Gueydan Memorial Guest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Gueydan, Louisiana.
- Location
- 1201 Third St, Gueydan, Louisiana 70542
- CMS Provider Number
- 195458
- Inspections on file
- 18
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Gueydan Memorial Guest Home during CMS and state inspections, most recent first.
The facility did not ensure residents' personal funds were accessible during non-banking hours, affecting 51 residents. During a resident council meeting, residents reported they could not access petty cash on weekends, as it was only available when the business office was open. The Social Services Director confirmed this practice and was unaware that petty cash needed to be accessible at all times.
The facility did not deliver mail to residents on Saturdays, affecting 49 residents. During a resident council meeting, several residents reported not receiving their unopened mail on Saturdays, with mail only being delivered when the office was open from Monday to Friday. The Secretary/Transportation Supervisor/Medical Record confirmed that no staff was available on Saturdays to deliver mail, resulting in Saturday mail being delivered on Monday morning.
The facility failed to follow its grievance policy, resulting in unresolved grievances and residents unaware of the grievance process. Only five grievances were filed over a year, with two unresolved. Residents reported not knowing how to file grievances, and the Social Services Director admitted to not understanding what should be filed as a grievance.
The facility failed to maintain a clean and sanitary kitchen, affecting 44 residents. Observations revealed food residue in the fryer, build-up on the deep freezer, and debris in the oven. Unlabeled and spoiled food items were found, and a staff member was seen without a beard restraint. The Dietary Manager confirmed these issues, acknowledging non-compliance with cleaning and labeling policies.
The facility failed to ensure accurate MDS assessments for three residents. A resident with End Stage Renal Disease did not have dialysis treatment reflected in their MDS. Another resident was incorrectly identified as using physical restraints, despite no evidence or orders for such. Additionally, a resident receiving continuous oxygen therapy was not documented as such in their MDS. These inaccuracies were confirmed during record reviews and interviews.
The facility failed to implement its smoking safety policy for residents identified as unsafe smokers. Despite the policy requiring smoking aprons and supervision, three residents with conditions like Alzheimer's and dementia were observed smoking without aprons. Staff interviews confirmed the policy was not followed, leading to a deficiency in accident hazard prevention.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during hospital transfers. Despite multiple transfers, there was no evidence of notification, and interviews confirmed the facility's practice of not sending bed-hold letters due to available open beds.
The facility failed to ensure proper oxygen delivery and care planning for two residents. One resident received oxygen at an incorrect rate, while another's care plan lacked focus on pneumonia management and continuous oxygen use, as confirmed by staff reviews.
The facility did not maintain RN coverage for 8 consecutive hours daily, as required. Time card reviews from January to March 2024 revealed insufficient RN hours on specific days in February and March. Interviews confirmed the lack of coverage, with the DON acknowledging the issue and a secretary unable to provide documentation for claimed RN hours.
A resident with dysphagia and other conditions was not provided a mechanically altered diet as ordered by the physician. The resident's meal tray included whole slices of meatloaf and garlic bread, contrary to the finely chopped texture specified in the dietary order. This was confirmed by an RN during an observation.
The facility did not maintain an effective infection control program by failing to conduct an annual review of its policies and procedures. The policy was last updated in 2018, and the DON/IP could not provide documentation of a recent review, admitting unawareness of the annual review requirement.
Inaccessibility of Residents' Personal Funds During Non-Banking Hours
Penalty
Summary
The facility failed to ensure that residents' personal funds were accessible during non-banking hours, affecting 51 residents who had deposited funds in the residents' trust fund. During a resident council meeting, several residents reported that they could not access petty cash on weekends, as it was only available when the business office was open during weekdays. The Social Services Director confirmed that petty cash was not available to residents on weekends and was unaware that it needed to be accessible at all times.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, which affected 49 residents. During a resident council meeting, three residents reported that they did not receive their unopened mail on Saturdays. Two of these residents stated that they only received their mail when the office was open from Monday through Friday. An interview with the Secretary/Transportation Supervisor/Medical Record (S4SEC) confirmed that there was no staff available in the business office on Saturdays to deliver mail to residents. As a result, mail received on Saturdays was not delivered to residents until the following Monday morning.
Failure to Follow Grievance Policy
Penalty
Summary
The facility failed to adhere to its grievance policy and procedure, which resulted in a deficiency. The policy, last revised in April 2017 and reviewed in April 2023, mandates that all grievances and complaints be investigated, recorded, and resolved promptly. However, the facility's grievance records from July 2023 to July 2024 showed only five grievances filed, with only three resolved. Two grievances lacked resolution and were not signed by the Administrator within the required five days. This indicates a failure to follow the established grievance process. Interviews with residents during a council meeting revealed that several residents were unaware of how to file grievances or whom to contact. One resident expressed that they were not informed if grievances were filed or resolved. The Social Services Director (S3SSD), responsible for handling grievances, admitted to being unsure about what should be filed as a grievance. She mentioned that the Activities Director (S9ACT) usually received complaints informally during morning coffee sessions, and these were discussed in staff meetings without formal grievance documentation. This lack of awareness and formal procedure adherence contributed to the deficiency.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect the 44 residents who consumed food from the kitchen. During an inspection, several deficiencies were observed, including food residue and dark black grease in the kitchen fryer, a build-up of brown substance on the outside of the deep freezer, and debris inside the conventional oven. Additionally, the facility's policies regarding food storage and labeling were not followed, as evidenced by unlabeled chicken base, spoiled cheese, dented canned goods, and unlabeled pasta, soda, vanilla flavoring, and cream potatoes. Furthermore, the facility did not adhere to its policy on personal hygiene, as a staff member was observed in the kitchen without a beard restraint. The walk-in refrigerator had food residue and debris on the floor, and a scoop was improperly stored inside a cereal container. The Dietary Manager confirmed these findings and acknowledged that the fryer should have been cleaned, the grease drained, and the conventional oven and deep freezer cleaned. The manager also confirmed that food items should be labeled with the date they were opened or prepped, and dented cans and discolored food should be discarded immediately.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The provider failed to ensure accurate assessments for three residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. Resident #14, who was diagnosed with End Stage Renal Disease and dependent on renal dialysis, had an MDS assessment that did not reflect the dialysis treatment received three times a week, as confirmed by the S5MDS during a record review and interview. Similarly, Resident #28, with diagnoses including Cognitive Communication Deficit and Dementia, was incorrectly identified as using physical restraints in the MDS assessment, despite no evidence or orders for such restraints being found in the resident's records or observed during room checks. Additionally, Resident #102, who had diagnoses of Pneumonia, Hypoxia, and Heart Failure, was receiving continuous oxygen therapy as per physician's orders. However, the MDS assessment failed to indicate the use of oxygen, which was confirmed by the S5MDS during a review of the resident's records. These inaccuracies in the MDS assessments highlight the provider's failure to ensure that the residents' assessments accurately reflected their current medical treatments and conditions.
Failure to Implement Smoking Safety Policy for Unsafe Smokers
Penalty
Summary
The facility failed to ensure the safety of residents who were identified as unsafe smokers by not implementing its own smoking policy. The policy required that residents deemed unsafe smokers be provided with a smoking apron and be supervised while smoking. However, during observations, three residents identified as unsafe smokers were seen smoking without wearing the required smoking aprons. These residents had various diagnoses, including Alzheimer's disease, dementia, major depressive disorder, anxiety disorder, and other conditions that could potentially affect their safety while smoking. Interviews with facility staff, including the Director of Nursing/Infection Preventionist and a Certified Nursing Assistant/Smoke Aide, revealed a lack of adherence to the facility's smoking policy. Despite acknowledging that the residents were unsafe smokers, staff members stated that the residents did not require a smoking apron. This was in direct contradiction to the facility's policy, which was confirmed by the Director of Nursing/Infection Preventionist during the review of the policy. The failure to provide smoking aprons as required by the policy resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide a written notice to a resident and their representative regarding the duration of the bed-hold policy during hospital transfers. This deficiency was identified during a review of the facility's policy titled 'Bed-Holds and Returns,' which mandates that residents and their representatives receive written information about bed-hold policies both in advance of any transfer and at the time of transfer. The review of Resident #102's electronic medical record and the Ombudsman Notification of Transfer logs revealed multiple hospital transfers without evidence of written notification being sent to the resident or their responsible party. Interviews conducted with the resident and the Director of Nursing/Infection Preventionist (S2DON/IP) confirmed the lack of written notification. The resident did not recall receiving any notice regarding bed-hold during hospital transfers. The S2DON/IP reported that the facility did not send out bed-hold letters because the Administrator believed it was unnecessary due to the availability of open beds. This practice was confirmed as no letter was sent to Resident #102 or their responsible party during the hospital transfers.
Oxygen Delivery and Care Plan Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice by not ensuring that oxygen was delivered at the ordered rate for two residents. Resident #2, who was admitted with diagnoses including Pneumonia, Sepsis, and Dementia, had a physician's order for oxygen at 2 liters per nasal cannula continuously. However, observations on two separate occasions revealed that the oxygen was set at 3 liters, contrary to the physician's orders. This discrepancy was confirmed by a Licensed Practical Nurse who reviewed the resident's orders and observed the incorrect oxygen setting. Resident #102, admitted with diagnoses including Pneumonia, Edema, Heart Failure, Tachycardia, and Anxiety, had a physician's order for continuous oxygen at 3 liters per nasal cannula due to pneumonia. Despite this, the resident's care plan did not include a focus or goal related to managing pneumonia symptoms, nor did it mention the continuous use of oxygen. This oversight was confirmed by a Minimum Data Set nurse who reviewed the care plan and acknowledged the absence of the necessary focus and intervention related to the resident's condition and treatment needs.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
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. This deficiency was identified through a review of time card reports from January 2024 through March 2024. On February 19, 2024, the Director of Nursing/Infection Preventionist (S2DON/IP) worked only 5.5 hours, and no other RN was recorded as working that day. On February 26, 2024, the combined RN coverage was only 7 hours and 48 minutes, with S11RN working 6.35 hours and S2DON/IP working 7 hours and 48 minutes. Additionally, on March 10, 2024, there was no documented RN coverage on the time card report, although a secretary (S4SEC) claimed that an RN (S10RN) worked that day but could not provide documentation to support this claim. Interviews conducted on August 7, 2024, confirmed these findings. S2DON/IP acknowledged the lack of 8 consecutive hours of RN coverage on the specified dates in February. S4SEC reported that S10RN worked on March 10, 2024, but failed to provide time card documentation to verify this information by the time of the exit conference.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
The facility failed to ensure that a resident received a mechanically altered diet as ordered by the physician. Resident #35, who was admitted with diagnoses including Non-infective Gastroenteritis, Colitis, and Dysphagia, had a physician's order for a No Added Salt (NAS) diet with finely chopped texture and regular consistency. Despite this order, an observation on 08/05/2024 revealed that the resident's meal tray contained a whole slice of meatloaf and a whole slice of garlic bread, neither of which were finely chopped as required. This discrepancy was confirmed by a registered nurse, S8RN, who acknowledged that the meal did not comply with the physician's dietary order for the resident.
Failure to Conduct Annual Review of Infection Control Policies
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not conducting a yearly review of the infection program policies and procedures. The facility's policy titled 'Infection Prevention and Control Program' was last updated in October 2018, indicating a lapse in the annual review requirement. During an interview, the Director of Nursing/Infection Preventionist (S2DON/IP) acknowledged responsibility for overseeing the infection control program but was unable to provide documentation of the last review of the IPCP policies and procedures. S2DON/IP also admitted to being unaware of the requirement for annual reviews of these 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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