Golden Age Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Denham Springs, Louisiana.
- Location
- 27090 Hwy 16, Denham Springs, Louisiana 70726
- CMS Provider Number
- 195524
- Inspections on file
- 26
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Golden Age Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment, requiring substantial ADL assistance, reported that a CNA was rough and consistently rude during care. Staff interviews confirmed the CNA displayed frustration and used an aggravated tone, with an LPN and the DON acknowledging the behavior was inappropriate and did not uphold the resident's right to dignity and respect.
A resident with a history of depression and prior sexual trauma was sexually abused by a visitor, who showed explicit images and forced non-consensual sexual contact in the resident's room. The incident was not immediately reported due to the resident's embarrassment, and staff did not observe any signs of distress or inappropriate behavior at the time. The abuse resulted in psychological harm, and the event only came to light after the resident disclosed it to staff, leading to law enforcement involvement.
A resident who was frequently incontinent of bowel had dried stool on the floor and bed sheet, which was not cleaned by staff. The CNA noticed the stool but did not clean it, and the administrator confirmed that nursing staff are responsible for maintaining a clean environment.
A resident with mental health diagnoses was admitted with a PASRR Level II determination, which included recommendations for Behavioral Health IOP, Crisis Planning, and Dementia Assessment. The facility failed to incorporate these recommendations into the resident's care plan, as confirmed by staff interviews. The oversight was acknowledged by the care plan nurse, social services director, MDS coordinators, and DON.
A resident who required assistance with showering did not receive scheduled showers for four days due to the absence of the shower aide and lack of action by hall CNAs. The facility's documentation confirmed the missed care, as no records were found for the scheduled shower.
The facility failed to ensure food was stored under sanitary conditions in unit refrigerators, as several items were found unlabeled during an inspection. An LPN confirmed that staff should label all outside food items with the resident's name and date, which was not done. The DON was informed and confirmed the labeling requirement.
A facility failed to accurately code a resident's MDS assessments for hospice care, despite physician orders indicating active hospice status. The resident, admitted with Adult Failure to Thrive, had incorrect MDS entries on two occasions, which were confirmed by the MDS Coordinator and the DON.
A facility failed to administer IV fluids according to professional standards for a resident with pneumonia and dehydration. The resident's IV site was not assessed, flushed, or documented daily, and was covered with an undated dressing. Staff confirmed the lack of proper monitoring and documentation, acknowledging the oversight.
A resident with severe cognitive impairment and multiple diagnoses was found to have a deformed leg by an LPN, who failed to report this significant change to the physician as required by the facility's policy. The NP and DON confirmed the lapse in communication, noting that the resident did not express pain, which may have influenced the LPN's decision not to report the condition.
The facility failed to implement physician's orders for two residents, resulting in a lack of a wheelchair alarm and visual cue for brakes for one resident, and the absence of TED hose for another. Staff confirmed these orders were not followed.
A resident with bilateral below-the-knee amputations and a history of falls was found on the floor, and a chair alarm was ordered as an intervention. However, the alarm was not implemented, as confirmed by staff interviews and observations, leading to a deficiency in maintaining a safe environment.
A resident requiring substantial assistance with bathing did not receive a scheduled bath, as confirmed by staff interviews and bath logs. The facility's policy required showers to be given as scheduled, but there was no documentation of a bath being administered on the missed date. Staff interviews revealed confusion over documentation responsibilities, leading to the deficiency.
A facility failed to maintain proper infection control practices during incontinence care for a resident. Two CNAs did not change gloves or perform hand hygiene after handling soiled linens and before touching clean items or the resident's belongings. Despite the facility's hand hygiene policy, the CNAs continued to use the same gloves throughout the care process, including when applying barrier cream and lotion. Interviews confirmed the CNAs' failure to adhere to hand hygiene protocols, and the DON acknowledged the lapse in proper procedure.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency was identified when staff failed to treat a resident with respect and dignity, as required. The resident, who had a diagnosis of unspecified dementia and moderately impaired cognition (BIMS score of 11), required substantial assistance with activities of daily living (ADLs). On the date in question, the resident reported that a CNA was rough when assisting her, prompting the resident to remove the CNA's hand and verbally express her discomfort. The resident also reported to an LPN that the CNA was consistently rude and disrespectful during care. Interviews with staff confirmed that the CNA displayed frustration and used an aggravated tone when interacting with the resident, including verbally disagreeing with her and telling her she could not walk. The LPN who entered the room observed the CNA's visible frustration and inappropriate behavior, and confirmed that such conduct was not suitable when providing care. The Director of Nursing also acknowledged that staff should not argue or disagree with residents and must always treat them with dignity and respect.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
A cognitively intact resident with a history of depressive episodes and prior sexual trauma was subjected to sexual abuse by a visitor. The visitor, who was known to the resident, showed her an explicit photo and later forced her to engage in non-consensual sexual contact in her room. The incident occurred after the visitor accompanied the resident from the patio to her room, where he shut the door and committed the act. The resident did not immediately report the abuse due to embarrassment, only disclosing the incident to staff several weeks later. Staff interviews and record reviews confirmed that the resident was not known to make false accusations and had no memory or behavioral issues documented at the time. Staff members observed the visitor and resident interacting outside and saw the visitor push the resident back to her room, but did not witness any inappropriate behavior or signs of distress. The visitor had not previously exhibited inappropriate conduct during visits, and staff were unaware of the incident until the resident reported it. The abuse resulted in actual psychological harm to the resident, who became tearful when recounting the event and reported that it triggered memories of past sexual trauma. The incident was later reported to law enforcement, leading to the arrest of the accused. The facility's records and interviews indicate that the abuse was not detected or reported by staff at the time it occurred, and the resident only received support and intervention after self-reporting the incident.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to maintain a sanitary environment for a resident who was frequently incontinent of bowel. On a specific date, a surveyor observed multiple spots of dried brown liquid stool on the floor between the resident's bed and the bathroom door, as well as a dried brown smear on the fitted sheet of the resident's bed. The resident reported an episode of stool incontinence two days prior, during which staff did not adequately clean the liquid stool from the floor and left the fitted sheet soiled. A CNA confirmed that she noticed the stool on the resident's floor and fitted sheet earlier that day but did not clean it. The facility's administrator stated that it was the responsibility of the nursing staff, including CNAs, to ensure a clean, homelike environment and confirmed that it was inappropriate for stool to remain on a resident's floor or sheets. The administrator expected nursing staff to clean up bodily fluids immediately when observed.
Failure to Incorporate PASRR Level II Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) Level II for a resident diagnosed with Generalized Anxiety Disorder, Schizophrenia, and Paranoid Schizophrenia. The resident was approved for a temporary nursing facility placement for 365 days, with specific recommendations including Behavioral Health Intensive Outpatient Program (IOP), Crisis Planning, and Assessment for Dementia. However, upon review, it was found that the resident's care plan did not incorporate the PASRR Level II determination and recommendations. Interviews with facility staff revealed that the responsibility for incorporating PASRR Level II recommendations into the care plan was not fulfilled. The staff members, including the care plan nurse and the social services director, acknowledged that the PASRR Level II information should have been included in the resident's care plan. The oversight was confirmed by multiple staff members, including the Minimum Data Set (MDS) coordinators and the Director of Nursing (DON), who verified that the care plan should have been updated in December 2024 when the PASRR Level II was received from the Office of Behavioral Health (OBH).
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, the facility did not provide scheduled showers for a resident who was cognitively intact and required supervision or touching assistance with showering. The resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays but did not receive a shower on a Saturday, leaving her without a shower for four days. Interviews with staff revealed that the shower aide was on vacation during the week the resident missed her shower, and it was the responsibility of the hall CNAs to provide showers in the aide's absence. However, the CNAs confirmed that they did not shower the resident and did not document any showers being given or reasons for not providing them. The Assistant Director of Nursing (ADON) confirmed the lack of documentation for the missed shower, indicating that the resident did not receive the scheduled care.
Improper Food Storage in Unit Refrigerators
Penalty
Summary
The facility failed to store food under sanitary conditions in the unit refrigerators, as observed during a tour of the facility. The inspection revealed several food items in the resident's unit refrigerator that were not properly labeled with the resident's name and date, as required by the facility's policy. Specifically, there was a brown paper bag with a wrapped breakfast sandwich, a plastic container with an unknown food, another plastic container with an unknown food, a foam cup with a pink liquid, and another plastic container with an unknown food, all lacking proper labeling. Interviews conducted with staff members confirmed the deficiency. An LPN acknowledged that staff should label all outside food items with the resident's name and date, and confirmed that the items observed were not properly labeled. The Director of Nursing was also made aware of the issue and confirmed that any food items brought in from outside the facility should be labeled with a date and the resident's name when stored in the unit refrigerator.
Inaccurate MDS Assessment for Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the hospice status of a resident. Specifically, Resident #23, who was admitted to the facility with a diagnosis of Adult Failure to Thrive, had physician orders indicating admission to hospice care effective 05/31/2024. However, the quarterly MDS assessments conducted on 07/30/2024 and 10/02/2024 incorrectly indicated that the resident was not receiving hospice care. Interviews with the MDS Coordinator (S4MDS) and the Director of Nursing (S2DON) confirmed that the MDS assessments were not coded correctly for hospice care, despite the resident's active hospice status.
Failure to Administer IV Fluids According to Standards
Penalty
Summary
The facility failed to administer intravenous (IV) fluids in accordance with professional standards of practice for a resident who required IV fluid therapy. The resident, who was admitted with diagnoses including pneumonia and dehydration, had an order for IV fluids on specific dates in February 2025. However, there were no physician orders for daily assessment, flushing, or discontinuation of the peripheral IV site. The Medication Administration Record (MAR) lacked documentation of daily assessments, flushing, or discontinuation of the IV site. Observations revealed that the resident's peripheral IV site was not visible and was covered with an undated, non-transparent, elastic ace dressing. The resident reported that the IV site hurt and had not been changed, flushed, or used since the last administration of IV fluids. Interviews with staff confirmed that the IV site was not assessed or flushed daily, and the dressing was not changed as required. The Director of Nursing acknowledged the lack of documentation and confirmed that the IV site should have been assessed, flushed daily, and changed or removed by a specific date.
Failure to Report Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure proper communication of a significant change in a resident's condition to the physician. A Licensed Practical Nurse (LPN) identified a deformity in a resident's leg but did not report this change to the resident's physician as required by the facility's Change in Condition Policy and Procedure. The resident, who had severe cognitive impairment and multiple diagnoses including Restless Leg Syndrome and Age-Related Osteoporosis, was found to have a deformed left leg by the LPN. Despite the observation, the LPN did not notify the physician, which was a breach of the facility's policy. Interviews conducted with the nursing staff revealed that the deformity was first reported by an aide to the LPN, who assessed the resident's leg but failed to communicate the finding to the physician. The Nurse Practitioner (NP) and the Director of Nursing (DON) confirmed that the LPN did not report the deformity, and both stated that they would have expected the LPN to notify the physician. The NP noted that the resident did not express pain during the assessment, only wincing slightly, which may have contributed to the LPN's decision not to report the condition. However, the facility's policy clearly mandates prompt communication of significant changes, which was not adhered to in this case.
Failure to Implement Physician's Orders for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, as evidenced by the lack of adherence to Physician's Orders. For Resident #6, who has a history of falling and muscle weakness, the facility did not provide a wheelchair alarm or a visual cue for wheelchair brakes, despite these being ordered by the physician. Observations and interviews confirmed that these safety measures were not in place, and staff acknowledged the oversight. Similarly, for Resident #7, who required orthopedic aftercare, the facility did not apply TED hose as ordered. Observations revealed that the TED hose were not worn by the resident and were found on top of a microwave, indicating they had not been used as prescribed. Staff interviews confirmed the failure to implement the physician's order for TED hose application.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not implementing a prescribed intervention after a fall. The resident, who had bilateral below-the-knee amputations and a history of falling, was found on the floor in her room. Following this incident, a nurse practitioner ordered a chair alarm to be placed in the resident's wheelchair as an intervention to prevent future falls. However, during observations and interviews conducted later, it was confirmed that the chair alarm was not present in the resident's wheelchair, despite the order being documented in the resident's care plan and physician orders. Interviews with staff, including a CNA, LPN, and the Assistant Director of Nursing, revealed that the resident often attempted to perform tasks without assistance, increasing the risk of falls. The staff confirmed that the chair alarm, which was intended to alert staff when the resident attempted to get up, was not implemented as required. This oversight in implementing the necessary intervention contributed to the deficiency in maintaining a safe environment for the resident.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary services to maintain personal hygiene, specifically in the context of scheduled bathing. The facility's policy required showers to be given as scheduled or as needed. However, a review of the resident's clinical record and bath log revealed that the resident, who required substantial assistance with bathing, did not receive a bath on a scheduled bath day. Interviews with staff members, including CNAs and the Assistant Director of Nursing (ADON), confirmed that the resident's scheduled bath days were Mondays, Wednesdays, and Fridays, and that the resident did not refuse baths. Despite this, there was no documentation of a bath being administered on the missed date. Interviews with the staff indicated a lack of clarity and accountability regarding who was responsible for documenting the baths. The CNAs stated that either the bath aide or the floor aides could document the baths, but there was no record of a bath being given on the missed date. The ADON and the Director of Nursing (DON) both confirmed that the resident should have received a bath on the scheduled day and that staff were expected to document the care provided. This lack of documentation and failure to provide the scheduled bath led to the deficiency noted in the report.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene and cleaning techniques during incontinence care for a resident. The facility's policy on hand hygiene, which lacked a revision date, outlined specific instances when hand hygiene should be performed, such as before and after direct resident contact, after handling soiled linens, and after removing gloves. However, during an observation, two CNAs were seen performing incontinence care on a resident without adhering to these guidelines. They failed to change gloves and perform hand hygiene after handling soiled linens and before touching clean items or the resident's belongings. The CNAs continued to use the same gloves throughout the care process, including when applying barrier cream and lotion to the resident, and when handling clean linens and the resident's personal items. Interviews with the CNAs confirmed their failure to perform hand hygiene and change gloves as required. The Director of Nursing also acknowledged that staff were trained to perform hand hygiene correctly and should have done so during the observed incontinence care.
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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