensure a pest-free environment for the residents.
The facility failed to ensure that the code status for two residents was documented and available for staff review. The advance directives were found in the Social Service Director's office and not in the residents' electronic records, as required.
The facility failed to maintain a safe, clean, comfortable, and homelike environment for four residents. Issues included unsecured light fixtures, holes in walls, exposed water pipes, and unsecured bathroom fixtures. These deficiencies were confirmed by the Administrator and Maintenance Supervisor.
The facility failed to provide necessary grooming and hygiene services to residents who were unable to perform these tasks themselves. Multiple residents were observed with long, dirty fingernails, unkempt beards, and strong body odors, despite their expressed needs and the confirmation of these issues by the DON.
The facility failed to provide adequate wound care and follow physician orders for several residents. One resident had new wounds that were not identified or reported, another had an unreported wound on his scrotum, and a third was observed without a prescribed hand roll for two months. These deficiencies indicate lapses in wound assessment, documentation, and adherence to care plans.
The facility failed to ensure proper documentation of medication administration for a resident with multiple diagnoses, leading to a deficiency in ensuring resident safety and well-being. Interviews revealed that the medications were not signed out when administered, indicating a lapse in adherence to the facility's medication administration policy.
The facility failed to ensure an RN provided services for 8 consecutive hours on specific dates. Review of PBJ Data time sheets revealed no staffing hours for the RN, and the Administrator confirmed the absence of documentation to prove RN coverage.
The pharmacist failed to report irregularities in the drug regimen review for three residents. For one resident, missing lab results were not addressed, while for two other residents, the lack of edema monitoring while on Furosemide was not reported. The ADON and DON confirmed these deficiencies.
The facility failed to ensure residents' drug regimens were free from unnecessary drugs by not performing edema checks for two residents on diuretics and not obtaining ordered lab tests for another resident. This was confirmed through record reviews and staff interviews.
The facility failed to store, prepare, and distribute food in accordance with professional standards, including improper temperature maintenance, lack of labeling, and inadequate training of the Dietary Manager. These deficiencies had the potential to affect all residents receiving meals from the kitchen.
The facility failed to provide sufficient nursing staff, not meeting the required 2.35 hours of care per patient per day on 11 out of 65 days. Two residents reported delays in care, especially during the night shift, which was confirmed by the DON.
The facility failed to provide the required CMS forms to inform two residents of changes in their Medicare covered services upon discharge, as confirmed by the facility's administrator and MDS nurse.
A resident with severe cognitive impairment was physically abused by a CNA, and the incident was not reported immediately by the witnessing CNAs. The abuse was only reported the following day, violating the facility's policy for immediate reporting of abuse allegations.
The facility failed to conduct a required quarterly smoking assessment for a resident with chronic conditions, despite policy mandates and the resident being assessed as an unsafe smoker. This lapse was confirmed by the facility's Director of Nursing and the Regional Director of Clinical.
The facility failed to ensure monthly State Adverse Actions Website checks for CNAs S23CNA, S24CNA, and S25CNA. Personnel files showed the first documented check on 05/03/2024, with no prior monthly checks. The S1Administrator confirmed the absence of documentation for the required checks before this date.
The facility failed to maintain safe resident care equipment for two residents, one with severe cognitive impairment and another with intact cognition, both requiring wheelchairs. Observations revealed a missing rubber cover on one resident's wheelchair handle and a torn armrest on another's wheelchair, issues that were confirmed by staff but not timely addressed.
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. Multiple residents were unaware of where the state inspection results were located. An observation revealed that the state inspection results were not labeled and were stored in a clear plastic bin on the wall, out of reach for residents in wheelchairs.
Failure to Maintain Clean and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents by not keeping their beds, furniture, and room fixtures clean and in good repair. For Resident #2, who was admitted with diagnoses including schizoaffective disorder, legal blindness, type 2 DM, peripheral vascular disease, seizures, and depression and had a BIMS score of 15 indicating no cognitive impairment, surveyors observed dirt and grime on the bed frame, bed rails, over-bed table frame, and the top of the nightstand. The top drawer of the nightstand was missing, and a white powdery substance was observed covering the air conditioner vent. These conditions were confirmed during a joint observation with the Administrator. For Resident #3, who had diagnoses including paraplegia, generalized muscle weakness, hypertensive heart disease with heart failure, and multiple myeloma not in remission, and a BIMS score of 12 indicating moderate cognitive impairment, surveyors observed dirt and stains on the bed frame, bed rails, over-bed table frame, and floor. Additionally, the over-bed table had broken and missing veneer, leaving exposed particle board. These environmental deficiencies were also confirmed during an observation with the Administrator.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for the use of psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents. Record reviews and staff interviews confirmed that for five residents with various diagnoses such as bipolar disorder, depression, dementia, schizophrenia, and schizoaffective disorder, there was no documented evidence of informed consent for the administration of these medications. The medications in question included Haldol, Seroquel, Escitalopram, Zyprexa, Clonazepam, Divalproex, Clozapine, Mirtazapine, Lorazepam, Sertraline, Depakote, and Geodon. Interviews with the Director of Nursing and the Regional Director of Clinical confirmed the absence of required consents in the residents' medical records. Some of the residents were noted to be cognitively intact based on their BIMS scores, indicating they were capable of providing consent. Despite this, the facility did not obtain or document consent for the use of psychotropic medications, as required, for any of the five residents reviewed.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the results of its most recent surveys were posted and accessible to residents. During an observation on 05/21/2025, it was found that only the results of the annual survey dated 05/08/2024 were available in the survey results binder for residents to view. However, the facility had undergone three additional surveys after the annual survey—on 09/26/2024, 04/01/2025, and 04/23/2025—which resulted in deficiencies, but the results of these surveys were not posted. This was confirmed during an interview with the facility administrator, who acknowledged that the results of the three subsequent surveys had not been made available to residents.
Inaccurate MDS Assessments and Missed Risk Evaluations
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of several residents, resulting in multiple deficiencies. For one resident with a history of cerebrovascular disease, neuropathy, and dementia, the quarterly MDS did not document a stage 3 pressure ulcer that was present and facility-acquired, nor was a Braden scale risk assessment completed quarterly as required. Interviews with nursing staff and record reviews confirmed that the pressure ulcer was omitted from the MDS and that the last Braden assessment had not been updated for several months. Another resident with severe cognitive impairment and multiple comorbidities experienced two falls prior to the quarterly MDS assessment, but these incidents were not documented in the MDS. Additionally, the required quarterly fall risk assessment was not completed, with the last assessment dated several months prior. Staff interviews confirmed the omission of the falls from the MDS and the lack of timely risk assessment. A third resident with severe cognitive impairment suffered a fall resulting in a laceration and stitches, but the MDS inaccurately recorded the number of falls with injury. In another case, a resident with traumatic brain injury and reduced mobility had pressure ulcers on admission, but the quarterly MDS did not reflect the presence of these wounds. Staff interviews and record reviews consistently confirmed that the MDS assessments were inaccurate and did not align with the residents' actual clinical conditions.
Failure to Provide Adequate Bathing and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for residents who were unable to perform activities of daily living independently. Multiple residents with significant medical conditions and cognitive impairments were observed to have unmet hygiene needs, including inadequate bathing and nail care. For example, one resident with cerebrovascular disease and major depression, who was cognitively intact and required assistance with personal hygiene, was found to have long, dirty fingernails despite having requested staff assistance to trim them. A licensed practical nurse confirmed the need for nail care after direct observation. Another resident with severe obesity, diabetes, and multiple mobility issues, who required maximal assistance for bathing and hygiene, reported not receiving scheduled bed baths. Documentation confirmed that this resident received significantly fewer baths than scheduled, with no record of refusals or alternative care provided. The director of nursing verified the lack of documentation for missed baths. Similarly, a resident with dementia and muscle weakness, requiring substantial assistance, was observed on multiple occasions to have very long fingernails, which was acknowledged by the director of nursing during an in-room observation. Additionally, a resident with cerebral infarction, diabetes, and psychiatric diagnoses, who was cognitively intact and required substantial assistance with personal hygiene, was observed to have lengthy facial hair on multiple occasions. Bathing documentation for this resident was also incomplete, with only a few baths recorded over a two-month period despite a regular schedule. Staff interviews confirmed the expected bathing schedule, and the director of nursing acknowledged the lack of documentation for completed baths.
Failure to Implement and Update Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure that two residents remained as free from accident hazards as possible by not implementing appropriate or new interventions after each fall. For one resident with severe cognitive impairment and multiple comorbidities, including dementia and heart failure, the care plan did not include interventions for all documented falls, and the intervention that was implemented—reminding the resident to call for assistance—was not appropriate given the resident's cognitive status. Additionally, two subsequent falls were not addressed with any new interventions or updates to the care plan. Another resident, who had intact cognition but was at risk for falls and required assistance with activities of daily living, experienced a fall that was not addressed in the care plan, and there was no documented evidence that any intervention was attempted after the incident. The Director of Nursing confirmed that new interventions were not implemented for either resident following their respective falls, and that the care plans were not updated to reflect these incidents.
Failure to Assess, Obtain Consent, and Document Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for three residents. Specifically, the facility did not assess residents for the risk of entrapment prior to the installation of bed rails, did not obtain informed consent from the residents or their representatives, did not secure physician orders for bed rail use, and did not update the residents' care plans to reflect the use of bed rails. These deficiencies were identified through record reviews, observations, and staff interviews. For one resident with diagnoses including type 2 diabetes, muscle weakness, heart failure, chronic kidney disease, and a history of repeated falls, there was no documentation of a bed rail assessment, informed consent, physician order, or care plan entry for the use of bilateral quarter bed rails, despite repeated observations of the resident with bed rails in the upright position. Another resident with acute necrotizing hemorrhagic encephalopathy, schizophrenia, muscle weakness, seizures, and lack of coordination was also observed with a quarter bed rail in use, but similarly lacked documentation of assessment, consent, physician order, or care plan inclusion for the bed rail. A third resident, who was cognitively intact and able to transfer with standby assistance, was observed with a right upper quarter bed rail in use. Record review confirmed the absence of a physician's order, care plan, or bed rail assessment for this resident. In all three cases, the Regional Director of Clinical confirmed that the required assessments, consents, orders, and care plan updates had not been completed prior to or during the use of bed rails.
Failure to Notify Physician of Elevated Blood Glucose Readings
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to follow physician orders for a resident with diabetes. Medical record review showed that the resident was admitted with a diagnosis of diabetes and had physician orders for accu-checks four times daily, with instructions to administer 10 units of insulin and notify the physician if results were 401 or greater. On multiple occasions, the resident's blood glucose readings exceeded 401, but there was no documentation that the physician was notified as required. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding physician notification for these elevated readings.
Failure to Document Clinical Rationale and Monitor Medication Irregularities
Penalty
Summary
The facility failed to ensure that a physician documented an adequate clinical rationale for denying a gradual dose reduction for a resident prescribed antipsychotic and antidepressant medications. Specifically, the physician declined the pharmacist's recommendation for a gradual dose reduction of Seroquel and Escitalopram, providing only the single word 'severity' as justification, which did not meet the facility's policy requirement for a valid clinical rationale. This was confirmed by the Director of Nursing, who acknowledged the lack of an adequate response from the physician. Additionally, the facility's consultant pharmacist did not identify or report irregularities related to the monitoring of prescribed medications for two residents. One resident, prescribed Levothyroxine, did not have appropriate monitoring of thyroid levels identified or reported by the pharmacist. Another resident, prescribed Atorvastatin Calcium, did not have the need for lipid panel monitoring identified or reported. The Regional Director of Clinical confirmed that these irregularities related to necessary lab work monitoring were not recognized by the pharmacist during the monthly drug regimen review.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies throughout the building on all days of the survey. Multiple residents reported ongoing issues with flies in their rooms, specifically during meal times, which required them to actively shoo flies away from their food. Surveyors directly observed several flies in the rooms of three residents on multiple occasions, and these residents confirmed that flies remained a persistent problem in their rooms and in the hallways. The administrator acknowledged awareness of the issue, confirming the presence of flies throughout the facility during the survey period.
Lack of Required Training and Competency Documentation for CNAs
Penalty
Summary
The facility failed to ensure that required dementia management and abuse prevention training was completed for two certified nursing assistants, as there was no documented evidence of this training in their personnel records. Additionally, four certified nursing assistants did not have documented evidence of competencies and skills training in their records. These deficiencies were confirmed by the Director of Nursing, who acknowledged the lack of documentation for dementia management, abuse prevention, and competencies/skills training for the affected staff members. The review of personnel records specifically identified missing documentation for dementia management and abuse prevention training for two staff members, and missing competencies and skills training for four staff members. The findings were based on both record review and confirmation through interview with facility leadership.
Failure to Provide Written Notice for Resident Room Change
Penalty
Summary
A deficiency occurred when the facility failed to provide written notice, including the reason for a room change, to a resident prior to moving her to a different room. The facility's policy requires that residents and their representatives receive a written explanation when a room change is initiated by the facility. In this case, the resident, who had intact cognition as indicated by a BIMS score of 15, was moved after an incident involving conflict with her roommate. Documentation in the medical record and interviews confirmed that the resident was verbally informed of the room change by the DON, but neither the resident nor her responsible party received the required written notice. The resident expressed dissatisfaction with the move, and the DON acknowledged that the facility did not follow its policy regarding written notification for room changes.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident, who was receiving Medicare Part A skilled services and had days remaining in their benefit period, with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS-10055) and Notice of Medicare Non-coverage (NOMNC, CMS-10123) prior to facility-initiated discharge from Medicare Part A services. Record review showed that the resident's skilled services episode began on 01/05/2025, with the last covered day on 02/03/2025, and the discharge from Medicare Part A was initiated by the facility before benefit days were exhausted. Documentation confirming that the required notices were provided to the resident was not found. An interview with the Clinical Reimbursement Specialist confirmed the absence of the completed forms for this resident.
Failure to Maintain Clean and Homelike Resident Environments
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents. In one resident's room, the air/heating unit had visible grime and debris on the air vents during multiple observations. Another resident's room was found to have grime and dust on the air/heating unit vents, which was confirmed by both the DON and Maintenance Director as needing cleaning. Additionally, a third resident's room had numerous dead flying insects stuck to the bathroom walls, heavy lint buildup on the bathroom ceiling vent, a toilet lid that was ajar with the inside visible, and black buildup inside the air conditioner unit. These conditions were confirmed by facility leadership during an observation and interview.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects and behaviors associated with psychotropic medications. The resident in question had multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, kidney failure, unspecified dementia with behavioral disturbance, and a history of substance abuse. The resident's care plan included interventions to administer medications as ordered and to monitor and document for side effects and effectiveness, as well as to review medications for possible causes of cognitive deficits. Despite these care plan interventions, a review of the Medication Administration Record (MAR) for April and May 2025 showed no documented evidence that staff monitored for side effects and behaviors every shift for the antipsychotic and antianxiety medications prescribed to the resident. This lack of documentation was confirmed during an interview with the Regional Director of Clinical, who acknowledged that there was no evidence of monitoring for the specified periods. The failure to monitor and document as required led to the cited deficiency.
Failure to Implement Care Plans for Smoking Safety and Fall Prevention
Penalty
Summary
The facility failed to implement the care plans for two residents as observed and documented by surveyors. One resident, with diagnoses including heart disease, COPD, diabetes, and moderate intellectual disabilities, was care planned to wear a smoking apron and be supervised while smoking. Despite this, the resident was observed on multiple occasions in the designated smoking area holding a lit cigarette without wearing the required smoking apron, even though staff were present and aware of the care plan requirements. Another resident, with a history of traumatic brain injury, reduced mobility, and moderate cognitive impairment, was care planned to have a fall mat placed at the bedside due to previous falls. However, repeated observations showed that the fall mat was propped against the wall away from the bed and not in use as intended. Staff interviews confirmed that the fall mat was not in place according to the care plan, and the care plan had not been individualized to the resident's needs.
Failure to Properly Store Respiratory Equipment and Post Oxygen Use Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such services, as evidenced by improper storage of nebulizer mouthpieces and lack of required oxygen use signage. For one resident with diabetes and shortness of breath, observations revealed the nebulizer mouthpiece was left exposed on a bedside dresser and on the bed, rather than being stored in a plastic bag as required. Another resident with COPD and multiple comorbidities also had a nebulizer mouthpiece left unbagged on the bedside table during multiple observations. In both cases, the DON confirmed that the mouthpieces should have been stored in bags when not in use. Additionally, a resident with morbid obesity, type 2 diabetes, COPD, and other conditions was observed receiving continuous oxygen therapy without any signage posted outside the room to indicate oxygen was in use and that smoking was prohibited. The DON confirmed that such signage should have been present. These failures were identified through observations, interviews, and record reviews, and involved three residents who required respiratory care.
Failure to Provide Prescribed Medications Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not ensuring that prescribed medications were available for administration. During a medication pass, it was observed that Vitamin D-2 400 units, ordered daily for one resident, was not present on the medication cart or in the medication room, and staff confirmed it was not available in the facility. Similarly, Farxiga 10 mg, also ordered daily for another resident, was not available on the cart or in the medication room, with staff and the Director of Nursing confirming its absence. These deficiencies were identified through direct observation, record review, and staff interviews, indicating that the facility did not have the necessary medications on hand for administration as ordered by physicians.
Failure to Monitor for Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring for edema while the resident was prescribed a diuretic. Record review showed that a resident with multiple diagnoses, including heart failure, chronic kidney disease, and dementia, was ordered Hydrochlorothiazide, a diuretic, to be administered daily. However, there was no documented evidence of edema monitoring for 13 instances in April and 16 instances in May, as indicated in the Medication Administration Records. Interviews with the DON and Regional Director of Clinical confirmed that monitoring for edema should have occurred and that there was no documentation of such monitoring during the specified periods.
Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 2 errors out of 27 observed medication administration opportunities, resulting in a 7 percent error rate. During a medication pass, a Licensed Practical Nurse (LPN) was unable to administer Vitamin D-2 400 units to one resident and Farxiga 10 mg to another resident because both medications were not available on the medication cart or in the facility at the time of administration. These omissions were confirmed by the LPN and verified through review of the physician's orders, which indicated that both residents were to receive these medications daily. The lack of medication availability directly led to the errors by omission.
Failure to Secure Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored properly in locked compartments, as required by policy and regulation. In one instance, a resident with a history of depression, bipolar disorder, and other medical conditions was observed to have a bottle of Flonase nasal spray on her bedside table and reported self-administering the medication as needed. Review of her medical record revealed there was no active order for Flonase, and the DON confirmed the medication was at the bedside and being self-administered. In another case, a resident with moderate cognitive impairment and multiple diagnoses was found with a medication cup containing two tablets on his bedside table, which were identified by an LPN as his night medications that should have been administered the previous night. There was no documentation of medication refusal for this resident, and the DON was notified of the incident. These observations demonstrate that medications were left unsecured at residents' bedsides, contrary to facility policy and accepted professional standards.
Failure to Hold and Document Required QAA Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required committee members present, as required. This deficiency was identified through record review and interview, which revealed that there was no documentation of any QAA meetings being held since the previous annual survey. During an interview, the administrator confirmed that the facility was unable to locate records of these meetings.
Improper Storage of Used Tube Feeding Syringe
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring proper storage of a used tube feeding syringe for a resident with cerebral infarction and dysphasia. Medical records indicated that the resident required medications to be crushed and flushed with water before and after administration. During observation, the syringe used for medication administration was found with an orange-colored liquid in the tip and the plunger still inserted, rather than being rinsed and disassembled as required. The DON confirmed in an interview that the syringe should have been properly cleaned and stored after use.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing data was posted in a prominent and accessible location as required. On two consecutive days, surveyors were unable to locate the daily staffing information for those dates during their observations. During an interview and observation, the DON confirmed that the daily staffing information had not been posted. This deficiency had the potential to affect any of the 68 residents residing in the facility, as the required staffing information was not made available to residents or visitors.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the State Survey Agency, as required by policy and regulation. Specifically, two residents were involved in separate incidents where timely reporting did not occur. One resident with multiple diagnoses, including chronic obstructive pulmonary disease, schizophrenia, and acute kidney failure, was found in bed with a laceration to the back of the head. The injury was classified as of unknown origin, and the resident was unable to communicate about the incident due to cognitive impairment. The incident was discovered by a CNA, and although the resident was sent to the hospital for treatment, the facility did not report the injury to the State Survey Agency within the required 2-hour timeframe, instead reporting it the following day. In a separate incident, another resident with significant cognitive and behavioral issues, who required one-on-one care, was involved in an episode where a CNA was overheard raising his voice and using inappropriate language after the resident grabbed his wrist. The agency LPN who overheard the incident did not report it to the DON immediately or within 2 hours, and the DON subsequently delayed reporting to the administrator. The administrator also failed to submit a report to the State Survey Agency within the required 2-hour window. These failures were confirmed through interviews and record reviews.
Verbal Abuse by CNA Toward Resident with Behavioral Challenges
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) verbally abused a resident with significant cognitive and behavioral challenges. The resident, who had diagnoses including anoxic brain damage, psychotic disorder, and required moderate to maximal assistance with activities of daily living, was on a 24-hour one-on-one care plan due to aggressive behaviors. During care, the resident grabbed the CNA's wrist, causing pain. In response, the CNA raised his voice and used inappropriate language toward the resident, which was overheard by an agency LPN. The CNA immediately apologized after the incident. The facility's policy prohibits all forms of abuse, including verbal abuse, and requires staff to maintain professional behavior even in challenging situations. The incident was reported by the agency LPN to the Director of Nursing (DON), who subsequently notified the administrator. The investigation confirmed that the CNA's conduct constituted verbal abuse, as defined by the facility's policy, due to the use of raised voice and inappropriate language in response to the resident's actions.
Failure to Provide Prescribed Pain Medication Due to Unavailability
Penalty
Summary
A resident with multiple complex medical conditions, including lumbar radiculopathy, open lumbar fracture, and chronic pain, was admitted with an order for Oxycodone-Acetaminophen 10-325 mg to be administered every 8 hours as needed for pain. Review of the medication administration records showed that the resident received this medication regularly in March, but it was not administered from April 1 through April 3. The controlled drug record confirmed that the medication was not available during this period. The resident's care plan specified that analgesia should be administered as ordered and that staff should anticipate and respond immediately to complaints of pain. During the period when the medication was unavailable, the resident expressed agitation and distress due to unrelieved pain, as documented in nurse's notes and confirmed in interviews with both the resident and staff. The nurse offered alternative pain relief options, such as Tylenol and ibuprofen, which the resident refused, and attempted non-pharmacological interventions without success. Both the DON and a corporate RN confirmed the unavailability of the prescribed pain medication for several days, resulting in the resident not receiving pain management in accordance with professional standards, the care plan, or the resident's preferences.
Failure to Provide 1:1 Supervision Results in Repeat Sexual Abuse Incident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, resulting in two separate incidents of alleged abuse. The first incident occurred when one resident entered another's room and touched her breast, as reported by the victim and confirmed by video footage. The accused resident was removed from the facility by law enforcement following this event. After the accused resident was returned to the facility by law enforcement, the facility's policy required 1:1 supervision for the resident to prevent further abuse. However, the assigned staff member did not provide continuous monitoring, as she also responded to other call lights on the unit. Video footage confirmed that the accused resident was left unsupervised and subsequently entered the victim's room a second time, where another allegation of sexual abuse was made. Both residents involved had moderate cognitive impairment, as indicated by their BIMS scores. The facility's own policies required immediate and continuous visual monitoring for residents placed on 1:1 care, but this was not implemented. Staff interviews and documentation confirmed that the required supervision was not maintained, directly leading to the second incident of alleged abuse.
Removal Plan
- Full body assessment completed on resident #1.
- Resident #1 was offered to be evaluated at the emergency room and declined.
- Police notified and the accused resident #2 was taken into custody.
- Accused resident #2 was placed on 1:1 upon return to facility.
- DON/Designee has put daily monitors in place for each shift for resident #1 that staff will ask resident if she feels safe in the facility with no psycho-social harm exhibited.
- DON/Designee has in-serviced all employees and agency personnel and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse (noting sexual and verbal), and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal return demonstrations of types of abuse, signs, and proper reporting procedures.
- A Statewide Incident Management System (SIMS) report was initiated.
Failure to Implement 1:1 Supervision After Abuse Allegation
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting abuse, specifically by not providing required one-to-one (1:1) supervision for a resident following an allegation of sexual abuse. After an initial incident in which a resident with moderate cognitive impairment reported that another resident entered her room and touched her breast, the alleged perpetrator was removed from the facility by law enforcement. However, upon the resident's return, the facility did not ensure continuous 1:1 monitoring as required by their own policy. Despite instructions for 1:1 supervision, the assigned staff member did not remain with the resident at all times and responded to other call lights, leaving the resident unsupervised. Video footage confirmed that the resident was left alone and subsequently entered the same resident's room a second time, where another allegation of inappropriate touching was made. Staff interviews and documentation revealed inconsistencies in monitoring and reporting, with some staff initially doubting the second incident and failing to provide accurate accounts of their supervision. The residents involved both had moderate cognitive impairment and complex medical histories, including conditions such as hemiplegia, aphasia, Parkinson's disease, and schizoaffective disorder. The failure to provide mandated supervision after a substantiated abuse allegation directly contradicted facility policy and resulted in a second incident of alleged abuse, constituting a deficiency and Immediate Jeopardy situation.
Removal Plan
- Resident #2 remained on 1:1 care and was sent to in-patient psych.
- Resident #1 was offered to be evaluated at ER and declined.
- Police notified of the second occurrence.
- Full body skin assessment of Resident #1 completed.
- DON/Designee has put daily monitors in place for each shift for resident #1 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited.
- DON/Designee has in-serviced all employees and agency personnel and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse, sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures.
- Staff involved received disciplinary action and resigned from her position at the facility.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe, as mandated by state law. The incident involved two residents, one of whom attempted to push the other out of a wheelchair and subsequently hit him in the back of the head with a walker. The resident who was struck refused medical evaluation, stating he was not seriously hurt. The incident was witnessed by staff, who separated the residents immediately. The facility's policy requires that any reasonable suspicion of a crime involving serious bodily injury be reported within two hours, but the incident was not reported to the state survey agency until the following morning. Resident #6, who was cognitively intact, and resident #7, who had moderate cognitive impairment, were involved in the altercation. The nurse's notes confirmed that there were no visible injuries to either resident following the incident. The Director of Nursing and the medical director were informed, but the exact time of notification was not documented. The delay in reporting the incident to the state agency was confirmed by the facility's administrator, indicating a failure to adhere to the established reporting procedures.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and psychosocial abuse by a Certified Nursing Assistant (CNA). The incident involved a cognitively impaired resident with multiple diagnoses, including major depressive disorder, dementia with behavioral disturbance, and anxiety. On the day of the incident, the resident was observed by two other CNAs being punched in the face, chest, and side multiple times by S4CNA after the resident grabbed the CNA's necklace. The resident sustained bruising and scratches as a result of the abuse. The facility's policy and procedure for Freedom from Abuse, Neglect, and Exploitation, dated March 2023, was not followed. The resident's medical records indicated a need for one-on-one care at all times, which was in place at the time of the incident. Despite this, the abuse occurred, and the resident was found with visible injuries by the oncoming shift CNAs, who immediately reported the incident to the Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON). The facility conducted an investigation, during which S4CNA initially denied any wrongdoing but later admitted to hitting the resident. The local Sheriff's department was notified, and S4CNA was arrested. Interviews with staff and review of statements confirmed the abuse, highlighting a significant failure in ensuring the resident's safety and adherence to the facility's abuse prevention policies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a pest-infested environment that affected four sampled residents and potentially all 82 residents in the facility. Observations over three days revealed multiple flies throughout the facility, including the dining room, resident hallways, and common areas. Specific incidents included flies on a resident's sheet near his head, three flies near another resident's bed, a fly on a dressing on a resident's leg, and a fly landing on a resident's face. The Regional Director of Clinical confirmed the facility's failure to ensure a pest-free environment for the residents.
Failure to Ensure Residents' Code Status Documentation
Penalty
Summary
The facility failed to ensure that the residents' code status was obtained and available for staff to review for two residents. For Resident #188, a review of the record revealed no documentation of an advance directive indicating the resident's code status. An interview with the Social Service Director (SSD) revealed that the advance directive was in the social folder in her office and not available to staff. The SSD mentioned that she is new and in the process of going through each resident's record and social folder. Similarly, for Resident #186, a review of the record also revealed no documentation of an advance directive indicating the resident's code status. The Director of Nursing (DON) confirmed that social services usually obtain the residents' advance directive upon admission. An interview with the SSD revealed that the advance directive was in the social folder in her office and not available to staff. Both the DON and the Regional Director of Clinical confirmed that the advance directive should have been obtained upon admission and entered into the resident's electronic record for staff review.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for four residents. Observations of Resident #44's room revealed a metal fluorescent light fixture that was only secured on one side and was leaning down, posing a potential safety hazard. This was confirmed by the Administrator and Maintenance Supervisor. Resident #83's room had multiple issues, including vertical holes in the wall behind the bed, gouged areas with missing paint, and a closet door that was not secured. Additionally, the bathroom had a toilet paper holder lying on the floor with small holes in the wall where it was previously attached. These issues were also confirmed by the Administrator and Maintenance Supervisor during their observation. Resident #64's room had a large hole in the wall next to the bed, exposing water pipes, and a folded blanket placed on the bathroom floor behind the toilet. These conditions were confirmed during an observation with the Administrator and Maintenance Director. Resident #74's bathroom had a large hole with exposed water pipes next to the toilet, which was also confirmed by the Administrator and Maintenance Director. These deficiencies indicate a failure to provide a safe and comfortable living environment for the residents, as required by the facility's policy for Physical Environment dated March 2023.
Failure to Provide Necessary Grooming and Hygiene Services
Penalty
Summary
The facility failed to ensure that residents who are unable to perform activities of daily living received the necessary services to maintain good grooming and personal hygiene. Resident #26, who had multiple diagnoses including hemiplegia, aphasia, and vascular dementia, was observed with long, dirty fingernails and an unshaven beard. Despite the resident's cognitive intactness and expressed need for grooming, the issues were not addressed even after being confirmed by the Director of Nursing (DON). Similarly, Resident #64, who required partial assistance with bathing and hygiene, was observed with a strong urine and body odor, dirty fingernails and toenails, and stained clothing. These conditions persisted over multiple days and were confirmed by the DON as needing attention. Resident #60, who required extensive assistance for all activities of daily living, was also observed with dirty and untrimmed fingernails and toenails. This was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), as well as the DON and the Regional Director of Clinical. Resident #44, who had severe cognitive impairment and required moderate assistance with personal hygiene, was observed with grime under their fingernails on multiple occasions. The DON confirmed the need for nail cleaning and trimming. Lastly, Resident #71, who was dependent on staff for personal hygiene, was observed with long, dirty fingernails and an unkempt beard and mustache. The resident expressed a desire for grooming assistance, which was not provided, and the DON confirmed the need for nail and beard trimming. These observations indicate a systemic failure to provide necessary grooming and hygiene services to residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for several residents. Resident #26, who was admitted with multiple diagnoses including hemiplegia, type 2 diabetes, and calciphylaxis wounds, had new wounds that were not identified or reported by the CNAs or floor nurses. These new wounds included areas on the left gluteal fold, right heel, left heel, and left inner knee, which were discovered during a wound treatment session. The Assistant Director of Nursing confirmed that these areas had not been previously identified or reported, indicating a failure in the facility's wound assessment and reporting process. Resident #39, who had diagnoses including stage 4 pressure ulcers, dementia, and bilateral above-the-knee amputation, was found to have an unreported wound on his right scrotum. Despite a CNA noticing redness and a small crack in the skin a week prior, this information was not properly documented or communicated to the treatment nurse. The wound was only identified and assessed after the surveyor's observation, revealing a significant lapse in the facility's wound care and documentation procedures. Resident #60, diagnosed with cerebral infarction and hemiplegia, was observed without a hand roll in his right hand, which was ordered to prevent contractures. Staff interviews confirmed that the hand roll had not been in place for at least two months, indicating a failure to follow physician orders and care plans. This deficiency highlights the facility's failure to ensure that prescribed treatments and preventive measures are consistently implemented for residents, compromising their care and well-being.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not have documentation of medications administered for one resident (#16) out of five residents reviewed for unnecessary medications. The facility's Pharmacy Services Medication Administration Policy aimed to provide residents with safe and accurate medication administration, but this was not adhered to in the case of resident #16. The resident had multiple diagnoses, including major depressive disorder, dementia with behavioral disturbance, and anxiety, and required extensive assistance with activities of daily living. The physician's orders for May 2024 included several medications to be administered at specific times, but there was no documented evidence of these medications being administered on two specific dates at 6:00 p.m. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the medications were not signed out when administered. The DON was unsure why the medications were not documented, and the LPN admitted to forgetting to sign out the medications on the specified dates. This lack of documentation and adherence to the medication administration policy indicates a deficiency in the facility's ability to ensure the safety and well-being of its residents through proper medication management.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day on 12/23/2023, 12/25/2023, 12/26/2023, and 12/30/2023. Review of the facility's Payroll Based Journal (PBJ) Data time sheets for these dates revealed no staffing hours for the RN, indicating that no RN worked the required 8 consecutive hours on those dates. An interview with the Administrator on 05/08/2024 confirmed the absence of documentation or time sheets to prove that an RN worked for the required hours on the specified dates.
Pharmacist Fails to Report Irregularities in Drug Regimen Review
Penalty
Summary
The pharmacist failed to report any irregularities to the attending physician, medical director, and director of nursing for three residents during the monthly drug regimen review. For Resident #26, the pharmacist did not address missing laboratory results that were ordered, including Chemistry 14, Glycated Hemoglobin (A1C), liver function tests (LFT), complete blood count (CBC), prostatic-specific antigen (PSA), and lipids. The Assistant Director of Nursing (ADON) confirmed that the pharmacist did not report the missing labs for Resident #26 during the drug regimen reviews for February, March, and April 2024. For Resident #64, the pharmacist did not address the lack of monitoring for edema while the resident was receiving Furosemide (Lasix). The medication administration records for April and May 2024 showed no documentation of edema checks prior to administering Lasix. Similarly, for Resident #53, there was no documented evidence of edema checks while the resident was receiving Furosemide and Spironolactone for edema. The Director of Nursing (DON) confirmed the absence of edema checks, and the pharmacist did not address this issue in the drug regimen reviews for March and April 2024.
Failure to Monitor Edema and Obtain Laboratory Tests
Penalty
Summary
The facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three of the five sampled residents reviewed for unnecessary medications. Specifically, the facility did not perform edema checks for two residents while they were taking a diuretic and failed to obtain ordered laboratory tests for another resident. Resident #26 had multiple diagnoses including hemiplegia, COPD, diabetes, and end-stage renal disease, among others. The facility did not obtain the Glycated Hemoglobin (A1C) for January and April 2024, the liver function test (LFT) for January 2024, or the complete blood count (CBC), prostatic-specific antigen (PSA), and lipids for July 2023 as ordered by the physician. This was confirmed by the Assistant Director of Nursing (ADON) during an interview on 05/08/2024. Resident #64, who had diagnoses including COPD, hypertension, and cirrhosis of the liver, had a physician's order for Furosemide (Lasix) 40 mg daily for edema. However, the April and May 2024 Medication Administration Records (MAR) showed no documentation of edema checks prior to administering the Lasix. Similarly, Resident #53, with diagnoses including myocardial infarction, obesity, and pulmonary embolism, had orders for Furosemide and Spironolactone for edema, but there was no documented evidence of edema checks. This lack of monitoring was confirmed by the Director of Nursing (DON) during an interview on 05/08/2024.
Deficiencies in Food Storage, Preparation, and Distribution
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an observation of the kitchen environment, the front of the ice machine was found open, exposing the inside of the machine and electrical components. The stand-up refrigerator had a temperature reading of 48 degrees Fahrenheit, and the walk-in refrigerator had a temperature reading of 61 degrees Fahrenheit, both of which are above the recommended safe storage temperatures. Additionally, there were no temperature logs maintained for the refrigerators and freezers. Unlabeled and unidentified food items were found in the stand-up refrigerator, and the Dietary Manager (S11DM) confirmed the lack of proper labeling and temperature logs. The S11DM also demonstrated improper use of chemical test strips for the 3-compartment sink and revealed a lack of training on how to check the sanitizer levels correctly. The 3-compartment sink was found without water in the sanitizer bin, and clean dishes were stacked in an upright position in the dishwashing area, which is not in accordance with professional standards. Further observations revealed that the electric thermometer used to check steam table temperatures was not cleaned between uses. The food temperature log had not been updated since March 24, 2024. The S11DM, who had been employed since April 1, 2024, admitted to having only restaurant management experience and confirmed that she did not receive training on managing a kitchen in a nursing facility. These deficiencies in food storage, preparation, and distribution practices had the potential to affect all residents receiving meals from the kitchen.
Insufficient Nursing Staff and Non-compliance with Care Plans
Penalty
Summary
The facility failed to provide a sufficient number of nursing service personnel to meet the required 2.35 hours of care per patient per day as mandated by state statute 9823, A. The review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form from 03/01/2024 to 05/04/2024 revealed that the facility did not meet the required hours on 11 out of 65 days. This was confirmed by the facility's administrator during an interview. Additionally, the Director of Nursing (DON) confirmed that there was insufficient CNA staffing on the evening and night shifts for multiple days in the last two weeks, affecting the care provided to residents. Resident #38, who has diagnoses of paraplegia, congestive heart failure, and generalized osteoarthritis, reported that CNAs took a long time to answer his call light, especially during the night shift. The DON confirmed the insufficient staffing on the night shift. Similarly, a family member of Resident #39 reported that the night shift was short-staffed, often having only one aide per hall. The DON confirmed that the facility was short one CNA on several shifts in the last two weeks, further corroborating the staffing issues. These deficiencies indicate that the facility did not ensure residents received nursing care in accordance with their care plans 24 hours per day.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to inform residents of changes in Medicare covered services as required. Specifically, the facility did not provide the necessary CMS forms to two residents who were discharged from Medicare Part A services with benefit days remaining. Resident #84 was discharged on April 4, 2024, without receiving Form CMS-10055 and Form CMS-10123. Similarly, Resident #236 was discharged on March 28, 2024, without receiving Form CMS-10123. These forms are essential for informing residents about their Medicare coverage and potential liability for services not covered. An interview with the facility's Minimum Data Set (MDS) nurse confirmed that Resident #236 had benefit days remaining and had a planned discharge. The facility's administrator revealed that the Director of Social Services, who was responsible for completing these forms, had only started her employment the previous week. The administrator confirmed that there was no documentation indicating that the required forms were provided to Residents #84 and #236, highlighting a lapse in the facility's compliance with Medicare notification requirements.
Failure to Immediately Report Abuse
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the facility administration. Resident #16, who had severe cognitive impairment and required extensive assistance with activities of daily living, was found with bruising and scratches on her body. The incident was initially reported by CNAs to an LPN, and an investigation was initiated. However, it was discovered that two CNAs witnessed another CNA physically abusing Resident #16 but did not report the abuse immediately. The abuse was only reported the following day when the CNAs provided statements to the Assistant Director of Nursing (ADON). The investigation revealed that on the day of the incident, Resident #16 had grabbed the necklace of the CNA who then became angry and physically assaulted the resident. The two witnessing CNAs were afraid to report the incident immediately. The facility administration was only notified of the abuse after the statements were collected, and the local Sheriff's department was contacted to start an investigation. The delay in reporting the abuse violated the facility's policy and procedure for abuse, which mandates immediate reporting of any abuse allegations.
Failure to Conduct Quarterly Smoking Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident's safe smoking practices as required by their policy. The policy mandates that smoking assessments be completed on admission, quarterly, with significant changes in condition, and as needed. The resident in question, who has chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease, was admitted to the facility and was assessed as an unsafe smoker. However, the facility did not conduct the required quarterly smoking assessment in February 2024, as confirmed by the review of the resident's medical records and interviews with the Director of Nursing and the Regional Director of Clinical. An observation on May 6, 2024, revealed the resident smoking a cigarette in the designated smoking area, despite the lack of a recent assessment. The resident's quarterly Minimum Data Set (MDS) assessment indicated no cognitive impairment, and her care plan noted extensive to total dependence for all activities of daily living. The failure to conduct the quarterly smoking assessment was confirmed by the facility's Director of Nursing and the Regional Director of Clinical, highlighting a lapse in adherence to the facility's smoking assessment policy.
Failure to Conduct Monthly State Adverse Actions Checks for CNAs
Penalty
Summary
The facility failed to ensure that monthly State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNAs) S23CNA, S24CNA, and S25CNA. Review of the personnel files revealed that S23CNA was hired on 12/08/2023, S24CNA on 08/28/2023, and S25CNA on 02/05/2024. However, the first documented State Adverse Actions check for all three CNAs was on 05/03/2024, with no prior monthly checks recorded. An interview with the S1Administrator confirmed the absence of documentation for the required monthly checks before 05/03/2024, and it was noted that the Human Resource Coordinator responsible for these checks was unavailable during the week of the interview.
Failure to Maintain Safe Resident Care Equipment
Penalty
Summary
The facility failed to maintain all resident care equipment in safe operating condition for two residents. Resident #48, who has severe cognitive impairment and requires a wheelchair for locomotion, was observed with a missing rubber protective cover on the right handle of his wheelchair. This issue was confirmed by an LPN and later acknowledged by the Director of Nursing and the Regional Director of Clinical, who admitted that the wheelchair should have been repaired in a timely manner. The duration of the issue was unknown to the staff involved. Resident #26, who has intact cognition and also requires a wheelchair for locomotion, was observed with a torn right armrest on his wheelchair, exposing the wood portion. This condition was observed on multiple occasions over several days. A CNA confirmed that she transfers the resident using the wheelchair with the torn armrest and admitted that she had never reported the issue. The facility's failure to address these equipment concerns had the potential to affect all 82 residents in the facility.
Failure to Post Survey Results Accessibly
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. During a Resident Council Meeting, multiple residents were unaware of where the state inspection results were located. An observation with the Administrator revealed that the state inspection results were not labeled and were stored in a clear plastic bin on the wall, out of reach for residents in wheelchairs. The Administrator confirmed that the state inspection results were not labeled and were not within reach of the residents in wheelchairs.
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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