Heritage Manor Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bossier City, Louisiana.
- Location
- 2575 Airline Drive, Bossier City, Louisiana 71111
- CMS Provider Number
- 195323
- Inspections on file
- 30
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Heritage Manor Health & Rehab during CMS and state inspections, most recent first.
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 on hospice with COPD, major depressive disorder, intact cognition, and dependence for transfers had multiple falls and a physician order for continuous 1:1 monitoring, including sitting near the nurses’ station for safety. The care plan noted repeated falls and that the resident removed oxygen tubing, yet the resident experienced an unwitnessed fall when a CNA left the room to gather supplies, and staff assigned to 1:1 monitoring also left to answer other call lights. The administrator and nursing leadership acknowledged there was no 1:1 monitoring policy and confirmed that the physician’s order for constant observation was not consistently followed.
A resident with severe cognitive impairment and multiple comorbidities returned from an ED visit after a fall with a diagnosed subacute-chronic olecranon fracture, a splint and sling in place, and instructions for orthopedic follow-up. Facility records showed no physician orders for fracture management or follow-up, and the comprehensive care plan lacked any interventions related to the elbow fracture. The resident reported not having seen a doctor again for the elbow. The MDS nurse, ADON, and DON each acknowledged that the care plan was not updated and that no follow-up orthopedic care or related orders were put in place.
Two residents, both cognitively intact, experienced repeated inappropriate sexual advances and physical contact from another resident, including incidents in both public and private areas. The facility failed to implement ongoing monitoring or safety measures following these reports, resulting in a deficiency for not protecting residents from abuse.
A resident with a history of major depressive disorder and anxiety was readmitted from a behavioral hospital with a discharge order for Divalproex Sodium DRT for mood stabilization. The facility failed to enter and administer this medication as ordered, as confirmed by staff interviews and medical record review.
A resident with multiple chronic conditions and recent fractures was transferred to another facility without proper documentation of the discharge date, time, events, or a discharge summary in the medical record. The ADON confirmed the absence of required discharge documentation.
A resident with multiple complex medical conditions was admitted without a baseline care plan being developed within 48 hours, as confirmed by record review and MDS nurse interview.
The facility did not ensure that call light systems were functional and accessible, resulting in a resident's calls for assistance going unanswered due to a non-working call light, and a hall bathroom lacking an emergency call light cord. Staff interviews and observations confirmed these deficiencies, with maintenance unaware of the issues and no designated staff to monitor the call system.
A resident with multiple psychiatric diagnoses and moderate cognitive impairment continued to receive several psychotropic medications without evidence that pharmacy requests for gradual dose reduction (GDR) were addressed by the physician. Additionally, recommendations from a Psych NP to decrease the dosage of one medication were not communicated to the physician, and no physician response was documented.
Two residents were affected by inaccurate or incomplete assessments. One resident with diabetes received daily insulin injections, but the MDS assessment failed to document these injections. Another resident who expired in the facility did not have a required discharge MDS assessment completed. These deficiencies were confirmed by the MDS/Care Plan Nurse.
A resident with complex medical conditions did not receive ordered laboratory tests, including a Vitamin D level and an annual lipid panel, as required by physician orders. Review of the medical record showed no results for these tests, and the ADON confirmed they were not completed.
A resident with multiple medical conditions and intact cognition was not provided with necessary grooming and hygiene assistance, as evidenced by repeated observations of an unshaved face and overgrown fingernails. The resident expressed a desire for nail trimming and shaving, and staff interviews confirmed that these services were not provided as required.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a failure to meet the resident's individualized care needs.
Surveyors found that three residents receiving oxygen therapy did not have their equipment properly maintained or labeled, including undated nasal cannulas and humidification bottles, empty humidification bottles, and concentrator filters with significant buildup. These deficiencies were confirmed by nursing leadership and were not in accordance with the facility's own respiratory care policies.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
The facility did not provide the minimum required nursing staff hours on one reviewed day, resulting in a shortfall of care hours for all residents, as confirmed by the administrator.
Two residents receiving psychotropic medications, including antipsychotics and antidepressants, were not monitored for behaviors, effectiveness, or side effects as required. The DON and ADON confirmed that no such monitoring was documented in the MARs or medical records.
Three medications were not administered as ordered to three residents because the medications were out of stock and unavailable during medication administration. This resulted in a medication error rate of 9.68%, exceeding the acceptable threshold. The DON confirmed the error rate was above 5%.
A resident with diabetes and a history of stroke was approved by SLP for a regular diet, but continued to receive a mechanical soft diet with chopped meats due to a failure in communication between nursing and dietary staff. The dietary manager and staff were unaware of the updated diet order, resulting in the resident not receiving the prescribed diet.
Surveyors found that food items in both the refrigerator and freezer were undated, improperly labeled, and not stored in sealed containers, contrary to facility policy. Additionally, the high temperature dishwasher failed to reach the required wash and rinse temperatures for proper sanitation. The Dietary Manager confirmed these deficiencies, which had the potential to affect all residents receiving meals.
The facility did not have a Water Management Plan or conduct monitoring for waterborne illnesses, as confirmed by maintenance staff who reported only checking water temperatures and being unaware of further requirements until recently.
The facility did not provide residents or their representatives with written notices specifying the reason for transfer, effective date, location, appeal rights, or bed-hold policy duration when residents were transferred or discharged. Staff interviews confirmed that only a basic Transfer/Discharge report was sent, lacking the required information, and that the State's LTC Ombudsman was not notified in writing as required.
A resident with multiple chronic conditions was not properly informed or provided with complete written information regarding the right to formulate an advance directive. The admission packet included an Advance Directive Acknowledgment Form, but it was left incomplete with no options selected, and this was confirmed by Social Services staff.
The facility did not maintain safe operating conditions for kitchen equipment, with water leaking from a sprinkler in the walk-in refrigerator and from the condenser in the freezer, resulting in ice buildup and the use of a wooden palate for safety. These issues persisted for about a month, with staff and administration aware but repairs not completed, potentially affecting all residents consuming food from the kitchen.
A resident with multiple complex diagnoses, including severe dementia and a recent vertebral fracture requiring a TLSO brace and therapy, was readmitted from a behavioral hospital. Despite notable changes in condition and new therapy orders, staff did not complete a significant change MDS assessment or update the care plan as required. Interviews with the DON and MDS nurse confirmed the assessment and care plan were not updated after the resident's readmission.
A resident admitted with multiple medical conditions did not receive a chest x-ray as required by physician standing orders. Review of the medical record and staff interviews confirmed that the admission chest x-ray was not completed or documented.
Nursing staff did not provide ongoing monitoring or assessment for a cognitively impaired resident after a fall, despite the resident having a history of vertebral fractures and reporting pain. An LPN examined the resident and notified the physician, who ordered Tylenol and an x-ray, but there was no documentation of Tylenol administration or continued assessment. The resident was later transferred to the hospital, where additional injuries were discovered, and the ADON confirmed the lack of required monitoring.
The facility did not report an allegation of an inappropriate sexual relationship between a staff member and a resident to the State Survey and Certification Agency as required. Despite internal awareness of the allegation and an investigation, the incident was not documented or reported because it was considered a rumor and not a formal complaint. The resident involved was cognitively intact and had multiple medical conditions. Staff interviews confirmed the lack of required reporting.
A resident with multiple advanced pressure ulcers did not receive wound care treatments as ordered, with several missed treatments documented in the TAR. Weekly wound measurements and staging were also not consistently performed or documented by an RN when the wound care NP was absent, despite the resident's complex medical needs and detailed physician orders.
The facility did not meet minimum required staffing hours on numerous days and failed to assign a licensed nurse as charge nurse for each shift. Staff and administration confirmed ongoing insufficient staffing levels, with no charge nurse designated, primarily due to a shortage of CNAs.
The facility did not provide 8 consecutive hours of RN coverage on two days and lacked a DON for over a month, as confirmed by staffing records and staff interviews. This affected all residents in the facility, with no staffing waivers in place.
The facility did not develop or implement comprehensive care plans for two residents with specialized medical devices, including an indwelling urinary catheter, a dialysis access site, and a PEG tube. These omissions were confirmed through record reviews, observations, and staff interviews, indicating a lack of individualized care planning for residents with complex medical needs.
Two residents with PEG tubes did not have their tube sites accurately documented during required weekly skin integrity assessments, despite physician orders for daily care. An LPN acknowledged that the electronic assessments were not properly completed, resulting in incomplete documentation for both residents.
A resident with multiple complex medical conditions was admitted with an indwelling urinary catheter, but there was no physician order for the catheter, no documentation of catheter care or urine monitoring, and no care plan interventions addressing the catheter. Staff confirmed these omissions, and the facility's own policy requirements for assessment and documentation were not followed.
A resident with a history of diabetes and chronic kidney disease, dependent on hemodialysis, had a dialysis access site in the right chest wall. Staff continued to document monitoring of a right arm AV shunt, which had been removed months earlier, and failed to assess or document care for the actual chest wall access site. The care plan and medical records did not reflect the resident's current dialysis needs, and both the LPN and interim DON confirmed the lack of appropriate monitoring and documentation.
Two residents had weekly skin assessments and dressing changes documented by an LPN in the electronic health record for dates when they were hospitalized and not present in the facility. The LPN confirmed these entries were inaccurate, as the assessments and treatments could not have been performed during the residents' absences.
Staff failed to follow Enhanced Barrier Precautions and infection control protocols for two residents, including not wearing protective gowns during high-contact care, not performing hand hygiene between glove changes, and using the same gauze and swabs on multiple wound areas. An LPN was also observed wearing jewelry that came into contact with soiled materials during wound and incontinence care, and both the LPN and a CNA had unprotected contact with soiled linens and residents during care.
A resident with a documented DNR order and LaPOST form experienced respiratory distress and was transferred to the hospital. Nursing staff did not inform EMS of the resident's DNR status, resulting in EMS initiating CPR despite the advance directive. The failure occurred because staff did not check or communicate the code status during the emergency.
The facility failed to provide quarterly financial statements to two residents, as required by their Personal Funds Policy. One resident's responsible party reported receiving only one statement, while another resident managing his own affairs reported never receiving a statement. Staff interviews confirmed a lack of awareness and documentation regarding the provision of these statements.
The facility failed to accommodate the needs of five residents by not ensuring call lights were within reach or functioning, and by not providing necessary incontinence briefs. Two residents had call lights out of reach, and another had a non-functioning call light. Additionally, two residents faced issues with the availability of incontinence briefs, with one having to purchase their own and another not having the required size available.
The facility did not promptly address concerns raised in resident council meetings, affecting all 58 residents. Despite a policy for handling grievances, residents reported delays of up to two months in receiving responses. Ongoing issues with medication, particularly pain management, were noted in council minutes, but staff actions were limited to explanations without timely resolution.
The facility failed to provide information on advance directives to four residents upon admission, as required by policy. Medical records lacked documentation confirming that residents or their representatives received the necessary information, as revealed in staff interviews.
A resident reported missing personal items, including cash and clothing, shortly after admission. The facility's grievance policy was not followed, as the investigation was limited to questioning the roommate, with no further documented actions or timely follow-up provided to the resident. This led to a deficiency in addressing the resident's grievances as per policy.
The facility did not conduct a criminal background check and sex offender registry check for a CNA before hiring, as required by its Abuse Prevention policy. The CNA, hired on 06/25/2020, had no such checks documented in their personnel record. An HR representative confirmed the absence of these checks, highlighting a failure in the facility's screening process.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in monitoring and treatment. A resident with chronic kidney disease was not monitored for anticoagulant use and AV shunt as ordered. Another resident using oxygen daily lacked a care plan and physician's order for oxygen use. A third resident was not care planned for oxygen use, and nebulizer treatment minutes were undocumented. Additionally, a resident with a PICC line did not have a care plan for its use and care, and the dressing was improperly maintained.
A resident with severe protein-calorie malnutrition did not receive weekly weights as ordered by the physician, and the registered dietician's recommendation to increase the house supplement was not implemented. The facility's policy required more frequent weigh-ins for residents with significant weight changes, but this was not followed, leading to a significant weight loss for the resident.
The facility failed to properly label feeding bottles for two residents with feeding tubes, as required by policy. One resident's bottle lacked their name, start time, and infusion rate, while another's was missing the name, start time, and nurse's initials. An LPN confirmed these deficiencies.
The facility failed to adhere to professional standards for respiratory care for three residents. Oxygen tubing and humidification bottles were not changed weekly for two residents, and a nebulizer mask was improperly stored for another. Staff confirmed these deficiencies, acknowledging the equipment should have been changed and stored according to policy.
A resident with a PICC line for IV antibiotics did not receive weekly dressing changes as required by facility policy. The dressing was observed to be undated, peeling, and dirty. Interviews confirmed the dressing had not been changed since the resident's admission, and the DON found no documentation of dressing changes in the medical records.
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 Provide Ordered 1:1 Monitoring After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan and to follow a physician’s order for continuous one-on-one monitoring for a resident with multiple falls. The resident was admitted under hospice services with diagnoses including chronic obstructive pulmonary disease and major depressive disorder, had intact cognition per a BIMS score of 14, and was dependent on staff for transfers. The physician ordered one-on-one monitoring at all times for safety, including placement in a wheelchair or Geri-chair near the nurses’ station for monitoring each shift. The comprehensive care plan documented multiple falls and that the resident removed oxygen tubing, and one-on-one monitoring at all times for safety was added after a fall at 3:08 a.m. However, the incident log and progress notes showed the resident also had an unwitnessed fall at 1:30 a.m., indicating the ordered one-on-one monitoring was not consistently provided. Staff interviews further confirmed that the one-on-one monitoring order was not followed as required. Nursing staff reported the resident would remove oxygen tubing, become confused, not use the call light, and attempt to ambulate without assistance. The ADON and DON both stated that one-on-one monitoring required a staff member to observe the resident at all times, yet acknowledged that the resident had an unwitnessed fall when a CNA left the resident unsupervised to gather supplies and that staff assigned to one-on-one monitoring would leave the room to answer other residents’ call lights. The administrator confirmed there was no facility policy for one-on-one monitoring and that the physician’s order for continuous one-on-one monitoring was not followed when the unwitnessed fall occurred. The physician confirmed that one-on-one monitoring at all times had been ordered to increase supervision after multiple falls.
Failure to Care Plan and Arrange Follow-Up for Olecranon Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan and to follow physician recommendations for a resident with a subacute-chronic olecranon fracture. The facility’s policy requires a comprehensive care plan with measurable objectives and timeframes to address each resident’s medical, nursing, mental, and psychosocial needs, including services identified in the comprehensive assessment. Resident #1, admitted with diagnoses including type 2 diabetes and chronic pain syndrome, had a Quarterly MDS showing a BIMS score of 06, indicating severe cognitive impairment. After rolling out of bed and falling on the left side, the resident was evaluated in a local ED, where a CT scan on 12/12/2025 showed a subacute to chronic olecranon fracture with distraction and mild rotation of the fracture fragment. A splint and sling were applied to the resident’s left arm, and discharge instructions directed the facility to schedule an orthopedic follow-up. Despite these instructions, review of the resident’s physician orders showed no orders entered for management or follow-up of the left olecranon fracture, and the comprehensive care plan contained no interventions related to the fracture or its management. The medical record did not show that an orthopedic follow-up appointment was ever scheduled or completed. In interviews, the resident reported having gone to the ED, receiving a splint and sling, and not returning to a doctor to have the elbow checked. The MDS nurse, responsible for updating care plans, stated she was not aware the resident had returned from the ED with a splint, sling, and an order for orthopedic follow-up, and acknowledged the care plan had not been updated. The ADON acknowledged that physician orders for care and follow-up of the fracture had not been entered and that the care plan should have been updated. The DON acknowledged that the resident did not receive orthopedic follow-up care and that care plan interventions were not updated.
Failure to Prevent and Monitor Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, specifically resident-to-resident sexual abuse. One resident with a history of traumatic brain injury reported being touched inappropriately by another resident in a public area, which made her feel uncomfortable. Another resident, who had diagnoses including hemiplegia, vascular dementia with agitation, and cognitive communication deficit, reported that the same accused resident had entered her room multiple times, attempted to put his hand down her diaper, and ran his hands up her leg, causing her distress. Both residents were found to be cognitively intact based on their BIMS scores. The facility's investigation revealed that one of the residents had previously attempted to report inappropriate behavior but did not do so because the accused stopped at that time. The investigation did not include or implement ongoing monitoring to ensure the safety of the residents following these incidents. The administrator acknowledged that no plans for ongoing monitoring were developed after the abuse was reported, resulting in a deficiency related to the facility's failure to prevent and address resident-to-resident abuse.
Failure to Administer Discharge-Ordered Psychotropic Medication After Readmission
Penalty
Summary
The facility failed to provide necessary care and services in accordance with a resident's goals for care and professional standards of practice. Specifically, upon readmission from a behavioral hospital, a resident with diagnoses including major depressive disorder, anxiety disorder, and cannabis use disorder did not receive an order for Divalproex Sodium DRT 250 mg, which was prescribed at discharge from the hospital for mood stabilization. Review of the resident's medical record and physician's orders confirmed the absence of this medication order. Interviews with facility staff, including a psychiatric nurse practitioner and the assistant director of nursing, confirmed that the psychotropic medication should have been ordered and administered upon the resident's return, but was not.
Failure to Document Resident Discharge and Communicate Transfer Information
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding the transfer or discharge of a resident. Specifically, for one resident with multiple complex diagnoses, including COPD, hypertension, bipolar disorder, chronic kidney disease, atrial fibrillation, and several fractures, the medical record did not contain documentation of the date, time, or events related to the discharge. Additionally, there was no discharge summary present in the resident's file. The facility census did not reflect the resident's presence, and during an interview, the Assistant Director of Nursing confirmed that the required discharge note was missing and acknowledged that the resident had been transferred to another nursing home.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one resident within 48 hours of admission, as required. Record review showed that the resident was admitted with multiple complex diagnoses, including chronic obstructive pulmonary disease, hypertension, bipolar disorder, chronic kidney disease stage 3, atrial fibrillation, and several fractures. Despite these significant medical needs, there was no evidence in the medical record of a baseline care plan being created to address the resident's immediate needs. This was confirmed during an interview with the MDS nurse, who acknowledged that a baseline care plan had not been developed for the resident.
Failure to Ensure Functional Call Light Systems and Emergency Call Cord Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of residents by not ensuring that call light systems were functional and accessible. One resident, admitted with diagnoses including spondylosis, scoliosis, and type 2 diabetes, was assessed as cognitively intact and totally dependent on staff for toileting and transfers. Despite being encouraged to use the call light for assistance, the resident reported that the call light did not work and that calls for help were not answered promptly. Observations confirmed that the call light outside the resident's door did not illuminate and calls for assistance went unanswered for an extended period, with staff present in the hallway not responding. Interviews with staff revealed that there was no unit or ward clerk to monitor the call system, and maintenance was unaware of the malfunction until the survey began. The DON confirmed the call light was not functioning and that the resident's needs were not accommodated. Additionally, the emergency call light cord was missing in a hall bathroom accessible from two rooms. This was confirmed during an observation and by an LPN, who acknowledged that the emergency call light cord should have been in place. These failures resulted in residents not having reliable means to request assistance, compromising the facility's ability to meet their needs in a timely manner.
Failure to Address GDR Requests and Communicate Psych NP Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was free from unnecessary drugs. Specifically, there was no evidence that pharmacy requests for gradual dose reductions (GDR) for medications including Risperidone, Seroquel, Cymbalta, and Temazepam were addressed by the physician over the past year. The resident in question had a history of multiple psychiatric diagnoses, including insomnia, major depressive disorder, bipolar disorder, and anxiety disorder, and was assessed as having moderate cognitive impairment. Despite ongoing orders for these medications, the required pharmacy GDR requests were not documented as being communicated to or considered by the physician. Additionally, the facility did not ensure that recommendations from a psychiatric nurse practitioner (Psych NP) to decrease the dosage of Risperidone were communicated to the physician. Progress notes from the Psych NP included recommendations to reduce the medication, but there was no evidence in the medical record that these recommendations were sent to the physician or that any physician response was received. Interviews with the DON and ADON confirmed the lack of documentation and communication regarding both the pharmacy GDR requests and the Psych NP's recommendations.
Failure to Accurately Complete Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for two of the sampled residents. For one resident with a diagnosis of type 2 diabetes mellitus with hyperglycemia, physician orders and the Medication Administration Record (MAR) showed that the resident received daily insulin injections. However, the quarterly Minimum Data Set (MDS) assessment for this resident indicated that no injections of any type were received during the 7-day look-back period. This discrepancy was confirmed by the MDS/Care Plan Nurse, who acknowledged that the MDS assessment was inaccurate. For another resident with multiple diagnoses, including rheumatoid arthritis, sepsis, myelodysplastic syndrome, and acute pulmonary edema, the medical record indicated that the resident was on hospice and expired in the facility. Despite this, a review of the medical record revealed that a discharge MDS assessment had not been completed following the resident's death. The MDS/Care Plan Nurse confirmed that the discharge MDS assessment was missing and should have been completed.
Failure to Complete Ordered Laboratory Tests for a Resident
Penalty
Summary
The facility failed to implement a complete care plan for a resident by not ensuring that ordered laboratory tests were completed. Specifically, a resident with multiple diagnoses, including morbid obesity, type 2 diabetes, Olgilvie syndrome, megacolon, hypomagnesemia, essential hypertension, and functional quadriplegia, had physician orders for a Vitamin D level and an annual lipid panel. Review of the resident's medical record did not show results for these laboratory tests, indicating they were not performed as ordered. This deficiency was confirmed during an interview with the Assistant Director of Nurses, who acknowledged that the required lab work had not been completed.
Failure to Provide Necessary Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, a resident with diagnoses including spondylosis, scoliosis, and type 2 diabetes, and who was assessed to have intact cognition, was observed on multiple occasions to have an unshaved face and fingernails that extended past the nail beds. The resident confirmed that he had not been shaved recently and that his fingernails had not been trimmed, expressing a desire for both services to be provided. Staff interviews corroborated these findings, with a CNA confirming the resident had not been shaved and should have been, and both the Assistant Director of Nursing and the Director of Nursing acknowledging that nail care and shaving should have been provided but were not. The deficiency was identified through direct observation, record review, and resident and staff interviews, demonstrating a failure to maintain the resident's grooming and personal hygiene as required.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical orders.
Failure to Maintain and Label Oxygen Equipment per Standards
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three out of four residents reviewed. Specifically, surveyors observed that oxygen supplies were not dated, humidification bottles were empty or not dated, and oxygen concentrator filters were covered with a thick layer of white buildup. For one resident with chronic obstructive pulmonary disease, the nasal cannula was not dated and the concentrator filter was dirty. Another resident, with diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen, was found with an empty humidification bottle and a concentrator filter coated in buildup. A third resident, admitted with acute respiratory failure and hypoxia, had both an undated humidification bottle and nasal cannula. Interviews with the Assistant Directors of Nursing confirmed these deficiencies, acknowledging that the oxygen equipment was not properly maintained or labeled according to facility policy. The facility's own oxygen administration policy requires humidifiers and tubing to be labeled with the date and time opened, and for equipment to be checked and cleaned at regular intervals. These requirements were not met for the residents observed, as documented by the surveyors.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Insufficient Nursing Staff Hours Provided
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the needs of all residents on one of the fourteen days reviewed. Specifically, on Sunday 07/20/2025, the facility's census was 53 residents, requiring 124.55 hours of care, but only 120.83 hours were provided, resulting in a shortfall of 3.72 hours. This deficiency was confirmed by the administrator during an interview, who acknowledged that the minimum required staffing hours were not met on that day. No additional details about specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not monitoring for behaviors, effectiveness, or side effects of psychotropic medications for two residents. One resident, with diagnoses including paranoid schizophrenia and major depressive disorder, was prescribed multiple psychotropic medications such as Risperidone, Trazodone, and Mirtazapine. Review of this resident's Medication Administration Records (MAR) for two consecutive months showed no documentation of monitoring for behaviors, effectiveness, or side effects related to these medications. The Director of Nursing confirmed that such monitoring was not performed as required. Another resident, diagnosed with schizoaffective disorder, bipolar disease, and other medical conditions, was prescribed Clonazepam, Olanzapine, and Mirtazapine. Review of the MAR and medical record for this resident also failed to show any monitoring for behaviors or side effects associated with the administration of these psychotropic medications. The Assistant Director of Nursing confirmed the absence of required monitoring for these medications.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5% by not administering prescribed medications as ordered to three residents during observed medication administration. Specifically, Miralax 17 gm was not given to two residents as ordered, and Omeprazole 20 mg was not administered to another resident. Review of physician orders confirmed that these medications were prescribed for constipation and for administration via PEG tube, respectively. Staff interviews revealed that the medications were out of stock and unavailable at the time of administration. A total of 31 medication administration opportunities were observed, with three errors identified, resulting in a medication error rate of 9.68%. The Director of Nursing confirmed the error rate exceeded the acceptable threshold.
Failure to Communicate and Implement Updated Diet Order
Penalty
Summary
The facility failed to follow the prescribed diet order for a resident with diagnoses including type 2 diabetes mellitus, hyperlipidemia, and cerebral infarction. The resident was initially placed on a Consistent Carbohydrate Diet (CCD) with No Added Salt (NAS), regular texture, and regular/thin liquids, following a swallow evaluation that cleared her for a regular diet. Despite this, the resident continued to be served a mechanical soft diet with chopped meats. Documentation showed that the resident had requested a change to whole foods, and a speech-language pathologist (SLP) had evaluated and approved the upgrade to a regular diet. The diet requisition form reflected this change, but the dietary department was not notified of the updated order. Observations confirmed that the resident was still being served chopped meats after the diet order had been changed. Interviews with dietary staff and the dietary manager revealed a lack of awareness regarding the updated diet order, with the dietary manager believing the resident was still on a mechanical soft diet. The SLP confirmed the resident was safe for a regular diet, and the Director of Nursing acknowledged that the dietary department had not been informed of the change, resulting in the resident not receiving the prescribed diet.
Deficient Food Storage and Dishwashing Practices Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection of the facility's refrigerator and freezer, multiple food items were found to be undated, improperly labeled, and not stored in sealed containers as required by facility policy. Specific observations included a box of bacon in unsealed plastic wrap, sliced lunchmeat leaking juices without a label, loose cabbage heads, chopped lettuce with browning, cubed ham, prepared biscuits, flour tortillas, and partially used bags of buns—all lacking proper dating and/or sealing. In the freezer, a foil pan of lasagna, partially used unsealed eggrolls, and an open bag of frozen corn were also undated and not stored in sealed containers. The Dietary Manager confirmed these items were not in compliance with storage and labeling procedures. Additionally, the facility's high temperature dishwasher did not meet the required temperature standards for safe dishwashing. The wash cycle was observed to reach only 140 degrees Fahrenheit, below the minimum required 150 degrees, and the rinse cycle temperature gauge was stuck at 175 degrees Fahrenheit, failing to reach the required minimum of 180 degrees. The Dietary Manager acknowledged that both the wash and rinse cycles did not meet the necessary temperature requirements for proper sanitation. These deficiencies had the potential to affect all residents receiving meals at the facility on the day of the survey.
Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to implement a water management program designed to minimize the risk of Legionella and other opportunistic pathogens. Review of facility policies revealed there was no Water Management Plan in place, nor was there evidence of monitoring for waterborne illnesses. During interviews, maintenance staff confirmed that their only water-related checks involved monitoring water temperatures, and they were not aware of any requirements for additional water testing or management. The staff also indicated that they had only recently received information about a Water Management Program and had just begun to take steps to conduct water monitoring, confirming that no such program or testing had previously been in place.
Failure to Provide Required Written Notices for Transfers, Discharges, and Bed-Hold Policies
Penalty
Summary
The facility failed to provide required written notices to residents and/or their representatives regarding transfers and discharges. Specifically, for four sampled residents who were transferred or discharged, there was no documentation of written notice specifying the reason for transfer, effective date, location, statement of the resident's appeal rights, or the duration of the bed-hold policy. The facility's bed-hold policy states that residents should be informed of these details at admission and prior to transfer, but record reviews showed that this was not done. Instead, staff reported that only a Transfer/Discharge report was sent with the resident, which did not include the necessary information about bed-hold policies or appeal rights. Interviews with facility staff, including the Medical Records staff, MDS/Care Plan Nurse, LPN, DON, and Administrator, revealed a lack of knowledge regarding who was responsible for providing the required written notices and what information should be included. Staff confirmed that the Transfer/Discharge report did not contain the required details and that notifications were typically made by telephone. Additionally, the facility did not notify the State's Long-Term Care Ombudsman in writing of any resident transfers or discharges, as required, and staff were unaware of this obligation.
Failure to Provide and Complete Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information to a resident or the resident's representative regarding the right to formulate an advance directive. Record review showed that a resident with severe morbid obesity, type 2 diabetes mellitus, unspecified lack of coordination, generalized muscle weakness, left shoulder pain, and unspecified osteoarthritis was admitted and had an Advance Directive Acknowledgment Form in the admission packet. However, the form was incomplete, with no options selected. During an interview, the Social Services staff confirmed that the Advance Directive Acknowledgment Form for this resident was not completed as required.
Failure to Maintain Safe Kitchen Equipment Conditions
Penalty
Summary
The facility failed to maintain all kitchen equipment in safe operating condition, as evidenced by multiple issues observed in the walk-in refrigerator and freezer. On observation, water was found dripping from a sprinkler into a bucket inside the walk-in refrigerator, and water was running from the condenser into a bucket and onto the floor in the walk-in freezer. There was also a wooden palate placed on the freezer floor and ice buildup on the wall and floor of the freezer. Staff interviews confirmed that the freezer had not been working for approximately one month, with ongoing water leaks from the condenser causing ice accumulation, and a persistent drip from the sprinkler in the refrigerator. The leaks and equipment issues had been present for about a month, and both the Administrator and Maintenance Supervisor were aware of the situation but repairs had not been completed. These deficiencies had the potential to affect any of the 51 residents consuming food from the kitchen, as confirmed by the Dietary Manager.
Failure to Complete Significant Change MDS Assessment After Resident Readmission
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for one resident following a re-entry admission from a behavioral hospital, despite notable changes in the resident's health status. The resident had a complex medical history, including severe vascular dementia with agitation, bipolar disorder, hypertension, atrial fibrillation, and a recent wedge compression fracture requiring the use of a TLSO brace and pain management. Physician orders indicated the need for occupational therapy five times a week for 30 days, and the resident had experienced a fall, a room change, and an emergency psychiatric evaluation. Despite these significant events and changes in condition, no significant change MDS assessment or care plan update was completed after the resident's readmission. Interviews with facility staff confirmed the deficiency. The DON acknowledged that a significant change assessment and MDS update should have been completed and attributed the failure to a system issue. The MDS nurse admitted that she had not completed the required assessment or updated the care plan since the resident's return from the behavioral hospital, despite recognizing that the resident's new use of a brace, therapy, and wheelchair indicated a need for such an assessment. The lack of timely interdisciplinary review and care plan revision following the resident's significant change in condition constituted the deficiency.
Failure to Complete Admission Chest X-ray per Standing Orders
Penalty
Summary
The facility failed to implement standing physician orders for a chest x-ray for one resident upon admission. Review of the resident's records showed that the required chest x-ray, as specified in the physician's COVID protocol standing orders, was not completed. The resident, who was admitted with multiple medical diagnoses including metabolic encephalopathy, cellulitis, repeated falls, tendon disorder, and mild cognitive impairment, did not have documentation of the chest x-ray in their health record. Interviews with the ADON and DON confirmed that the admission standing order for the chest x-ray was not carried out, and there was no evidence that the procedure was performed as required.
Failure to Monitor and Assess Resident After Fall
Penalty
Summary
Nursing staff failed to ensure appropriate monitoring and assessment of a resident following a fall, as required by the facility's clinical protocol. After being found on the floor by an LPN, the resident, who had significant cognitive impairment and a history of vertebral fractures, was examined and reported pain in the left wrist and arm. The physician was notified and ordered extra strength Tylenol, and an x-ray was performed. However, there was no documentation that the ordered Tylenol was administered, nor was there evidence of continued monitoring or assessment for injuries, pain, or changes in condition after the fall. The resident was later transferred to a hospital emergency room for a psychiatric evaluation, where additional injuries, including a black and blue bruise to the coccyx area and pain upon turning, were noted. Hospital staff reported that the only information received from the transferring facility was that the resident had fallen two days prior and had wrist pain, with an x-ray performed. The Assistant Director of Nursing confirmed that there was no documentation of ongoing monitoring or assessment after the fall, as required by facility policy.
Failure to Timely Report Allegation of Staff-Resident Sexual Relationship
Penalty
Summary
The facility failed to complete required reporting to the State Survey and Certification Agency in a timely manner regarding an allegation of an inappropriate sexual relationship between a staff member and a resident. According to the facility's Abuse Prevention Policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than 2 hours if the allegation involves abuse or results in serious bodily injury, or within 24 hours if not. Additionally, the results of all investigations must be reported to the State Survey Agency within 5 working days. However, a review of the facility's reporting records and incident logs revealed no documentation of this allegation being reported as required. The incident involved a resident with multiple medical diagnoses, including fractures, bipolar disorder, insomnia, and muscle weakness, who was found to be cognitively intact based on a BIMS score of 15 out of 15. The allegation surfaced as a rumor among staff regarding a possible sexual relationship between the resident and a CNA. The administrator acknowledged hearing the rumor but did not report it to the State Survey and Certification Agency, citing that it was only a rumor and not a formal complaint or report from a resident. No incident report was created, and the only documentation related to the investigation was found in the CNA's personnel file. Interviews with facility staff confirmed that the allegation was not reported to the State Survey and Certification Agency. The Director of Clinical Operations stated that an internal investigation was conducted and concluded there was nothing to report, characterizing the situation as staff gossip. The MDS nurse also reported hearing the rumor but did not report it, believing it to be unsubstantiated gossip. As a result, the facility did not fulfill its obligation to report the allegation of abuse in accordance with federal and state requirements.
Failure to Provide and Document Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not perform pressure ulcer treatments as ordered by the physician, with the Treatment Administration Record (TAR) showing that several wound care treatments were missed on multiple dates. The missed treatments included daily and every-other-day wound care for various sites, such as the right mid back, sacrum, hips, knees, toes, buttocks, and lower legs, as prescribed in the resident's physician orders. Additionally, the facility did not consistently measure and stage the resident's pressure ulcers according to professional standards. While an outside wound care Nurse Practitioner (NP) typically performed weekly measurements and staging, there were instances when the NP was absent, and the required assessments were not completed by a Registered Nurse (RN) as expected. Documentation was lacking for wound measurements and staging on specific dates, and staff interviews confirmed that neither the interim DON nor the Director of Clinical Operations had performed or documented these assessments during the relevant periods. The resident involved had a complex medical history, including multiple stage 3 and 4 pressure ulcers, burns, contractures, and a recent admission to hospice care. Despite the presence of detailed wound care orders, the facility's failure to carry out and document the prescribed treatments and assessments resulted in a deficiency related to the provision of pressure ulcer care and prevention.
Failure to Maintain Minimum Nursing Staff and Assign Charge Nurse on Each Shift
Penalty
Summary
The facility failed to provide the minimum required staffing hours for 20 out of 37 days reviewed, as evidenced by the Nursing Personnel Staffing Pattern Reporting Forms. On multiple dates, the facility was short by several hours of required nursing staff, including both licensed nurses and CNAs. Interviews with staff confirmed that on these dates, the facility did not meet the required minimum staffing hours, and there were no staffing waivers in place. The average daily census during this period was reported to be 60-62 residents. Additionally, the facility did not ensure that a licensed nurse was designated as a charge nurse for each shift. During interviews, LPNs on duty were unable to identify a charge nurse for their shift, and the administrator was also unable to specify who was in charge. The administrator and HR confirmed that insufficient staffing and the lack of a designated charge nurse were ongoing issues, primarily due to a shortage of CNAs.
Failure to Maintain Required RN Coverage and DON Presence
Penalty
Summary
The facility failed to provide 8 consecutive hours per day of Registered Nurse (RN) coverage for 2 out of 37 days reviewed, and did not have a Director of Nursing (DON) on staff for 33 consecutive days. Review of staffing records showed no RN coverage on two specific days, and interviews with multiple LPNs and the administrator confirmed the absence of both an RN and a DON during the specified periods. The administrator also confirmed that the facility had an average daily census of 60-62 residents and did not have any staffing waivers in place during this time frame. These deficiencies were identified through record review and staff interviews, which verified the lack of required RN coverage and the absence of a DON, potentially affecting all 59 residents according to the facility's census report.
Failure to Develop and Implement Comprehensive Care Plans for Specialized Medical Devices
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for two out of five sampled residents. For one resident with diagnoses including Type 2 diabetes mellitus, chronic kidney disease, morbid obesity, congestive heart failure, generalized edema, and dependence on renal dialysis, the care plan did not address the presence or care of an indwelling urinary catheter or a right chest wall dialysis access site. This omission was confirmed through record review, observation, and staff interview, despite the resident being cognitively intact and able to report the presence of these devices. Another resident, admitted with hemiplegia and hemiparesis following cerebrovascular disease, acute and chronic respiratory failure, moderate protein-calorie malnutrition, and a gastrostomy, was observed to have a PEG tube. However, the comprehensive care plan did not include any problems, goals, or approaches for PEG tube care. This deficiency was confirmed by both observation and staff interview, as the resident's care plan lacked documentation for the required care of the feeding tube.
Failure to Accurately Document PEG Tube Site Assessments
Penalty
Summary
The facility failed to ensure that two residents with PEG tubes received treatment and care in accordance with professional standards of practice. Specifically, the weekly skin integrity assessments for both residents did not accurately document the presence or condition of their PEG tube sites on multiple occasions, despite physician orders requiring daily cleaning and dressing of the sites. The electronic medical records for these residents showed that the required skin assessments did not reflect the PEG tube wounds as mandated by facility policy and physician orders. Both residents had significant medical histories, including hemiplegia, chronic respiratory failure, malnutrition, and dementia, and were nonverbal or rarely understood. During interviews, the LPN/Treatment Nurse acknowledged that the skin assessments for these residents were not completed accurately and admitted to simply clicking through the electronic assessments without proper documentation of the PEG tube sites. This failure resulted in the lack of accurate and complete skin integrity reviews for residents with feeding tubes, contrary to facility policy and professional standards.
Failure to Provide Appropriate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident admitted with an indwelling urinary catheter. Despite the resident having a complex medical history including morbid obesity, type 2 diabetes with chronic kidney disease, diabetic foot ulcers, congestive heart failure, generalized edema, dependence on renal dialysis, and a malignant neoplasm, there was no physician order for the indwelling urinary catheter in the resident's active orders. Observations revealed the resident had a urinary catheter draining cloudy urine, and interviews confirmed the resident was admitted with the catheter. However, the Minimum Data Set (MDS) assessment did not indicate the presence of an indwelling catheter, and the care plan only addressed a urinary tract infection (UTI) without any interventions related to catheter care. Further review of the Medication Administration Record (MAR) showed no documentation of catheter care or monitoring of urine characteristics such as color, amount, or consistency. Staff interviews confirmed that catheter care was performed and urine was emptied, but there was no designated place for documentation. The Director of Nursing and other staff acknowledged the lack of a physician order, absence of monitoring and documentation, and missing care plan interventions for the indwelling catheter, all of which are inconsistent with professional standards and the facility's own catheter care policy.
Failure to Monitor and Document Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident requiring dialysis, specifically neglecting to accurately assess and monitor the resident's dialysis access site. The resident, who had a history of type 2 diabetes mellitus with chronic kidney disease and was dependent on renal dialysis, had a dialysis access site located in the right chest wall. Despite this, the resident's medical record, including the Minimum Data Set (MDS) and care plan, did not reflect the current dialysis access site or include interventions for its monitoring. Instead, active physician orders and documentation incorrectly referenced a right arm arteriovenous (AV) shunt, which the resident no longer had, as it had been removed approximately three months prior. Observations and interviews confirmed that nursing staff continued to document monitoring of a right arm graft, including assessments for bruit and thrill, even though the resident's access site was in the chest wall and did not require such assessments. There was no documented monitoring of the actual chest wall dialysis access site, and the care plan lacked any interventions related to this site. Both the LPN and the interim Director of Nursing acknowledged the absence of appropriate monitoring and documentation for the resident's current dialysis access site.
Inaccurate Documentation of Skin Assessments and Dressing Changes
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two of five sampled residents, specifically regarding weekly skin assessments and dressing changes. For one resident with multiple complex diagnoses, including diabetes with foot ulcers and a traumatic amputation, weekly skin assessments were documented in the electronic health record for dates when the resident was actually hospitalized and not present in the facility. The LPN/treatment nurse confirmed that these entries were made in error and should not have been completed for a resident who was not in the facility. For another resident with a history of right femur fracture, congestive heart failure, hemiplegia, and dementia, the facility's records showed both a skin assessment and PEG tube dressing changes documented on dates when the resident was hospitalized and not present in the facility. The LPN/treatment nurse acknowledged that these assessments and treatments could not have been performed as documented, confirming the inaccuracy of the medical records for those dates.
Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) and proper infection control practices for two of five sampled residents. For one resident with a PEG tube and multiple complex diagnoses, a physician order required EBP, including the use of a protective gown during high-contact care. However, during an observed dressing change of the PEG tube, the LPN did not wear a protective gown as required. Another resident with a history of diabetes, chronic kidney disease, foot ulcers, and a sacral wound had physician orders for EBP and specific wound care protocols. During wound care and incontinence care, the LPN and a CNA failed to don protective gowns before providing high-contact care, including wound dressing changes and handling soiled linens. The LPN was observed leaning against soiled bed linens, wearing a bracelet with dangling charms that came into contact with soiled materials, and not performing hand hygiene between glove changes or between dirty and clean tasks. The same section of gauze and betadine swab was used on multiple wound areas, contrary to accepted infection control principles. Both the LPN and CNA were observed with their unprotected upper bodies in contact with soiled linens and the resident during care. The LPN confirmed during an interview that she did not follow required infection control practices, including the use of a protective gown, proper hand hygiene, and removal of jewelry before care. These actions directly contributed to the facility's failure to prevent the potential development and transmission of communicable diseases and infections.
Failure to Honor Resident's DNR Order During Emergency Transfer
Penalty
Summary
The facility failed to honor a resident's advance directive regarding Do Not Resuscitate (DNR) status. The resident, who was cognitively intact and had multiple significant diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and acute respiratory failure, had a clearly documented DNR order in the medical record. The DNR status was supported by both physician orders and a signed LaPOST form, and the resident's care plan reflected the DNR status. During an episode of respiratory distress, nursing staff responded by increasing oxygen and attempting a breathing treatment. When the resident did not improve, 911 was called. Upon arrival, EMS initiated CPR, despite the resident's DNR status. Both the RN and LPN present at the time confirmed in interviews that they did not inform EMS of the resident's DNR order. The LPN specifically stated that in the haste to transfer the resident to the hospital, she did not check the code status and acknowledged that she should have done so. The facility's policies required that advance directives be readily accessible in the medical record, that staff communicate code status to EMS, and that residents' wishes be honored. However, these procedures were not followed during the incident, resulting in the resident receiving resuscitation efforts contrary to her documented wishes and advance directives.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements to residents and their responsible parties, as required by their Personal Funds Policy. This deficiency was identified during a review of personal funds accounts for five residents, where it was found that two residents did not receive the necessary statements. The facility's policy mandates that individual financial records be available to residents through quarterly statements and upon request. However, interviews and record reviews revealed that these statements were not consistently provided. Resident #1, who has a diagnosis of dementia and other medical conditions, had a responsible party who reported receiving only one statement since the resident's admission. Resident #3, who manages his own affairs, reported never receiving a statement. Interviews with facility staff, including the Social Services representative and the Business Office Manager, confirmed a lack of awareness and documentation regarding the provision of these statements. The Administrator also confirmed the facility's inability to provide evidence of compliance with the policy.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs of five residents by not ensuring that call lights were within reach or functioning, and by not providing necessary incontinence briefs. Two residents had call lights that were out of reach, with one resident's call light wedged between the foot of the mattress and bed, and another's call light cord dangling from the bed rail and touching the floor. Both residents had cognitive impairments but no functional impairments to their extremities. Another resident, who was cognitively intact but had an impairment in one upper extremity, reported that their call light was not functioning, and despite informing the staff, the issue was not resolved promptly. Additionally, two residents faced issues with the availability of incontinence briefs. One resident, who was cognitively intact, reported having to purchase their own briefs due to the facility's failure to provide them, which was confirmed by the Director of Nursing (DON) who acknowledged issues with ordering and receiving supplies. Another resident, also cognitively intact and requiring bariatric incontinence briefs, reported not having any briefs available for two weeks. The DON confirmed the lack of bariatric briefs, despite having other sizes in stock, indicating a failure to meet the specific needs of the resident.
Failure to Address Resident Council Concerns Promptly
Penalty
Summary
The facility failed to promptly address concerns raised during resident council meetings, affecting the entire census of 58 residents. The facility's policy on filing grievances and complaints outlines a process for addressing issues, including investigation and reporting within specific timeframes. However, interviews with resident council members revealed that staff did not listen to or act promptly on issues brought to their attention. Residents reported that responses to their concerns could take up to a month or two, and they were not informed about the reasons for delays. A review of the resident council minutes from the past three months highlighted ongoing issues with medication, particularly concerning the pharmacy and pain medication. Despite these issues being repeatedly raised, the facility's actions were limited to explanations during meetings, without timely resolution. This lack of prompt action and communication from the staff led to a deficiency in honoring the residents' rights to organize and participate in resident/family groups effectively.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents were provided with information regarding the formulation of advance directives upon their admission. This deficiency was identified for four residents out of a sample of twenty-four. The facility's policy mandates that upon admission, residents or their representatives should receive written information and instructions about advance directives. However, the medical records for these residents did not contain documentation confirming that such information was provided. Interviews with the medical records staff revealed that there was no documentation available to confirm that advance directive information had been given to the affected residents. The facility's policy requires that the existence or non-existence of an advance directive be documented in the resident's medical record, and if an advance directive exists, a copy should be filed in the resident's record. The lack of documentation indicates a failure to adhere to this policy, resulting in the deficiency noted by the surveyors.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policy by not thoroughly investigating, documenting findings, and following up on grievances within the required timeframe for a resident's missing personal property. The policy mandates that upon receiving a grievance, the social services director must investigate and submit a report to the administrator within 24 hours, and the resident must be informed of the findings within three working days. However, in the case of a resident who reported missing items such as cash, clothing, and food, the investigation was limited to questioning the resident's roommate, with no further documented actions or follow-up provided to the resident. The resident reported multiple instances of missing items, including cash and personal belongings, shortly after being admitted to the facility. Despite the grievances being documented and communicated to the Director of Nursing and the Administrator, the social services staff assumed that the administration would handle the follow-up, which did not occur in a timely manner. The lack of a thorough investigation and communication with the resident about the findings and corrective actions led to a deficiency in honoring the resident's right to voice grievances without reprisal and ensuring prompt resolution as per the facility's policy.
Failure to Conduct Background Checks for CNA
Penalty
Summary
The facility failed to ensure that a criminal background check and sex offender registry check were conducted prior to hiring a Certified Nursing Assistant (CNA), identified as S14. The facility's policy on Abuse Prevention mandates that employee background checks be conducted to prevent the employment of individuals with a history of abuse, neglect, mistreatment, or misappropriation of property. However, a review of S14 CNA's personnel record, who was hired on 06/25/2020, revealed the absence of these checks. During an interview, the Human Resources representative, S17, confirmed that the required checks were not found in S14 CNA's personnel record, indicating a lapse in the facility's adherence to its own screening procedures.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, leading to deficiencies in their care. Resident #6, who had chronic kidney disease and diabetes, was not monitored for anticoagulant use and AV shunt as ordered. The Treatment Administration Record (TAR) showed multiple instances where monitoring for bleeding, bruising, and AV shunt assessment was not completed. The Director of Nursing acknowledged these lapses during an interview. Resident #23, with a history of heart failure and other conditions, was using oxygen daily for shortness of breath, but there was no care plan or physician's order for oxygen use. The resident confirmed daily oxygen use, and the Director of Nursing admitted that an order and care plan should have been in place. Similarly, Resident #30, who had respiratory failure and other serious conditions, was not care planned for oxygen use, and there was no documentation of nebulizer treatment minutes. Additionally, the resident was observed without an abdominal binder, contrary to physician orders. Resident #54, with a PICC line for intravenous treatment, did not have a care plan addressing the use and care of the PICC line. The dressing on the PICC line was observed to be peeling and improperly maintained. The MDS Coordinator confirmed the absence of a care plan for the PICC line, indicating a failure to ensure proper care and monitoring for this resident.
Failure to Implement Physician Orders and Dietician Recommendations
Penalty
Summary
The facility failed to ensure that a resident received care as ordered by the physician and as per the facility's policy regarding nutrition. Specifically, the resident, who was diagnosed with severe protein-calorie malnutrition, did not have weekly weights recorded as ordered by the physician. The facility's policy required residents to be weighed upon admission, readmission, and monthly thereafter, with more frequent weigh-ins for those with significant weight changes. However, the resident's weights were not consistently recorded weekly, as evidenced by the gaps in the documented weights in the Electronic Health Record. Additionally, the registered dietician's recommendations to increase the resident's house supplement intake were not implemented. The dietician had recommended increasing the MedPass supplement to 120 ml three times a day, but this change was not made. The resident's care plan highlighted the potential for impaired nutritional status and included approaches to maintain the diet ordered and encourage compliance. Despite these measures, the resident experienced a significant weight loss of 14.02% by July, which was confirmed by the facility's Corporate Nurse and Director of Nursing during interviews.
Improper Labeling of Feeding Bottles for Residents with Feeding Tubes
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with feeding tubes, specifically in the labeling of feeding bottles. Resident #30, who was admitted with diagnoses including Gastrostomy, Dysphagia, and Brainstem Stroke Syndrome, had a physician's order for Glucerna 1.5 at 60 ml/hr for 22 hours. However, during an observation, it was noted that Resident #30's feeding bottle was not labeled with the resident's name, the time the feeding was started, or the rate of infusion. This was confirmed by an LPN who acknowledged the labeling was incomplete. Similarly, Resident #257, admitted with diagnoses such as Cerebral Edema, Major Depressive Disorder, Type 2 Diabetes, and Gastrostomy Status, had a physician's order for Glucerna 1.5 cal at 55 ml/hr every shift. An observation revealed that the feeding bottle at Resident #257's bedside was not labeled with the resident's name, the date and time feeding was initiated, or the nurse's initials. The same LPN confirmed that the labeling was not done as required by the facility's policy.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents who required oxygen and/or respiratory treatments. For two residents, the facility did not change the oxygen tubing and humidification bottles weekly as required by their policy. Specifically, one resident's oxygen tubing was found undated and improperly stored, and the humidification bottle was also undated. Another resident's oxygen tubing was not dated, and the humidification bottle was out of date, indicating it had not been changed weekly as required. Additionally, the facility did not properly store a nebulizer mask for another resident. The nebulizer mask was found unlabeled and the tubing was stored on top of the nebulizer instead of in a labeled plastic bag as per the facility's policy. Interviews with nursing staff confirmed these deficiencies, acknowledging that the equipment should have been changed and stored according to the facility's procedures.
Failure to Conduct Weekly PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure that nursing and related services were provided to assure the safety and maintenance of the highest practicable physical, mental, and psychosocial well-being of a resident. Specifically, the facility did not conduct weekly dressing changes for a resident's PICC line, as required by their policy. The resident, who was admitted with a history of infection and inflammatory reaction due to an internal joint prosthesis, had a PICC line in place for intravenous antibiotic treatment. Despite physician orders to change the PICC dressing weekly, the dressing had not been changed since the resident's admission. Observations revealed that the PICC line dressing was undated, peeling, and dirty, with black edges and additional tape applied over it. Interviews with the resident and facility staff confirmed that the dressing had not been changed since the resident's hospital discharge. The Director of Nursing reviewed the medical records and confirmed the absence of documentation for any dressing changes, indicating a lapse in following the facility's protocol for PICC line care.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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