Cypress Point Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bossier City, Louisiana.
- Location
- 4910 Airline Drive, Bossier City, Louisiana 71111
- CMS Provider Number
- 195452
- Inspections on file
- 19
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cypress Point Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not post the required state agency contact information in a location that was easily accessible or visible to residents and their representatives. The information was placed in a framed document outside the business office, at the end of a hallway with limited traffic, and was not displayed on televisions as believed by the administrator.
Four residents with complex medical conditions were transferred to the ED for evaluation or at the request of a representative, but neither they nor their representatives received the required written notice detailing the reason for transfer, effective date, location, appeal rights, or bed-hold policy, as confirmed by record review and DON interview.
A resident with a new diagnosis of Delusional Disorder was not referred for a Level II PASARR, despite the addition of this mental illness to their medical record. The initial PASARR did not indicate a mental illness, and no updated screening was completed after the new diagnosis, as confirmed by facility staff.
Two residents were found with medications left at their bedsides without proper physician orders or care plans for self-administration. One cognitively impaired resident had a cup of powder with an illegible label, and another cognitively intact resident had eye drops, both of which staff confirmed should not have been accessible without authorization.
Two residents requiring respiratory care did not receive services in accordance with professional standards and facility policy. One resident's oxygen tubing and humidifier were not changed weekly as required, and another resident's nebulizing mask was left undated and improperly stored. The DON and an LPN confirmed these lapses in respiratory equipment maintenance and storage.
The facility failed to label the start times on tube feeding containers for three residents, as required by their policy. An LPN confirmed the omission during observations. The residents involved had various medical conditions, including traumatic brain injury and dysphagia.
A resident with chronic pain did not receive adequate pain management as the facility failed to conduct daily pain assessments as required by the care plan. Despite receiving routine pain medications, the resident reported ongoing pain, and there was no documentation of the resident's response to the medication. An LPN confirmed the absence of daily pain assessments.
A resident with a history of falls and moderately impaired cognition did not have the prescribed landing strips in place at their bedside, as required by their care plan and physician's orders. Observations revealed the landing strips were folded and not positioned correctly, which was acknowledged by a nurse and noted by the resident's responsible party.
Failure to Post State Agency Contact Information in Accessible Location
Penalty
Summary
The facility failed to post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups in a manner that was accessible and understandable to residents and their representatives. Observations revealed that the required information was posted on a framed, letter-sized document outside the business office, at the end of a hallway that was not easily noticeable from the main hallway. The posting was positioned with the bottom of the frame 64 inches above the floor, making it less accessible. The hallway where the posting was located only contained the business office and two staff bathrooms, further limiting its visibility to residents and their representatives. A review of the facility's admission packet showed that it included a document stating the complaint telephone number was posted in an accessible and visible location, as required by state regulations. However, during interviews, the administrator acknowledged that the print could be larger and the document could be positioned lower on the wall. Additionally, although the administrator believed the information was displayed on televisions by the nursing stations, observations confirmed that the state agency complaint address and phone number were not shown on the television during the observed period.
Failure to Provide Required Written Transfer/Discharge Notices and Bed-Hold Information
Penalty
Summary
The facility failed to provide required written notices to residents and/or their representatives regarding transfers to the emergency department. Specifically, for four residents with various diagnoses including paraplegia, major depressive disorder, Parkinson’s disease, osteoporosis, chronic obstructive pulmonary disease, anxiety disorders, metabolic encephalopathy, and osteoarthritis, there was no documentation of written notice specifying the reason for transfer, effective date, location, statement of appeal rights, or information about the bed-hold policy. Each resident was transferred to a local emergency department for medical evaluation or at the request of a representative, but the medical records lacked evidence that the mandated notifications were given. The facility’s own policy requires that residents and their families or legal representatives receive written information about bed-hold and readmission policies upon admission and when leaving the facility. This includes instructions on the duration of bed-hold, charges, and the need for a signed agreement if the bed is to be reserved. Despite this policy, record reviews and staff interviews confirmed that the required written transfer/discharge notices were not provided to the affected residents or their representatives at the time of transfer.
Failure to Refer for Level II PASARR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR (Pre-admission Screening and Resident Review) after a new diagnosis of Delusional Disorder was added to the resident's medical record. The resident was originally admitted with diagnoses including unspecified dementia, moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The initial Level I PASARR screen did not indicate suspicion or diagnosis of a mental illness. However, after the new diagnosis of Delusional Disorder was documented, there was no evidence in the medical record that a new PASARR was completed or submitted. This was confirmed during an interview with the corporate nurse, who acknowledged that a new PASARR should have been completed following the updated diagnosis.
Failure to Follow Safe Medication Administration Practices
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents by not following safe medication administration practices. For one resident with moderate cognitive impairment and a history of metabolic encephalopathy and cerebrovascular events, a medication cup containing powder with an illegible label was found at the bedside. There was no physician's order or care plan authorizing self-administration of this medication, and staff confirmed that medications should not be left at the bedside. The medication was identified as Zeasorb powder, which was ordered for preventative skin care, but not for self-administration. For another resident, who was cognitively intact and had chronic respiratory and eye conditions, a bottle of Refresh Tears eye drops was found on the bedside table. The resident reported self-administering the drops, but there was no physician's order or care plan for self-administration. Staff acknowledged that the medication should not have been left in the room and that there was no authorization for the resident to self-administer the eye drops. These findings demonstrate a failure to follow facility policy and professional standards regarding medication administration and supervision.
Failure to Adhere to Respiratory Care Protocols and Equipment Storage
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents who required respiratory services. For one resident with chronic obstructive pulmonary disease and other medical conditions, the oxygen humidified water container and tubing were observed to be dated ten days prior, despite a physician's order and facility policy requiring weekly changes. The Director of Nursing confirmed that the tubing should have been changed weekly but was not. For another resident with chronic obstructive pulmonary disease and congestive heart failure, the nebulizing mask was found placed on top of the nebulizing machine, undated, and not stored in a bag as required by facility policy. An LPN acknowledged that the nebulizing mask was not properly stored or dated. These findings indicate that the facility did not adhere to its own policies regarding the maintenance and storage of respiratory equipment for residents receiving respiratory care.
Failure to Label Tube Feeding Start Times
Penalty
Summary
The facility failed to provide appropriate treatment and services for three residents who were receiving tube feeding. The deficiency was identified through record reviews, observations, and interviews. The facility's policy for Nasogastric/Gastrostomy Tube Feedings requires that labels on tube feeding containers include the resident's name, date, start time, initials of the nurse, and the rate of feeding. However, during observations, it was found that the tube feeding containers for all three residents did not have the start time labeled, which is a requirement according to the facility's policy. Resident #1, who has a history of diffuse traumatic brain injury, dysphagia, and hemiplegia following a cerebral infarction, was observed receiving Isosource 1.5 at 45 ml/hr without the start time labeled on the feeding container. Similarly, Resident #19, diagnosed with aphasia, cognitive impairment, and a persistent vegetative state, was receiving Promote with fiber 1.0 at 35 ml/hr, also without the start time labeled. Resident #34, with a history of hemiplegia and dysphagia following a cerebral infarction, was receiving Isosource 1.5 at 45 ml/hr, again without the start time labeled. In each case, the LPN confirmed that the labels were incomplete and should have included the start time.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as #62, who was reviewed for pain management. The deficiency was identified through record reviews and interviews, revealing that the facility did not perform daily pain assessments as required by the resident's Comprehensive Plan of Care. This plan, which was active since September 2021, mandated daily pain assessments using a 1-10 scale, monitoring for worsening symptoms, and notifying the physician of any changes. Despite these requirements, the clinical records for June 2024 showed that while pain medications were administered routinely, there was no documentation of the resident's response to these medications or evidence of daily pain assessments. Resident #62 had a medical history that included intervertebral disc degeneration, accidental poisoning by unspecified drugs, and chronic pain. The resident's medication orders included Hydrocodone-Acetaminophen, Morphine Sulfate ER, and Acetaminophen, all prescribed for chronic pain management. During interviews, the resident expressed ongoing pain despite receiving routine medications and indicated a lack of additional pain relief options. An LPN confirmed that while the resident received routine pain medications, daily pain assessments were not conducted, contributing to the deficiency in care.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure appropriate interventions were in place for a resident identified as high risk for falls. Resident #23, who had a history of a femur fracture, anxiety disorder, and dementia, was noted to have moderately impaired cognition. The resident's care plan included the use of landing strips on both sides of the bed to prevent falls, as per a physician's order dated February 21, 2024. However, during observations on June 25 and June 26, 2024, it was noted that the landing strips were not in place as required. Further observations revealed that the landing strips were folded and placed in the corner of the resident's room, rather than being positioned on either side of the bed. This oversight was acknowledged by a registered nurse during an interview, and the resident's responsible party expressed concern about the absence of fall mats upon visiting the resident's room. The lack of adherence to the prescribed fall prevention measures constituted a deficiency in the facility's fall prevention program.
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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