Grand Cove Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Charles, Louisiana.
- Location
- 1525 W Mcneese St., Lake Charles, Louisiana 70605
- CMS Provider Number
- 195376
- Inspections on file
- 19
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grand Cove Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and hypertensive heart disease had an EMR progress note documenting Multaq 400 mg as 2 tablets BID for paroxysmal atrial fibrillation, a regimen exceeding the usual and maximum recommended single dose. Review of the MAR showed no corresponding physician order for Multaq, current or discontinued. The DON confirmed the absence of any Multaq order, and a later progress note indicated the Multaq order had been entered as 2 tablets BID instead of 1 tablet BID. The medical director confirmed this entry was incorrectly documented in the resident’s medical record, demonstrating incomplete and inaccurate medical record documentation.
A resident with multiple mental health diagnoses repeatedly refused hygiene and nail care over several months. Despite staff and hospice documentation of these refusals and notifications to nursing staff, the care plan was not updated to reflect the refusals or include interventions. Staff interviews confirmed awareness of the refusals but acknowledged the care plan did not address them.
A resident's care plan was not revised to reflect her current ability to perform activities of daily living independently, except for showering, despite updated assessments and interviews confirming her improved status. The care plan continued to indicate a need for assistance in multiple areas, which was not consistent with the resident's actual needs.
Several residents did not receive their prescribed medications within the required timeframes, as medications scheduled for specific times were administered significantly late. Staff, including LPNs and the DON, confirmed the late administration of both morning and evening medications, which did not comply with the facility's medication administration policy.
A resident's quarterly MDS assessment was not completed and submitted to CMS within the required 14-day timeframe. Review of records and staff interview confirmed the assessment was finalized after the deadline.
A resident's MDS assessment was incorrectly coded to indicate use of an anticoagulant but not an antiplatelet, despite the resident receiving Plavix, an antiplatelet medication, during the assessment period. This error was confirmed through EMAR review and staff interview.
Two residents with hemiplegia and diabetes who required significant assistance with personal hygiene were observed with unkempt facial hair and long, curling fingernails. Staff confirmed frequent refusals of ADL care by one resident, but these refusals and related needs were not addressed in the care plans for either resident.
A resident prescribed Carbidopa-Levodopa for Parkinson's disease experienced a discrepancy between the physician's order, which called for one 50-200 mg tablet three times daily, and the medication blister pack, which contained 25-100 mg tablets labeled to give two tablets three times daily. An LPN identified the inconsistency during medication pass, flagged the medication, and administered only one tablet, while the DON confirmed the mismatch between the order and packaging. The eMAR did not document the irregularity.
Dietary staff did not consistently use gloves, hair restraints, or proper sanitary procedures during food preparation and service. A cook prepared pureed food without gloves or a facial hair restraint, another staff member measured food temperatures without gloves, and a dietary aide used an uncleaned ice scoop after it contacted a drink. These actions were confirmed by the dietary manager and were not in accordance with facility policy, potentially affecting all residents receiving food and beverages.
A facility failed to complete a timely reentry MDS assessment for a resident who was readmitted after a hospital stay. The resident, diagnosed with a UTI and Vascular Dementia, returned to the facility without the required assessment being initiated. A nurse confirmed the oversight during a review, highlighting a deficiency in the assessment process.
A provider failed to ensure an accurate assessment for a resident with Schizophrenia and Bipolar Disorder. The resident's EMR indicated a PASRR Level II determination, recommending specialized services, but this was not reflected in the SC MDS assessment. The staff member responsible was unaware of the PASRR Level II status.
The facility failed to securely store and discard expired medications, as evidenced by an expired container of Gavilyte G found in an unlocked refrigerator meant for resident food. The Assistant Director of Nursing confirmed that the medication, prescribed to a resident, should not have been accessible in this manner and should have been discarded.
A facility failed to maintain effective infection control when an LPN did not follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during a nephrostomy tube dressing change for a resident. The LPN entered the room without a gown or gloves and did not change gloves or perform hand hygiene between dressing changes on the resident's bilateral nephrostomy tubes. This breach was confirmed by the LPN, the Assistant Director of Nursing/Infection Preventionist, and the Director of Nursing.
Inaccurate Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident, as required by its own medical records policy and accepted professional standards. The facility’s policy states that each resident must have an electronic clinical record that is complete, accurate, readily accessible, and systematically organized, including assessments, care plans, services provided, and diagnostic information. For one resident with dementia and hypertensive heart disease without heart failure, the electronic medical record contained a progress note dated 02/10/2026 documenting a dosing regimen for Multaq 400 mg as 2 tablets by mouth twice daily for paroxysmal atrial fibrillation. This documented regimen exceeded the usual dosing of 1 tablet twice daily and the maximum recommended single dose of 1 tablet, as indicated by an FDA black box warning. Further review of the resident’s February 2026 MAR showed no evidence of any physician’s order for Multaq, either current or discontinued, despite the progress note describing Multaq dosing. During interviews, the DON confirmed that the resident did not have a physician’s order for Multaq in the EMR. The DON also reviewed a subsequent progress note dated 02/12/2026 that stated an order review had identified Multaq as entered as 2 tablets/400 mg BID instead of the correct 1 tablet/400 mg BID, and that the order was immediately changed. The medical director later confirmed that this documentation had been entered incorrectly in the resident’s medical record, demonstrating that the resident’s EMR contained inaccurate and incomplete medication documentation.
Failure to Address and Care Plan for Repeated Refusals of Hygiene and Nail Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's repeated refusals of hygiene and nail care. Record reviews showed that the resident, who had diagnoses including schizoaffective disorder, unspecified dementia, anxiety disorder, and major depressive disorder, consistently refused hygiene care daily over a two-month period and refused nail care on multiple occasions. Hospice aide visit notes also documented refusals of nail care, with notifications made to nursing staff. Despite these ongoing refusals, the resident's care plan did not include any identification of the refusal of care or interventions to address it. Interviews with facility staff, including LPNs and the nurse responsible for MDS and care plan updates, confirmed that the refusals were known and occurred frequently, yet were not reflected in the care plan. The staff acknowledged that the care plan should have included these issues and interventions but did not.
Failure to Update Care Plan Following Change in ADL Status
Penalty
Summary
The facility failed to revise the comprehensive, person-centered care plan for one resident following changes in her activities of daily living (ADL) status. Record review showed that the resident was admitted with diagnoses including congestive heart failure, anxiety, and depression, and her most recent assessment indicated she was independent in most ADLs except for requiring some assistance with bathing. However, the care plan continued to list her as needing partial or moderate assistance with bathing, supervision for transfers, and assistance with toileting, despite her current ability to perform most tasks independently except for showering. Interviews with the resident and a corporate registered nurse confirmed that the care plan had not been updated to reflect the resident's current ADL abilities.
Failure to Administer Medications on Time as Ordered
Penalty
Summary
The facility failed to provide services that meet professional standards of quality by not administering medications on time as ordered for three out of eleven sampled residents. According to the facility's policy, medications are to be administered no more than one hour before or after the scheduled time. For one resident with diagnoses including congestive heart failure, anxiety, and depression, evening medications scheduled for 8:00 p.m. and 9:00 p.m. were administered significantly late, at 10:14 p.m. and 10:25 p.m. The resident confirmed not receiving medications at the expected times, and the Director of Nursing verified the late administration upon review of the medication administration record. Additionally, another resident was observed receiving multiple morning medications due at 9:00 a.m. at 11:36 a.m., with the LPN confirming the late administration. A third resident's medications, due at 8:00 a.m. and 9:00 a.m., were also administered late, as confirmed by both observation and staff interview. These findings demonstrate that the facility did not adhere to its own medication administration policy, resulting in late delivery of prescribed medications for multiple residents.
Failure to Complete and Submit Quarterly MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment was completed and submitted to CMS within the required timeframe. Record review showed that the assessment for one resident had an Assessment Reference Date (ARD) of 05/06/2025, but the assessment was not completed and signed until 06/05/2025, exceeding the 14-day completion requirement. During an interview, the staff member responsible for MDS assessments confirmed that the assessment was not completed within the CMS-mandated period.
Inaccurate MDS Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment regarding the use of antiplatelet medication. Specifically, the quarterly MDS for a resident with an Assessment Reference Date (ARD) of 02/12/2025 indicated that the resident was taking an anticoagulant but not an antiplatelet medication. However, review of the electronic medication administration record (EMAR) for February 2025 showed that the resident had been administered Plavix, which is an antiplatelet medication, during the MDS lookback period. This discrepancy was confirmed during an interview and record review with the staff member responsible for MDS coding, who acknowledged the incorrect coding on the assessment.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with significant care needs. One resident, admitted with hemiplegia, type 2 diabetes mellitus, and morbid obesity, was documented as being dependent on staff for personal hygiene. Observations revealed the resident was unshaven with long, unkempt facial hair and fingernails that were long, curling, and had brown debris underneath. Staff interviews confirmed that the resident frequently refused ADL care, and this issue had been reported to administration. However, a review of the resident's care plan showed that these refusals and the need to address them were not included in the care plan. Another resident, also with hemiplegia and type 2 diabetes mellitus, required substantial to maximal assistance for personal hygiene. Observation showed this resident had long, curling fingernails. The report documents that the care plans for both residents did not address their specific needs related to personal hygiene and refusals of care, as identified through record reviews, staff interviews, and direct observation.
Failure to Ensure Consistent Medication Orders and Packaging
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) identified a discrepancy between the physician's order and the instructions on the medication blister pack for a resident prescribed Carbidopa-Levodopa for Parkinson's disease. The physician's order and the electronic Medication Administration Record (eMAR) both specified to administer one 50-200 mg extended-release tablet by mouth three times daily. However, the blister pack available in the medication cart contained 25-100 mg tablets and was labeled to administer two tablets by mouth three times daily, which would match the total prescribed dose but differed in tablet strength and instructions. During medication administration, the LPN noticed the inconsistency and flagged the medication pack with a sticker indicating a direction change, while also confirming that only one 25-100 mg tablet was administered to the resident at that time. The Director of Nursing (DON) reviewed the orders, eMAR, and blister pack, confirming the mismatch between the physician's order and the medication packaging. There was no documentation in the eMAR to indicate the irregularity or conflict between the orders and the medication available for administration.
Failure to Follow Food Safety Standards in Dietary Services
Penalty
Summary
Dietary staff failed to adhere to professional standards for food service safety in several observed instances. One dietary cook was seen preparing pureed food without wearing gloves and without a facial hair restraint, despite facility policy requiring hair restraints to prevent hair from contacting food. Another dietary staff member was observed measuring food temperatures at the steam table without wearing gloves. Additionally, a dietary aide was seen scooping ice into glasses and tapping the ice with the back of the scoop, causing the drink to drip onto the scoop, and then returning the uncleaned scoop to the ice bin for further use. These actions were confirmed by the dietary manager, who acknowledged that all staff should use appropriate hair restraints, gloves, and sanitary procedures as outlined in facility policy. These deficiencies were observed during food preparation and service, with the potential to affect all 80 residents who consumed food and beverages prepared in the kitchen. The facility's policies on employee work practices and hand sanitation were reviewed and found to require the use of hair restraints, gloves, and proper sanitary procedures, which were not followed during the observed incidents.
Failure to Complete Timely Reentry MDS Assessment
Penalty
Summary
The facility failed to complete a reentry Minimum Data Set (MDS) assessment in a timely manner for Resident #14, who was part of a sample of 25 residents. This deficiency had the potential to affect the entire census of 73 residents. Resident #14 was initially admitted to the facility with diagnoses including a Urinary Tract Infection and Vascular Dementia. The resident was hospitalized on May 27, 2024, and returned to the facility on May 30, 2024. However, a review of the resident's MDS assessments revealed that a reentry assessment had not been initiated following the readmission from the hospital. During an interview and record review on June 5, 2024, a Registered Nurse (S7RN) confirmed that Resident #14 had a recent hospital stay and was readmitted to the facility. The nurse verified that the reentry assessment was overdue and had not been initiated, confirming the deficiency in the facility's assessment process.
Inaccurate Resident Assessment Due to PASRR Omission
Penalty
Summary
The provider failed to ensure that a resident's assessment accurately reflected the resident's status, specifically for one resident out of three reviewed in a sample of 25. The deficiency had the potential to affect a census of 73 residents. The resident in question was admitted with diagnoses including Schizophrenia and Bipolar Disorder. A review of the resident's electronic medical record (EMR) showed a PASRR Level II determination, indicating a serious mental illness and recommending nursing home admission with specialized services. However, the resident's Significant Change (SC) Minimum Data Set (MDS) assessment did not reflect the PASRR evaluation. During an interview, the staff member responsible for completing the SC MDS confirmed that the PASRR was not identified in the assessment and was unaware of the resident's PASRR Level II status.
Expired Medication Found in Unlocked Resident Refrigerator
Penalty
Summary
The facility failed to ensure that medications were stored securely and discarded upon expiration, as evidenced by an expired medication being found in an unlocked refrigerator designated for resident food storage. The policy review indicated that the facility's medication storage policy required a lock and key system to secure medications and a separate area for storing discontinued, expired, or unusable medications. However, during an observation, it was found that the facility did not adhere to this policy. An observation conducted with the Assistant Director of Nursing (S3ADON) revealed that a refrigerator labeled 'Resident Refrigerator' was unlocked and centrally located on Hall A. This refrigerator was intended for resident food items and was accessible to residents and their families at any time. Inside this refrigerator, a half-full container of Gavilyte G, a laxative prescribed to a resident, was found. The prescription label indicated that the medication had expired. S3ADON confirmed that the medication belonged to a resident and acknowledged that it should not have been stored in the resident food refrigerator and should have been discarded due to its expiration.
Infection Control Breach During Nephrostomy Tube Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by a Licensed Practical Nurse (LPN) not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during a nephrostomy tube dressing change for a resident. The resident, who was on EBP due to bilateral nephrostomy tubes, required the use of gown and gloves for high-contact care activities. However, the LPN entered the resident's room without wearing a gown or gloves, despite the presence of an EBP sign and available PPE outside the room. During the dressing change, the LPN did not change gloves or perform hand hygiene after removing the soiled dressing and before cleaning the wound site. Additionally, the LPN failed to change gloves or perform hand hygiene between the dressing changes on the left and right nephrostomy tubes. These actions were confirmed by the LPN, the Assistant Director of Nursing/Infection Preventionist, and the Director of Nursing, all acknowledging the failure to follow the facility's infection control policies and procedures.
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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