Heritage Manor Of Baton Rouge Ii
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 9301 Oxford Place Ave, Baton Rouge, Louisiana 70809
- CMS Provider Number
- 195389
- Inspections on file
- 33
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Heritage Manor Of Baton Rouge Ii during CMS and state inspections, most recent first.
Three residents receiving pain management medications had administrations recorded on narcotic log sheets but not on their MARs. Interviews with an LPN and the DON confirmed that facility procedures require matching documentation on both records, but this was not done for multiple administrations of Oxycodone/Acetaminophen and Morphine Sulfate for residents with conditions such as osteoarthritis, pressure ulcers, and spinal stenosis.
A facility failed to ensure staff wore proper PPE during care for a resident on Enhanced Barrier Precautions (EBP) due to a sacral pressure ulcer. Despite facility policy requiring gloves and gowns for high-contact activities, a CNA was observed providing perineal care without a gown. The CNA acknowledged the oversight, and the DON confirmed the requirement for gown use in such cases.
A resident with dementia and a protective order was removed from a locked unit by family members without staff supervision. The facility failed to report the incident to law enforcement and the state agency, resulting in Immediate Jeopardy. The administration believed the resident had not eloped since she left with family, despite policy requirements.
A resident with a protective order and an open EPS case was removed unsupervised from a locked unit by family members due to the facility's failure to develop and implement a comprehensive care plan. Staff were not informed of the protective order, leading to the resident's disappearance and subsequent location with a family member two days later.
A resident with a history of wandering and a protective order was allowed to leave a locked unit unsupervised with unknown family members, resulting in the resident being missing for two days. The facility failed to document and communicate the resident's elopement risk and protective order to staff, leading to inadequate supervision and the resident's elopement.
A resident with dementia and an active protective order was removed from a locked unit by unknown family members without staff supervision. The facility failed to communicate the resident's elopement risk and protective order to staff, resulting in the resident being missing for two days. The incident was not reported to authorities, highlighting administrative oversights.
The facility failed to accurately code the MDS assessments for three residents regarding the use of wander/elopement alarms. Despite having wander guards in place, the MDS assessments were incorrectly coded as not using these alarms. Staff interviews confirmed the inaccuracies, and the Director of Nursing acknowledged the expectation for accurate coding.
The facility failed to maintain a sanitary and safe environment, with unsanitary AC units in resident rooms, cracked ceiling tiles, chipped floor tiles, and an unclean bathroom. A resident expressed concern about the impact of these conditions on her health. Staff acknowledged the need for regular cleaning and maintenance, but issues persisted due to lack of materials and oversight.
The facility failed to incorporate PASARR Level II recommendations into the care plans of four residents with serious mental illnesses, resulting in inaccurate MDS coding and lack of necessary services. Despite specific recommendations for counseling, therapy, and crisis intervention, these were not documented or implemented, as confirmed by facility staff.
A resident with PTSD did not receive trauma-informed care due to multiple oversights in documentation and communication among staff. The PTSD diagnosis was not reflected in the MDS or care plan, and staff were unaware of necessary interventions. Social assessments inaccurately recorded no history of trauma, and the psychiatric nurse practitioner did not inquire about PTSD due to the resident's nonverbal status. The lack of awareness and proper documentation led to the deficiency.
A long-term care facility was found to have a medication error rate of 41.03%, exceeding the acceptable limit of 5%. Two residents were affected by these errors: one resident received Furosemide without a required blood pressure check, and another resident's medications were administered outside the prescribed time window. These deficiencies were confirmed through observations and interviews with the involved LPNs and the DON.
The facility failed to store drugs and biologicals according to professional principles, as 22 loose pills were found on Med Cart B. This was confirmed by an LPN and the DON, indicating non-compliance with the facility's medication storage policy.
A facility failed to maintain proper infection control during perineal care for a resident with a history of UTIs. A CNA did not perform hand hygiene after removing soiled gloves and before applying clean ones, and continued to handle the resident's clothing and wheelchair with soiled gloves. Interviews confirmed the failure to follow infection control procedures, which could potentially lead to UTIs.
A resident with cognitive impairment was physically abused by another resident on the smoking patio, resulting in scratches to her arm and face. The incident was confirmed through video footage and staff reports, highlighting a failure to protect the resident from harm despite the facility's policy against abuse.
A resident was transferred to a hospital and not accepted back due to aggressive behaviors and elopement risk, but the facility failed to document the justification for the discharge in the medical record. Interviews with the hospital social worker and facility staff confirmed the absence of necessary documentation, highlighting a deficiency in the facility's discharge process.
A resident was transferred to a hospital due to behaviors that endangered safety, and the facility initiated a discharge the following day. However, the Ombudsman was not provided with the discharge notification until eight days later, despite being verbally informed of the transfer. This lapse in notification compliance could affect any of the 119 residents in the facility.
A facility failed to complete and transmit a reentry MDS assessment for a resident in a timely manner. The resident returned from the hospital, and although the assessment was initiated, it was not completed or transmitted within the required time frames. Staff confirmed the oversight, acknowledging the 7-day completion and 14-day transmission deadlines were missed.
A resident with Dysphagia and Gastrostomy had a physician's order for continuous tube feeding, which was not followed as the feeding pump was found turned off. Staff confirmed the feeding should have been infusing continuously, highlighting a failure to adhere to the care plan and physician's directives.
A staff member failed to follow Enhanced Barrier Precautions by not wearing a gown during incontinent care for a resident with multiple wounds, despite facility policy requiring both gown and gloves for high-contact activities. The oversight was acknowledged by the staff member and confirmed by the Director of Nursing, indicating a lapse in infection control adherence.
The facility did not post daily nurse staffing information as required by its policy, which mandates posting details such as the facility name, current date, total number and actual hours worked by nursing staff, and resident census. Observations revealed missing documentation for specific dates, and the administrator confirmed the oversight, acknowledging the failure to comply with the policy.
Failure to Accurately Document Medication Administration on MARs
Penalty
Summary
The facility failed to maintain accurate medication administration records (MAR) in accordance with professional standards for three residents. For each resident, there were discrepancies between the narcotic log sheets and the MARs. Specifically, medications such as Oxycodone/Acetaminophen and Morphine Sulfate were documented as administered on the narcotic log sheets, but these administrations were not recorded on the corresponding MARs for multiple dates. One resident with primary generalized osteoarthritis and multiple wounds, who was also under hospice care, had several instances where the narcotic log indicated administration of Oxycodone/Acetaminophen, but the MAR did not reflect these administrations. Another resident with a stage 2 pressure ulcer and chronic pain, also on hospice, had Morphine Sulfate administration documented on the narcotic log but not on the MAR. A third resident with spinal stenosis and a stage 2 pressure ulcer, also under hospice care, had multiple doses of Oxycodone/Acetaminophen recorded on the narcotic log but not on the MAR. Interviews with nursing staff, including an LPN and the DON, confirmed that facility procedures require nurses to document medication administration on both the narcotic log and the MAR. Both staff members acknowledged that the narcotic log and MAR should match, and confirmed that in these cases, the MARs did not accurately reflect the administrations recorded on the narcotic logs.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to proper infection prevention and control protocols, specifically regarding the use of Personal Protective Equipment (PPE) during care activities for a resident on Enhanced Barrier Precautions (EBP). The facility's policy, revised in March 2024, mandates the use of gloves and gowns for high-contact activities such as changing briefs or assisting with toileting for residents with conditions like pressure ulcers. Resident #3, who was admitted with a diagnosis of a sacral pressure ulcer, was on EBP as per physician orders starting August 1, 2024. On March 19, 2025, an observation was made of a Certified Nursing Assistant (CNA) providing perineal care to Resident #3 without wearing a gown, despite the EBP sign on the resident's door indicating the requirement for both gloves and a gown. The CNA acknowledged the oversight and confirmed the resident's EBP status due to a wound. The Director of Nursing (DON) was informed of the incident and confirmed that staff should wear a gown when providing care to residents on EBP.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an incident of neglect involving a resident's elopement in a timely manner to the State Survey Agency and local law enforcement. The incident involved a resident with a history of dementia, encephalopathy, altered mental status, and housing instability, who was residing in a locked unit due to wandering behaviors. Despite having an active protective order against family members, the resident was removed from the facility by two unknown family members without staff supervision or knowledge. On the evening of the incident, a CNA allowed the resident's daughter and granddaughter to take the resident outside for a visit. When the CNA checked on the resident, it was discovered that the resident was no longer on the premises, and her belongings were missing. The facility's staff, including the LPN and DON, were informed of the resident's disappearance, but law enforcement and the state agency were not notified immediately as required by state law. The facility's administration, including the Administrator and Regional Vice President, decided not to report the incident to law enforcement or the state agency, believing that the resident had not eloped since she left with family members. This decision was made despite the facility's policy requiring the reporting of such incidents. The failure to report the incident resulted in an Immediate Jeopardy situation, as the resident was located two days later with a family member, highlighting the potential for more than minimal harm to all residents in the facility.
Removal Plan
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. Identified as two residents with secure care bracelets and 32 residents on the secure care unit.
- All resident electronic charts and hard copy charts were audited by the DON and ADON to ensure that no other residents had an order for protection. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMs reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
- Completion date - The likelihood for serious harm will no longer exist.
Failure to Implement Comprehensive Care Plan Leads to Resident's Unsupervised Removal
Penalty
Summary
The facility failed to develop and implement a Comprehensive Person-Centered Care Plan for a resident, which resulted in an Immediate Jeopardy situation. The resident, who resided on a locked unit due to wandering behaviors, was admitted with a known protective order and an open Elderly Protective Service (EPS) case against family members. Despite these critical details, the facility did not ensure that staff were aware of the protective order or the EPS case, leading to the resident being removed from the facility by family members without supervision. The deficiency was highlighted when staff allowed two unknown family members to take the resident outside unsupervised. The staff, including a CNA and an LPN, were not informed about the protective order and EPS case, which would have prompted them to be more cautious. The resident was later found with a family member two days after being removed from the facility, indicating a significant lapse in communication and care planning. Interviews with various staff members, including the Care Manager, Social Worker, and Director of Nursing, revealed that the facility did not have a process in place to communicate critical information about protective orders and EPS cases to direct care staff. This lack of communication and failure to incorporate these details into the resident's care plan directly contributed to the resident's unsupervised removal from the facility, posing a risk to the resident's safety.
Removal Plan
- Corrective actions for the alleged deficient practice of the facility failing to ensure a comprehensive person-centered care plan to ensure nursing staff were aware of Resident #3's needs and make staff aware of Resident #3's current protective orders against 3 family members.
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit).
- All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurses' station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident from the locked unit. The resident, who had a history of wandering behaviors and was admitted with a protective order and an open Elderly Protective Services (EPS) case against family members, was allowed to leave the facility unsupervised with two unknown family members. This incident occurred despite the resident being identified as an elopement risk due to their medical conditions, including dementia and encephalopathy. The resident's clinical records indicated a risk for elopement, but the necessary precautions were not documented or communicated effectively to the staff. The resident was not included in the facility's wander guard list or the elopement risk list, and the staff was not informed of the protective order or the EPS case. This lack of communication and documentation led to the resident being removed from the facility without supervision, resulting in the resident being missing for two days before being located with a family member. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk and the protective order. The CNA responsible for the resident on the day of the incident was unaware of these risks and allowed the resident to leave with family members unsupervised. The LPN and other staff members also confirmed they were not informed of the resident's status, which contributed to the failure to prevent the elopement.
Removal Plan
- Facility NFA contacted Elderly Protective Services to alert them resident #3 left the facility. NFA alerted the facility Ombudsman that the resident's family removed her from the facility.
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. Identified as two residents with secure care bracelets and 32 residents on the secure care unit.
- All resident electronic charts and hard copy charts were audited by the DON and ADON to ensure that no other residents had an order for protection. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission. The DON will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
Failure to Communicate Protective Order and Elopement Risk Leads to Resident's Unauthorized Removal
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency that compromised the safety and well-being of a resident. The deficiency involved the failure to communicate critical information about a resident's protective order and elopement risk to direct care staff. This oversight led to an incident where the resident, who was on a locked unit due to wandering behaviors, was removed from the facility by unknown family members without staff supervision or knowledge. The resident was missing for two days before being located with a family member. The resident in question had a history of dementia, encephalopathy, and altered mental status, and was admitted to the facility with an active protective order against family members due to domestic abuse concerns. Despite these significant risk factors, the facility did not develop a comprehensive care plan or implement interventions to ensure staff were aware of the protective order or the open Elderly Protective Services (EPS) case. The Director of Nursing (DON) and other administrative staff failed to update the elopement risk list and did not communicate the resident's status to direct care staff, contributing to the resident's unauthorized removal from the facility. Additionally, the facility did not report the elopement incident to the state agency or local law enforcement as required by state law. The DON and Administrator were aware of the resident's disappearance but chose not to notify authorities, believing the resident had not eloped since she left with family members. This decision was made despite the inability to identify the family members involved and the existing protective order. The lack of timely reporting and communication further exacerbated the situation, highlighting significant administrative oversights in handling the resident's care and safety.
Removal Plan
- Facility NFA contacted Elderly Protective Services to alert them Resident #3 left the facility.
- NFA alerted the facility Ombudsman that the resident's family removed her from the facility.
- All resident electronic charts and hard copy charts were audited by the DON and ADON to ensure that no other residents had an order for protection.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689.
- Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely.
- Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- Regional [NAME] President will oversee in-servicing/monitoring of the NFA and administrative staff to ensure all audits are completed appropriately and timely.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time.
- All staff that were not present will be in-serviced prior to their next shift.
- The staff were in-serviced regarding: Residents with EPS cases.
- All residents with EPS cases will have a care plan and the information communicated to the staff immediately.
- All visits will be supervised.
- Should anyone try to leave with the resident the police will be called and it will be reported to the state.
- The Administrator and DON will be notified.
- Any resident classified as an elopement risk will be placed in the binder at the nurse's station.
- In the instance of elopement, the police will be called and a report shall be made to the state.
- The in-servicing was completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee.
- A master list of all staff was generated by the Human Resources Director.
- The DON and ADON used this list to retrain every staff member.
- The ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON.
- This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop.
- These audits will continue for every new admission for the next 30 days.
- The DON will audit 5 residents who are an elopement risk 3 times a week for four weeks and routinely thereafter.
- The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/communicated to staff.
- Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team.
- The Quality Assurance (QA) Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 times a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time.
- Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
Inaccurate MDS Coding for Wander/Elopement Alarms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents regarding the use of wander/elopement alarms. Resident #3, who was admitted with a diagnosis of Dementia, had a wander guard task initiated on February 4, 2025, but the Admission MDS with an Assessment Reference Date (ARD) of February 6, 2025, was incorrectly coded as not using a wander/elopement alarm. Similarly, Resident #R2, with diagnoses including Alzheimer's disease and Dementia, had a wander guard task initiated on July 31, 2024, but the Quarterly MDS with an ARD of January 19, 2025, was also incorrectly coded as not using the alarm. Resident #R3, diagnosed with Dementia, had a similar issue with the Quarterly MDS dated December 18, 2024, being inaccurately coded. Interviews with staff members confirmed the inaccuracies in the MDS coding. S4CM, responsible for MDS, acknowledged the error in Resident #3's Admission MDS, confirming that it should have been coded as using a wander/elopement alarm. Similarly, S5MDS confirmed the inaccuracies in the MDS assessments for Residents #R2 and #R3, stating that both should have been coded as using the alarms. The Director of Nursing (S3DON) also reviewed the findings and confirmed the inaccuracies, expecting staff to code MDS assessments accurately.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. Observations revealed unsanitary conditions in resident rooms and common areas. In Room B, the air conditioning unit vent was covered with a copious amount of black specks, and in Room E, the AC unit had dry brown and red liquid stains. Ceiling tiles in Hall A and Room B were not maintained, with cracks and brown water spots observed. Room C had chipped floor tiles, creating a potential hazard. Bath D was found in an unsanitary state, with light fixtures and ceiling vents covered in a gray fluffy substance, and the laminate flooring had spaces filled with black residue and was sticky. Interviews with staff and residents confirmed these observations. A resident in Room B expressed concern that the black substance on the AC unit could worsen her breathing issues. Staff members acknowledged the need for regular cleaning and maintenance, admitting that the AC units should be wiped daily and bathrooms cleaned at least once daily. The maintenance staff was aware of the cracked ceiling tiles and chipped floor tiles but lacked the materials to make repairs. The administrator confirmed the need for cleanliness and maintenance, acknowledging the unacceptable state of the AC units and the need for repairs in Bath D.
Failure to Implement PASARR Level II Recommendations
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) Level II determinations and recommendations for four residents. These residents were identified as having serious mental illnesses or related conditions, requiring specific services and interventions as outlined in their PASARR Level II Evaluation Summaries. However, the facility did not incorporate these recommendations into the residents' care plans, nor did they accurately code the PASARR Level II status in the Minimum Data Set (MDS) assessments. Resident #2, diagnosed with Paranoid Schizophrenia, Major Depressive Disorder, Schizoaffective Disorder, and Anxiety Disorder, was approved for admission with specific recommendations for counseling, crisis intervention, and therapy. Despite these recommendations, the resident's care plan lacked documentation of the PASARR Level II and the necessary services were not implemented. Similarly, Resident #10, with diagnoses including Dementia and Schizoaffective Disorder, was not provided with the recommended training and therapy services, and their PASARR Level II status was inaccurately coded. Residents #27 and #100 also experienced similar deficiencies. Resident #27, with Paranoid Schizophrenia and Dementia, was not provided with the recommended crisis intervention and therapy services. Resident #100, diagnosed with PTSD, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder, did not receive the recommended services for independent living skills and structured leisure activities. In all cases, the facility staff confirmed the inaccuracies in the MDS coding and the absence of PASARR Level II documentation in the care plans.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's clinical record indicated an admission with a PTSD diagnosis, yet the Admission Minimum Data Set (MDS) did not reflect this diagnosis, and the care plan lacked any mention of PTSD. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, revealed a lack of awareness regarding the resident's PTSD diagnosis and the necessary interventions to prevent triggers or trauma reoccurrence. The psychiatric notes and physician's progress notes confirmed the PTSD diagnosis, but the social history and assessments inaccurately recorded that the resident had not experienced traumatic events or symptoms. The psychiatric nurse practitioner admitted to not inquiring about the resident's PTSD due to her nonverbal status and did not contact the responsible party for further information. The social worker and her assistant, responsible for completing social assessments, failed to identify the PTSD diagnosis, leading to a lack of appropriate referrals and interventions. The MDS coordinator acknowledged that the PTSD diagnosis was not coded in the MDS, which would have prompted the creation of a care plan. The administrator confirmed the oversight in assessing the resident for PTSD and the absence of a care plan addressing the diagnosis and potential triggers. This series of oversights and miscommunications among the staff resulted in the resident not receiving the trauma-informed care required by professional standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 41.03% error rate observed during medication administration for two residents. A total of 39 medication administration opportunities were observed, resulting in 16 errors. This deficiency was identified during observations, interviews, and record reviews conducted by surveyors. For Resident #23, the facility did not adhere to the physician's order to check blood pressure before administering Furosemide 20 MG. The resident's clinical record indicated a diagnosis of Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Edema Unspecified. The physician's order specified that Furosemide should be held if the systolic blood pressure was less than 100. However, the LPN administering the medication failed to obtain the resident's blood pressure prior to administration, which was confirmed during an interview with the LPN and the Director of Nursing (DON). Resident #31 experienced a medication timing error. The resident's clinical record included diagnoses such as Chronic Diastolic Heart Failure and Vascular Dementia, among others. The MAR indicated that several medications were scheduled for administration at 8:00 a.m., but they were administered after 9:00 a.m., outside the acceptable window of one hour before or after the scheduled time. This was confirmed by the LPN responsible for the administration and the DON, who acknowledged that the medications were given outside the prescribed timeframe, constituting a medication error.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles. During an observation of Med Cart B, 22 loose medication pills were found, which is against the facility's policy that requires medication carts to be maintained in a clean and orderly manner. This observation was confirmed by S6LPN, who acknowledged that there should be no loose medication pills on the cart. Additionally, S2DON confirmed the same during an interview, indicating a lapse in adherence to the facility's medication storage policy.
Inadequate Infection Control During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically during the provision of perineal care for a resident with a history of urinary tract infections (UTIs). The facility's policy on perineal care, revised in January 2024, outlines the necessity of performing hand hygiene and proper glove use to prevent infections. However, during an observation, a CNA was seen assisting a resident with perineal care without adhering to these guidelines. The CNA did not perform hand hygiene after removing soiled gloves and before applying clean ones, and continued to handle the resident's clothing and wheelchair with soiled gloves. Interviews with the CNA, another CNA, and the Director of Nursing (DON) confirmed the observations and acknowledged the failure to follow proper infection control procedures. The resident involved had a documented history of UTIs, with recent infections noted in September, November, and late November 2024. The DON confirmed that the improper glove use and lack of hand hygiene could potentially lead to UTIs, highlighting the importance of adhering to the facility's infection control policies.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #1, who was cognitively impaired with a BIMS score of 9, was found with scratches on her arm and face after an altercation on the smoking patio. The incident was reported as physical abuse, with Resident #2, who was cognitively intact with a BIMS score of 15, identified as the aggressor. Resident #2's clinical record indicated a history of physical behavioral symptoms directed towards others. On the day of the incident, staff members observed Resident #1 with injuries and reported the situation to the Director of Nursing. The facility's administration reviewed video footage confirming that Resident #2 had hit Resident #1. The incident was documented in the facility's state agency reportable incidents, and interviews with staff and residents corroborated the occurrence of the altercation. The facility's policy strictly prohibits conduct resulting in resident abuse, yet the incident occurred, indicating a failure to protect Resident #1 from physical harm by another resident.
Failure to Document Justification for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident's medical record contained the required documentation for an emergency transfer and discharge. Specifically, the clinical record of a resident who was admitted and later transferred to a local hospital did not include documentation justifying the reason for the discharge. The facility's Emergency Transfer Log indicated that the resident was transferred to the hospital and was not accepted back due to aggressive behaviors and elopement risk. However, there was no documentation in the resident's physician or nursing notes to support this decision. Interviews conducted with the social worker at the hospital and the facility's Director of Nursing (DON) confirmed the lack of documentation. The DON acknowledged that the resident exhibited aggressive behaviors and was an elopement risk, which were the reasons for not accepting the resident back. The Administrator also confirmed the absence of documentation justifying the discharge, despite acknowledging the resident's aggressive behavior upon admission. This lack of documentation constitutes a deficiency in the facility's handling of the resident's transfer and discharge process.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the discharge of a resident who was transferred to a local hospital. The resident was admitted to the facility and later transferred due to an emergency situation involving behaviors that endangered the safety of individuals in the facility. The facility initiated the discharge on the day following the transfer, but the Ombudsman was not provided with a copy of the discharge notification until eight days later, despite being verbally informed of the transfer. Interviews with facility staff confirmed that the discharge was initiated by the facility and that there was no documentation proving that the Ombudsman was notified immediately as required. The Ombudsman only received the discharge letter after requesting it, indicating a lapse in the facility's compliance with notification requirements. This deficiency had the potential to affect any of the 119 residents residing in the facility.
Failure to Timely Complete and Transmit Reentry MDS Assessment
Penalty
Summary
The facility failed to ensure a reentry MDS assessment was completed and transmitted timely for one of the residents reviewed for Resident Assessment. The resident was admitted to the facility and later sent to the hospital. Upon returning to the facility, a reentry MDS assessment was opened but remained incomplete and was never transmitted. Interviews with staff confirmed that the assessment was performed but not completed or transmitted within the required time frames. The staff acknowledged that they had 7 days to complete the assessment and 14 days from the reentry date to transmit it, but these deadlines were not met.
Failure to Implement Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to ensure that physician's orders for tube feedings were implemented for a resident with specific medical conditions. The resident, who was admitted with diagnoses including Dysphagia Oropharyngeal Phase and Gastrostomy, had a physician's order for a continuous tube feeding of Peptamen at 65 ml/hour to deliver necessary calories and protein. However, during an observation, it was found that the tube feeding pump was turned off, despite the bag containing 700 ml of formula labeled for that day. Interviews with staff confirmed the deficiency. A staff member acknowledged that the tube feeding should have been infusing continuously as per the physician's orders. The Director of Nursing also confirmed that nurses are required to follow all physician orders regarding tube feedings and that there were no orders to hold the feeding for this resident. This oversight indicates a failure to adhere to the established care plan and physician's directives for the resident's nutritional needs.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) during resident care. Specifically, a staff member, identified as S4S, did not adhere to the Enhanced Barrier Precautions (EBP) policy while performing incontinent care for a resident with multiple wounds, including gangrene and pressure ulcers. The facility's policy required the use of both gown and gloves for high-contact activities, but S4S only wore gloves during the care of the resident, who was on EBP due to her condition. The deficiency was observed during a survey when signage on the resident's door indicated the need for EBP, yet the staff member failed to comply with the gown requirement. During an interview, S4S acknowledged the oversight and confirmed the resident's EBP status due to her wounds. The Director of Nursing (S2DON) also confirmed the expectation for staff to wear gowns when in direct contact with residents on EBP, highlighting a lapse in adherence to the facility's infection control protocols.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location accessible to residents and visitors, as required by their policy. The policy, dated June 2024, mandates that the facility must post specific information daily, including the facility name, current date, total number and actual hours worked by nursing staff, and the resident census. An observation on August 1, 2024, at 9:45 a.m. revealed that the staffing data sheet dated July 30, 2024, lacked documentation of the actual hours worked by registered nurses, licensed practical nurses, or certified nurse aides. Additionally, there was no documentation of staffing data sheets for July 31, 2024, or August 1, 2024. During an interview on August 1, 2024, at 9:46 a.m., the administrator (S1ADM) confirmed that the staffing data sheets should include the actual hours worked by nursing staff and should be completed and posted daily. The absence of this information was acknowledged as a failure to comply with the facility's policy, potentially affecting any of the 122 residents residing in the facility.
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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