Guest House Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in West Monroe, Louisiana.
- Location
- 109 Guest House Drive, West Monroe, Louisiana 71292
- CMS Provider Number
- 195551
- Inspections on file
- 30
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Guest House Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents with significant medical conditions were observed using wheelchairs with cracked and torn armrest padding. These deficiencies were confirmed by the DON, and both residents required wheelchairs for mobility and moderate assistance with transfers.
The facility failed to protect a resident from the wrongful use of their belongings or money, resulting in a deficiency related to safeguarding personal property and funds.
A resident with severe cognitive impairment and multiple diagnoses was kept in a geri-chair with a lap tray that could not be removed independently. Staff interviews and record reviews confirmed there was no physician order or documentation for releasing the lap tray every two hours, as required by policy. Facility staff were unaware of the need for scheduled releases, resulting in noncompliance with restraint protocols.
A resident with multiple mental health diagnoses was transferred to and from an inpatient psychiatric facility due to aggressive and combative behaviors. After returning, facility staff did not submit a required PASARR review to the state-designated authority, and interviews confirmed staff were unaware of this requirement.
A resident with multiple medical and psychiatric diagnoses, including PTSD, did not have a person-centered care plan with measurable objectives and timeframes addressing PTSD, despite being cognitively intact and requiring maximal assistance with daily living. The absence of such a care plan was confirmed by the DON.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall after rolling out of bed while attempting to use the bathroom. The only intervention added was for CNA staff to offer toileting assistance during rounding, which was already part of existing in-service training, resulting in no new or effective intervention being implemented to address the resident's fall risk.
A resident receiving continuous oxygen therapy did not have the required 'no smoking, oxygen in use' signage posted outside their room, as mandated by facility policy. The DON confirmed the absence of signage despite the resident's ongoing oxygen therapy and multiple chronic respiratory conditions.
A resident with multiple chronic conditions was prescribed Eliquis, an anticoagulant, but there was no physician's order or documentation to monitor for signs and symptoms of bleeding as required by the care plan, despite the known risks associated with anticoagulant therapy.
A medication room was found unlocked and propped open without any nursing staff present, contrary to facility policy requiring secure storage of drugs and biologicals. Staff interviews confirmed that only authorized nurses should have access and that the room should always be locked when unattended.
A facility allowed a CNA to work with an expired certification from another state. The CNA's personnel file showed the certification was not current in the state of employment. Interviews confirmed the CNA provided services to residents after the certification expired.
A resident with vascular dementia and a history of falls was inaccurately assessed regarding the use of bed rails. Despite observations showing bed rails in use, the assessment marked them as not indicated. The RN responsible for the assessment confirmed the inaccuracy, revealing she was instructed by the previous DON to avoid marking bed rail use to prevent high restraint indicators. The facility's administration was notified of the findings.
Two residents in a facility had bed rails installed without documented assessments for entrapment risk. One resident, with severe cognitive impairment and a history of falls, had no assessment despite a BIMS score of 03. Another resident, with moderate cognitive impairment and a BIMS score of 08, also lacked an assessment. The Maintenance Supervisor confirmed the absence of documentation, and the Administrator and Regional Director were notified.
The facility failed to ensure CNAs conducted walk-through rounds and provided reports during shift changes, affecting two residents. One resident, with multiple health issues, was not checked on by the day shift CNA until 8:15 a.m., and the night shift CNA did not perform a walk-through or report. Another resident, requiring extensive assistance, was similarly neglected. Despite training, CNAs did not follow protocols, leading to deficiencies in care.
The facility failed to transmit encoded, accurate, and complete MDS data to CMS in a timely manner for three residents. The last transmitted assessments for these residents were either admission or quarterly assessments, and the required fourteen-day discharge assessments were not submitted. An LPN confirmed the oversight.
A facility failed to develop and implement a comprehensive care plan for a resident with a skin rash. Despite multiple treatments and a dermatology consultation, the care plan did not address the resident's skin condition. The DON confirmed the omission, indicating a deficiency in care planning.
Two residents in an LTC facility received inadequate respiratory care. One resident was given oxygen at a higher rate than prescribed, with undated tubing and an uncovered nebulizer mask. Another resident's oxygen concentrator had a dirty buildup, despite orders for continuous oxygen therapy. These issues were confirmed by the DON and an LPN.
A facility failed to ensure a licensed pharmacist conducted a thorough monthly drug regimen review, resulting in a resident receiving clonazepam beyond the recommended period without a documented rationale. The resident, with multiple diagnoses including Alzheimer's and anxiety disorder, had an active order for clonazepam as needed for agitation, but no stop date was provided. The pharmacist did not report this irregularity to the physician or DON, and staff confirmed the lack of documentation and communication.
A resident with severe cognitive impairment was prescribed clonazepam 0.5 mg PRN for agitation without a stop date or documented rationale for extended use. The medication was administered multiple times over several months, and facility staff confirmed the absence of necessary documentation from the physician, leading to a deficiency in medication management practices.
The facility did not perform monthly State Adverse Action checks for CNAs hired between February and May 2024, despite initial checks at hiring. This was confirmed by clerical staff, indicating a lapse in compliance with required procedures.
The facility did not comply with state laws by failing to obtain a criminal history check for a CNA upon hire. The personnel file for the CNA, hired in May 2023, lacked documentation of the required check, which was confirmed by clerical staff.
A resident with severe cognitive impairment experienced an incident where a CNA raised her voice and used improper language after the resident fell. This was witnessed by a Ward Clerk, who failed to report the incident immediately as required by the facility's policy. The delay in reporting was confirmed by the DON and Administrator.
A facility failed to thoroughly investigate allegations of verbal abuse towards a resident with severe cognitive impairment. Despite policy requirements, key witnesses were not interviewed or asked to provide statements. The incident involved a CNA allegedly raising her voice and using improper language after the resident fell. Video footage lacked clarity and audio, and the investigation was incomplete.
Failure to Maintain Wheelchairs in Good Repair for Two Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents who required wheelchairs for mobility and moderate assistance with transfers. Observations conducted on multiple occasions revealed that both residents were using wheelchairs with cracked and torn armrest padding. These deficiencies were confirmed during joint observations with the Director of Nursing. The affected residents had medical histories including chronic heart failure, osteoarthritis, chronic kidney disease, Alzheimer's disease, arthritis, asthma, and cardiac arrhythmia, and both were documented as requiring wheelchairs for mobility in their most recent quarterly MDS assessments. The failure to ensure that the wheelchairs were maintained in good repair directly impacted the residents' environment and comfort, as evidenced by the physical condition of the wheelchair armrests observed and confirmed by facility staff.
Failure to Protect Residents' Belongings and Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that residents' personal property and funds were safeguarded against misuse or unauthorized access. Specific actions or omissions by staff or facility systems that led to the wrongful use of residents' belongings or money were observed and cited as the basis for the deficiency. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Release Physical Restraint and Document Required Intervals
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. Observations revealed that the resident, who had severe cognitive impairment and diagnoses including Parkinson's disease, psychosis, restlessness, and anxiety, was consistently seated in a geri-chair with a lap tray in place. The resident was unable to remove the lap tray independently, and staff confirmed that the tray was not being released every two hours as required by facility policy. There was no physician's order or documentation for the scheduled release of the lap tray to allow for range of motion or repositioning. Interviews with facility staff, including a CNA, LPN, DON, corporate consultant, and RN administrator, confirmed a lack of awareness and documentation regarding the need to release the lap tray every two hours. The facility's policy requires that restrained residents be given the opportunity for motion and exercise for at least ten minutes every two hours and be repositioned on all shifts, but these actions were not documented or carried out for this resident. The absence of both a physician's order and documentation of required releases constituted a failure to comply with restraint use protocols.
Failure to Notify State Authority for PASARR Review After Psychiatric Stay
Penalty
Summary
The facility failed to notify the state-designated mental health disability authority for a Pre-admission Screening and Resident Review (PASARR) when a resident with multiple mental health diagnoses experienced a significant change in mental and physical status. The resident, who had a history of dementia, bipolar disorder, panic disorder, PTSD, and other mental health conditions, was admitted from an inpatient psychiatric facility. After admission, the resident exhibited combative and aggressive behaviors, leading to a transfer back to an inpatient psychiatric facility for further management. Despite the resident's return to the facility following the psychiatric stay, staff did not submit a PASARR review to the designated state authority as required. Interviews with the Social Service Director and the Administrator confirmed they were unaware of the requirement to send a PASARR review after an inpatient psychiatric stay. Record review showed no documentation of a PASARR review following the resident's psychiatric hospitalization, despite the resident's behavioral changes and the need for reassessment.
Failure to Develop Person-Centered Care Plan for PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Record review showed that the resident, who had multiple diagnoses including Parkinson's disease, breast cancer, edema, transient ischemic attack, dementia, PTSD, major depressive disorder, and atrial fibrillation, required maximal assistance with all activities of daily living and was cognitively intact according to a recent assessment. Despite the identification of PTSD in the resident's assessment, the current care plan did not include person-specific, measurable goals or interventions for PTSD. This omission was confirmed during an interview with the DON, who acknowledged that a care plan addressing PTSD should have been in place for the resident.
Failure to Implement Effective Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was as free from accident hazards as possible by not implementing an appropriate intervention following a fall. The resident, who had vascular dementia, a history of repeated falls, and severe cognitive impairment (BIMS score of 7), required substantial to maximal assistance with mobility and transfers. The resident was found on the floor after an unwitnessed fall, having rolled out of bed while attempting to go to the bathroom. The care plan identified the resident as being at risk for falls, and the incident report documented the fall event. Following the fall, the only intervention added to the care plan was for CNA staff to offer toileting assistance during rounding. However, this intervention was not appropriate, as CNA staff had already been in-serviced to round on residents every two hours and as needed. The failure to implement a new or effective intervention after the fall resulted in the resident not being as free from accident hazards as possible.
Failure to Post Required Oxygen in Use Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was receiving continuous oxygen therapy. Observations revealed that the resident was receiving oxygen at 4 liters per minute via nasal cannula, but there was no signage posted outside the resident's room indicating 'no smoking, oxygen in use' as required by the facility's Oxygen Administration policy. The policy, last revised in October 2010, specifically states that an 'Oxygen in Use' sign should be placed on the outside of the room entrance door when oxygen is being administered. The resident involved had multiple medical diagnoses, including chronic respiratory failure with hypoxia, interstitial pulmonary diseases, and other chronic conditions, and was admitted with orders for continuous oxygen therapy and BIPAP during sleep. Documentation confirmed that the resident was receiving oxygen and BIPAP as ordered. During an interview, the DON confirmed that the resident was on continuous oxygen and acknowledged that the required signage was not posted, which was consistent with the observations made during the survey.
Failure to Monitor for Bleeding in Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was free from unnecessary drugs by not monitoring for signs and symptoms of bleeding in a resident receiving anticoagulant therapy. Record review showed that a resident with diagnoses including acute on chronic congestive heart failure, chronic pulmonary edema, atrial fibrillation, and hypertension was prescribed Eliquis, an anticoagulant considered a high-risk medication. The resident's care plan identified a risk for abnormal bleeding and specified monitoring for symptoms such as bleeding gums, bruises, petechiae, nosebleeds, tarry stools, and hematuria. However, there was no physician's order in place for such monitoring, and the Medication Administration Record confirmed the resident received Eliquis without documentation of monitoring for bleeding as outlined in the care plan.
Unsecured Medication Room Found Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required. During an early morning observation, the medication room door was found unlocked and propped open with a wooden board, with no nursing staff present in the nurse's station or medication room. A CNA confirmed the medication room was unsecured and unattended, and an LPN verified that the room should have been locked and that only authorized nurses are permitted access. The Director of Nursing also confirmed that medication rooms are to remain locked at all times when staff are not present and that the door should never be propped open. These findings were based on direct observation, staff interviews, and review of the facility's policy, which states that medications and biologicals must be stored securely and only accessible to licensed nursing, medical, or pharmacy personnel.
Expired CNA Certification Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had a valid and current certification before allowing them to work. Specifically, the facility allowed S5CNA to work with an expired certification from a different state. S5CNA's personnel file indicated that their certification had expired, and they did not have a current certification in the state where they were employed. Interviews with the facility's administrator and CNA supervisor confirmed that S5CNA provided services to residents after their certification had expired.
Inaccurate Bed Rail Assessment for Resident with Dementia
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status regarding the use of bed rails. The resident, who was recently admitted, had a diagnosis of vascular dementia with behavioral disturbance and a history of falls. The Admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment. Observations on two separate occasions revealed that the resident had bed rails in use, which were not accurately reflected in the Bed Rail assessment. The assessment incorrectly marked that side rails/assist bars were not indicated, despite their presence. The inaccuracy in the assessment was confirmed by the registered nurse (RN) who completed it. During an interview, the RN disclosed that she had been instructed by the previous Director of Nursing (DON) to avoid marking the use of bed rails to prevent the facility from appearing to have a high indicator use for restraints. This led to the inaccurate documentation of the resident's need for bed rails. The facility's administrator and regional director of operations were informed of these findings.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation. This deficiency was observed in two residents who had 1/4 bed rails installed on their beds without documented evidence of an assessment for entrapment risk. Resident #1, who was recently admitted with vascular dementia and a history of falls, had severe cognitive impairment as indicated by a BIMS score of 03. Despite this, there was no documented assessment for bed rail entrapment risk, and the Bed Rail assessment indicated that side rails were not needed. The RN responsible for the assessment could not recall if the resident required bed rails at the time of the assessment or currently. Similarly, Resident #2, admitted with a left femur fracture, major depressive disorder, and insomnia, had moderate cognitive impairment with a BIMS score of 08. Observations revealed that this resident also had 1/4 bed rails installed without any documented assessment for entrapment risk. The Maintenance Supervisor confirmed the lack of documentation for both residents, and the Administrator and Regional Director of Operations were informed of these findings.
Failure in CNA Shift Change Protocols
Penalty
Summary
The facility failed to ensure that nursing staff, specifically Certified Nursing Assistants (CNAs), were competent in providing necessary care and services to maintain resident safety and well-being. The deficiency was identified through record reviews and interviews, revealing that CNAs did not conduct walk-through rounds or provide reports during shift changes. This failure affected two out of three sampled residents, compromising the continuity of care and potentially impacting the residents' physical, mental, and psychological well-being. Resident #1, who was cognitively intact and had a history of multiple health issues including multiple myeloma and dementia, was not checked on by the day shift CNA until 8:15 a.m., despite the expectation of rounds every two hours. The night shift CNA, who last checked on the resident at 5:00 a.m., did not perform a walk-through or provide a report to the incoming staff. Similarly, Resident #2, who required extensive assistance and was always incontinent, was not attended to by the day shift CNA until 8:15 a.m. The night shift CNA also failed to conduct a walk-through or report to the oncoming staff. Interviews with the Director of Nursing (DON) and CNA Supervisor confirmed that the facility's protocol required CNAs to make rounds every two hours and conduct walk-throughs with reports at shift changes. Despite an in-service training conducted on these procedures, the involved CNAs did not adhere to the established protocols, as evidenced by their signatures on the training sign-in sheet. This lack of compliance with the facility's procedures led to the identified deficiencies in resident care.
Failure to Timely Transmit MDS Data for Discharged Residents
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for three residents. Specifically, the facility did not submit a fourteen-day discharge assessment for three residents who were reviewed. Resident #43 was admitted and discharged, with the last transmitted MDS assessment being an admission assessment completed on March 19, 2024. Resident #48 was admitted and discharged, with the last transmitted MDS assessment being an admission assessment completed on March 5, 2024. Resident #94 was admitted and discharged, with the last transmitted MDS assessment being a quarterly assessment completed on March 6, 2024. An interview with an LPN/MDS nurse confirmed that the required minimum data set assessments were not submitted within fourteen days of discharge for these residents.
Failure to Implement Comprehensive Care Plan for Resident with Skin Rash
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified with a skin rash. On observation, the resident exhibited a dark patchy red rash on the face, back, and arms, and was unaware of the cause. The resident's medical record indicated diagnoses including dermatitis, arthritis, stage 3 chronic kidney disease, mild cognitive impairment, and atrial fibrillation, along with allergies to sulfonamide antibiotics. Initial treatment for the rash began with hydrocortisone ointment and Claritin, followed by various medications including Benadryl, Prednisone, and Diflucan, and a dermatology consultation was ordered. Despite these treatments, a review of the current plan of care revealed no documented problems or needs related to the skin condition or rash. The Director of Nursing confirmed that the care plan did not address the resident's skin condition, indicating a failure to implement a comprehensive care plan that met the resident's needs. This oversight highlights a deficiency in the facility's care planning process for this resident.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. Resident #25, who had multiple diagnoses including chronic obstructive pulmonary disease and was admitted to hospice, was observed receiving oxygen at 5 liters per minute via nasal cannula, contrary to the physician's order of 3 liters per minute. The oxygen tubing was not dated, and the nebulizer mask was neither covered nor dated. These observations were confirmed by the Director of Nursing, who acknowledged the discrepancies in oxygen administration and equipment maintenance. Resident #71, diagnosed with chronic systolic congestive heart failure and other conditions, was observed using an oxygen concentrator that had a dirty buildup on both the front panel and the filter. Despite physician orders for continuous oxygen therapy at 3 liters per minute, the concentrator's cleanliness was neglected. This was confirmed by an LPN and later reported to the Director of Nursing, who was informed of the need for cleaning the concentrator.
Failure in Medication Management Due to Inadequate Pharmacist Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review for a resident, leading to a deficiency in medication management. Specifically, the pharmacist did not report irregularities to the physician and the Director of Nursing for a resident who was receiving as-needed doses of the psychotropic medication clonazepam beyond the recommended 14 days without a documented rationale or duration date for administration. The resident, who was admitted with multiple diagnoses including Alzheimer's disease, dementia, and anxiety disorder, had an active physician order for clonazepam 0.5 mg to be administered as needed for agitation, with no stop date provided. The resident's medical records and narcotic log indicated that clonazepam was administered on multiple occasions over several months, yet there was no documentation from the physician justifying the continued use of the medication. Additionally, the consultant pharmacist's monthly review did not address the ongoing use of clonazepam, nor was there any notification to the physician or the Director of Nursing about the need for the medication. Interviews with facility staff confirmed the lack of documentation and communication regarding the medication's extended use, highlighting a lapse in the facility's medication management procedures.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication use, specifically regarding the administration of a PRN psychotropic medication. Resident #15, who was admitted with multiple diagnoses including Alzheimer's disease, dementia, and anxiety disorder, was prescribed clonazepam 0.5 mg as needed for agitation. The physician's order, dated May 23, 2024, did not include a stop date, and there was no documented rationale for extending the use of this medication beyond 14 days, as required by regulations. The resident's medical record and narcotic log indicated that clonazepam was administered on multiple occasions in May, June, and July 2024. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of a documented rationale for the continued use of the PRN medication. The LPN noted that the medication was used to manage behaviors such as hollering, crying, and making repetitive noises, but the lack of documentation from the physician regarding the necessity of prolonged use constituted a deficiency in the facility's medication management practices.
Failure to Conduct Monthly State Adverse Action Checks for CNAs
Penalty
Summary
The facility failed to ensure that monthly State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNAs). This deficiency was identified in the personnel files of four CNAs, who were hired between February and May 2024. Although initial State Adverse Action checks were conducted upon hiring, there was no documented evidence of these checks being performed on a monthly basis thereafter. This lapse was confirmed during an interview with a clerical staff member, who acknowledged that the monthly checks were not obtained.
Failure to Obtain Criminal History Check for CNA
Penalty
Summary
The facility failed to comply with state laws by not obtaining a criminal history check upon hire for a Certified Nursing Assistant (CNA), identified as S8CNA. According to the Long Term Minimum Licensing Standards, statute 9759 A, nursing facilities are required to perform statewide criminal history checks on non-licensed personnel, including CNAs. A review of S8CNA's personnel file, who was hired on 05/15/2023, showed no documented evidence of a criminal history check being conducted. This deficiency was confirmed during an interview with S9Clerical on 05/15/2024, who acknowledged the absence of the required documentation.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment witnessed by staff were reported immediately to their supervisor or the Director of Nursing. This deficiency was identified in the case of a resident with severe cognitive impairment due to Alzheimer's disease, among other diagnoses. The resident experienced an incident where a Certified Nursing Assistant (CNA) raised her voice and used improper language after the resident fell. The incident was witnessed by a Ward Clerk, who did not report it immediately as required by the facility's policy. The incident occurred when the Ward Clerk and a Licensed Practical Nurse (LPN) heard the resident yell out. The Ward Clerk observed the CNA attempting to lift the resident improperly and using a harsh tone. Despite witnessing this, the Ward Clerk delayed reporting the incident until two days later. The Director of Nursing and the Administrator confirmed that the Ward Clerk should have reported the alleged abuse immediately, as per the facility's policy on recognizing and reporting signs of abuse or neglect.
Failure to Investigate Alleged Verbal Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The incident in question occurred when a Certified Nursing Assistant (CNA) allegedly raised her voice and used improper language towards the resident after a fall. Despite the facility's policy requiring thorough investigation of abuse allegations, including interviewing witnesses and obtaining written statements, there was no documented evidence that key witnesses were interviewed or provided statements. Interviews with staff revealed that the Director of Nursing (DON) and the Administrator did not interview or obtain statements from the Ward Clerk and another CNA who were present during the incident. Video footage reviewed by the Administrator did not capture the incident clearly, and there was no audio available. The lack of documented interviews and statements from witnesses indicates a failure to adhere to the facility's abuse investigation policy, resulting in an incomplete investigation of the alleged verbal abuse.
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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