Desoto Retirement & Rehab Ctr, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansfield, Louisiana.
- Location
- 635 Schley Street, Mansfield, Louisiana 71052
- CMS Provider Number
- 195556
- Inspections on file
- 16
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Desoto Retirement & Rehab Ctr, Llc during CMS and state inspections, most recent first.
A CNA verbally abused a resident with multiple medical conditions by using loud, profane, and derogatory language while assisting with mobility. The incident was captured on video by the resident's family and later confirmed through investigation. Although the resident did not report feeling abused, the CNA's conduct met the facility's definition of verbal abuse, and the facility failed to protect the resident's right to be free from such treatment.
A resident was subjected to verbal abuse by a CNA, as evidenced by a video provided by the resident's sister. Although the incident was promptly brought to the attention of facility leadership and an investigation was initiated, the required report to the state agency was not submitted within the mandated two-hour window, resulting in noncompliance with reporting requirements.
The facility failed to accurately document the use of bedrails in the MDS assessments for three residents, despite physician orders indicating their necessity for bed mobility assistance. This discrepancy was confirmed by the MDS coordinator, highlighting a deficiency in the facility's assessment process.
The facility failed to develop comprehensive care plans for two residents, omitting critical interventions for conditions such as diabetes, hypertension, and impaired mobility. This oversight was acknowledged by the MDS coordinator, indicating a lack of individualized care planning.
The facility failed to provide necessary nail care for two residents, leading to deficiencies in personal hygiene. One resident with multiple health issues had untrimmed fingernails with a brown substance, while another resident with a history of fractures and muscle weakness had long toenails. Both residents expressed dissatisfaction with their nail care, and staff confirmed the need for trimming, indicating a lapse in the facility's nail care policy.
A resident with a contracted right hand did not receive care according to physician orders, as the palm protector was not used, and the resident's fingernails were long and discolored. The resident sometimes refused the palm protector, but these refusals were not documented, and the care plan was not updated to reflect the resident's condition. An LPN was unable to locate the palm protector and acknowledged the need for care plan updates.
The facility failed to ensure proper use and maintenance of bed rails for two residents, lacking safety assessments and informed consent. One resident with multiple health issues had bilateral bed rails without a care plan or consent, while another with a fracture and muscle weakness had quarter side rails without a risk assessment or consent. The DON confirmed these deficiencies.
The facility failed to ensure proper medication administration and storage for two residents. An LPN documented administering insulin before it was given, and another LPN stored an inhaler in a resident's room without an order for self-administration. The DON confirmed these actions were against protocol.
The facility failed to provide current pharmaceutical services by having expired medications on two medication carts. Observations revealed that Vitamin D 25 mcg with a best used by date of January 2025 was available on both carts. LPNs confirmed the medications were expired, and the DON reported that carts should be checked monthly to discard expired medications.
A facility failed to follow infection control practices during incontinence care for a resident with cognitive and physical impairments. A CNA placed soiled items on the resident's overbed table and floor, and did not change gloves before touching surfaces, risking cross-contamination. Additionally, a water cooler was improperly stored in a resident's room instead of the hallway, as confirmed by the DON.
A facility failed to transmit a completed resident's assessment within the required 7-day period. The resident, admitted with conditions such as hypertensive heart disease and obesity, had an MDS assessment marked as in progress. The MDS coordinator acknowledged the assessment was completed but not transmitted as required.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple complex diagnoses, including malnutrition, anxiety, schizophrenia, dementia, and gastrostomy status. The MDS coordinator confirmed the oversight during an interview.
A resident with COPD was found to have an unclean oxygen concentrator filter, contrary to the facility's guidelines requiring weekly cleaning. Observations showed the resident using continuous oxygen with a filter containing fluffy gray particles. Interviews with an LPN and the DON confirmed the oversight.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbal abuse toward a resident who had multiple complex medical conditions, including cerebral infarction, stroke, peripheral vascular disease, diabetes, heart disease, COPD, kidney failure, and dementia with behavioral disturbances. The resident was cognitively intact, required partial to moderate assistance with mobility and transfers, and had documented impairments in range of motion. The incident took place when the CNA entered the resident's room and used loud, profane, and derogatory language, instructing the resident to get up off the floor and onto the bed in a manner that was both forceful and inappropriate. The CNA's statements included explicit language and commands, and the interaction was captured on video by the resident's family, who had installed a camera in the room. The CNA admitted to making inappropriate comments out of frustration, acknowledging that her language and behavior were not suitable while caring for the resident. The video evidence confirmed that the CNA used profane language and spoke loudly and disparagingly in the presence of the resident. Although the resident did not report feeling disrespected or abused during subsequent interviews, the CNA's conduct met the facility's definition of verbal abuse, which includes the use of oral or gestured communication that is disparaging or derogatory, regardless of the resident's perception or response. The incident was initially discovered by the resident's family, who shared the video with facility administration. The investigation revealed that the CNA had been allowed to return to work after an initial suspension, and the full extent of the incident was not immediately recognized by all facility leadership. The Director of Nursing (DON) and former administrator did not view the complete video until later, and the investigation was not thoroughly conducted at first. The deficiency was cited based on the failure to protect the resident's right to be free from verbal abuse by a staff member.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to comply with required reporting procedures for suspected abuse, specifically in the case of a resident who was subjected to verbal abuse by a CNA. According to the facility's policy, allegations of abuse must be reported to the state survey agency and other authorities within two hours of the allegation being made. In this incident, the resident's sister provided video evidence of the CNA using derogatory and profane language toward the resident. The incident was brought to the attention of the facility's former administrator and DON, who acknowledged the unprofessional conduct and initiated an investigation, including suspending the CNA. Despite being made aware of the allegation on the same day it was reported by the resident's sister, the facility did not enter the required report into the Self-Reported Incident Management System (SIMS) until several days later, well beyond the mandated two-hour timeframe. The DON confirmed that the report should have been submitted promptly on the day the allegation was made, but it was not entered until a week later. This delay constituted a failure to meet state law and facility policy requirements for timely reporting of abuse allegations.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents during the observation period. Specifically, the MDS assessments for these residents did not accurately document the use of bedrails, which were ordered by physicians to assist with bed mobility. Resident #5, who had severe mental cognition impairment and required extensive assistance for bed mobility, had physician orders for side rails, but the MDS did not indicate their use. Similarly, Resident #21, with moderate cognitive impairment and dependence on assistance for toileting and hygiene, had orders for bedrails, yet the MDS failed to reflect this. Resident #50, with moderate cognitive impairment and requiring assistance for bed mobility and transfers, also had orders for enablers to aid in bed mobility, but the MDS did not document their use. During an interview, the MDS coordinator confirmed that the MDS assessments for these residents did not include the use of bedrails as indicated in the physician orders. This discrepancy highlights a failure in accurately coding the MDS, which is crucial for ensuring that residents' needs and care requirements are properly documented and addressed. The oversight in accurately reflecting the use of bedrails in the MDS assessments for these residents represents a deficiency in the facility's assessment process.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #28's care plan did not include necessary interventions for several conditions, including oxygen therapy, type 2 diabetes mellitus, hypertension, activities of daily living self-care deficit, impaired mobility due to amputation, anticoagulant therapy, unsafe smoking habits, and diuretic use. This oversight was acknowledged by S4 MDS during an interview, indicating a lack of comprehensive planning for the resident's complex medical needs. Similarly, Resident #118's care plan was incomplete, failing to address critical issues such as nutrition, hypertension, insomnia, and anemia. The absence of these elements in the care plan was also confirmed by S4 MDS, highlighting a significant gap in the facility's approach to individualized care planning. These deficiencies suggest a systemic issue in the facility's ability to create and implement effective care plans tailored to the specific needs of its residents.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care services to two residents, leading to deficiencies in personal hygiene and grooming. Resident #43, who has a history of cerebrovascular disease, heart failure, epilepsy, chronic atrial fibrillation, and end-stage renal disease, was found to have untrimmed fingernails with a brown substance underneath. This resident, with moderately impaired cognition, required assistance with activities of daily living, including grooming. Despite the resident's expressed desire to have their nails trimmed, the facility did not ensure this care was provided, as confirmed by the Director of Nursing. Similarly, Resident #63, who has a history of a wedge compression fracture, lack of coordination, and generalized muscle weakness, was observed with long toenails that had grown over the nail bed. This resident, with intact cognition, also expressed dissatisfaction with the length of their toenails. The facility's failure to provide timely nail care was confirmed by an LPN, who acknowledged the need for the resident's toenails to be trimmed. These observations indicate a lapse in adhering to the facility's nail care policy, which outlines regular nail maintenance as part of the residents' care plans.
Failure to Follow Physician Orders for Palm Protector
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a contracted right hand, as per physician orders and professional standards of practice. The resident, who has diagnoses including end-stage renal disease, hypertensive heart disease, and major depressive disorder, was ordered to use a palm protector on the right hand to prevent complications such as skin breakdown. However, observations revealed that the palm protector was not in use, and the resident's hand was tightly closed with long, discolored fingernails that had grown over the nail bed, potentially leading to skin integrity issues. Interviews and record reviews indicated that the resident sometimes refused the palm protector, but there was no documentation of these refusals or attempts to apply the protector. The resident's care plan and MDS did not accurately reflect the resident's limitations in range of motion or refusals of care. Additionally, the LPN was unable to locate the palm protector and acknowledged the need for updated care planning based on the resident's refusals and the condition of the resident's fingernails, which could contribute to skin breakdown.
Failure to Ensure Proper Use and Consent for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for two residents, leading to deficiencies in safety assessments and informed consent. Resident #43, who has a history of cerebrovascular disease, heart failure, epilepsy, chronic atrial fibrillation, and end-stage renal disease, was observed with bilateral bed rails without a documented care plan addressing bed rail use or a signed consent for their installation. Despite having moderately impaired cognition and requiring two-person assistance for bed mobility, there was no evidence of a risk assessment for entrapment or a discussion of risks and benefits with the resident or their representative. Similarly, Resident #63, with a history of a wedge compression fracture, lack of coordination, and generalized muscle weakness, was observed with quarter side rails raised on both sides of the bed. Although this resident had intact cognition and required assistance with bed mobility, the facility failed to document a care plan specific to the use of quarter side rails and did not obtain a signed consent. Additionally, there was no assessment conducted for the risk of entrapment prior to the installation of the bed rails. The Director of Nurses confirmed these deficiencies during an interview.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for two residents, leading to deficiencies in nursing services. For Resident #24, an LPN administered Sucralfate but prematurely documented the administration of Humalog, which was not given at the time of documentation. The LPN acknowledged that the Humalog was due later and had not been administered, despite the resident's blood sugar being 310 earlier, indicating a need for the medication closer to meal time. The Director of Nursing confirmed that medications should not be documented in the electronic medication administration record until they are actually administered. For Resident #26, an LPN was observed without the resident's prescribed Fluticasone-Salmeterol Inhaler on the medication cart, finding it instead in the resident's room. The LPN confirmed that the inhaler should have been stored on the medication cart, as the resident did not have an order for self-administration. The Director of Nursing reiterated that the medication should not have been kept in the resident's room, highlighting a failure in proper medication storage and administration procedures.
Expired Medications Found on Facility's Medication Carts
Penalty
Summary
The facility failed to provide current pharmaceutical services to meet the needs of each resident by having expired medications available for use on two medication carts. During an observation of Medication Cart 1 for Hall 1, it was found that Vitamin D 25 mcg had a best used by date of January 2025, which was confirmed by an LPN to be expired and should not have been available. Similarly, an observation of the Medication Cart for Hall 2 revealed the same expired Vitamin D 25 mcg, which was also confirmed by another LPN. The Director of Nursing reported that medication carts should have been checked at the end of each month to discard expired medications, indicating a lapse in the facility's medication management process.
Infection Control Lapses in Incontinence Care and Equipment Storage
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident with moderately impaired cognition and physical limitations due to macular degeneration and hemiplegia. During an observation, a CNA was seen retrieving towels and a draw pad from a linen cart and placing them on the resident's overbed table along with personal items. The CNA used wet towels to perform perineal care and placed the used towels back on the overbed table. The CNA also placed a used incontinence brief on the floor and reused towels to clean the resident's buttocks and rectal area. After completing the care, the CNA disposed of the soiled items on the floor and touched various surfaces, including the bed remote and door knob, without changing gloves, leading to potential cross-contamination. Additionally, the facility failed to store patient equipment properly, as observed with a water cooler containing ice for resident drinking being stored in an occupied resident's room on a secured unit. A CNA confirmed the storage location and reported no alternative storage space on the unit. The Director of Nursing acknowledged that the water cooler should be stored in the hallway rather than in a resident's room, indicating a lapse in maintaining a sanitary environment for residents.
Failure to Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to transmit a completed resident's assessment within the required 7-day period for one resident out of 31 sampled. The resident, who was admitted with diagnoses including hypertensive heart disease without heart failure, obesity, anemia, and insomnia, had an MDS assessment marked as in progress. During an interview, the MDS coordinator acknowledged that the assessment was completed but had not been transmitted as required.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident. The resident was admitted with multiple diagnoses, including unspecified protein-calorie malnutrition, generalized anxiety disorder, undifferentiated schizophrenia, unspecified dementia with agitation, anorexia, other specified extrapyramidal and movement disorders, major depressive disorder, impulsive disorder, and gastrostomy status. A review of the resident's medical records revealed that a baseline care plan was not completed upon admission. During an interview, the MDS coordinator acknowledged that the baseline care plan was not developed as required.
Failure to Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD). The deficiency was identified when the oxygen concentrator filter for the resident was observed to have a moderate amount of fluffy gray particles, indicating it had not been cleaned as required. The facility's Respiratory Equipment - Infection Control Guidelines specify that housekeeping is responsible for cleaning oxygen concentrator filters weekly, which was not adhered to in this case. The resident, who was admitted with a diagnosis of COPD, had a physician's order for oxygen at 2 liters per nasal cannula as needed for shortness of breath or when oxygen saturation was below 90%. Observations on multiple occasions revealed the resident wearing continuous oxygen, with the concentrator filter remaining uncleaned. Interviews with the LPN and the Director of Nursing confirmed the oversight, acknowledging that the filter was dirty and should have been cleaned according to the facility's guidelines.
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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