Evangeline Oaks Guest House
Inspection history, citations, penalties and survey trends for this long-term care facility in Carencro, Louisiana.
- Location
- 240 Arceneaux Road, Carencro, Louisiana 70520
- CMS Provider Number
- 195578
- Inspections on file
- 30
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Evangeline Oaks Guest House during CMS and state inspections, most recent first.
A resident with a chronic stage 4 sacral pressure ulcer, diabetes, and UTI received ordered wound care during which a treatment nurse and a CNA failed to follow the facility’s hand hygiene and Enhanced Barrier Precautions policies. Despite an EBP sign on the door requiring gown and glove use for wound care, neither staff member wore a gown. The nurse repeatedly removed soiled gloves, placed them on the bedside table and bed linens, and donned clean gloves without performing hand hygiene between glove changes, including after cleansing the wound and while cleaning multiple episodes of bowel incontinence and changing briefs. Used gloves were not discarded in the trash as required. In interviews, the nurse and CNA acknowledged they knew the requirements for hand hygiene and PPE use, while the DON and another nurse confirmed that gown and glove use and hand hygiene between glove changes were required for this resident’s wound care.
A resident with hemiplegia, hemiparesis after cerebral infarction, and type 2 DM had a care plan and MD order requiring heel lift boots while in bed due to risk for skin breakdown related to decreased mobility and incontinence. On multiple observations, the resident was in bed without the heel lift boots. A CNA reported not knowing the resident was supposed to wear the boots or where they were located, and an LPN stated she was not very familiar with the resident’s care. After reviewing the orders, the LPN confirmed the resident had an order for heel lift boots while in bed and that they were not in use as ordered.
An agency RN providing wound care to a resident with a stage 4 sacral pressure ulcer, diabetes, and UTI failed to follow infection control practices and had no documented competency validation. During an observed treatment, the RN and a CNA did not wear gowns despite Enhanced Barrier Precautions signage, and the RN repeatedly changed gloves without performing hand hygiene, placed used gloves on surfaces instead of discarding them, and continued wound care and incontinence care without sanitizing or washing hands. The RN later acknowledged not using hand sanitizer or soap and water between glove changes, not changing gloves after cleansing the wound before applying gentian violet, and placing soiled gloves on the bed. She reported having performed wound care for all residents for two weeks without training on facility policies or procedures and without shadowing another treatment nurse, and the administrator confirmed there was no documentation of training or competency assessment for this agency RN.
A resident with multiple serious health conditions experienced a fall during staff assistance, but the LPN on duty failed to immediately notify the correct physician and responsible party, instead notifying the wrong individuals. Facility leadership confirmed that required notifications were not made promptly, in violation of facility policy.
A resident with end stage renal disease, diabetes, and atrial fibrillation experienced a fall from a wheelchair on a van lift before dialysis. The resident's representative was not promptly notified and later expressed concerns to the DON. Despite facility policy requiring grievances to be filed and investigated, no grievance was documented for this incident.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific staff actions or resident involvement are provided.
A LPN's BLS certification expired and was not renewed as required by facility policy, as confirmed by personnel record review and interviews with the LPN and DON.
A resident with multiple chronic conditions did not receive laboratory tests as ordered by the physician, including a lipid panel, PSA, and urine for microalbumin, which were scheduled for June. The DON confirmed that these tests were not completed as required.
A resident dependent on staff for toileting and personal hygiene due to hemiplegia and incontinence was not provided with incontinent care every two hours as required by the care plan. The resident participated in activities and was brought to lunch without being checked or changed, resulting in her being found soaking wet after more than five hours without care. Staff interviews confirmed the lapse in following the care plan.
A resident with COPD and other medical conditions was not provided with continuous oxygen therapy as ordered by the physician. Observations showed the resident was without oxygen during activities and meals, and staff confirmed the oxygen tank was empty and the therapy was not being administered as required.
A resident with multiple respiratory and cardiac conditions was found to have an oxygen nasal cannula not stored in a sealed bag as required, and physician orders for BIPAP lacked clear instructions on when it should be used. Staff confirmed the equipment was not stored properly and that BIPAP use was not clearly defined, leading to deficiencies in respiratory care.
A resident's medical record indicated that daily cleaning of a CPAP/BIPAP mask was completed, but direct observation revealed the mask was still soiled. An LPN admitted to documenting the cleaning before performing the task, contrary to facility policy, and the DON confirmed that such documentation practices were not allowed.
The facility did not update the nurse staffing information daily as required. Observations on March 3, 2025, revealed that the posted data was from February 11 and 12, 2025. The DON confirmed the information was outdated and should have been updated daily.
A resident with severe cognitive impairment and multiple diagnoses, including Huntington disease, was found with long and unclean fingernails despite having an order for nail care. The facility's staff, including a CNA and the Quality Assurance Nurse, confirmed the need for trimming and cleaning, highlighting a failure to adhere to the facility's nail care policy.
A resident, who was cognitively intact, was injured when hit by a door in the facility. The incident occurred on a specific date, but the physician and responsible party were not notified until two days later, contrary to the facility's policy. Interviews revealed that the delay was due to a lack of awareness by the staff involved, and the Director of Nursing confirmed the notification should have been immediate.
A facility failed to write a telephone order and obtain a wound culture in a timely manner for a resident with severe pressure ulcers and other conditions. The treatment nurse noted a strong odor and drainage from the wounds and received orders to collect wound cultures. However, the cultures were not collected and sent to the lab until two days later, and no telephone order was documented, leading to a deficiency.
A facility failed to document an incident where a resident was hit in the head by a door opened by an LPN. The resident, who was cognitively intact, recalled the incident, but the nurse's notes did not reflect this occurrence. The DON confirmed the incident should have been documented, highlighting a deficiency in maintaining accurate medical records.
A resident in the facility, with moderately intact cognition, reported and was observed to have a room with a rotten back door frame and damaged wall. The Maintenance Supervisor and Administrator confirmed the poor condition, acknowledging the failure to maintain a safe and comfortable environment.
The facility failed to ensure residents received mail on Saturdays, affecting 95 residents. The Business Office was closed on weekends, and weekend staff did not have access to retrieve the mail, which was then distributed on Mondays. The Director of Nursing was unaware of the mail delivery process, and the local post office confirmed that someone from the facility had requested no weekend mail delivery.
The facility failed to store food in accordance with professional standards by not following appropriate food handling practices. Expired food items were found in the walk-in cooler and dry storage area, and several opened items were not labeled with the date and time they were opened. Additionally, temperature logs for the kitchen's coolers and freezer were absent for an entire week.
A resident with severe cognitive impairment and multiple diagnoses was addressed as 'girl' by a CNA when she requested ice, which she found disrespectful. The resident expressed her preference to be called by her name, and the DON confirmed that the facility's policy on dignity and respect was not followed.
The facility failed to organize monthly resident council meetings as required. While meetings were documented for January and February 2024, there were no records for March and April 2024. Interviews with residents and the Activity Director confirmed the lack of monthly meetings, with the Activity Director unable to provide supporting documentation.
A resident with chronic pain and an above-knee amputation reported a cracked and peeling ceiling in his room, which had been in disrepair since his admission. Maintenance staff confirmed the issue and admitted that their routine checks did not include ceilings, focusing only on call lights and beds.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly coded for receiving an injectable medication, while another was not coded for the use of a lap tray restraint despite multiple observations and physician orders indicating its use.
The facility failed to implement person-centered care plans by not repositioning a resident every two hours and not providing necessary communication tools, and by not monitoring bedframe padding for another resident as required.
The facility failed to invite a resident and their Responsible Party (RP) to the care planning meeting, despite the resident having intact cognition and expressing concerns about their care. The facility's policy required such invitations and documentation if participation was not practicable, but neither was done in this case.
A facility failed to ensure a resident with multiple diagnoses participated in activities as per her care plan after returning from the hospital. Staff were unaware of her return and did not assist her in engaging in activities, leading to a deficiency.
A resident with an indwelling urinary catheter was observed multiple times without the catheter being properly secured to his thigh, contrary to his care plan. The facility's nursing staff failed to implement the intervention to tape the catheter, as confirmed by an LPN and the MDS coordinator, indicating a lapse in following established protocols to prevent urinary catheter-associated complications.
The facility failed to maintain a medication error rate below five percent by administering medications late for two residents during the morning medication pass. The errors were confirmed by an LPN, resulting in a calculated error rate of 6.25%, exceeding the acceptable threshold.
The facility failed to submit accurate payroll data for RN staffing, missing 8 consecutive hours of RN coverage on several weekend days. The issue was confirmed through data review and staff interviews, with the Office Manager unable to identify the specific problem.
A facility failed to maintain an infection prevention and control program when a housekeeper exited a resident's contact isolation room with soiled PPE. The resident had an ESBL infection, and the housekeeper was unaware of the requirement to change PPE each time she entered and exited the room. This was confirmed by an LPN and the Director of Nursing/Infection Control Preventionist.
The facility failed to provide accessible call systems for three residents, leading to their inability to call for assistance. One resident's call bell was clamped to a curtain, another's was placed out of reach on the bed, and a third resident was unable to use the press button call bell due to contracted hands. These deficiencies were confirmed by staff observations and interviews.
The facility failed to maintain a clean, comfortable, and homelike environment, with multiple rooms observed to have various deficiencies such as soiled items on the floor, leaking faucets, and unclean surfaces. Interviews confirmed that these issues should have been reported and addressed.
The facility failed to ensure a resident's urinary catheter bag was kept private, as observed when the resident was in the dining room with the bag uncovered. An LPN/CNA Supervisor acknowledged the oversight, which violated the facility's dignity policy.
An LPN left a medication cart unlocked and unattended with the keys on top while at the nurses' station. Another LPN/CNA Supervisor confirmed the cart should not have been left unlocked and unattended. The DON stated the cart should be locked when not in use and keys should not be left on top.
The facility failed to ensure proper laundry processing by not connecting the detergent dispenser hose to a washing machine, leading to unsanitary conditions for residents' clothing and linens. This issue was observed and confirmed by the Housekeeping Supervisor and Laundry Staff, who admitted to using the machine without detergent for multiple loads.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to wound care for one resident. The facility’s hand hygiene policy required use of alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after contact with a resident’s skin, after handling used dressings or contaminated equipment, and after removing gloves. The facility’s Enhanced Barrier Precautions (EBP) policy required gown and glove use for high-contact resident care activities, including wound care, for residents with wounds, and specified that EBPs remain in place for the duration of the resident’s stay or until wound resolution. The resident involved had a stage 4 sacral pressure ulcer, type 2 diabetes, and a UTI, with a physician’s order for sacral wound care including cleansing, application of gentian violet, collagen, and silver alginate, and covering with a dry dressing. During an observed wound care treatment, the treatment nurse and a CNA entered the resident’s room, which had an EBP sign posted instructing staff to wear gown and gloves for wound care, but neither staff member wore a gown. The treatment nurse removed the resident’s soiled dressing, removed her gloves, placed them on the bedside table, and donned clean gloves without performing hand hygiene between glove changes. She then cleansed the wound and applied gentian violet without changing gloves or performing hand hygiene after cleansing the wound. When the resident had a bowel movement, the nurse removed her gloves, placed them on the bed sheet, left the room without performing hand hygiene, returned with wipes and gloves, and again donned clean gloves without hand hygiene before cleaning the bowel movement. The nurse continued to alternate between cleaning bowel movements, changing briefs, and performing wound care while repeatedly removing used gloves, placing them on the bed sheet, and donning clean gloves without performing hand hygiene between glove changes or after glove removal. She exited and re-entered the room without hand hygiene after glove removal and did not discard used gloves in the trash as required. In interviews, the nurse acknowledged she did not bring hand sanitizer into the room, did not perform hand hygiene between glove changes, did not change gloves after cleansing the wound before applying gentian violet, and placed soiled gloves on the resident’s bed instead of discarding them. The CNA confirmed awareness of the EBP sign and the requirement to wear a gown and gloves for direct care but did not wear a gown. The DON/infection control nurse and another nurse assisting with infection control confirmed that hand hygiene between glove changes, proper glove disposal, and use of gown and gloves for wound care under EBP were required and were not followed in this instance.
Failure to Follow Care Plan and MD Orders for Heel Lift Boots
Penalty
Summary
The deficiency involves the facility’s failure to implement a complete care plan and follow physician’s orders for a resident who required heel lift boots while in bed. The resident’s EHR showed an admission date of 12/22/2005 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The resident’s care plan identified a potential for skin breakdown related to decreased mobility, incontinence, and hemiplegia, with an intervention specifying heel lift boots while in bed. A physician’s order dated 03/24/2025 also directed that the resident wear heel lift boots while in bed every day shift. On multiple observations, the resident was found in bed without the ordered heel lift boots. On 02/23/2026 at 2:50 p.m., and again on 02/24/2026 at 9:11 a.m. and 10:55 a.m., the resident was observed in bed without the heel lift boots in place. When questioned, the CNA who entered the room stated she did not know the resident was supposed to have heel lift boots on and did not know where they were in the room. The LPN assigned to the resident for that shift stated she was not very familiar with the resident’s care because she was not normally assigned to that resident. After reviewing the orders, the LPN confirmed there was an order for heel lift boots while in bed and acknowledged that the resident should have been wearing them but was not.
Lack of Competency Validation and Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to ensure that an agency treatment nurse had the necessary competencies and followed infection control practices while providing wound care to a resident with a stage 4 sacral pressure ulcer, type 2 diabetes, and a UTI. The resident had a physician’s order for sacral wound care that included cleansing with wound cleanser, applying gentian violet, collagen, and silver alginate, and covering with a dry dressing. During an observed wound care procedure, the agency nurse and a CNA did not wear gowns despite an Enhanced Barrier Precautions sign on the resident’s door requiring gowns and gloves for wound care. The nurse repeatedly removed soiled dressings and handled the wound and surrounding areas without performing hand hygiene between glove changes, and placed used gloves on the bedside table and bed sheets instead of discarding them appropriately. During the procedure, the resident had two bowel movements, and the nurse left and re-entered the room multiple times, changing gloves but never performing hand hygiene with sanitizer or soap and water between glove changes or before resuming wound care. The nurse confirmed in interviews that she did not bring hand sanitizer into the room, did not perform hand hygiene between glove changes, did not change gloves after cleansing the wound before applying gentian violet, and placed soiled gloves on the bed instead of discarding them. She also stated she had been performing wound care for all residents for the previous two weeks without being trained on the facility’s policies and procedures, without shadowing or receiving direction from the prior treatment nurse, and with only the physician’s orders as guidance. The administrator confirmed there was no documented evidence that this agency nurse had been trained on facility policies and procedures or that her competency to provide wound care for all residents had been verified.
Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's physician and responsible party following an incident in which the resident experienced a fall during staff assistance. According to the facility's policy, the attending physician and the resident's family are to be promptly notified and the time of notification documented. However, review of the incident report revealed that the wrong physician and responsible party were notified after the fall. The resident involved had significant medical conditions, including end stage renal disease, dependence on renal dialysis, type 2 diabetes, and atrial fibrillation. Interviews with facility staff confirmed that the LPN on duty did not immediately notify the correct physician or responsible party, mistakenly believing there was a 72-hour window for notification. The Director of Nursing and the Administrator both verified that the correct notifications were not made as required by policy. The deficiency was identified through record review and staff interviews, which showed a failure to follow established procedures for timely and accurate notification after a resident injury.
Failure to File Grievance After Resident Incident
Penalty
Summary
The facility failed to file a grievance for one resident after an incident involving a fall from a wheelchair on a van lift prior to the resident's scheduled dialysis. The facility's policy states that any resident, family member, or appointed representative may file a grievance or complaint regarding care, treatment, staff behavior, theft, or any other concerns, and that grievances may be submitted orally or in writing. Upon receipt, the grievance officer is required to review and investigate the allegations and submit a written report to the Administrator within five working days. However, review of the facility's grievance log showed no grievance was filed for this incident. The resident involved had multiple diagnoses, including end stage renal disease, dependence on renal dialysis, type 2 diabetes, and atrial fibrillation. The resident's representative reported being upset due to delayed notification about the fall and subsequently spoke in person with the DON about her concerns. The DON confirmed the conversation but denied filing a grievance, and the incident was not documented in the grievance log as required by facility policy.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Lapse in Staff BLS/CPR Certification
Penalty
Summary
The facility failed to ensure that staff maintained current CPR certification as required by its policy and procedures. Specifically, one LPN's BLS certification had expired and was not renewed by the required date, as confirmed through personnel record review and interviews with both the LPN and the Director of Nursing. The facility's policy mandates that key clinical staff maintain up-to-date BLS/CPR certification, but this requirement was not met in this instance.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to implement the plan of care by not following physician orders for laboratory testing for one of three sampled residents. Record review showed that a resident with diagnoses including essential hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia, and hyperlipidemia was readmitted to the facility and had physician orders for a lipid panel every six months and annual PSA and urine for microalbumin tests, all scheduled for June. Further review of the resident's medical record did not reveal evidence that these laboratory tests were obtained as ordered during the specified month. During an interview and record review with the Director of Nursing, it was confirmed that the required laboratory tests were not completed as per the physician's orders.
Failure to Provide Timely Incontinent Care per Care Plan
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis, hypertension, and COPD was assessed as cognitively intact but dependent on staff for mobility, toileting, and personal hygiene due to limited range of motion and incontinence. The resident's care plan required staff to check for dryness and provide personal care every two hours. On the day in question, the resident was observed participating in activities and then brought to the dining room for lunch without being returned to her room for incontinent care as specified in her care plan. Later, when the resident was transferred to bed after lunch, her pants were found to be soaking wet. Staff confirmed that the resident had not been changed or provided with incontinent care for over five hours, with the last care provided early that morning. Interviews with the DON and CNA supervisor confirmed that the resident should have been checked and provided with care every two hours, and that this did not occur as required.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebrovascular disease, hypertension, and COPD was admitted to the facility and had a physician's order for continuous oxygen at 2 liters per nasal cannula to maintain oxygen saturation above 92%. The resident's care plan included interventions for respiratory therapy, assessment for respiratory distress, and administration of oxygen as ordered. Despite these orders, multiple observations on the same day revealed the resident was not receiving oxygen while in the dayroom and dining room, even though an oxygen tank was present in the wheelchair holder. Staff interviews confirmed the deficiency: a CNA was unaware of the resident's oxygen needs, and an LPN verified that the oxygen tank was empty and that the resident was not receiving the ordered continuous oxygen therapy. The DON also confirmed that the resident should have been on continuous oxygen per the physician's order. These findings indicate that the facility failed to ensure the resident received safe and appropriate respiratory care as ordered.
Failure to Store Respiratory Equipment Properly and Specify BIPAP Use
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring proper storage of respiratory equipment and by not specifying the frequency for BIPAP use in the physician's orders. Specifically, a resident with diagnoses including COPD, heart failure, dementia, morbid obesity, and obstructive sleep apnea was observed with an oxygen nasal cannula hanging freely from a wheelchair and not stored in a sealed, dated storage bag as required by facility policy. Staff interviews confirmed that the nasal cannula should have been stored properly when not in use, but this was not done after the resident was transferred to bed. Additionally, the physician's orders for the resident included the use of BIPAP but did not indicate when the BIPAP should be applied. Staff interviews revealed that the resident only wore BIPAP at night, and the DON stated that BIPAP should be applied any time the resident was sleeping, including naps. The lack of a specified frequency for BIPAP use in the physician's orders contributed to the deficiency in respiratory care for the resident.
Inaccurate Documentation of CPAP Cleaning
Penalty
Summary
The facility failed to ensure that medical records were accurately documented and maintained in accordance with professional standards for one resident. The facility's policy requires concise, accurate, and complete documentation of assessments, interventions, and treatments. A review of a resident's medical record showed a physician's order for daily cleaning of a CPAP/BIPAP mask and tubing, which was documented as completed on the Medication Administration Record (MAR) for a specific date. However, direct observation of the resident's CPAP mask on that date revealed brown residue and beard hairs inside the mask, indicating it had not been cleaned as required. Further investigation included an interview with an LPN who admitted to documenting the cleaning of the CPAP mask before actually performing the task, stating that she was allowed to document tasks as complete even if they had not yet been done. The Director of Nursing later clarified that nurses were not permitted to document completion of tasks prior to actually completing them. This discrepancy between documentation and actual care provided led to the deficiency cited in the report.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was updated and posted daily as required. On March 3, 2025, at 10:00 AM, an observation was made of the nurse staffing data displayed on a whiteboard at the facility's entrance. The data showed dates from February 11 and February 12, 2025, indicating that the information had not been updated for several weeks. During an interview at 10:45 AM on the same day, the Director of Nursing (S1DON) confirmed that the staffing data was outdated and acknowledged that it should have been updated daily but was not.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary grooming services to a resident who was unable to perform activities of daily living independently. The resident, diagnosed with Huntington disease, mood affective disorder, depression, and anxiety disorder, was severely impaired cognitively with a BIMS score of 6 and required maximum assistance for all activities of daily living. Despite having an active physician's order to trim nails as needed, the resident was observed with long and unclean fingernails, with a dark brown substance accumulated under them. On the morning of March 5, 2025, a Certified Nursing Assistant (CNA) confirmed the resident's fingernails were long and dirty, requiring trimming and cleaning. This observation was further corroborated by the Quality Assurance Nurse, who also confirmed the need for nail care. The Director of Nursing acknowledged that the resident's nails should have been trimmed and cleaned, indicating a lapse in the facility's adherence to its policy and procedure for nail care, which mandates regular cleaning and trimming of nails.
Failure to Notify Physician and Responsible Party of Resident Injury
Penalty
Summary
The facility failed to ensure immediate notification of a resident's physician and responsible party following an incident where the resident was injured. Resident #5, who was cognitively intact with a BIMS score of 14, was hit in the head by a door on 01/04/2025. The incident report indicated that the physician and responsible party were not notified until 01/06/2025, two days after the incident occurred. This delay in communication was contrary to the facility's policy, which requires prompt notification of such incidents. Interviews conducted during the investigation revealed that the resident experienced a headache following the incident and requested to be sent to the emergency room. The LPN who attended to the resident on 01/06/2025 confirmed that neither the nurse practitioner nor the responsible party was aware of the incident until that day. Additionally, an agency LPN stated she was unaware of the incident, which contributed to the lack of timely notification. The Director of Nursing acknowledged the delay in notifying the responsible parties and confirmed that the notification should have occurred on the day of the incident.
Failure to Timely Obtain and Document Wound Culture Order
Penalty
Summary
The facility failed to write a telephone order and obtain a wound culture in a timely manner as ordered by a physician for a resident. The resident was admitted with multiple severe conditions, including stage 4 pressure ulcers, sepsis, and severe protein-calorie malnutrition. On a specific date, the treatment nurse noted a strong odor and drainage from the resident's wounds and contacted the wound care clinic. The physician ordered wound cultures to be collected and sent to the lab on the same day. However, the wound cultures were not collected and sent to the lab until two days later. The Director of Nursing confirmed that there was no telephone order written by the treatment nurse for the wound cultures, and the delay in sending the cultures to the lab was not in accordance with the physician's orders. This failure to act promptly and document the order led to a deficiency in the facility's care for the resident.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by not documenting an incident involving a resident. The incident occurred when a resident, who was cognitively intact with a BIMS score of 14, was hit in the head by a door opened by a nurse. The resident, who had diagnoses including anxiety disorder, fibromyalgia, and osteoarthritis, recalled the incident and stated that the door hit her head, causing her to also hit her head on the wall. However, a review of the resident's nurse's notes from the date of the incident did not reveal any documentation of this occurrence. Interviews conducted with the involved parties confirmed the incident. The Agency Licensed Practical Nurse (LPN) involved in the incident recalled opening the door and hitting the resident's food tray but was unaware that the resident's head was hit. The Director of Nursing (DON) also recalled the incident and acknowledged that the nurse should have documented it in the nurse's notes. Despite the incident being reported in the facility's Incident Report, the lack of documentation in the resident's medical records constitutes a failure to adhere to the facility's policy on charting and documentation.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as evidenced by the condition of a resident's room. The resident, who was admitted with diagnoses including Unspecified Dementia and Essential Hypertension, had a moderately intact cognitive status with a BIMS score of 10. During an observation and interview, the resident expressed concerns about the rotten wood on the back door frame of his room. The observation confirmed the presence of rotten wood on the bottom left side of the door frame, approximately one foot in height. Additionally, two breaks in the sheetrock were observed on the north wall, left side of the resident's bed. Further interviews and observations with the Maintenance Supervisor and the Administrator confirmed the poor condition of the door frame and the wall. The Maintenance Supervisor demonstrated the extent of the damage by kicking the lower portion of the door frame, causing the wood to crumble. Both the Maintenance Supervisor and the Administrator acknowledged that the door frame and the wall should not have been in such a state, indicating a failure to provide a safe and well-maintained environment for the resident.
Failure to Ensure Timely Mail Delivery on Weekends
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, which had the potential to affect 95 residents. The facility's policy stated that mail and packages would be delivered to residents within 24 hours of delivery, except on weekends and holidays. However, it was found that the facility did not receive mail from the post office on Saturdays or Sundays, as confirmed by a document dated 05/21/2024 and signed by the Administrator. During a resident council meeting, a resident voiced concerns about not receiving mail on Saturdays, stating that the Business Office did not work on weekends. An interview with the Business Office staff confirmed that the office was closed on weekends and weekend staff did not have access to retrieve the mail, which was then distributed on Mondays by the Activity Director. Further interviews revealed that the Director of Nursing was unaware of the mail delivery process on Saturdays. A call to the local post office confirmed that someone from the facility had requested that mail not be delivered on weekends, although the postal employee could not confirm who made this request or how long it had been in effect. This failure to ensure timely mail delivery on weekends was a clear deviation from the facility's policy and affected the residents' access to communication methods.
Failure to Follow Food Handling Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards by not following appropriate food handling practices. During a tour of the kitchen, expired food items were found in the walk-in cooler and dry storage area. Specifically, six unopened containers of yogurt and three unopened containers of orange jello were past their expiration dates. Additionally, several opened food items, including containers of ranch dressing, sliced jalapenos, pickles, mayonnaise, sour cream, honey mustard, lemon juice, yellow mustard, and a gallon of milk, were not labeled with the date and time they were opened. The Dietary Supervisor confirmed these items were expired and should have been discarded, and that the opened items should have been labeled with the date and time they were opened but were not. Further observations revealed two opened squeeze bottles of grape jelly on the counter that were not labeled with the date and time they were opened. In the dry storage room, several opened food items, including pasta, chocolate cake mix, bread crumbs, taco seasoning, and peanut butter, were found to be expired. Additionally, the temperature logs for the kitchen's reach-in cooler, walk-in cooler, and walk-in freezer were absent for an entire week. The Dietary Supervisor confirmed that temperatures were supposed to be checked and logged daily but were not done for the specified week.
Failure to Address Resident Respectfully
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not addressing her by her name. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 06, and multiple diagnoses including Bipolar disorder, Chronic kidney disease stage 4, and Type 2 diabetes mellitus. During observation rounds, the resident asked a CNA for some ice and was addressed as 'girl' by the CNA, which the resident found disrespectful and inappropriate given her age and preference to be called by her name. The resident expressed her dissatisfaction with being called 'girl' and emphasized her desire to be addressed by her name. The CNA involved denied speaking to the resident in a disrespectful manner. However, the Director of Nursing (DON) confirmed that the facility's goal is to make residents feel valued and cared for, and acknowledged that the resident should not have been addressed as 'girl'. The facility's policy on dignity and respect clearly states that residents should be addressed by their name of choice and not labeled, which was not adhered to in this instance.
Failure to Conduct Monthly Resident Council Meetings
Penalty
Summary
The facility failed to organize resident group meetings monthly, as required. A review of the Resident Council Meeting Binder showed that meetings were held in January and February 2024, but there were no records of meetings for March and April 2024. Interviews with the Resident Council President and three other residents confirmed that the facility had not been conducting monthly meetings. The Activity Director claimed that monthly meetings were being held but could not provide documentation to support this claim.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident diagnosed with chronic pain and acquired absence of the right leg above the knee. The resident, who had intact cognition, reported that the ceiling across from his bed was cracked, peeling, and hanging since his admission. Maintenance staff confirmed the disrepair and admitted that ceilings were not part of their routine checks, which only included call lights and beds. The maintenance supervisor corroborated this, revealing that the maintenance log only documented checks for beds and call lights.
Inaccurate MDS Assessments for Medications and Restraints
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. Resident #63's quarterly MDS assessment inaccurately indicated that the resident had received an injectable medication for one day in April 2024. However, a review of the resident's electronic Medication Administration Record (eMAR) for April 2024 showed no evidence of any injectable medication being administered. The Minimum Data Set Coordinator (MDSC) confirmed the inaccuracy after reviewing the records and was unable to recall any injectable medication given to the resident during that period. Resident #89's quarterly MDS assessment failed to accurately reflect the use of a restraint. The resident, who had diagnoses including Alzheimer's Disease and Congested Heart Failure, was observed multiple times with a lap tray in place, which was used as a restraint for poor trunk control. Despite this, the MDS assessment did not code the resident for the use of any restraints. The MDSC confirmed that the resident should have been coded for the use of a restraint, as indicated by the resident's care plan and physician orders. The failure to accurately code the use of restraints was verified through interviews and record reviews.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for Resident #198 by not ensuring she was repositioned every two hours and not providing a notebook and pen for communication. Despite the care plan indicating the need for these interventions due to her immobility and difficulty making herself understood, observations on multiple occasions revealed that Resident #198 was not repositioned as required and did not have the necessary communication tools. Staff members, including an LPN and Social Services, confirmed the absence of these items and were unaware of the resident's needs as outlined in her care plan. Additionally, the facility failed to monitor the padding on Resident #82's bedframe as required. The resident's physician's orders and MAR indicated that padding should be monitored every shift for safety. However, observations on multiple occasions showed that the padding was on the floor and not attached to the bedframe. An LPN confirmed that the padding was not intact and should have been monitored every shift, indicating a failure to adhere to the care plan and physician's orders for Resident #82.
Failure to Invite Resident and RP to Care Planning Meeting
Penalty
Summary
The facility failed to ensure that a resident and/or a resident's Responsible Party (RP) was invited to the resident's care planning meeting. This deficiency was identified for one resident out of a sample of 34, with the potential to affect a census of 95. The facility's policy stated that the interdisciplinary team is responsible for the development of resident care plans and that residents and their representatives are encouraged to participate. However, the policy also required documentation if participation was not practicable, which was not done in this case. Resident #70, who had a BIMS score of 14 indicating intact cognition, reported that he had never been invited to a care plan meeting despite expressing concerns about his catheter. The Minimum Data Set Coordinator (MDSC) confirmed that invitations were typically sent to the RP, but not to the residents, and that there was no documentation indicating that Resident #70 or his RP had been informed or had refused to attend. The RP also confirmed that she had never received an invitation to the care plan meeting.
Failure to Provide Activities Based on Care Plan
Penalty
Summary
The facility failed to ensure that activities were provided based on the care plan for a resident diagnosed with Major Depressive Disorder, Pneumonia, Cerebrovascular accident, and Adult failure to thrive. The resident's care plan included an intervention to encourage participation in at least one activity per week and to assist the resident with activities as needed. However, after the resident's return from the hospital, there was no record of the resident being engaged in any activities, and observations confirmed that the resident remained in her room while other residents participated in activities in common areas. Interviews with staff revealed that the Activity Director was not aware of the resident's return from the hospital until the day after, and the Social Services staff confirmed that the resident had not been assisted to participate in activities since her return. Prior to hospitalization, the resident was regularly up and out of her room, indicating a significant change in the resident's engagement in activities post-hospitalization. This lack of engagement in activities was not in accordance with the resident's care plan, leading to the identified deficiency.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an indwelling urinary catheter. Resident #70, who had diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Chronic Kidney Disease, was observed on multiple occasions without his catheter being properly secured to his thigh as per his care plan. The catheter bag was observed hung on the bed rail and chair below his waist, and the catheter tubing was not taped to his thigh, which was confirmed by an LPN during an interview. The resident's care plan specifically included an intervention to tape the catheter to his thigh to prevent complications such as urinary tract infections (UTIs). However, this intervention was not implemented by the nursing staff, as confirmed by the MDS coordinator who stated that all nurses have access to the care plan and are responsible for ensuring that all interventions are followed. The observations and interviews revealed that the facility did not adhere to its own policy titled 'Catheter Care, Urinary,' which aims to prevent urinary catheter-associated complications, including UTIs. The failure to secure the catheter as per the care plan indicates a lapse in following established protocols, potentially putting the resident at risk for complications. This deficiency was identified during a review of the resident's care and through direct observations and interviews with the nursing staff, highlighting a gap in the implementation of the resident's care plan and the facility's catheter care policy.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that their medication error rate was less than five percent by not administering medications at the right time for two residents during the morning medication pass. Specifically, the facility's policy allowed for medications to be administered within two hours before or after their prescribed time. However, during an observation on 05/20/2024, it was noted that medications for two residents were administered late. Resident #51 had an order for Rivastigmine 6 mg to be administered at 8 a.m. and 8 p.m., but it was given at 10:20 a.m. Resident #90 had an order for Gabapentin 100 mg to be administered twice a day, but it was given at 10:27 a.m. The errors were confirmed by the LPN during an interview. There were 32 opportunities for medication administration observed, with 2 errors noted, resulting in a calculated error rate of 6.25%. This error rate exceeds the acceptable threshold of less than five percent, as stipulated by the facility's policy. The deficient practice had the potential to affect a census of 95 residents in the facility.
Failure to Submit Accurate RN Staffing Data
Penalty
Summary
The facility failed to ensure accurate payroll data information was submitted for direct care staffing as required. The review of the facility's Payroll Base Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2024 revealed that the facility did not submit staffing data that verified 8 consecutive hours of Registered Nurse (RN) coverage during several weekend days. Specifically, the facility lacked RN coverage for 8 consecutive hours on 10/14/2023, 10/15/2023, 10/28/2023, 10/29/2023, 11/11/2023, 11/12/2023, 11/25/2023, 11/26/2023, 12/09/2023, 12/10/2023, and 12/23/2023. This deficiency was identified through data review and interviews with the facility's staff, including the Consultant Administrator, Administrator, and Office Manager, who confirmed the issue during the survey conducted on 05/20/2024. During the interview, the Office Manager stated that she had attempted to communicate with CMS to correct the missing RN hours but had no documentation or evidence of such contact. She provided the RN clock-in data for the days in question, which confirmed that an RN was not present in the facility for at least 8 hours on the flagged weekend days. The Office Manager speculated that there might have been an error with the RN's PBJ number, leading to a transmission error, but she could not specifically identify the problem. The PBJ Staffing Report 1705D marked the RN coverage data as an infraction, confirming the facility's failure to submit the required staffing data to CMS accurately.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to maintain an infection prevention and control program as evidenced by staff not removing PPE before exiting a resident's room who was on contact isolation precautions. The facility's policy required staff to wear gloves, gowns, and masks when entering the room and to remove these items before leaving. However, a housekeeper was observed exiting the room with soiled gloves and a soiled gown, which was against the facility's policy. This incident was confirmed by a Licensed Practical Nurse (LPN) who stopped the housekeeper from fully exiting the room with the soiled PPE. The resident involved had been admitted with diagnoses including Schizoaffective disorder, Bipolar disorder, and Chronic obstructive pulmonary disease, and was on contact isolation due to an Extended-spectrum beta-lactamase (ESBL) infection in the urine. The housekeeper was unaware of the requirement to change PPE each time she entered and exited the room, which was confirmed during an interview. The Director of Nursing/Infection Control Preventionist also confirmed that the housekeeper should not have exited the room with soiled PPE.
Failure to Provide Accessible Call Systems
Penalty
Summary
The facility failed to provide a functional call system for three residents, leading to deficiencies in their ability to call for assistance. Resident #37, who has a history of Type 2 diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, and weakness, was observed unable to reach her call bell, which was clamped to the curtain instead of being within her reach. This was confirmed by an LPN who acknowledged that the call bell should not have been placed there. Similarly, Resident #62, diagnosed with end-stage renal disease, Type 2 diabetes mellitus, and peripheral vascular disease, was found unable to reach her call bell, which was placed in the middle of her bed. The resident expressed that she could not call for assistance to obtain a meal tray after returning from dialysis, and this was confirmed by a CNA who admitted the call bell should have been within reach. Resident #83, who suffers from acute embolism and thrombosis of unspecified deep veins of the lower extremity and major depressive disorder, was found unable to use her call bell due to her hands being contracted and clenched in a fist. The resident stated she had been hollering for help for a long time without response. A CNA confirmed that the resident was unable to use the press button call bell, and the DON also verified that the call bell was inappropriate for the resident's condition. These observations and interviews highlight the facility's failure to ensure that call systems were accessible and usable for these residents, as required by their care plans and facility policy.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents. Observations revealed multiple deficiencies across several rooms. Room A had a tan blanket, pillow, blue gloves, an adult brief, green clothing hanger, and two turn cushions on the floor. Room B and C had a white substance at the base of the faucets, with Room C's faucet leaking. Room D had a blue surgical mask and paper on the floor. Room E had paper towel, a brown cigarette bud, brown colored stains on the fall mats, a purple pillow on the floor, and a large brown stain in the corner of the room on the floor. Room F had three dresser drawers with a green and white substance on the exterior of the drawers. Room G had a towel on the floor inside the shower. Interviews with the housekeeping supervisor and an LPN confirmed that the rooms should not have paper, clothing, and soiled gloves on the floor. They also acknowledged that the faucets with the white substance and the leaking faucet should have been reported and replaced. The housekeeping supervisor added that the dresser in Room F needs to be replaced. The facility's maintenance problem document did not reveal that the faucets in Rooms B and C were in disrepair, indicating a failure in reporting and addressing maintenance issues in a timely manner.
Failure to Maintain Privacy of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure that Resident #4 was treated with respect and dignity by not keeping the urinary catheter bag contained and private. The facility's Quality of Life - Dignity policy, revised on October 4, 2022, mandates that residents be treated with dignity and respect at all times, including helping residents keep urinary catheter bags contained and private. Resident #4, who has diagnoses including Schizophrenia, Hydronephrosis with renal and ureteral calculous obstruction, and Benign prostatic hyperplasia, was observed on April 15, 2024, sitting in his wheelchair in the dining room with his urinary catheter bag uncovered. During an interview at the same time, an LPN/CNA Supervisor acknowledged that the catheter bag was uncovered and should have been in a privacy bag.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure a medication cart was locked and the medication cart keys were not left on top of the cart when left unattended and/or out of view during medication administration. On 04/16/2024 at 2:14 p.m., an LPN left her medication cart unlocked and unattended while she sat at the nurses' station talking on the telephone and with other staff. Further observation at 2:15 p.m. revealed that the LPN left the medication cart keys on top of the unlocked and unattended medication cart. An immediate interview with another LPN/CNA Supervisor confirmed that the cart should not have been left unlocked and unattended. The LPN admitted to leaving the cart unlocked and unattended with the keys on top. The Director of Nursing stated that the medication cart should be locked at all times when the nurse was not administering medications and that the keys should not have been left on top of an unattended medication cart.
Failure to Ensure Proper Laundry Processing
Penalty
Summary
The facility failed to properly process potentially contaminated resident clothing and linens, leading to a deficiency in producing sanitary laundry and preventing the transmission of communicable diseases. During an observation in the laundry room, it was found that one of the washing machines had its detergent dispenser hose disconnected, which meant that detergent was not being dispensed during wash cycles. This issue was confirmed by the Housekeeping Supervisor, who acknowledged that the hose should have been connected for proper washing. The Laundry Staff also admitted to using the machine for multiple loads of laundry without the detergent dispenser hose being connected, indicating a lack of awareness about the necessity of the hose for proper detergent dispensing. The facility's policies on laundry processing were reviewed and found to be lacking in specific dates, which could contribute to the oversight. The Laundry Staff reported seeing the disconnected hose since the previous day and continued to use the machine without detergent, further exacerbating the issue. This failure to ensure proper laundry processing procedures compromised the sanitary condition of the residents' clothing and linens, potentially increasing the risk of communicable disease transmission among the 98 residents in the facility.
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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