Heritage Manor Of Houma
Inspection history, citations, penalties and survey trends for this long-term care facility in Houma, Louisiana.
- Location
- 852 Centurion Lane, Houma, Louisiana 70360
- CMS Provider Number
- 195485
- Inspections on file
- 20
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Heritage Manor Of Houma during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food service operations, including staff not wearing proper hair restraints, unlabeled and improperly stored food items, unsanitary kitchen shelving, inadequate hand hygiene, improper utensil handling, chemicals stored near food, and nutritional supplements left unrefrigerated and unlabeled on medication carts. Staff and administration confirmed these practices did not meet required standards.
A resident with impaired mobility and cognition, identified as being at risk for falls, did not have the care plan intervention of brake extenders with highlighted tape implemented on their wheelchair. Multiple observations and staff interviews confirmed the absence of this intervention over several days.
A resident with an indwelling Foley catheter was observed on multiple occasions to have their catheter collection bag hanging off the side of the bed and touching the floor. Staff confirmed that the bag should not have been in contact with the floor, and no explanation was provided by facility administration for this lapse in catheter care.
A resident was administered the wrong enteral feeding formula, receiving Isosource 1.5 instead of the physician-ordered Nutren 2.0 at the prescribed rate. This error was confirmed by observation, record review, and staff interviews, with both the LPN and DON acknowledging the mistake.
A resident receiving continuous oxygen therapy had their oxygen tubing in use well beyond the facility's required 7-day replacement schedule. Observations and staff interviews confirmed that the tubing had not been changed as per infection control policy, and no explanation was provided by facility administration.
Surveyors identified multiple instances where staff documented care or interventions in the EMR that did not match actual observations, such as missing safety devices, incorrect enteral feeding documentation, and unchanged oxygen tubing. There were also discrepancies between electronic and paper records for code status, and missing documentation for scheduled bathing. Staff interviews confirmed the inaccuracies, and facility leadership could not provide explanations for the deficient practices.
The facility did not post required contact isolation signage for two residents with ESBL UTIs and failed to ensure CNAs followed Enhanced Barrier Precautions and hand hygiene protocols during incontinence and catheter care for a resident with an indwelling urinary catheter. Staff were unaware of required precautions and did not perform hand hygiene or change gloves as required.
A resident who required assistance with oral hygiene did not receive consistent oral care, as evidenced by observations of a thick substance on her teeth and lack of documentation. Interviews revealed that oral care was only provided when the resident complained, and staff acknowledged the need for setup and monitoring during oral care, which was not consistently documented.
The facility failed to maintain Ice Machine f in a sanitary condition, with unknown substances found on the grate and outlet. The Dietary Manager was unaware of cleaning responsibilities, and Maintenance staff admitted to neglecting monthly cleaning. The Administrator confirmed the unsanitary state.
The facility failed to use the approved disinfectant, Virex, for cleaning shower chairs between resident use in two shower rooms. Staff used a heavy-duty floor cleaner instead, as Virex was unavailable. Interviews with CNAs, the DON, and the Administrator confirmed the deficiency in infection control practices.
The facility failed to complete the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for two residents before terminating their Medicare Part A services. The facility's policy mandates issuing the SNFABN at least three days prior to service termination, but this was not done, as confirmed by staff interviews.
The facility failed to provide a bed-hold notice upon hospital transfer for two residents. The Bed Hold Agreements were signed but not dated, and the facility's practice involved calling the resident or their representative on the seventh day following hospitalization to review the bed hold policy. The Administrator noted that the facility should call the resident representative if a resident was sent to the emergency room.
A facility failed to refer a resident diagnosed with schizoaffective disorder for a required PASARR Level II evaluation. Despite the diagnosis being recorded in the resident's electronic medical record, there was no evidence of the evaluation being completed. Interviews with facility staff confirmed the lack of documentation and indicated that Social Services should have initiated the referral process.
A facility failed to accurately complete a Level 1 PASARR for a resident with major depressive disorder. Despite requiring daily antidepressant medications, the resident's PASARR inaccurately documented no mental illness. Staff interviews confirmed the assessment's inaccuracy was not verified upon admission.
Widespread Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Multiple deficiencies were identified in the facility's food service operations, including failures in staff hygiene, food labeling, and storage practices. Observations revealed that dietary staff did not consistently wear appropriate hair or facial hair restraints while preparing food, with some staff having unrestrained hair and mustaches or beards without proper coverings. Additionally, food items stored in refrigerators and freezers were found without required labels indicating contents or dates of storage, and shelving in the kitchen was observed to be covered with a gray, dusty, and sticky substance, indicating inadequate cleaning. Further deficiencies were noted in hand hygiene and utensil handling. Staff were observed retrieving items from food with ungloved hands and failing to perform hand hygiene after handling trash before distributing clean plates. Utensils used for serving food were placed directly on top of food items after being touched with ungloved hands, contrary to sanitary guidelines. Chemicals, such as a sanitizing solution, were also found stored next to food items on serving tables, and staff did not recognize the potential hazard of this practice. The facility also failed to follow manufacturer guidelines for the storage and use of nutritional supplements. Opened cartons of Med Plus 2.0 nutritional supplement were left unrefrigerated on medication carts without being labeled with the date and time of opening, and were available for resident consumption beyond the recommended four-hour window. Staff interviewed were unaware of the storage requirements for these supplements, and the administrator confirmed the observations as deficiencies.
Failure to Implement Fall Prevention Interventions for At-Risk Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as being at risk for falls due to impaired mobility and cognition. The resident's care plan, initiated on 05/19/2025, specified the use of brake extenders with highlighted tape on the resident's wheelchair as a fall prevention measure. However, multiple observations conducted between 07/28/2025 and 07/31/2025 consistently showed that the resident's wheelchair did not have the required brake extenders with highlighted tape. This was confirmed by both direct observation and staff interviews, including with an LPN and the facility administrator, who did not provide any explanation to dispute the findings.
Catheter Collection Bag Found Touching Floor
Penalty
Summary
A deficiency was identified when a resident with an indwelling Foley catheter, who was dependent for all care, was observed on two separate occasions to have their urinary catheter collection bag hanging off the side of the bed and touching the floor. The resident's medical records confirmed the presence of an indwelling catheter as per physician's orders. During interviews, a CNA acknowledged that the catheter bag was touching the floor and confirmed that it should not have been. The facility administrator was presented with these findings and did not provide any further explanation to dispute the observations. These findings were based on direct observations, interviews with staff, and review of the resident's medical records, all of which confirmed that appropriate catheter care was not maintained for the resident in question.
Incorrect Enteral Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that a resident received the correct enteral feeding formula as ordered by the physician. According to the facility's policy, all enteral feedings are to be administered in accordance with verified medical necessity and physician's orders. However, review of the resident's medical record showed an order for Nutren 2.0 at 50 mL per hour, but observation revealed that Isosource 1.5 was being administered at the same rate. The enteral feeding bag was labeled with the start date and time, confirming the incorrect formula was in use. Interviews with the LPN and DON confirmed that the resident had received the wrong enteral feeding formula, and the administrator did not provide any explanation to dispute these findings. The deficiency was identified through observation, interviews, and record review, specifically noting the administration of an incorrect enteral feeding formula to a resident who had a physician's order for a different product.
Failure to Replace Oxygen Tubing per Infection Control Policy
Penalty
Summary
The facility failed to maintain a resident's oxygen tubing in a sanitary manner according to its own infection control policy. Facility policy required that oxygen tubing and cannulas be replaced every 7 days. Record review showed a physician's order for the resident to receive continuous oxygen via nasal cannula. During observations on two separate days, the resident's oxygen tubing was found to have a date written on it indicating it had not been changed for over three weeks. Interviews with an LPN confirmed that the tubing should have been changed weekly, and the administrator did not provide an explanation for the failure to follow policy. These findings were based on direct observation, record review, and staff interviews, all of which confirmed that the required schedule for changing oxygen tubing was not followed for the resident receiving continuous oxygen therapy.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the electronic medical records (EMR) for several residents, as evidenced by discrepancies between documented care and actual observations, as well as missing or incorrect entries. For one resident, the care plan required wheelchair brake extenders with highlighted tape due to recent falls, yet multiple observations revealed the device was not present, despite staff documenting that all safety devices were in place. Interviews with CNAs revealed a lack of knowledge regarding the specific safety interventions required, and documentation was completed without verifying the actual presence of the devices. Another resident's administration history indicated receipt of a specific enteral feeding formula, but direct observation showed a different formula was being administered, and the feeding bag was labeled with an incorrect date. The LPN responsible acknowledged the documentation was inaccurate. Additionally, a resident's oxygen tubing was documented as being changed weekly, but observations showed the tubing had not been changed according to the documented schedule, and staff were unable to confirm when it was last changed. Further deficiencies included a mismatch between a resident's documented code status in the electronic record (Full Code) and the paper record (DNR), with staff interviews confirming the electronic record was incorrect. For another resident, there was no documentation to show whether scheduled baths or showers were provided or refused on multiple dates, and the DON confirmed that such documentation should have been completed. In each case, the administrator and DON were unable to provide explanations or evidence to dispute the findings.
Failure to Implement Infection Control Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in several deficiencies. For two residents with physician orders and care plans indicating strict contact isolation due to ESBL urinary tract infections, there was no contact isolation signage posted on their doors as required by facility policy. This was confirmed by observation and by the Director of Nursing, who acknowledged the absence of the necessary signage for both residents. Additionally, a resident on Enhanced Barrier Precautions (EBP) due to an indwelling urinary catheter did not receive care in accordance with EBP policy. A CNA performed catheter and incontinence care without donning a gown, contrary to the facility's EBP policy, and was unaware that the resident was on barrier precautions. Furthermore, another CNA failed to perform hand hygiene or change gloves during incontinence care for the same resident, despite facility policy and CDC guidelines requiring hand hygiene between resident contact and after glove removal. Both CNAs confirmed their lapses during interviews.
Failure to Assist Resident with Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with oral care for a resident who was cognitively intact but required setup or clean-up assistance with oral hygiene. The resident's Minimum Data Set (MDS) assessment indicated a need for assistance, and the care plan included an intervention to assist with oral hygiene as needed. However, observations on multiple occasions revealed a thick white and gray substance on the resident's teeth, indicating a lack of proper oral care. Documentation of personal hygiene activities showed no evidence that oral care was provided on several specified dates. Interviews with the resident and staff confirmed that the resident only received oral care when she complained, and it was not consistently provided as required. The Certified Nursing Assistant (CNA) acknowledged that oral care should be completed during specific shifts and documented accordingly, but the Director of Nursing (DON) confirmed the absence of documentation to support that the resident received the necessary oral care.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary condition, specifically Ice Machine f, as observed during a kitchen inspection. The bottom grate of the machine was found to have an unknown white and gray substance, along with a thin shiny film, and the outlet where ice and water exited had a brown unknown substance. During interviews, the Dietary Manager was unaware of who was responsible for cleaning the machine, and the Maintenance staff admitted that the machine had not been cleaned for over a month and a half, despite the requirement for monthly cleaning. The Administrator confirmed the unsanitary condition of the machine upon inspection.
Inadequate Infection Control in Shower Rooms
Penalty
Summary
The facility failed to ensure proper infection control practices were followed in two shower rooms, as staff did not clean the shower chairs between resident use with the approved disinfectant. The facility's procedure required the use of Virex, an approved disinfectant, to be sprayed on the shower chair, left for three minutes, and then wiped with a clean damp cloth between each use. However, during the survey, it was observed that the staff used a heavy-duty floor cleaner instead of Virex, which was not available in the shower rooms. Interviews with the CNAs assigned to the shower rooms revealed that they were aware that Virex was the approved disinfectant but confirmed its unavailability. The Director of Nurses and the Administrator also confirmed that Virex should have been used and acknowledged its absence in the shower rooms. This deficiency highlights a lapse in adherence to the facility's infection control procedures, as the approved disinfectant was not utilized as required.
Failure to Provide Advance Beneficiary Notice for Medicare Part A Termination
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS-10055, was completed prior to the discontinuation of Medicare Part A services for two residents. According to the facility's policy, the SNFABN must be issued at least three days before terminating services when the resident has days remaining in the benefit period and will remain in the facility under custodial care. However, for Resident #364, whose last day of Medicare Part A services was on January 11, 2024, there was no documented evidence of a signed CMS-10055 form prior to the termination of services. Similarly, for Resident #365, whose last day of Medicare Part A services was on June 12, 2024, the facility also failed to provide documented evidence of a signed CMS-10055 form before the termination of services. Interviews with facility staff confirmed the deficiency. On July 17, 2024, the Accounts Manager acknowledged that the required form was not completed for Residents #364 and #365 before the termination of their Medicare Part A services. Additionally, on July 18, 2024, the Administrator confirmed the absence of the completed CMS-10055 forms for these residents, acknowledging that the forms should have been completed as per the facility's policy.
Failure to Provide Bed-Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice upon hospital transfer for two residents. According to the facility's Bed Hold Policy, when a resident is transferred to the hospital, a completed form specifying the duration of the bed-hold should be provided to the resident. However, for both residents investigated, the Bed Hold Agreements were signed but not dated. One resident had an emergency transfer to the hospital, and the other also experienced an emergency transfer. Interviews revealed that the facility's practice was to have the Bed Hold Agreement signed upon admission, and the Accounts Manager would call the resident or their representative on the seventh day following hospitalization to review the bed hold policy. The Administrator indicated that if a resident was sent to the emergency room, the facility should call the resident representative regarding the bed hold policy.
Failure to Conduct PASARR Level II Evaluation for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure that a resident diagnosed with schizoaffective disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. The resident, identified as Resident #57, was diagnosed with schizoaffective disorder on a specific date, but there was no evidence in the electronic medical record that a Level II evaluation was completed. Interviews with the Assistant Administrator and the Administrator confirmed the absence of documentation for the required evaluation. The Administrator indicated that Social Services should have referred the resident for the Level II evaluation, but this action was not taken.
Inaccurate PASARR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of a Level 1 Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with major depressive disorder. The resident, who was admitted on an unspecified date, required daily antidepressant medications as noted in their Minimum Data Set assessment dated 05/31/2024. However, the Level 1 PASARR assessment completed on 07/02/2018 inaccurately documented that the resident did not have a mental illness, with no psychiatric diagnosis selected or identified. Interviews with the Admissions Coordinator, Assistant Administrator, and Administrator confirmed that the PASARR was not verified for accuracy upon the resident's admission.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
