Flannery Oaks Guest House
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 1642 N. Flannery Road, Baton Rouge, Louisiana 70815
- CMS Provider Number
- 195477
- Inspections on file
- 23
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Flannery Oaks Guest House during CMS and state inspections, most recent first.
The facility failed to complete quarterly MDS assessments for two residents within the required timeframe. According to the facility's policy, all MDS assessments should be completed and transmitted according to the most current RAI manual. One resident's assessment was not completed by the required date, and another resident's assessment was also delayed. Interviews with staff confirmed that the assessments were not completed in a timely manner.
A resident with cognitive intactness was involved in a physical altercation with a CNA after becoming upset over a missing breakfast item. The resident hit the CNA, who retaliated by hitting the resident, leading to the CNA's termination. The incident was reported, and no injuries were noted on the resident.
The facility failed to ensure accurate resident assessments, including PASRR evaluations, discharge statuses, and the presence of pressure ulcers. Staff interviews confirmed discrepancies in the MDS documentation for multiple residents.
The facility failed to refer a resident with a newly identified mental health diagnosis for a PASRR Level II Evaluation as required. The resident had a diagnosis of Psychosis not due to a substance or known physiological condition, and the facility did not resubmit a new Level I PASRR Screen and Determination after the new diagnosis was identified.
The facility failed to maintain a Level 1 PASRR form for a resident with Schizophrenia. The resident was admitted with this diagnosis, but the facility did not have or submit the required PASRR documentation, as confirmed by the administrator.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's urinalysis results were not reported to the consulting provider as ordered, and another resident's frequent refusals and behaviors were not addressed in the care plan. Staff interviews confirmed lapses in communication and documentation processes.
The facility failed to provide two residents with the therapeutic diets prescribed by their healthcare providers, resulting in missing dietary supplements on their meal trays. Observations and interviews confirmed that staff were unaware of the dietary requirements, and meal tickets did not reflect the necessary supplements due to a communication lapse between the DON and dietary supervisor.
The facility failed to identify and address a resident's PTSD diagnosis, resulting in a lack of appropriate care planning and interventions. Staff members were either unaware of the diagnosis or did not take necessary actions to address it, leading to inadequate care for the resident's condition.
The facility failed to limit PRN orders for psychotropic medications to 14 days for two residents receiving hospice services. Both residents had orders for Ativan without stop dates, which was confirmed by the Director of Nursing.
The facility failed to ensure accurate documentation of medical records for a resident receiving Risperdal. The medication was prescribed for Major Depressive Disorder in the physician's orders and MAR, but the Pharmaceutical Consultant Report indicated it was for Delusional Disorder. Interviews revealed a lack of clarity regarding responsibility for updating diagnoses linked to psychotropic medications.
The facility failed to ensure documentation of pneumococcal immunization status for two residents. The responsible staff member confirmed that the documentation and administration of the vaccine were incomplete for all residents during the specified period.
The facility failed to report an alleged incident of physical abuse within the required 2-hour timeframe. A resident with severe cognitive impairment was observed hitting another resident. The incident was reported to the administrator, who did not consider it abuse and did not report it to the state agency as required by policy.
The facility failed to obtain physician's orders for medications delivered for a resident, resulting in a delay in administering prescribed antibiotics. The resident, with multiple diagnoses including Chronic Kidney Disease and Acute Kidney Failure, did not receive her medications until several days after they were delivered.
A resident with severe cognitive impairment and muscle wasting had a physician's order to be fed all meals, but staff failed to provide the necessary feeding assistance. Observations and interviews confirmed that the resident was left to feed himself, contrary to the hospice plan of care and physician's orders, leading to a deficiency in care.
The facility failed to ensure drugs and biologicals were labeled according to professional principles. Two tubes in a specimen refrigerator were found without a resident's name, date and time collected, or a second identifier. Staff confirmed this was against policy and professional standards.
The facility failed to maintain an infection control program for a resident with an indwelling catheter. The resident, who had severe cognitive impairment and multiple diagnoses, was observed with the catheter bag improperly placed on several occasions. Both an LPN and the DON confirmed the improper placement and the increased risk of infection it posed.
The facility failed to electronically transmit discharge MDS assessments for two residents upon their discharge. Staff confirmed that the assessments should have been completed and transmitted on the respective discharge dates.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete quarterly assessments for two of the three residents reviewed for Resident Assessment. According to the facility's MDS Policy and Procedure, all Minimal Data Set (MDS) assessments are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Resident #1 had a Quarterly MDS with an Assessment Reference Date (ARD) of 12/18/2024, which was not completed by the required date of 01/01/2025. Similarly, Resident #3 had a Quarterly MDS with an ARD of 12/11/2024, which was not completed by 12/25/2024. Interviews with S4MDS and S2DON confirmed that the Quarterly Assessments should be completed within 14 days of the ARD, and both residents' assessments were not completed in a timely manner.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The resident, who had diagnoses including Vascular Dementia, Depression, and Anxiety Disorder, was involved in a physical altercation with a Certified Nursing Assistant (CNA). The altercation occurred when the resident became upset over not receiving coffee with breakfast and threatened to hit the CNA. The resident then hit the CNA, who retaliated by hitting the resident. The incident was documented in the facility's Self-Reported Incident Report and was corroborated by witness statements and interviews. A housekeeper witnessed the altercation and confirmed that the CNA hit the resident on the forehead after being struck by the resident. The Director of Nursing (DON) and the Administrator were notified immediately, and the CNA was terminated following the incident. The facility's policy on abuse prevention and prohibition clearly states that any form of physical abuse, including hitting or slapping, is not tolerated. Interviews with staff and the resident confirmed the sequence of events. The resident acknowledged hitting the CNA and being hit in return. The DON assessed the resident for injuries, and no injuries were noted. The facility's policy dictates that any staff member hitting a resident constitutes abuse, and this was acknowledged by multiple staff members during interviews. The incident was reported to the police, and the resident's responsible party was notified.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected the residents' status in several instances. For two residents, the facility did not correctly mark that they had been evaluated for PASRR, despite their clinical records showing Level II PASRR approvals. Interviews with staff confirmed that the MDS assessments for these residents were inaccurate. Additionally, the facility failed to accurately reflect the discharge status of another resident, who was discharged to home but was incorrectly documented as discharged to a short-term general hospital. Staff interviews confirmed the discrepancy in the discharge documentation. Furthermore, the facility did not accurately document the presence of pressure ulcers for a resident who had a Stage 3 pressure ulcer on the right buttock and an unstageable ulcer on the right heel. The resident's Admission MDS did not indicate the presence of these pressure ulcers, despite active diagnoses and ongoing wound care orders. Staff interviews confirmed that the MDS should have reflected the resident's current wound care status. These inaccuracies in resident assessments indicate a failure to ensure that the MDS accurately captured the residents' conditions and statuses.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required. Resident #36 was admitted with a diagnosis of Psychosis not due to a substance or known physiological condition, with the onset date of 08/25/2017. The most recent Level I PASRR Screening and Determination for this resident was performed on 08/18/2017, prior to the new diagnosis. There was no documentation available to show that a new Level I PASRR Screen and Determination was submitted following the addition of the new mental illness diagnosis on 08/25/2017. An interview with the facility administrator confirmed that the resident's Pre-admission Level I PASRR Screen and Determination was last submitted on 08/18/2017 and that the facility did not resubmit a new Level I PASRR Screen and Determination after the new diagnosis was identified. The resident's most recent Minimum Data Set (MDS) indicated significant cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 0, and included the diagnosis of Psychotic Disorder and Unspecified Psychosis not due to a substance or known physiological condition.
Failure to Maintain PASRR Documentation for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for one resident reviewed for PASRR. The resident was admitted with a diagnosis of Schizophrenia, which is a relevant mental illness listed on the Level I PASRR Screen and Determination. Despite this, the facility did not have a copy of the resident's most recent Level 1 PASRR Screen and Determination and had not submitted one upon the resident's admission. This was confirmed by the facility administrator during an interview.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For Resident #23, the facility did not report the urinalysis results to the consulting provider as ordered. The resident had multiple diagnoses, including chronic kidney disease and urinary tract infection, and was at risk for infection. Despite an order to fax the urinalysis results to the urologist, the results were not sent, as confirmed by the Director of Nursing (DON) and the urologist's medical assistant. The DON admitted to not sending the results and explained the process for handling lab orders, which was not followed in this case. For Resident #86, the facility did not ensure the care plan was comprehensive and individualized, particularly regarding the resident's frequent refusals and behaviors. The resident, who was severely cognitively impaired and had multiple diagnoses including chronic kidney disease and a feeding tube, frequently refused tube feedings and care related to his catheter. Despite documentation of these refusals and behaviors in nurse's notes and the 24-hour Communication Report log, the care plan was not updated to address these issues. The MDS coordinator, responsible for care plans, was unaware of the resident's frequent refusals and behaviors, indicating a breakdown in communication and documentation processes. Interviews with staff, including the LPN and DON, confirmed that refusals of care and behaviors should be documented and communicated to the MDS coordinator for care plan updates. However, this process was not followed for Resident #86, resulting in a lack of appropriate interventions in the care plan. The DON confirmed that the care plan should have been updated to reflect the resident's needs and behaviors, but this was not done, leading to a deficiency in providing person-centered care.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure that two residents, who were prescribed therapeutic diets, received the necessary dietary supplements as ordered by their healthcare providers. Resident #9, who had severe cognitive impairment and a history of significant weight loss, was not provided with protein juice, pudding, or ice cream as per her physician's orders. Observations on multiple occasions confirmed that these items were missing from her meal trays, and staff were unaware of the dietary requirements. The resident's care plan and meal tickets did not reflect the prescribed dietary supplements, contributing to her continued weight loss. Similarly, Resident #78, who was under hospice care with a diagnosis of muscle wasting and atrophy, did not receive the prescribed protein juice, pureed soup, or ice cream with his meals. Observations and interviews with staff confirmed that these items were consistently missing from his meal trays. The hospice nurse and dietary staff were unaware of the resident's dietary orders, and the meal tickets did not include the necessary supplements. This oversight was attributed to a communication lapse between the Director of Nursing (DON) and the dietary supervisor during their weekly meetings. Interviews with the DON and dietary supervisor revealed that the failure to implement the dietary orders was due to missed communication during their weekly discussions about residents at high risk for weight loss. The DON admitted to not providing the dietary supervisor with the updated orders for Residents #9 and #78, resulting in the dietary staff being unaware of the necessary additions to the residents' meal trays. This deficiency highlights a critical gap in the facility's process for ensuring that dietary orders are accurately communicated and implemented.
Failure to Address Resident's PTSD Diagnosis
Penalty
Summary
The facility failed to identify and address a resident's past history of trauma and triggers related to PTSD. Resident #86 was admitted with multiple diagnoses, including PTSD, but the care plan did not include any interventions for PTSD. The social assessment conducted upon admission did not identify the PTSD diagnosis, and the CNA assigned to the resident was unaware of the PTSD condition. The LPN was aware of the diagnosis but confirmed that no interventions were in place to address it. The Director of Nursing stated that a routine social assessment should be completed for residents with PTSD, but this was not done in this case. The Social Worker who completed the assessment was not aware of the PTSD diagnosis at the time of the assessment. The Psychiatric Nurse Practitioner also confirmed that a PTSD evaluation should have been completed but was not. Interviews with the resident's responsible party and various staff members revealed a lack of communication and awareness regarding the resident's PTSD diagnosis. The responsible party stated that no one at the facility had discussed the PTSD diagnosis with her. The Psychiatric Nurse Practitioner acknowledged that the facility staff should have been aware of the PTSD diagnosis and that a PTSD evaluation should have been conducted. The failure to identify and address the resident's PTSD resulted in a lack of appropriate care planning and interventions for the resident's condition.
Failure to Limit PRN Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for two residents receiving hospice services. Resident #63 was admitted with diagnoses including Anxiety Disorder, Delusional Disorders, Major Depressive Disorder, and Restlessness and Agitation. The resident had a physician's order for Ativan 1 mg tablet every 4 hours as needed (PRN) for anxiety/agitation, written on 03/13/2024, without a stop date. This order was reflected in the May 2024 Medication Administration Record (MAR) without a stop date. Similarly, Resident #78, who was admitted to the facility and a local hospice agency, had a physician's order for Ativan 1 mg tablet every 4 hours PRN for anxiousness, written on 05/08/2024, also without a stop date. The Director of Nursing (S2DON) confirmed that Ativan is a psychotropic medication and acknowledged that both residents had PRN orders for Ativan without stop dates, which is a violation of the requirement to limit PRN orders for psychotropic medications to 14 days and indicate the duration.
Inaccurate Documentation of Medical Records for Psychotropic Medication
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident receiving unnecessary medications. Resident #24 was admitted with diagnoses including Delusional Disorders and Major Depressive Disorder. The physician's orders and the Medication Administration Record (MAR) for May 2024 indicated that Risperdal was prescribed for Major Depressive Disorder. However, the Pharmaceutical Consultant Report dated May 2, 2023, documented that Risperdal was prescribed for Delusional Disorder. This discrepancy was confirmed by the Director of Nursing (S2DON) during an interview, who acknowledged that the records were inaccurate. Interviews with the Director of Nursing (S2DON) and the Medical Records staff (S5MR) revealed a lack of clarity regarding responsibility for updating diagnoses linked to psychotropic medications. S2DON stated that medical records should review pharmaceutical consultant reports and adjust diagnoses accordingly, while S5MR indicated that she was not responsible for this task. This miscommunication and lack of proper documentation led to the inaccurate medical records for Resident #24.
Failure to Document Pneumococcal Immunization Status
Penalty
Summary
The facility failed to develop procedures to ensure documentation indicating whether residents received the pneumococcal immunization or did not receive it due to medical contraindication or refusal. Specifically, the records for two residents lacked documentation of their pneumococcal immunization status from 10/01/2023 to 05/13/2024. The facility's policy required that each resident's immunization status be determined upon admission and documented accordingly. However, the responsible staff member confirmed that the documentation and administration of the pneumococcal vaccine were incomplete for all residents during the specified period.
Failure to Report Physical Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse within the required 2-hour timeframe to the State Survey Agency. The incident involved a resident with severe cognitive impairment, who was observed hitting another resident in the face. The incident was witnessed by a CNA, who immediately separated the residents and reported the event to her supervisor. However, the administrator, who was informed of the incident around 12:30 p.m. on the same day, did not consider it to be physical abuse and therefore did not report it to the state agency as required by the facility's policy. The facility's policy mandates that any suspected physical abuse must be reported to the state agency and local law enforcement within 2 hours. Despite this, the incident was not documented in the facility's incident log or reported to the state agency. Interviews with the CNA and the administrator confirmed the timeline of events and the failure to report the incident as required. The resident involved had a history of dementia and traumatic subdural hemorrhage, which contributed to her severe cognitive impairment.
Failure to Obtain Physician's Orders for Delivered Medications
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of quality by not obtaining physician's orders when medications were received from the pharmacy for a resident. Resident #23, who was admitted with multiple diagnoses including Stage 3 Chronic Kidney Disease and Acute Kidney Failure, did not receive prescribed antibiotics in a timely manner. The resident had an appointment with her urologist and was prescribed Levaquin, Pyridium, and Macrobid, which were delivered to the facility on 05/10/2024. However, the medications were not administered until 05/13/2024 because the facility did not have the necessary physician's orders. Interviews revealed that the facility's staff, including the Infection Preventionist and Nurse Practitioner, were unaware of the medication delivery without orders until 05/13/2024. The Director of Nursing stated that nursing staff should have obtained the orders as quickly as possible. The delay in obtaining the physician's orders resulted in the resident not receiving her prescribed antibiotics for several days, despite the medications being delivered to the facility on time.
Failure to Follow Feeding Assistance Orders
Penalty
Summary
The facility failed to provide care and services in accordance with the orders written for dining for a resident who required feeding assistance. Resident #78, who was admitted to the facility and later to a local hospice agency with a diagnosis of Muscle Wasting and Atrophy, had a physician's order to be fed all meals due to diminished nutrition and hydration from disease progression. Despite this, observations on multiple occasions revealed that the resident was left to feed himself without staff assistance, contrary to the hospice plan of care and physician's orders. Interviews with staff, including a CNA and an LPN, confirmed that the resident had an active order to be fed all meals, but this order was not being followed. The resident's weight log indicated a decline in weight over a two-month period, further emphasizing the need for adherence to the feeding assistance order. The hospice nurse also confirmed that the resident required feeding assistance to ensure he ate adequately. The Director of Nursing acknowledged the active order and the expectation for staff to implement it as written. The failure to follow the feeding assistance order represents a deficiency in the care provided to the resident, potentially impacting his nutritional status and overall well-being.
Failure to Properly Label Specimens
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. During an observation of a medication storage room, two tubes filled with yellow fluid were found in a refrigerator labeled 'Specimens.' These tubes did not have a resident's name, date and time collected, or a second identifier. This was confirmed by S3IP during the observation and by S2DON and S1ADM during subsequent interviews. All three staff members acknowledged that specimens should be labeled with the resident's name, date and time collected, and a second identifier as per common professional standards and the lab provider's policy. The lab provider's policy, reviewed in January 2024, specifically requires that urinalysis and culture and susceptibility tubes be labeled with the patient's first and last name, a second identifier, and the date and time of specimen collection. The failure to adhere to this policy was observed on May 14, 2024, at 8:27 a.m. in MR1. This deficiency was confirmed through interviews with S3IP, S2DON, and S1ADM, who all stated that they would expect all specimens collected to be properly labeled according to the policy and professional standards.
Failure to Maintain Infection Control for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain an infection control program for a resident with an indwelling catheter. Resident #86, who was readmitted to the facility with multiple diagnoses including Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, and Cystitis, was observed with improper catheter management. The resident, who had severe cognitive impairment as indicated by a BIMS score of 7, was seen on multiple occasions with the catheter bag improperly placed. On one occasion, the catheter bag was hooked to a trash can, and on another, it was being dragged on the floor. Additionally, the catheter bag was observed in the resident's bed, not below the level of the bladder, and half full of urine flowing back into the bladder. These observations were confirmed by both an LPN and the Director of Nursing, who acknowledged the improper placement of the catheter bag and the increased risk of infection it posed. The observations and interviews revealed that the facility did not ensure the indwelling catheter bag was kept below the level of the bladder, out of the trash can, and off the floor. The LPN and DON both confirmed the correct procedures for catheter management, indicating a lapse in adherence to infection control protocols. This deficiency highlights a failure in maintaining a safe and sanitary environment to prevent the development and transmission of infections, particularly for residents with indwelling catheters.
Failure to Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to electronically transmit a subset of items upon a resident's discharge for two of the five residents reviewed for discharge. Resident #38 was admitted to the facility and later discharged, but did not have an electronically transmitted discharge MDS assessment. Similarly, Resident #84 was admitted and discharged without an electronically transmitted discharge MDS assessment. During interviews, S6MDS confirmed that discharge assessments for both residents should have been completed and transmitted on their respective discharge dates. S2DON also confirmed that MDS staff should have completed and transmitted the discharge assessments after the residents were discharged from 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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