Grace Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Slaughter, Louisiana.
- Location
- 1181 Hwy 19, Slaughter, Louisiana 70777
- CMS Provider Number
- 195258
- Inspections on file
- 31
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Grace Nursing Home during CMS and state inspections, most recent first.
Two CNAs transferred a resident with severe cognitive impairment and multiple medical conditions using a draw sheet instead of the required mechanical lift with two-person assistance, as specified in the care plan. The improper transfer resulted in the resident sustaining a displaced fracture of the left humerus, requiring emergency evaluation and ongoing pain management.
A resident with severe cognitive impairment and dependent on staff for transfers was injured when two CNAs, unfamiliar with her care needs, transferred her without using the required Hoyer lift, resulting in a fractured arm. The DON and Administrator, after internal investigation, did not report the incident as neglect to the State Survey Agency within the required timeframe, contrary to facility policy.
A resident with severe cognitive impairment and multiple mobility-related diagnoses was transferred between bed and wheelchair by two CNAs using a draw sheet, rather than the required Hoyer lift with two staff as specified in the care plan. Both CNAs did not verify the resident's transfer requirements in the electronic system before performing the transfer, and the DON confirmed the care plan was not followed.
A resident with severe cognitive impairment and a PEG tube had a care plan that did not match current physician's orders for enteral feeding and NPO status. The care plan listed incorrect water flush rates and allowed snacks between meals, which conflicted with the NPO order. Both an LPN and the DON confirmed the care plan was not updated to reflect the resident's current needs.
Expired medications were found on a medication cart, including eye drops without expiration dates and a nasal inhaler past its expiration date. An LPN confirmed the oversight, and the DON stated that staff nurses were responsible for checking expiration dates.
The facility failed to maintain an effective infection prevention and control program. A resident with wounds was transferred without Enhanced Barrier Precautions, and another with a urinary catheter lacked necessary precautions. Additionally, an LPN did not follow hand hygiene protocols during wound care, and a CNA used improper technique during catheter care.
A resident with cognitive intactness and significant medical conditions experienced a lack of dignity when staff failed to empty his urinal in a timely manner. The urinal, containing 400 cc of urine, was left at the bedside from early morning through breakfast and lunch, despite the resident's request for it to be emptied. Staff, including the CNA and DON, confirmed the oversight and acknowledged the disrespectful nature of serving meals with the urinal present.
A resident, who was cognitively intact, reported being physically assaulted by his roommate, who had a history of aggressive behaviors and cognitive impairment. Despite the facility's policy on abuse prevention, no additional staff training or interventions were implemented following the incident. The resident was moved to another room, and the aggressor was sent for evaluation, but no further actions were taken to address the deficiency.
A facility failed to refer a resident with a new mental health diagnosis for a PASRR Level II evaluation. The resident, initially diagnosed with Depression, was later diagnosed with Brief Psychotic Disorder, but the facility did not update the PASRR or request a Level II evaluation. The social worker acknowledged the oversight, and the DON was unaware of the requirement.
A resident, who was cognitively intact, was found with medications left at her bedside by an LPN, who did not observe her taking them. The resident did not have physician orders to self-administer medications. The DON confirmed that medications should not be left at the bedside for residents unable to self-administer.
A facility failed to label oxygen tubing and humidifier bottles with the date of last change for a resident with chronic respiratory conditions, as required by their policy. Staff confirmed the oversight, acknowledging that equipment should be changed and labeled every seven days.
The facility failed to store and prepare food under sanitary conditions, as a package of block cheese was found improperly labeled and dated in the walk-in cooler. Staff confirmed that the cheese should have been labeled with a discard date and used within 7 days of opening, in accordance with the facility's policy. This deficiency was acknowledged by the Dietary Manager and the Administrator.
The facility did not make survey results from the past three years, including recent complaint surveys, accessible to residents, family members, and the public. Observations showed no survey results displayed at the entrance or dining area. The administrator confirmed the binder with survey results was kept in his office and not available for public view, acknowledging that these should have been accessible.
A resident with severe cognitive impairment was left outside overnight without care due to staff assuming she was out on pass with family. The facility's ineffective system for tracking residents' whereabouts led to the resident not receiving necessary care and medications, resulting in hospitalization for multiple health issues.
The facility did not post the required contact information for state agencies and advocacy groups, nor did it provide information on how residents can file complaints with the State Survey Agency. This was confirmed during facility tours and an interview with staff, indicating non-compliance with regulations.
A resident was left outside in a wheelchair for over 14 hours after another resident opened a door, allowing her to exit. The facility failed to report this neglect incident to the state agency within the required 24-hour period, as confirmed by the administrator. The resident was found with wet clothes and a red bottom, indicating neglect.
A resident with severe cognitive impairment suffered a skin tear and bruising when their arm became caught in an assist bar during a care procedure. The facility failed to conduct an entrapment risk assessment or obtain informed consent for the use of assist bars, which were installed at the family's request. Staff interviews confirmed the absence of formal procedures for assessing risk or obtaining consent for assist bars, which were used on resident beds.
Failure to Verify Transfer Status Results in Resident Injury
Penalty
Summary
Two certified nursing assistants (CNAs) failed to verify the required transfer method for a resident who was dependent on staff for transfers and required a mechanical lift with two-person assistance, as documented in her care plan. Both CNAs were unfamiliar with the resident's specific needs and did not consult the electronic kiosk or care plan to confirm the appropriate transfer method. Instead, they transferred the resident using a draw sheet, both from bed to wheelchair and later from wheelchair back to bed, without using the required Hoyer lift. The resident, who had significant medical conditions including Parkinson's Disease, a history of falls, a left artificial knee joint, and a right below-knee amputation, was also severely cognitively impaired and unable to advocate for herself. After being transferred back to bed by the CNAs, the resident yelled out in pain. An x-ray was ordered, revealing a closed displaced fracture of the proximal end of her left humerus. She was subsequently sent to the emergency room for evaluation and treatment, and upon return, continued to experience pain and required her arm to be immobilized in a sling. Interviews with the involved CNAs confirmed that neither had checked the resident's care plan or the electronic system to verify the required transfer assistance prior to performing the transfer. Both CNAs admitted they should have checked the resident's transfer status. The Director of Nursing and other staff confirmed that the resident's care plan clearly indicated the need for a Hoyer lift with two-person assistance for all transfers, and that the staff did not follow this plan, resulting in the resident's injury.
Failure to Timely Report Suspected Neglect Following Resident Injury During Transfer
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe after a resident sustained an injury during a transfer. According to facility policy, all alleged violations involving neglect must be reported immediately, but not later than two hours if serious bodily injury is involved, or within 24 hours if not. In this case, a resident with severe cognitive impairment, dependent on staff for transfers, was transferred from a wheelchair to bed by two CNAs who did not verify the required method of transfer. The resident, who required a Hoyer lift with two staff assist per her care plan, was instead transferred using a draw sheet, resulting in her yelling out in pain and later being diagnosed with a fractured left humerus. Interviews with the CNAs involved revealed that neither was familiar with the resident's specific transfer needs and neither checked the care plan or system to confirm the appropriate transfer method prior to the incident. Both CNAs acknowledged that they should have verified the resident's transfer requirements. The Director of Nursing (DON) and Administrator were notified of the incident on the day it occurred, and an internal investigation determined that the injury resulted from improper transfer technique, which was not in accordance with the resident's care plan. Despite these findings, the Administrator did not report the incident to the State Survey Agency, as required by facility policy and regulation. Both the DON and Administrator stated they did not initially consider the incident to be neglect, viewing it instead as a mistake. As a result, the required notification to the State Survey Agency was not made, constituting a failure to report suspected neglect in a timely manner.
Failure to Follow Care Plan for Dependent Transfer
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident who required assistance with transfers. The resident, who had diagnoses including Parkinson's Disease, unspecified osteoarthritis, a history of falls, a left artificial knee joint, and a right below-knee amputation, was assessed as severely cognitively impaired and dependent for chair/bed transfers. The care plan specified that the resident required a Hoyer lift with two staff for all transfers. However, on the day in question, two CNAs who were unfamiliar with the resident's needs transferred her between bed and wheelchair using a draw sheet instead of the required Hoyer lift. Both CNAs confirmed in interviews that they did not check the resident's care plan or the electronic system to verify the required transfer method before performing the transfer. The Director of Nursing confirmed that the resident was not transferred according to her plan of care and that staff are expected to verify the required assistance level if they are unsure. The CNAs involved stated they should have checked the system or asked for guidance but did not do so prior to transferring the resident. This failure to follow the established care plan resulted in the resident not receiving care as planned for her specific needs.
Care Plan Not Updated to Reflect Current Physician's Orders
Penalty
Summary
The facility failed to develop and maintain a comprehensive, person-centered care plan that accurately reflected a resident's current physician's orders. Specifically, the care plan for a resident with diagnoses including dysphagia following cerebral infarction and a gastrostomy did not match the active physician's orders regarding enteral feeding and water flush rates. The physician's orders specified Glucerna 1.5 at 60 cc/hr via PEG with a 40 ml/hr flush and an NPO diet, but the care plan listed a 60 ml/hr water flush and included an intervention to allow snacks between meals, which contradicted the NPO order. During interviews, both an LPN and the DON confirmed that the care plan did not accurately reflect the current physician's orders. The discrepancies were identified through review of the resident's clinical record, MDS assessment indicating severe cognitive impairment, and direct comparison of the care plan with the physician's orders. The staff acknowledged that the care plan should have been updated to align with the resident's current medical needs and orders.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles, specifically regarding the availability of expired medications for administration. During an observation of Med Cart 1, it was found that a bottle of lubricant eye drops and another bottle of eye drops, both dated from August 2024, had no expiration dates, and a nasal inhaler with an expiration date of August 17, 2024, was still present. An LPN confirmed that eye drop medications should only be used for 30 days and acknowledged that the expired nasal inhaler should have been removed but was not. The Director of Nursing stated that staff nurses were responsible for checking medication carts for expired medications and that nurses administering medications should check expiration dates before use. He confirmed that the eye drops were beyond their 30-day use period and the nasal inhaler was expired and should have been discarded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #107, staff did not implement Enhanced Barrier Precautions (EBP) during a transfer, despite the resident having wounds that required such precautions. The Certified Nursing Assistant (CNA) involved admitted to not wearing gloves or a gown during the transfer, which was confirmed by the Director of Nursing (DON) as a high-contact activity necessitating EBP. Resident #271, who had an indwelling urinary catheter, was not provided with EBP measures upon admission. There was no signage or personal protective equipment (PPE) available at the resident's door, which was acknowledged by both the Licensed Practical Nurse (LPN) and the DON. The DON confirmed that EBP should have been implemented for residents with urinary catheters. Additionally, the facility's staff failed to adhere to proper hand hygiene protocols during wound care for Resident #107. The LPN performing the wound care did not use hand sanitizer or wash hands between glove changes, which was contrary to the facility's hand hygiene policy. Furthermore, improper infection control techniques were used during catheter care for Resident #35, as the CNA cleaned the catheter tubing in the wrong direction, which was acknowledged as incorrect by both the CNA and the DON.
Failure to Maintain Resident Dignity by Timely Urinal Management
Penalty
Summary
The facility failed to ensure that a resident's right to a dignified existence was upheld, as evidenced by the improper handling of a urinal in the resident's room. Resident #50, who is cognitively intact and has diagnoses including the acquired absence of both legs above the knee, anxiety, and PTSD, reported that his urinal was not emptied in a timely manner. Despite having meals in his room, the urinal containing 400 cc of urine was left at his bedside from 6:00 a.m. and remained there through breakfast and lunch, which the resident found disrespectful. Observations and interviews confirmed that the urinal was not emptied by staff during their shifts, even though it was in plain sight and should have been addressed. The CNA responsible for Resident #50 acknowledged that the urinal had not been emptied during her shift and confirmed that meals were served with the urinal present. The Director of Nursing also confirmed the oversight and agreed that serving meals with a urinal at the bedside was disrespectful to the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which constitutes a deficiency in ensuring residents' rights to be free from abuse. Resident #28, who was cognitively intact with a BIMS score of 15, reported being physically assaulted by his roommate, Resident #100, who also had a history of aggressive behaviors and a BIMS score of 8, indicating cognitive impairment. The incident occurred when Resident #28 was awakened by Resident #100 punching and elbowing him, causing fear and distress. This incident was reported to an LPN, who confirmed the assault with Resident #100. Despite the facility's policy on abuse prevention, there were no additional staff training or interventions implemented following the incident. The Director of Nursing and the Administrator were informed of the altercation, and while Resident #28 was moved to another room and Resident #100 was sent to the emergency room for evaluation, no further actions were taken to address the deficiency. The lack of further interventions or staff in-service training highlights the facility's failure to adequately prevent and respond to resident-to-resident abuse.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. Resident #11 was admitted with a diagnosis of Depression and later received an additional diagnosis of Brief Psychotic Disorder on 09/28/2023. However, the facility did not update the resident's Level I PASRR to include this new diagnosis, nor did they resubmit a request for a Level II evaluation and determination. During an interview, the social worker responsible for submitting PASRRs confirmed that a request should have been made following the new diagnosis but was not. The Director of Nursing was also unaware of the need to resubmit the Resident Review form for a PASRR Level II referral after the resident's new diagnosis. This oversight resulted in the facility's failure to comply with the required procedures for residents with mental health diagnoses.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure that nursing staff adhered to professional standards of quality by leaving medications at the bedside of a resident who did not have physician orders to self-administer medications. Resident #82, who was cognitively intact with a BIMS score of 13, was observed with seven pills in a medication cup and a 4-ounce cup of liquid supplement on her bedside table. The resident reported that an LPN had given her the medications and left the room without observing her take them. The LPN confirmed this account and acknowledged that the medications should not have been left at the bedside. The Director of Nursing also confirmed that medications should not be left at the bedside for residents unable to self-administer medications.
Failure to Label Oxygen Equipment in Accordance with Policy
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for a resident receiving oxygen therapy. Specifically, the facility did not label the oxygen tubing and humidifier bottle with the date they were last changed, as required by the facility's policy. The policy mandates that pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every seven days or when the water level becomes low. During an observation, it was noted that the oxygen tubing and humidifier bottle for a resident with chronic respiratory conditions were not labeled with the date of the last change. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the facility's policy was to change all oxygen tubing and humidifier bottles every seven days on Sunday, and that they should be labeled with the date of change. However, the staff acknowledged that the resident's equipment was not labeled as required. This oversight was identified during a survey, highlighting a deficiency in adhering to the facility's infection control procedures related to oxygen administration.
Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions, as observed during a survey. During an initial tour of the facility's kitchen, a package of block cheese was found in the walk-in cooler, wrapped in plastic wrap, opened, and dated 08/24/2024, which was not in compliance with the facility's policy. The policy required all foods stored in the refrigerator or freezer to be covered, labeled, and dated, with refrigerated foods labeled and dated to ensure they are used prior to expiration, frozen, or discarded. Interviews with staff confirmed that the opened cheese should have been labeled with a discard date and used within 7 days of opening. The staff acknowledged the failure to comply with the policy, which was confirmed by the Dietary Manager and the Administrator.
Survey Results Not Accessible to Public
Penalty
Summary
The facility failed to ensure that all survey results from the past three years, including complaint surveys since the last annual survey, were accessible for residents, family members, legal representatives, and the public. On October 14, 2024, observations were made at the facility's entrance and dining area, revealing the absence of a binder or display of survey results. During an interview, the administrator confirmed that the survey results binder was not available for public view and was instead kept in his office. The administrator acknowledged that survey results from annual recertification surveys dated October 2023, October 2022, and October 2021, as well as complaint surveys from August 27, 2024, and September 5, 2024, should have been accessible to the public but were not.
Resident Neglect Due to Ineffective Tracking System
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a severely cognitively impaired resident being left outside overnight without necessary care. The resident, who required extensive assistance, self-propelled outside the facility without staff knowledge. Staff assumed the resident was out on pass with family, leading to a lack of care and medication administration for over 14 hours. The resident was found the next morning, lethargic and wet with urine, and was subsequently transferred to the hospital with conditions including Hypertensive Urgency, Hyponatremia, Dehydration, and Mild Acute Kidney Injury. The facility's system for tracking residents' whereabouts was ineffective, as staff failed to verify whether the resident was signed out on pass. Interviews revealed that staff relied on assumptions and information from the resident's roommate rather than checking the sign-out log or contacting the family. This oversight resulted in the resident not receiving incontinence care or medications as required by her care plan. The incident highlighted a breakdown in communication and procedure among the staff. Multiple staff members, including CNAs and LPNs, did not verify the resident's location, leading to neglect. The facility's policy on identifying neglect was not effectively implemented, as staff did not ensure the resident's safety and well-being, resulting in significant harm.
Failure to Post Required Contact Information for State Agencies
Penalty
Summary
The facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, including the State Survey Agency, as well as a statement on how residents may file a complaint with the State Survey Agency. This deficiency was identified during a brief tour of the facility on September 3, 2024, at 2:00 p.m., where no such postings were observed. The issue was further confirmed during a subsequent tour on September 4, 2024, at 11:36 a.m., with staff member S8SS, who acknowledged the absence of the required postings. Additionally, an interview with S1ADM on the same day at 11:43 a.m. confirmed the lack of postings, indicating a failure to comply with regulations that ensure residents are informed about how to report suspected violations of state or federal nursing facility regulations.
Failure to Report Resident Neglect Incident
Penalty
Summary
The facility failed to report an alleged neglect incident involving a resident to the state survey agency within the required 24-hour timeframe. The incident involved a resident who was found outside the facility in a wheelchair, having been there for over 14 hours. The resident was discovered by staff at 8:30 a.m. after being outside since the previous evening. The facility's policy mandates that all alleged violations involving neglect be reported immediately, but no later than 24 hours if the incident does not involve abuse and has not resulted in serious bodily injury. However, the facility administrator confirmed that the incident was not reported to the state agency. The incident began when another resident opened a door, allowing the resident in question to wheel herself out onto the patio and eventually get stuck between the fence and sidewalk. The resident remained outside overnight, and was found the next morning with wet clothes and a red bottom, indicating potential neglect. The facility's failure to report this incident in a timely manner constitutes a deficiency in adhering to their own policies and state regulations regarding the reporting of neglect.
Failure to Assess Entrapment Risk and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from bed rails and did not obtain informed consent for their use. The facility's policy on bed rails requires an interdisciplinary evaluation, assessment of alternatives, and informed consent before bed rails are used. However, for one resident with severe cognitive impairment, there was no documentation of an entrapment risk assessment or consent for the use of bed rails. The incident involved a resident with Alzheimer's Disease, Dementia, and Generalized Muscle Weakness, who required moderate staff assistance for bed mobility. During a routine care procedure, the resident's arm became caught in the assist bar, resulting in a skin tear and bruising. The staff involved did not realize the resident's arm was caught until after the injury occurred. The facility's incident investigation confirmed the lack of assessment and consent for the use of assist bars, which were used at the request of the resident's family. Interviews with facility staff revealed that there was no formal process for assessing entrapment risk or obtaining consent for the use of assist bars, which were considered different from bed rails. The facility did not perform risk assessments or obtain consents for the assist bars, which were used on resident beds. The staff acknowledged the absence of these procedures, and the facility's Director of Nursing confirmed that no other interventions were considered before the installation of the assist bars.
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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