Deerfield Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delhi, Louisiana.
- Location
- 522 Main Street, Delhi, Louisiana 71232
- CMS Provider Number
- 195393
- Inspections on file
- 20
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Deerfield Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not develop care plans that clearly identified whether one or more staff were required to assist with ADLs for several residents with complex medical needs. Despite regular assessments and staff meetings, care plans lacked specific instructions, leaving CNAs without clear guidance on the level of assistance needed for each ADL.
The facility did not develop a care plan for a resident's request to discharge to the community, despite her being cognitively intact and having communicated her wishes to staff. Additionally, the facility failed to implement a physician-ordered fall mat intervention for another resident at high risk for falls, as repeated observations showed the fall mat was not in place.
A resident with diabetes and severe cognitive impairment had physician orders for insulin to be administered if blood sugar exceeded 300 mg/dL. On two occasions, blood sugar readings were above this threshold, but there was no documentation that insulin was given as ordered. The DON confirmed the insulin was not administered in accordance with the physician's instructions.
Surveyors observed that the facility did not maintain proper food storage and hygiene standards, including thawed and unsealed frozen foods, soiled storage containers, improper thawing of meat, and failure to change gloves or use tongs during meal service. The Dietary Manager confirmed these issues, and 53 residents were served meals from the affected kitchen.
The facility did not conduct or document required quarterly QAA meetings with the necessary committee members for two consecutive quarters, as confirmed by record review and staff interviews.
Staff failed to consistently implement Enhanced Barrier Precautions, including wearing gowns during high-contact care for residents with wounds or indwelling devices, and did not use required signage to indicate EBP status. PPE was not properly used during wound and catheter care, and infection control practices were not maintained, as confirmed by staff interviews and direct observation.
A resident was provided with side rails on a new bed without the facility completing the required bed rail and mattress safety assessment, bed rail use assessment form, or obtaining informed consent. Observations showed both upper and lower quarter rails were in the upright position, contrary to the physician's order, and the DON confirmed these assessments and consents were not completed prior to use.
A resident with multiple cognitive and physical impairments was provided with bed rails without the facility completing a risk assessment, reviewing risks and benefits with the resident or representative, or obtaining informed consent as required by policy. Observations confirmed the use of both upper and lower quarter rails, despite the physician's order specifying only the upper rail, and documentation for required assessments and consent was missing. The DON acknowledged these omissions during the survey.
An LPN failed to obtain vital signs for a resident with significant cardiac history after being unable to get a pulse oximetry reading due to cold and swollen fingers. The resident was given medications and became nauseated, but the LPN did not recall if vital signs were checked. Both the ADON and the resident's physician confirmed that vital signs should have been obtained in this scenario.
A resident, who was cognitively intact and independent with wheelchair use, was subjected to physical and verbal abuse by a CNA. The resident made inappropriate remarks, leading to a confrontation where the CNA pushed the resident, causing them to fall from their wheelchair, and then verbally abused them. Witnesses confirmed the incident, which violated the facility's abuse policy.
The facility failed to ensure that two residents who were unable to perform activities of daily living received necessary nail care. Both residents, with various medical conditions, were observed to have long, jagged, and dirty fingernails despite requesting assistance. The facility did not adhere to its own nail care guidelines, leading to poor grooming and personal hygiene for the residents.
The facility failed to follow physician orders for multiple residents, including not applying compression stockings, not administering oxygen at the correct rate, and not flushing a G-tube before medication administration. These deficiencies were confirmed through observations and staff interviews.
The facility failed to document the sites of subcutaneous diabetic injections for three residents, despite administering the medications as ordered. This deficiency was confirmed through interviews with the DON and ADON, highlighting a lapse in ensuring nursing staff competencies.
The pharmacist failed to identify and report irregularities in the medication administration records for two residents. Both residents had insulin orders, but the medical records for March and April 2024 lacked documentation of the injection sites. The DON and ADON confirmed the absence of this documentation and acknowledged that the pharmacist did not notify the facility of these irregularities.
The facility failed to follow prescribed diets and portion sizes for residents on pureed and mechanical soft diets. Residents did not receive the correct type of cornbread or the required 4 ounces of chicken, as specified in the menu approved by the Registered Dietician. The Dietary Manager and Administrator confirmed these deficiencies.
The facility failed to provide a pressure relieving device for a high-risk resident with multiple diagnoses, including dementia and muscle wasting, despite the care plan indicating the need for such a device. Observations over several days and staff interviews confirmed the deficiency.
A resident with multiple diagnoses was administered Alprazolam PRN for anxiety beyond the recommended 14-day period. Despite a pharmacist's recommendation to limit the use, the physician denied the dose reduction, and the medication was administered on multiple occasions past the limit, as confirmed by the DON.
Failure to Specify Staff Assistance Levels in ADL Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that clearly identified the required level of staff assistance for activities of daily living (ADLs) for five out of six sampled residents. Medical record and MDS assessment reviews showed that these residents had significant dependencies, including needs for assistance with toileting, personal hygiene, and transfers from bed to chair. However, their care plans did not specify whether one or more staff members were required to assist with each ADL. Interviews with the DON and CNAs confirmed that the care plans lacked this critical information, making it unclear for staff to determine the appropriate level of assistance needed for each resident. The residents involved had complex medical histories, including diagnoses such as dementia, psychosis, hypertensive heart disease, diabetes, pressure ulcers, Alzheimer's, osteoporosis, hypoglycemia, and schizoaffective disorder. Despite regular MDS assessments and weekly meetings to review residents' assistance needs, the facility did not incorporate this information into the care plans. Staff interviews further confirmed that there was no additional assessment tool in use to determine the specific number of staff required for each ADL, and the care plans remained incomplete in this regard.
Failure to Develop and Implement Care Plans for Discharge Planning and Fall Prevention
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to discharge planning and fall prevention. For one resident with a history of cerebral infarction, hemiplegia, and other significant medical conditions, there was no care plan focus area addressing her request to be discharged to the community, despite her being cognitively intact and having discussed her desire for independent living with staff over six months prior. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's discharge wishes, and no documentation or care plan was initiated to address her request. For another resident with multiple diagnoses, including a high risk for falls as indicated by a fall risk assessment, the facility failed to implement a physician-ordered intervention for a fall mat to be placed at the bedside. Despite the care plan and physician orders specifying the need for a fall mat, repeated observations over several days confirmed that no fall mat was present. Staff interviews corroborated that the intervention was not in place as required.
Failure to Administer Insulin as Ordered for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not administering insulin as ordered. According to the facility's policy, medications are to be administered safely, timely, and as prescribed, including following the prescriber's orders regarding timing. Review of the medical record for a resident with multiple diagnoses, including diabetes mellitus and severe cognitive impairment, showed a physician's order for Regular Insulin to be administered subcutaneously if blood sugar exceeded 300 mg/dL. Documentation revealed that on two occasions, the resident's blood sugar readings were significantly above the threshold (425 mg/dL and 381 mg/dL), but there was no evidence that insulin was administered as ordered. The DON confirmed in an interview that the insulin was not given when the resident's blood sugar was greater than 300 mg/dL, as required by the physician's order.
Failure to Maintain Food Safety and Hygiene Standards in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by multiple observations in the kitchen. Surveyors found that the freezer contained several items that were thawed instead of being kept solid, including onion rings, waffles, egg patties, cookies, and omelets, with some items left open to air. In the dry storage area, an opened bag of noodles was stored in an unsealed plastic zip bag. Storage containers for flour, corn meal, and sugar were visibly soiled with food particles and a sticky substance. Additionally, frozen chopped ham was observed thawing at room temperature in a sink, which is not an appropriate thawing method. During meal service, the Dietary Manager was observed handling serving trays and plates with gloved hands and then placing bread on residents' plates without changing gloves or using tongs, resulting in potential cross-contamination. The Dietary Manager acknowledged these lapses in hygienic practices during interviews. The facility reported that 53 residents were served meals from the kitchen during the period of observation.
Failure to Hold and Document Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required committee members present, as evidenced by the absence of documentation for the 4th quarter of 2024 and the 1st quarter of 2025. Record review showed that QAA meetings were conducted in the second and third quarters of 2024, but there was no evidence of meetings for the subsequent two quarters. During interviews, the Administrator and Director of Nursing confirmed that they could not provide documentation of QAA meetings with the required participants for the specified periods. No information regarding residents or their medical conditions was included in the report, and the deficiency centers solely on the facility's failure to document and conduct required QAA meetings with appropriate membership.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBPs) as required. Staff did not wear appropriate personal protective equipment (PPE), such as gowns, during high-contact care activities for multiple residents with wounds or indwelling medical devices. For example, during wound care for several residents, both the LPN and DON only wore gloves and did not don gowns, despite facility policy and physician orders indicating the need for EBPs. Staff interviews confirmed the lack of gown use and acknowledged the oversight. Additionally, the facility did not consistently use signage or indicators outside resident rooms to identify those requiring EBPs. The facility's policy called for an orange sticker by the resident's name outside the door to indicate EBP status, but observations revealed that several residents who required EBPs due to wounds, indwelling catheters, dialysis access, or feeding tubes did not have any such indicator. Staff interviews further confirmed that the required signage was missing for these residents, and some staff were unaware of which residents were on EBPs. The facility also failed to maintain proper infection control practices during catheter care. In one instance, a CNA performed catheter care by wiping towards the insertion site and did not change gloves after the task, subsequently touching the resident's gown, bed linens, and rails with contaminated gloves. This improper technique was confirmed by facility leadership during interviews. These failures were observed across multiple residents with significant medical histories, including vascular ulcers, pressure injuries, indwelling catheters, dialysis access, and feeding tubes.
Failure to Complete Bed Rail Safety Assessment Prior to Side Rail Use
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not conducting a required bed rail and mattress safety assessment prior to implementing the use of side rails. Multiple observations over several days showed that a resident's bed had both the top and bottom quarter rails in the upright position on one side, with the other side of the bed against the wall. The facility's policy requires an interdisciplinary evaluation of the sleeping environment, compatibility checks between bed components, and completion of a bed rail use assessment and informed consent prior to the use of side rails. However, documentation revealed that the bed rail/mattress safety assessment, bed rail use assessment form, and informed consent were not completed before the side rails were used for this resident. Interviews with the DON confirmed that the required assessments and consent forms were not completed prior to the use of both the upper and lower quarter side rails. Additionally, the DON acknowledged that the physician's order was only for the upper quarter rail to assist the resident with positioning, and that the lower quarter rail should not have been in the upright position. The facility had recently acquired new beds with non-removable side rails, but staff failed to ensure compliance with their own policy and procedures regarding bed safety and side rail use.
Failure to Assess, Inform, and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for a resident. Specifically, staff did not review the risks and benefits of bed rail use with the resident or their representative, nor did they obtain informed consent prior to installation. Additionally, the required assessment for risk of entrapment from bed rails was not completed before the bed rails were put in use. These omissions were identified for one resident out of four reviewed for bed rail use. Observations over several days showed that the resident's bed consistently had both the top and bottom quarter rails in the upright position on the right side, with the left side of the bed against the wall. The resident was observed both in bed and in a wheelchair during these times. The resident had multiple diagnoses, including unspecified psychosis, lack of coordination, gait abnormalities, seizures, dementia, pseudobulbar affect, and intellectual disabilities. The physician's order specified the use of bilateral upper side rails for bed mobility assistance, safety, and security, but did not include the lower rail. Record review revealed that the bed rail/mattress safety assessment, bed rail use assessment form, and informed consent documentation were not completed prior to the use of the side rails. The DON confirmed that the lower quarter side rail should not have been in the up position and that the required assessments and consent had not been completed before the side rails were utilized. The facility's policy requires these steps to be taken before bed rails are used, but they were not followed in this case.
Failure to Obtain Vital Signs After Unsuccessful Pulse Oximetry
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to obtain vital signs for a resident after being unable to obtain a pulse oximetry reading due to the resident's cold and swollen fingers. The resident, who had a medical history including acute on chronic congestive heart failure, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, fluid overload, coronary angioplasty implant/graft, and a cardiac defibrillator, was administered medications and subsequently became nauseated. The LPN did not recall if vital signs were taken following the inability to obtain a pulse oximetry reading. The Assistant Director of Nursing and the resident's physician both confirmed that vital signs should have been checked in this situation.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by staff. The incident involved a resident who was cognitively intact and independent with wheelchair use, as indicated by their Minimum Data Set assessment. On the day of the incident, the resident was found on the floor by their wheelchair on the smoking patio, with no reported injuries. Interviews revealed that the resident had been making disrespectful and sexually inappropriate remarks to staff, which led to a confrontation with a CNA. The CNA reportedly pushed the resident, causing the wheelchair to tip over and the resident to fall to the ground. The CNA then verbally abused the resident before walking away. Witnesses confirmed the resident's inappropriate behavior and the CNA's response, which included physical and verbal abuse. The facility's abuse and neglect policy defines abuse as the willful infliction of injury or intimidation, which aligns with the actions taken by the CNA. The incident was confirmed by the Administrator in Training and the Director of Nursing, highlighting a failure in the facility's duty to protect residents from abuse, as outlined in their policy.
Failure to Provide Necessary Nail Care for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents, one with diagnoses including myelopathy, COPD, and type 2 diabetes mellitus, and another with diagnoses including dementia, major depressive disorder, and type 2 diabetes mellitus, were observed to have long, jagged, and dirty fingernails. Both residents required assistance with ADLs and were unable to trim their own nails due to their medical conditions and physical limitations. Despite the facility's policy and procedure related to nail care, which mandates daily cleaning and regular trimming of nails, and specifies that diabetic nail care should be performed by a Registered Nurse, the residents' fingernails were not properly maintained. Interviews with the residents and the Director of Nursing confirmed that the residents had requested assistance with nail care but did not receive it. The observations and interviews revealed that the facility did not adhere to its own guidelines, resulting in the residents' poor grooming and personal hygiene.
Failure to Follow Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. For resident #23, who had diagnoses including hypertension, dementia, and edema, the facility did not apply compression stockings as ordered by the physician. Observations on multiple occasions revealed the resident's feet and ankles were edematous, and interviews with staff confirmed they were unaware of the order for compression stockings, indicating a lapse in communication and adherence to the care plan. For resident #6, who had diagnoses including paranoid schizophrenia, COPD, and diabetes mellitus, the facility did not administer oxygen as ordered by the physician. Observations showed the resident receiving oxygen at 3.5 L/min instead of the prescribed 2 L/min. Additionally, during a medication administration via G-tube, the LPN did not flush the tube with 30 cc of tap water before administering medications, as required by the physician's orders. Interviews with the DON confirmed these discrepancies. Resident #26, with diagnoses including cellulitis, type 2 diabetes mellitus, and COPD, also did not receive oxygen therapy as ordered. Observations revealed the resident receiving oxygen at varying rates (3.5 L/min and 3 L/min) instead of the prescribed 2 L/min continuously. Interviews with the ADON and DON confirmed that staff were not following the physician's orders for oxygen administration, highlighting a consistent issue with adherence to prescribed treatments across multiple residents.
Failure to Document Injection Sites for Diabetic Medications
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 document the sites of subcutaneous diabetic injections for three residents. Resident #31, who had multiple diagnoses including type 1 diabetes, received insulin injections as ordered, but the injection sites were not documented in the March and April Medication Administration Records (MARs). This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #26, with diagnoses including type 2 diabetes mellitus and unspecified dementia, received Novolog insulin injections without documentation of the injection sites in the March and April MARs. This was confirmed by both the Assistant Director of Nursing (ADON) and the DON. Additionally, Resident #40, who had diagnoses including type 2 diabetes and hypertension, received a Mounjaro injection without documentation of the injection site in the April MAR. This was also confirmed by the ADON. These lapses in documentation indicate a failure to ensure that nursing staff had the necessary competencies to provide safe and effective care for residents requiring subcutaneous injections.
Pharmacist Failed to Report Medication Administration Irregularities
Penalty
Summary
The pharmacist failed to identify and report irregularities in the medication administration records for two residents. Resident #31, who has multiple diagnoses including type 1 diabetes, was prescribed various insulin medications. However, the medical records for March and April 2024 showed no documentation of the injection sites for the insulin doses administered. The Director of Nursing (DON) confirmed that injection sites should be documented and acknowledged the lack of such documentation. Additionally, the pharmacist did not notify the facility of these irregularities. Similarly, Resident #26, who has diagnoses including type 2 diabetes and other chronic conditions, had an order for Novolog insulin with specific instructions for administration. The medication administration records for March and April 2024 also lacked documentation of the injection sites for the insulin doses. Both the Assistant Director of Nursing (ADON) and the DON confirmed the absence of this documentation and acknowledged that the pharmacist did not report these irregularities to the facility's medical team.
Failure to Follow Prescribed Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that the menus were followed for residents prescribed pureed and mechanical soft diets. Specifically, residents who were ordered pureed diets did not receive pureed cornbread, and those on mechanical soft diets did not receive moist cornbread as specified in the menu approved by the Registered Dietician. Additionally, residents who were supposed to receive 4 ounces of chicken were instead given one chicken leg, which did not meet the required portion size. These deficiencies were observed during the lunch meal on 04/08/2024. Interviews with the Dietary Manager confirmed that the prescribed diets were not followed, and the portion sizes were inadequate. The Administrator was informed of these issues, confirming that the menu approved by the Registered Dietician was not adhered to during the lunch meal. This failure affected multiple residents, compromising their nutritional needs as prescribed by their dietary plans.
Failure to Provide Pressure Relieving Device for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Resident #39, who had multiple diagnoses including diabetes, dementia with behavioral disturbances, and muscle wasting with atrophy, was identified as high risk for pressure ulcers. Despite this, the resident's care plan, which included an intervention to provide pressure reducing surfaces on the bed and chair, was not followed. Observations on multiple occasions revealed that the resident's wheelchair did not have a pressure relieving device, which was confirmed by both a Certified Nursing Assistant and a Licensed Practical Nurse. The Director of Nursing also confirmed that the resident should have had a pressure relieving device in her wheelchair. The resident had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, and was dependent on staff for toileting hygiene and required moderate assistance with transfers. The resident was also incontinent of bowel and bladder, further increasing the risk for pressure ulcers. Despite these risk factors and the care plan in place, the facility did not provide the necessary pressure relieving device in the resident's wheelchair, as observed over several days and confirmed through staff interviews.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication use, specifically for a resident with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, and chronic obstructive pulmonary disease. The physician ordered Alprazolam 0.25 mg to be given as needed for anxiety, but this order extended beyond the recommended 14-day period for PRN psychotropic medications. Despite a recommendation from the pharmaceutical consultant to limit the PRN use to 14 days, the physician denied the gradual dose reduction, citing that the dose was minimally effective. The medication was administered on multiple occasions beyond the 14-day limit, which was confirmed by the Director of Nursing during an interview.
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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