Delta Grande Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 3001 South Grande Street, Monroe, Louisiana 71202
- CMS Provider Number
- 195530
- Inspections on file
- 14
- Latest survey
- February 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Delta Grande Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure proper use and monitoring of physical restraints for residents, as evidenced by the use of lap trays on wheelchairs without physician orders and monitoring. A resident with Alzheimer's and dementia was observed with a lap tray without proper documentation, while another resident with similar conditions had a verbal order but lacked monitoring records. Additionally, a resident with Parkinson's was placed in a geri-chair with a lap tray daily without a physician's order, and staff were unsure about the required release for range of motion exercises.
A facility failed to monitor a resident's oxygen saturation every shift as ordered by the physician. The resident, with a history of chronic respiratory failure and tracheostomy, required monitoring to ensure oxygen saturation remained above 92%. However, records from January and February 2025 showed no documentation of this monitoring, a deficiency confirmed by the Assistant Director of Nurses.
The facility failed to ensure nursing staff demonstrated necessary competencies, as evidenced by missing documentation for essential care procedures for two residents. One resident required Foley catheter and peg site care, but documentation was missing numerous times. Another resident required edema monitoring, which was not recorded 14 times. Observations confirmed the presence of edema, highlighting a deficiency in staff competency and documentation.
A facility failed to implement a gradual dose reduction for a resident prescribed Cymbalta for depression. Despite a Consultant Pharmacist's request to reduce the dosage from 90 mg to 30 mg, the Nurse Practitioner delayed addressing the request, and the dosage remained unchanged in the physician orders. The ADON confirmed the discrepancy, indicating a lapse in medication management.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring such measures due to medical conditions like tracheostomies, PEG tubes, and Foley catheters. Staff did not use gowns and gloves as required, and necessary signage was missing. Observations and staff interviews confirmed these lapses, indicating a deficiency in infection control practices.
A resident with severe cognitive impairment and dependence on staff for ADL care did not receive necessary nail care. Despite requests for assistance, the resident's fingernails and toenails were observed to be long and in need of trimming. The ADON confirmed the need for nail care upon observation.
A pharmacist failed to address a medication dosage discrepancy for a resident with depression, who was prescribed Cymbalta at 90 mg daily. Despite a request for dosage reduction and documentation by a Nurse Practitioner to reduce the dosage to 30 mg, the pharmacist did not ensure the physician orders were updated, resulting in the resident continuing to receive the higher dosage. This oversight was confirmed by the ADON, indicating a lapse in the facility's medication review process.
Two residents with severe cognitive impairments and indwelling urinary catheters did not have comprehensive care plans in place. Despite their complex medical conditions and dependency on staff for daily activities, the facility failed to develop and implement necessary care plans, as confirmed by the Assistant Director of Nurses.
A facility failed to notify a resident's responsible party of significant changes in the resident's wound care status. The resident, who was severely cognitively impaired and required assistance with daily activities, experienced wound deterioration and refused treatment on multiple occasions. Despite these changes, there was no documentation of communication with the responsible party, as confirmed by interviews with the wound care nurse and the DON.
Failure to Ensure Proper Use and Monitoring of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless medically necessary, as evidenced by the use of lap trays on wheelchairs without proper physician orders and monitoring. Resident #61, who was admitted with Alzheimer's disease, heart disease, and dementia, was observed with a lap tray on his wheelchair on multiple occasions. Despite having an informed consent and pre-restraining evaluation for the lap tray, there was no physician order or documentation of monitoring the release of the lap tray every two hours, as confirmed by the Assistant Director of Nursing (ADON). Similarly, Resident #38, diagnosed with Alzheimer's, anxiety disorder, and dementia, was observed with a lap tray on his wheelchair. Although there was a verbal order for the lap tray, there was no documented evidence of monitoring the release of the lap tray every two hours. The ADON confirmed the lack of documentation for monitoring, which is a requirement according to the facility's policy on the use of restraints. Resident #23, with a diagnosis of Parkinson's disease and cognitive impairment, was also observed with a lap tray attached to a geri-chair without a physician's order. Staff interviews revealed that the resident was placed in the chair with the lap tray daily, but there was uncertainty about whether the tray was released every two hours for range of motion exercises. The ADON confirmed the absence of an active physician's order and monitoring documentation for the lap tray, indicating a failure to comply with the facility's restraint policy.
Failure to Monitor Oxygen Saturation as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's oxygen saturation levels as ordered by the physician. The resident, who had a complex medical history including non-traumatic acute subdural hemorrhage, chronic respiratory failure, and tracheostomy status, was supposed to have their oxygen saturation monitored every shift. The physician's orders specified that if the oxygen saturation fell below 92%, the physician and respiratory therapist should be notified. However, a review of the medication administration records for January and February 2025 revealed that the nurses did not document checking the resident's oxygen saturation every shift as required. This deficiency was confirmed during an interview with the Assistant Director of Nurses, who acknowledged the failure to monitor the resident's oxygen saturation as ordered.
Deficiency in Nursing Staff Competency and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to care for residents' needs, as evidenced by the lack of documentation for essential care procedures for two residents. Resident #2, who has multiple diagnoses including Parkinson's disease, vascular dementia, and profound intellectual disabilities, required Foley catheter care every shift and peg site care. However, there was no documented evidence of peg site care 87 times in January 2025 and 55 times in February 2025, and Foley catheter care was not documented 10 times in January 2025 and 4 times in February 2025. Interviews with the LPN and ADON confirmed the absence of documentation and the lack of an order for peg site care. Resident #41, diagnosed with hemiplegia following cerebral infarct, hypertensive heart disease with heart failure, diabetes mellitus, and chronic kidney disease, had an active physician order for edema monitoring every shift. Despite this, edema monitoring was not recorded 14 times in February 2025. Observations revealed that the resident had 2 plus edema in the right lower leg, which was confirmed by the ADON. The failure to document these care procedures indicates a deficiency in the facility's ability to ensure that nursing staff possess the necessary competencies to meet residents' care needs.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) for a resident who was prescribed Cymbalta for depression. The resident had multiple diagnoses, including acute respiratory failure, anxiety disorder, and depression. A Consultant Pharmacist requested a dosage reduction from 90 mg to 30 mg in October 2024, but this request was not addressed by the Nurse Practitioner until December 2024. Despite the Nurse Practitioner documenting that the Cymbalta dosage had been reduced to 30 mg, the physician orders for December 2024, January 2025, and February 2025 continued to reflect a dosage of 90 mg. The Assistant Director of Nurses (ADON) confirmed during a review that the Cymbalta dosage remained at 90 mg and was never decreased as documented. This oversight indicates a failure in the medication management process, as the facility did not implement the requested dosage reduction, potentially exposing the resident to unnecessary medication levels. The deficiency was identified through record review and interviews, highlighting a lapse in following through with the Consultant Pharmacist's recommendation for a dosage reduction.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy and procedures for six residents who required such precautions due to their medical conditions. The EBP policy, dated April 1, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not adhere to these requirements, as they only wore gloves and did not don gowns during procedures such as changing dressings and briefs for residents with tracheostomies, PEG tubes, and other indwelling medical devices. For instance, Resident #7, who had a tracheostomy and PEG tube, was observed receiving care without the staff donning the required gowns, despite the resident's door indicating the need for EBP. Similarly, Resident #19, who had a Foley catheter, and Resident #21, with a colostomy, Foley catheter, and PEG tube, did not have the necessary EBP signage outside their rooms, and staff did not use the required PPE during care activities. These lapses were confirmed through interviews with staff, who acknowledged the absence of PPE supplies and signage. Additionally, Residents #25, #42, and #60, who had various medical conditions necessitating EBP, also lacked proper signage and PPE usage during care. Observations and staff interviews confirmed that these residents, who had conditions such as Tessio catheters, arterial ulcers, and indwelling urinary catheters, were not provided with the required EBP measures. The facility's failure to implement its EBP policy and procedures for these residents highlights a significant deficiency in infection prevention and control practices.
Failure to Provide Nail Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate nail care, which is a part of activities of daily living (ADL) assistance. The resident, who was admitted with diagnoses including cerebral infarction, diabetes, and heart failure, was assessed with a severe cognitive impairment and was dependent on staff for ADL care. During observations and interviews, it was noted that the resident had long fingernails and toenails, which he reported had not been trimmed despite requesting assistance from the staff. The Assistant Director of Nurses confirmed the need for nail trimming upon observation.
Pharmacist Fails to Address Medication Dosage Discrepancy
Penalty
Summary
The pharmacist failed to identify and report irregularities in the medication regimen of a resident, leading to a deficiency in the facility's medication management. The resident, who had multiple diagnoses including depression, was prescribed Cymbalta at a dosage of 90 mg daily. A Consultant Pharmacist Communication to the Physician requested a dosage reduction on 10/23/2024, but this request was not addressed until 12/26/2024 by a Nurse Practitioner, who documented a reduction to 30 mg. Despite this documentation, the physician orders for December 2024, January 2024, and February 2024 continued to reflect the original 90 mg dosage. The pharmacist conducted monthly drug regimen reviews on November 29, 2024, and December 31, 2024, but failed to address the discrepancy between the documented dosage reduction and the physician orders. The Assistant Director of Nursing confirmed that the pharmacist did not follow up on the dosage reduction request or the subsequent documentation by the Nurse Practitioner, resulting in the resident continuing to receive the higher dosage of Cymbalta. This oversight highlights a lapse in the facility's medication review process, as the pharmacist did not ensure that the physician's orders were updated to reflect the correct dosage.
Lack of Comprehensive Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for two residents with indwelling urinary catheters. Resident #1, who was admitted with multiple diagnoses including type 2 diabetes mellitus with foot ulcer, chronic obstructive pulmonary disease, and a history of urinary tract infections, was found to have an indwelling catheter without a corresponding care plan. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a need for assistance with all activities of daily living. Despite these needs, the medical record lacked a comprehensive care plan addressing the management of the indwelling catheter. Similarly, Resident #4, admitted with conditions such as convulsions, dementia, and major depressive disorder, also had an indwelling catheter without a comprehensive care plan. The MDS assessment for this resident also showed severe cognitive impairment and dependency on staff for all daily activities. The absence of a care plan for the indwelling catheter was confirmed by the Assistant Director of Nurses during an interview, highlighting a deficiency in the facility's care planning process for residents with specific medical needs.
Failure to Notify Responsible Party of Resident's Change in Status
Penalty
Summary
The facility failed to ensure proper communication of a resident's change in status to the responsible party. A resident with multiple diagnoses, including type 2 diabetes mellitus with a foot ulcer, chronic obstructive pulmonary disease, and pressure ulcer of the sacral region, was admitted to the facility. The resident was severely cognitively impaired, requiring assistance with all activities of daily living. Despite significant changes in the resident's wound care status, including deterioration of the wound and refusal of treatment, there was no documentation that the responsible party was notified of these changes. The wound care documentation revealed several instances where the responsible party was not informed of changes in the resident's condition or treatment plan. On multiple occasions, the resident's wound care orders were changed, the wound deteriorated, and the resident refused treatment, yet there was no record of communication with the responsible party. Interviews with the wound care nurse and the Director of Nursing confirmed that the responsible party was not notified, as there was no documentation to support such communication.
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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