Ferncrest Manor Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 14500 Haynes Blvd., New Orleans, Louisiana 70128
- CMS Provider Number
- 195214
- Inspections on file
- 38
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ferncrest Manor Living Center during CMS and state inspections, most recent first.
Staff failed to maintain proper bed elevation for a resident receiving enteral feeding, did not change the enteral feeding administration set every 24 hours as ordered, and allowed a CNA to place and restart a resident's enteral feeding, which is outside their scope of practice. These actions did not comply with physician orders or facility policy regarding enteral feeding care.
A resident receiving enteral feeding had missing documentation in the eMAR for required residual checks, and there were conflicting physician's orders for the feeding rate. The DON confirmed that nursing staff did not document the residual checks as required by facility policy.
A CNA failed to provide privacy for a resident during incontinence care by not drawing the privacy curtain, resulting in the resident being visible from the doorway and to a roommate. The DON confirmed that privacy should have been maintained during the care.
Surveyors observed unsanitary conditions in the dining room, including dead insects, a severed reptile tail, particle build-up, and peeling wallpaper, as well as dirty air vents. In three hallways, there was a significant accumulation of black, brown, and gray particles along baseboards and doors, dried brown substances on walls, extensive damaged sheetrock, and a rusted exit door. Facility staff confirmed these areas were not maintained as required, resulting in an environment that was not clean or homelike.
A resident's annual MDS Assessment was completed and signed by an RN but was not transmitted to CMS within the required 7-day period. Instead, the assessment was submitted several weeks after completion, as confirmed by staff interview and record review.
Surveyors found that the facility did not maintain accurate reconciliation of controlled substances for all medication carts reviewed, with missing signatures from both off-going and oncoming nurses on numerous shifts. Interviews with LPNs and the DON confirmed that the required reconciliation process and documentation were not consistently followed, and approved logs were not always used. No evidence was provided to show that the receipt and disposition of controlled drugs were properly documented during the identified periods.
A nurse left a medication cart unlocked and unattended for 10 minutes, with 55 tablets of metoprolol tartrate and two vials of Zosyn unsecured on top. The LPN responsible was at the nursing desk with her back to the cart, and both the LPN and DON acknowledged the medications should not have been left unattended.
The facility did not properly label and date food items stored in the walk-in cooler and failed to maintain required documentation of dishwashing machine temperature and sanitizer checks, as confirmed by the Dietary Manager and Administrator.
The facility did not hold its required quarterly QAA committee meeting during the first quarter of the year and failed to document the Infection Preventionist's attendance at the most recent QAA meeting. The DON confirmed both the missed meeting and the absence of the IP.
Surveyors found that clean mop heads were stored next to dirty ones in the contaminated laundry area, clean linen was kept in open carts adjacent to soiled linen in hallways, and two residents' suction canisters were not changed as scheduled. Staff interviews confirmed these practices, and supervisors acknowledged they did not follow infection control protocols.
Two residents who required staff assistance for ADLs and transfers were found with call lights out of reach—one on the floor at the head of the bed and another clipped to a curtain—contrary to facility policy, as confirmed by an LPN and a CNA.
A resident's MDS assessment inaccurately recorded the discharge destination as a short term general hospital, while documentation and staff interview confirmed the resident was actually discharged to home.
A resident with multiple medical conditions and a physician's order for nightly alprazolam did not receive the medication as prescribed on two occasions, and facility records lacked documentation of daily administration. The DON confirmed the absence of evidence for consistent medication administration, resulting in a failure to meet professional standards.
The facility did not ensure an RN was on duty for at least 8 hours on a reviewed day, as only the DON worked and was present for less than the required time, with no documentation to show compliance.
A facility-wide assessment did not include documented evidence of specific LPN and CNA staffing needs for day, night, and weekend shifts. The administrator was unable to explain why this information was missing from the assessment.
A resident with blindness and a conduct disorder was verbally and physically abused by a maintenance staff member in the smoking area. The staff member made derogatory remarks and engaged in a physical altercation, resulting in the resident sustaining injuries. The incident was captured on surveillance footage and witnessed by other staff members, leading to the staff member's termination.
The facility did not provide required behavioral health training to staff, despite having residents with psychiatric diagnoses and behavior management needs. Personnel records for a maintenance worker, a smoking aide, a social worker, and two CNAs lacked documentation of such training, as confirmed by the DON.
A facility failed to report a physical abuse allegation involving a resident and a maintenance staff member to the Louisiana Department of Health within the required 2-hour timeframe. The incident, which involved derogatory remarks and a physical altercation resulting in minor injuries to the resident, was reported the following day, exceeding the mandated reporting window. The facility's policy requires immediate notification through the State Incident Management System (SIMS) for such incidents.
A facility failed to maintain adequate respiratory staffing, resulting in a missed ventilator check for a resident with chronic respiratory failure. The facility's policy required two RTs per shift, but only one was present during a critical period, leading to a lapse in care when the resident's ventilator alarmed.
The facility failed to ensure that CNAs from a Nurse Staffing Agency were trained on tracheostomy and ventilator safety before being assigned to the Technology Dependent Unit. Two CNAs were assigned without documented evidence of training, as confirmed by interviews with facility staff, including the CNA Supervisor, Respiratory Director, DON, and Administrator.
A resident's medication was not administered as ordered on multiple occasions due to the drug not being available, despite the facility's emergency medication kit containing the required medication. The DON confirmed that the physician should have been contacted for an order to change or hold the medication, but no such order was obtained.
The facility failed to implement enhanced barrier precautions for residents with indwelling devices or wounds, did not properly identify and contain resident care items, and nursing staff did not adhere to hand hygiene protocols during gastrostomy dressing changes. Additionally, a wound care nurse improperly disposed of a soiled dressing.
The facility failed to develop care plans with measurable interventions for three residents with specific medical needs, including a resident with contact dermatitis, a resident receiving hospice services, and a resident with an indwelling urinary catheter. The DON confirmed that the care plans should have been developed but were not.
A facility failed to maintain clean and trimmed fingernails for a severely impaired resident who required substantial assistance for bathing. Observations revealed the resident's fingernails had an unknown black substance and were excessively long. Staff confirmed the need for nail care, but there was no documentation of it being performed despite daily bed baths.
The facility failed to ensure that a resident's indwelling urinary catheter was properly secured, as required by the physician's order and care plan. Multiple observations revealed the catheter was not secured, causing it to be pulled taut during care activities. Interviews with staff confirmed the securement device was not in place, leading to a deficiency in care.
The facility failed to ensure that the gastrostomy tube sites of two residents were cleaned as ordered by the physician. One resident did not receive the prescribed care on multiple dates, and another resident did not have a standing order for site care implemented upon admission.
The facility failed to maintain a pest-free environment, as evidenced by maggots in a resident's gastrostomy tube site and flies observed in various areas, including the kitchen, dining room, and on a resident's bed linens. The facility's exit door had an opening large enough for pests to enter, which was not addressed until the surveyor's visit.
Failure to Follow Enteral Feeding Orders and Protocols
Penalty
Summary
The facility failed to follow physician orders and facility policy regarding the care and management of enteral feedings for two residents. For one resident, the head of the bed was observed to be elevated to only 30 degrees on multiple occasions while enteral feeding was infusing, despite a physician's order requiring a 45-degree elevation at all times except during care. Additionally, the same resident's enteral feeding administration set was not changed every 24 hours as ordered; it was observed to be in use beyond the prescribed time frame, with significant feeding already infused through the set. In another instance, a CNA placed a resident's enteral feeding on hold and restarted it during incontinence care, which was outside the CNA's scope of practice according to facility policy and confirmed by the DON and Administrator. The facility's policy specifies that only trained and qualified LPNs and RNs are permitted to prepare, store, administer, or adjust enteral feedings. These actions and inactions resulted in the facility not ensuring that enteral feedings were managed according to physician orders and facility protocols.
Failure to Maintain Accurate Medical Records for Enteral Feeding
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident receiving enteral feeding. According to the facility's documentation policy, all services provided to a resident must be recorded in the medical record. For the resident in question, physician's orders required staff to check enteral feeding residuals every four hours and to administer Jevity 1.5 at specified rates. However, review of the electronic Medication Administration Record (eMAR) showed missing documentation for several required residual checks on specific dates and times. Additionally, there were two active, conflicting physician's orders for the rate of enteral feeding, which the Director of Nursing acknowledged should not have occurred. The Director of Nursing also confirmed that nursing staff failed to document the required residual checks in the eMAR.
Failure to Ensure Resident Privacy During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) provided incontinence care to a resident without ensuring privacy. During the care, the CNA did not announce her presence when a surveyor knocked on the door and entered the room. The resident's limbs and incontinence brief were visible from the doorway, and the privacy curtain was not drawn, allowing the resident's roommate to observe the care being provided. The Director of Nursing confirmed in an interview that the CNA should have pulled the privacy curtain or otherwise provided privacy during the incontinence care. These observations demonstrate a failure to maintain the resident's privacy and confidentiality during personal care, as required by facility policy and resident rights.
Failure to Maintain Clean and Homelike Environment in Dining Room and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in both the dining room and hallways, as evidenced by multiple observations of unsanitary and poorly maintained conditions. In the dining room, surveyors observed a significant accumulation of dead insects on window sills, a severed reptile tail, and particle build-up around door jambs and ledges. Additionally, five ceiling air vents above dining tables had an unknown light gray substance surrounding them, and wallpaper was found peeling in two areas. These findings were confirmed by both the Housekeeping Supervisor/Dietary Manager and the Plant Operations Manager, who acknowledged that such conditions did not present a clean or homelike environment. In the hallways, surveyors noted an accumulation of black, brown, and gray particles along baseboards, door jambs, and the lower portions of multiple resident room doors across all three hallways observed. There were also multiple areas with dried brown substances in splatter and drip patterns on the walls, as well as extensive missing or damaged sheetrock throughout the hallways. The bottom of a metal exit door near the dining room was also found to be rusted and cracked, with rust spots present. These conditions were again confirmed by facility staff, who acknowledged the lack of required maintenance and cleanliness. Interviews with facility staff, including the Housekeeping Supervisor/Dietary Manager, Plant Operations Manager, and Administrator, confirmed that the observed areas were not maintained as required by facility policy. Staff acknowledged that housekeeping was responsible for cleaning floors, door jambs, baseboards, and walls, while maintenance was responsible for repairing sheetrock, walls, and handrails. The staff further confirmed that the current state of the environment did not meet the standards for a clean or homelike setting.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to transmit the annual Minimum Data Set (MDS) Assessment for one resident within the required 7-day timeframe after completion. Specifically, the annual MDS Assessment for the resident was completed and electronically signed by the RN Assessment Coordinator on 04/17/2025. However, review of the Final Validation Report showed that the assessment was not submitted to the Centers for Medicare & Medicaid Services (CMS) database until 05/29/2025. During an interview, the RN confirmed that the assessment was completed on 04/17/2025 but not transmitted until 05/29/2025, acknowledging that it should have been transmitted within 7 days of completion as required.
Failure to Accurately Reconcile Controlled Substances Across Medication Carts
Penalty
Summary
The facility failed to maintain an accurate and complete system for reconciling controlled substances across all six medication carts reviewed. Documentation revealed that on numerous occasions, the required signatures from both off-going and oncoming nurses were missing from the Narcotic Nurse Sign on/off logs for each medication cart. These omissions occurred on multiple shifts throughout the month, with some carts lacking signatures for both nurses on consecutive days and shifts. In several instances, there was no documented evidence of the receipt and disposition of all controlled drugs for the specified dates and times. Interviews with nursing staff confirmed that the reconciliation process was not consistently followed as required. One LPN acknowledged that the sign on/off log for a medication cart was not completed as it should have been, and that both nurses were supposed to reconcile the controlled substances together at shift change and sign the log. Another LPN admitted to signing the log at the beginning of her shift, rather than at the end, which was not the correct procedure. Additional staff interviews indicated that the approved reconciliation logs were not used for certain medication carts during the relevant shifts. The Director of Nursing confirmed that the Narcotic Nurse Sign on/off logs were not completed with the necessary signatures at the beginning and/or end of shifts as required. The DON also acknowledged that the approved logs were not used for some medication carts. There was no documentation provided by the facility to dispute these findings or to demonstrate that the required reconciliation of controlled substances had occurred during the identified shifts.
Unattended and Unsecured Medication Cart
Penalty
Summary
A nurse failed to secure medications by leaving Medication Cart b unlocked and unattended for 10 minutes. During this time, 55 tablets of metoprolol tartrate 25 mg and two vials of Zosyn 4.5 grams were observed unsecured on top of the cart. The nurse responsible for the cart was sitting at the nursing desk with her back turned to the cart, leaving the medications unsupervised. Both the nurse and the Director of Nursing acknowledged that the medications should not have been left unattended and that the cart should have been locked when not supervised. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Label Food and Maintain Dishwashing Logs
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in the walk-in cooler, as required by its own Food Receiving and Storage policy. During an observation, several food containers, including cooked carrots, barbeque sauce, and multiple containers of chicken noodle soup, were found covered but not labeled or dated. The Dietary Manager confirmed that these items should have been labeled and dated according to facility policy, but were not. Additionally, the facility did not maintain accurate records of dishwasher temperature and sanitizer concentration checks, as outlined in its Dishwashing Machine Use policy. The dishwashing water temperature and sanitizer log had not been documented from after lunch on one date until breakfast nine days later, with no records for the intervening meals. The Dietary Manager and Administrator both acknowledged that the required documentation was missing for this period, despite policy requiring checks and documentation before each meal service.
Failure to Hold Quarterly QAA Meetings and Ensure Infection Preventionist Participation
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Assessment (QAA) committee met at least quarterly, as required. Review of the QAA meeting sign-in sheets showed that the most recent meeting occurred on 04/09/2025, with the previous meeting on 10/09/2024, and no documentation was provided to show a QAA meeting was held during the first quarter of 2025. Additionally, the Infection Preventionist (IP) was not documented as attending the 04/09/2025 QAA meeting, and the Director of Nursing confirmed in an interview that the IP did not attend and that the committee did not meet during the required timeframe.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several key areas. Clean mop heads were observed stored in open containers next to dirty mop heads and adjacent to dirty laundry within the contaminated laundry area. Multiple staff interviews confirmed that this was the usual storage practice, and the Housekeeping Supervisor acknowledged that clean mop heads should not have been stored in this manner. The facility administrator was unable to provide an explanation for this storage practice. Additionally, clean linen was not stored in a sanitary manner, as open carts of clean linen and supplies were placed next to, and sometimes touching, containers of contaminated linen in various hallways. Staff interviews revealed that it was common practice for CNAs to place clean and contaminated linen next to each other during linen changes, and that contaminated linen should have been covered and separated from clean linen. Furthermore, two residents who required suction canisters had canisters that were not changed according to the facility's schedule, with canisters dated several days prior and containing white and yellow liquid. The Respiratory Director confirmed that the canisters should have been changed on specific days, but this was not done.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of three sampled residents who required assistance with activities of daily living and transfers. For one resident, who required substantial to maximal assistance for self-care and was dependent on staff for transfers, the call light was observed on the floor at the head of the bed, out of the resident's reach while lying in bed. This was confirmed by an LPN, who acknowledged that the call light was not accessible as required by facility policy. For another resident, who was dependent on staff for ADLs, transfers, and mobility, the call light was found clipped to the curtain and not within reach while the resident was in bed. A CNA confirmed that the call light was not accessible and should have been within reach. The facility's policy, as stated by the administrator, requires that call lights be accessible to all residents at all times.
Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding discharge status. Specifically, for one resident, the Discharge MDS with an Assessment Reference Date of 03/12/2025 incorrectly documented that the resident was discharged to a short term general hospital. However, a review of the resident's progress note for the same date indicated that the resident had a planned discharge to home. During an interview, the MDS Coordinator confirmed that the discharge status recorded in the MDS was incorrect and did not reflect the actual discharge destination.
Failure to Administer Medication as Ordered and Incomplete Documentation
Penalty
Summary
The facility failed to administer a prescribed medication, alprazolam 0.5 mg, to a resident as ordered by the physician. Review of the resident's electronic medical record and narcotic administration record showed that the medication was not given on two specific days within a 16-day period, and there was no documented evidence that the medication was administered daily as required. The Director of Nursing confirmed that the facility could not provide documentation to show that the medication was given according to the physician's orders. The resident involved had multiple diagnoses, including cerebrovascular vasospasm, diabetes mellitus, hypertension, malignant melanoma, anxiety disorder, morbid obesity, and major depressive disorder. The resident was cognitively intact, as indicated by a BIMS score of 14. Despite clear physician orders for nightly administration of alprazolam to treat anxiety, the facility's records indicated missed doses and incomplete documentation, resulting in a failure to meet professional standards of quality in medication administration.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 hours on one of the days reviewed for staffing requirements. Specifically, on 04/19/2025, the only RN present was the Director of Nursing (DON), who clocked in at 9:01 AM and clocked out at 11:13 AM, working less than the required 8 hours. Review of staffing records and time sheets confirmed that no other RN worked that day, and there was no documented evidence to show that an RN was present for the required duration. Both the DON and the Administrator confirmed during interviews that the DON was the only RN on duty and that there was no documentation to support compliance with the 8-hour requirement.
Facility Assessment Lacks Specific Nursing Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific nursing staffing needs for Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) for day, night, and weekend shifts. A review of the most recent facility assessment, dated 05/07/2025, revealed no documented evidence that these specific staffing requirements were addressed. During an interview, the administrator was unable to provide an explanation for the omission of this information from the assessment. This deficiency was identified through both record review and staff interview, with no additional details provided regarding the impact on residents or specific patient conditions at the time of the deficiency.
Resident Abused by Maintenance Staff
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by a staff member, resulting in actual harm. The incident involved a resident with blindness and a conduct disorder, who was involved in a verbal and physical altercation with a maintenance staff member. The altercation occurred in the smoking area, where the staff member made derogatory remarks about the resident's family and girlfriend, leading to a physical confrontation. The resident, who was cognitively intact and used a wheelchair for mobility, was pushed by the staff member, resulting in injuries to the resident's right face and left hand. The facility's surveillance footage captured the staff member hovering over the resident, pointing fingers, and making contact with the resident's face, which led to the resident falling out of the wheelchair. The incident was witnessed by other staff members, who confirmed the verbal and physical abuse. The facility's policy on abuse prevention was not adhered to, as the staff member failed to de-escalate the situation and instead engaged in abusive behavior. The resident sustained a pinpoint open area on the face and hand, with subsequent swelling and tenderness. The facility's investigation substantiated the abuse, and the staff member was terminated for violating the code of conduct.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that staff members received the required behavioral health training, as determined by a facility assessment. The assessment indicated that the facility had 58 residents with psychiatric diagnoses and 14 residents requiring behavior management. However, upon review of personnel records for five staff members, including a maintenance worker, a smoking aide, a social worker, and two certified nursing assistants (CNAs), there was no documented evidence that any of these individuals had received the necessary behavioral health training. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged the absence of evidence for the required training.
Failure to Timely Report Physical Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse to the Louisiana Department of Health within the required 2-hour timeframe. The incident involved a resident and a maintenance staff member, where the staff member allegedly made derogatory remarks and engaged in a physical altercation with the resident. The altercation resulted in the resident flipping out of their wheelchair and sustaining minor injuries. The incident occurred on November 19, 2024, at 2:00 PM, but was not reported until November 20, 2024, at 9:35 AM, exceeding the mandated reporting window. The facility's policy requires immediate notification to the designated representatives through the State Incident Management System (SIMS) within 2 hours if an allegation involves physical abuse or results in bodily harm. Despite this policy, the Director of Nursing was informed of the incident shortly after it occurred, and the administrator acknowledged the delay in reporting without providing an explanation. The failure to report the incident in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements for reporting abuse allegations.
Inadequate Respiratory Staffing Leads to Missed Ventilator Check
Penalty
Summary
The facility failed to ensure adequate respiratory staff were available to provide necessary respiratory care and services for a resident. The facility's policy required two respiratory therapists (RTs) per shift in the Technology Dependent Unit (TDU) to perform ventilator checks every four hours. However, on 08/31/2024, from 7:03 p.m. to 10:27 p.m., only one RT was present, contrary to the facility's staffing requirements. This staffing shortage led to a missed ventilator check for a resident who was dependent on mechanical ventilation and tracheostomy care. The resident in question had diagnoses of cardiorespiratory conditions and chronic respiratory failure with hypoxia, requiring tracheostomy care twice daily and ventilator checks every four hours. On the evening of 08/31/2024, the scheduled 8:00 p.m. ventilator check was performed prematurely at 6:06 p.m. by the day shift RT, leaving a gap in monitoring. The night shift RT did not perform a ventilator check before the resident's ventilator alarmed at 9:53 p.m., indicating a lapse in the required care and monitoring due to insufficient staffing.
Inadequate Training for CNAs on Tracheostomy and Ventilator Safety
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) from a Nurse Staffing Agency (NSA) were adequately trained on tracheostomy and ventilator safety before being assigned to the Technology Dependent Unit (TDU), which houses residents with tracheostomies and ventilators. This deficiency was identified for two CNAs, S6CNA and S7CNA, who were assigned to the TDU without documented evidence of receiving the necessary training. The facility's in-service records from February to September 2024 did not show any evidence of training for these CNAs, and the facility was unable to provide such documentation. Interviews with facility staff, including the CNA Supervisor, Respiratory Director, Director of Nursing (DON), and the Administrator, confirmed that the NSA CNAs did not receive the required training on tracheostomy and ventilator safety before their assignments. The CNA Supervisor and Respiratory Director acknowledged the lack of training and orientation provided to the CNAs by the respiratory staff. The DON and Administrator also confirmed that the CNAs should have been trained prior to their assignments in the TDU, highlighting a lapse in ensuring staff competency for the care of technology-dependent residents.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medication was available and administered as ordered. Resident #6, who was admitted with a diagnosis of Gastrostomy status and later diagnosed with Contact Dermatitis, was prescribed Cephalexin suspension to be administered via gastric tube three times a day for seven days. Despite the medication being received by the facility on the same day it was ordered, there was no documented evidence that the medication was administered at the scheduled times on multiple occasions. Specifically, the medication was not administered on 05/08/2024 at 6:00 a.m., 2:00 p.m., and 10:00 p.m., as well as on 05/09/2024 at 6:00 a.m., and 05/11/2024 at 6:00 a.m. The reasons documented for the missed doses included the drug not being available and waiting on pharmacy delivery, despite the facility's emergency medication kit containing Cephalexin 250mg. In an interview, the Director of Nursing (DON) confirmed that the facility's emergency medication kit contained the required medication and stated that the resident's physician should have been contacted for an order to change or hold the medication if it could not be obtained from the pharmacy. There was no documented evidence that such an order was obtained. This failure to administer the medication as ordered and to follow proper procedures for obtaining or holding the medication led to the deficiency identified in the report.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were implemented for residents with indwelling devices or wounds. Specifically, five residents with conditions such as gastrostomy status, tracheostomy status, and pressure ulcers did not have enhanced barrier precautions signage or personal protective equipment (PPE) in their rooms. Staff members, including LPNs and RNs, performed care activities such as wound care and gastrostomy tube site care without wearing gowns, as required by the facility's policy. Interviews with staff revealed a lack of awareness and training regarding enhanced barrier precautions, contributing to the deficiency. The facility also failed to ensure resident care items were properly identified and contained. Observations revealed unlabeled and uncontained items such as plastic urinals and wash basins in resident rooms. Staff confirmed that these items should have been labeled and contained in plastic bags with the resident's initials, but this was not done. Additionally, nursing staff did not adhere to proper hand hygiene protocols while performing gastrostomy dressing changes. Observations showed that RNs and LPNs did not perform hand hygiene or change gloves between handling soiled and clean items during gastrostomy tube site care. Furthermore, a wound care nurse placed a visibly soiled dressing directly onto a resident's bed, which was against infection control practices. Interviews with staff confirmed these lapses in hand hygiene and infection control practices.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure care plans with measurable interventions were developed for three residents with specific medical needs. Resident #6, who was admitted with a gastrostomy status and later diagnosed with contact dermatitis, returned from the hospital with an order for oral antibiotics and a left lower abdominal wound. However, there was no documented evidence that a care plan reflecting these changes in condition was developed. The Director of Nursing (DON) confirmed that the care plan should have been updated but was not. Additionally, Resident #474, who was admitted with respiratory failure, gastrostomy status, and tracheostomy status, had orders for a monthly catheter change and was admitted to hospice services. Despite these significant medical needs, there was no documented evidence of a care plan with measurable interventions for the resident's indwelling urinary catheter or hospice care. The DON acknowledged that the care plan should have been developed but was not. Observations over several days confirmed that Resident #474 had an indwelling urinary catheter in place, yet no care plan was documented to address this. The lack of care plans for these residents indicates a failure in the facility's responsibility to develop and implement comprehensive care plans that meet all the residents' needs, as required by regulatory standards. This deficiency was identified through record reviews, observations, and interviews conducted by the surveyors.
Failure to Maintain Clean and Trimmed Fingernails for Resident
Penalty
Summary
The facility failed to maintain clean and trimmed fingernails for Resident #74, who was severely impaired and required substantial assistance for bathing. Observations on two separate occasions revealed that the resident's fingernails had an unknown black substance underneath and were excessively long. Interviews with staff, including an LPN, the Director of Nurses, and the Assistant Director of Nursing, confirmed that the resident's fingernails needed care and should have been trimmed and cleaned. Despite daily bed baths documented for the resident, there was no documentation of nail care being performed during the observed period.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter was properly secured to prevent pulling. Resident #475, who was dependent on staff for toileting, had a physician's order dated 02/26/2024 for staff to use a securement device such as a Stat Lock on her catheter every shift. However, multiple observations on 05/14/2024 and 05/15/2024 revealed that the catheter was lying under the resident's left lower extremity without a securement device in place. This lack of securement caused the catheter to be pulled taut during routine care activities, such as wound care and catheter care, performed by the staff. Interviews with the Infection Preventionist/Assistant Director of Nursing and the Director of Nursing confirmed that the securement device was not in place as required by the physician's order and the resident's comprehensive care plan. The observations and interviews indicated that the facility did not adhere to the prescribed care plan and physician's orders for Resident #475, leading to the potential for harm due to the unsecured catheter. The staff's failure to use the securement device as ordered was evident during multiple care activities, highlighting a lapse in infection control practices and proper catheter management. The Director of Nursing confirmed that the securement device should have been in place to prevent pulling on the catheter tubing, but it was not, resulting in a deficiency in the care provided to Resident #475.
Failure to Provide Gastrostomy Tube Site Care
Penalty
Summary
The facility failed to ensure that the gastrostomy tube sites of two residents were cleaned as ordered by the physician. Resident #1 had a physician's order to cleanse the gastrostomy site daily with wound cleanser, pat dry, and cover with a drain sponge. However, the Electronic Medication Administration Record (EMAR) revealed that Resident #1 did not receive the prescribed gastrostomy site care on multiple dates in March and April 2024. The Director of Nursing (DON) confirmed that the order was entered incorrectly, resulting in the resident not receiving the necessary care as per the physician's orders. Resident #2 was admitted to the facility with a gastrostomy tube but did not have a standing order for gastrostomy site care implemented upon admission. The review of the resident's April 2024 EMAR showed no documented evidence that the resident received gastrostomy tube site care since admission. The DON confirmed that the standing order for gastrostomy site care was not implemented for Resident #2, which should have been done upon admission.
Failure to Maintain a Pest-Free Environment
Penalty
Summary
The facility failed to maintain an environment free from pests, as evidenced by multiple observations and interviews. Maggots were found in a resident's gastrostomy tube site, and flies were observed on another resident's gastrostomy tube during site care. Additionally, flies were seen in various areas of the facility, including the kitchen, dining room, and on a resident's bed linens. The facility's exit door on Hall Z was found to have an opening large enough for pests to enter, which was acknowledged by the administrator but not addressed until the surveyor's visit. Interviews with staff and the pest control provider revealed that the facility had an ongoing problem with flies and had not contacted the pest control provider for extra services in the past month. The Director of Nursing confirmed the increased risk of parasites due to the presence of flies. The administrator admitted to noticing the door issue previously but did not realize its significance. These actions and inactions contributed to the deficiency in maintaining a pest-free environment.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
