Heritage Manor Of Opelousas
Inspection history, citations, penalties and survey trends for this long-term care facility in Opelousas, Louisiana.
- Location
- 7941 I-49 South Service Road, Opelousas, Louisiana 70570
- CMS Provider Number
- 195321
- Inspections on file
- 26
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heritage Manor Of Opelousas during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions did not receive four scheduled doses of Lotrisone cream as ordered by the physician. Review of the MAR/TAR showed no documentation of administration for these doses, and the DON confirmed the missed treatments.
A cognitively impaired resident fell and sustained a severe head injury after being left unattended in a wheelchair during transportation. The resident, who required extensive assistance and had severely impaired cognitive skills, was left alone by the driver while the van was moved, resulting in a fall and significant injuries.
A LTC facility failed to maintain an effective infection control program, leading to several deficiencies. An LPN improperly used a single-patient insulin pen on another resident, risking exposure to blood-borne pathogens. The same LPN also failed to disinfect a glucometer between uses. Additionally, staff did not adhere to Enhanced Barrier Precautions, with multiple instances of not wearing required PPE during high-contact activities. These actions were confirmed by the Infection Control Preventionist.
The facility failed to properly store drugs, as loose pills were found in the bottom of all three medication carts checked. During observations, various loose tablets and capsules were discovered under residents' medication blister packs in Carts A, B, and C, indicating a failure to maintain medication carts in a clean and orderly manner as per the facility's policy.
A resident did not receive quarterly financial statements as required by facility policy. Despite being cognitively intact and requesting the statements, the facility failed to provide them. Interviews with staff revealed a lack of documentation and training regarding the issuance of these statements, affecting the facility's entire census.
A resident's wheelchair was found with a large amount of yellow food-like residue, violating the facility's policy on maintaining clean equipment. An LPN confirmed the wheelchair's unclean state, which should not have occurred. The resident had been admitted with unspecified dementia.
A facility failed to complete and submit a Minimum Data Set (MDS) assessment to CMS in a timely manner for a resident who was discharged. The discharge assessment was not opened, completed, or transmitted for over 120 days, as confirmed by the MDS coordinator.
A facility failed to accurately complete the MDS for a resident, resulting in a deficiency. The resident, with multiple diagnoses, had an MDS that incorrectly coded the use of restraints, despite no active physician order for such. An LPN confirmed the error, having mistakenly coded bed rails as a restraint.
The facility failed to implement and develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident did not have heel protectors applied as required, another experienced significant weight loss without it being addressed in the care plan, and a third resident's urinary catheter and UTI were not included in her care plan. Staff confirmed these oversights during the survey.
A facility failed to involve a cognitively intact resident and his representative in care planning. The resident was not invited to meetings, and an invitation sent to his daughter was mailed to an incorrect address. No evidence of quarterly care plan meetings was found after a certain date.
A resident with muscle weakness and a low BIM score required extensive assistance with ADLs, including oral care. Despite the care plan's directive for C.N.A.s to assist with daily oral hygiene, observations revealed inadequate oral care, with a white milky substance between the resident's teeth. Interviews with staff confirmed the resident's need for total assistance, which was not being met.
Two residents in the facility had respiratory equipment that was not stored according to professional standards. A resident's nebulizer mask was left open to air on a bedside table, while another resident's BiPAP mask was found with dried residue and not stored in a bag. LPNs confirmed the improper storage and lack of cleaning.
A resident with multiple diagnoses, including pain-related conditions, did not receive prescribed Tylenol for reported severe pain on two occasions. Despite notifying the LPN, the resident's pain was not documented or managed as per the care plan, highlighting a failure in pain management by the facility.
The facility failed to ensure nursing staff demonstrated competencies in safe injection practices and proper application of bed bolsters, affecting two residents. An LPN administered insulin using a pen intended for another resident, and CNAs were not adequately trained on using bed bolsters, leading to a resident's fall. The DON confirmed the lack of comprehensive staff education on these issues.
The facility failed to follow the recipe for pureed steamed rice, affecting eight residents on pureed diets. The cook used an excessive amount of milk, resulting in a mixture that was too thin, and added thickener to adjust the consistency. The Dietary Manager confirmed the recipe was not followed correctly.
A facility failed to coordinate care for a resident receiving hospice services by not obtaining necessary information from the hospice agency. The hospice certification had expired, and the last nurse visit note was outdated. The DON admitted to not reviewing hospice documentation, and the Medical Records Supervisor confirmed the lack of updated records. The resident had diagnoses of dementia, pain, and unspecified protein-calorie malnutrition.
A resident at high risk for falls was left unattended in the bathroom by a CNA, resulting in a fall and injury. Despite the facility's policy requiring supervision for high-risk residents, the CNA left the resident alone, leading to a bruise and hematoma. The incident was confirmed by multiple staff members, and the administration acknowledged the failure to follow the policy.
A resident with severe cognitive impairment was found with a head laceration and blood on his pillow. The LPN on duty did not notify the facility's administration of the injury, contrary to the facility's policy. The resident was treated at the emergency room, but the Administrator and DON were only informed the next day by the resident's responsible party.
A resident with a history of osteoarthritis and a recent fall did not receive prescribed pain medication despite showing signs of pain. The LPN acknowledged the resident's pain but did not administer the medication, and the DON confirmed that the medication should have been given.
Failure to Administer Prescribed Topical Medication as Ordered
Penalty
Summary
The facility failed to follow the care plan for a resident who was admitted with multiple diagnoses, including acute on chronic diastolic heart failure, urinary tract infection, chronic kidney disease, unspecified dementia, cerebral ischemia, and essential hypertension. The resident was assessed as severely cognitively impaired, with a BIMS score of 05. According to the physician's order, the resident was to receive Lotrisone cream twice daily for seven days. Review of the Medication Administration Record and Treatment Administration Record for the specified month revealed that four doses of the prescribed Lotrisone cream were not administered as ordered, with no documentation indicating the doses were given on the specified dates. The Director of Nursing confirmed that these doses were missed after reviewing the resident's records.
Inadequate Supervision During Transportation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident during transportation, resulting in a severe accident. The incident occurred when a driver left the resident unattended in a wheelchair on a sidewalk while moving the transportation van. During this time, the resident fell from the wheelchair, striking her head on the concrete pavement, which led to significant injuries including bilateral parenchymal and subarachnoid hemorrhages. The resident involved had a history of dementia, anxiety disorder, and hemiplegia following a cerebral infarction, affecting her cognitive abilities and physical mobility. Her medical records indicated she required extensive assistance for transfers and had severely impaired cognitive skills, making her particularly vulnerable to accidents if left unsupervised. Despite these needs, the resident was left alone, leading to the fall and subsequent head injury. Interviews with the driver and the Director of Nursing revealed that the facility lacked a specific policy for supervising residents during transportation. The driver admitted to leaving the resident unattended, which was against the expected practice of maintaining resident safety and supervision during transport. This oversight directly contributed to the resident's fall and injury.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, leading to several deficiencies. One significant issue involved the improper use of insulin multi-dose pens. A Licensed Practical Nurse (LPN) used a previously used insulin pen, intended for single-patient use, to administer insulin to another resident. This action was confirmed by the LPN, who admitted to not checking the label on the pen before administration. The incident placed multiple residents at risk of exposure to blood-borne pathogens. Another deficiency was observed in the cleaning protocol for glucometers. The same LPN was seen using a blood glucose monitor on a resident and then placing it back on the medication cart without disinfecting it. The LPN admitted to only cleaning the monitor at the beginning and end of her shift, contrary to the facility's policy, which requires cleaning after each use. This practice was confirmed by the Director of Nursing and the Infection Control Preventionist, who both stated that the glucometer should be disinfected between uses. Additionally, staff failed to adhere to Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE). Multiple instances were noted where staff did not wear the required gown and gloves during high-contact activities with residents on EBP. For example, a Certified Nursing Assistant (CNA) assisted a resident without wearing gloves or a gown and did not sanitize her hands before moving to another resident's room. Another LPN was observed flushing a resident's PEG tube without wearing a gown, despite the resident being on EBP. These actions were confirmed by the Infection Control Preventionist, who acknowledged the lapses in following the facility's infection control policies.
Improper Drug Storage in Medication Carts
Penalty
Summary
The facility failed to properly store drugs as evidenced by loose pills found in the bottom of medication cart drawers for all three medication carts checked. During an observation, Cart A and Cart C were inspected with an LPN, revealing four loose pills in Cart A and eight loose pills in Cart C, including various tablets and capsules of different colors and shapes. Similarly, Cart B was observed with another LPN, where one small green oval tablet was found loose under the residents' medication blister packs. This indicates a failure to maintain medication carts in a clean and orderly manner as per the facility's policy on medication storage.
Failure to Provide Resident Financial Statements
Penalty
Summary
The facility failed to provide a resident with individual financial records through quarterly statements and/or upon request, as required by their policy. The policy, last reviewed in August 2021, mandates that quarterly statements be provided to all residents or their representatives within 30 days after the end of the quarter. A resident, who was admitted in September 2023 and is cognitively intact with a BIMS score of 15, reported not receiving these statements. Despite the resident's request for a copy of his financial statement, the facility did not provide the information. Interviews with facility staff revealed a lack of documentation and training regarding the issuance of financial statements. The Administrative Assistant and Accounts Manager both confirmed that there was no documented evidence that the resident had received his quarterly financial statements. The Accounts Manager admitted that neither she nor the Administrative Assistant were trained to document when financial statements were issued. This deficiency had the potential to affect the facility's entire census of 107 residents.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to maintain the cleanliness of a wheelchair for one resident, leading to a deficiency in providing a safe, clean, comfortable, and homelike environment. The facility's policy on equipment and supplies, last reviewed in January 2024, mandates that resident care equipment be cleaned and decontaminated after use according to the manufacturer's recommendations. However, during an observation on August 26, 2024, a resident was found sitting in a wheelchair that had a large amount of yellow food-like residue on the seat, foot pedal bars, and wheels. An LPN confirmed the wheelchair was dirty and acknowledged it should not have been in that condition. The resident involved had been admitted with a diagnosis of unspecified dementia.
Failure to Timely Submit MDS Assessment Post-Discharge
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was completed and submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for a resident who was discharged. The resident was admitted and later discharged, but there was no documented evidence that a discharge assessment was opened, completed, or transmitted. An interview with the MDS coordinator confirmed that the resident was discharged home, and the discharge assessment had not been addressed for over 120 days, which exceeded the required timeframe for submission.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia affecting the right dominant side, chronic obstructive pulmonary disease, and muscle weakness, had a significant change MDS that incorrectly coded the use of restraints. Upon review, it was found that there was no active physician order for restraints as of August 1, 2024. An interview with the LPN responsible for the MDS confirmed that the bed rails were mistakenly coded as a restraint, highlighting an error in the assessment process.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #36, who was at risk for further skin breakdown due to severe protein-calorie malnutrition and a stage 4 pressure ulcer, did not have bilateral heel protectors applied while in bed as per her care plan. Despite documentation indicating that the heel protectors were applied, observations and staff interviews confirmed that the resident was not wearing them during the survey period. Resident #76 experienced significant weight loss, as noted in his Minimum Data Set (MDS) assessment, but his care plan did not address this issue. The assessment nurse confirmed the oversight and acknowledged that the weight loss should have been included in the care plan. Similarly, Resident #105, who had a urinary catheter and a recent urinary tract infection (UTI), did not have these conditions addressed in her care plan. The assessment nurse confirmed the omission, recognizing that the care plan should have included interventions for the urinary catheter and UTI.
Failure to Facilitate Resident Participation in Care Planning
Penalty
Summary
The facility failed to ensure the participation of a resident and his representative in the care planning process. The resident, who was cognitively intact with a BIMS score of 15, was admitted to the facility and was his own representative. Despite this, he reported not being invited to any care plan meetings. The facility's social services staff mailed an invitation to the resident's daughter, but it was sent to an incorrect address, different from the one provided by the daughter. Additionally, there was no documented evidence of quarterly care plan meetings being conducted after a specific date, nor evidence that the resident's daughter was invited to these meetings.
Failure to Provide Oral Care for Resident Requiring Assistance
Penalty
Summary
The facility failed to provide adequate oral care for a resident, identified as Resident #64, who required extensive assistance with all activities of daily living (ADLs) due to muscle weakness and a Brief Mental Exam (BIM) score of 10. The resident was admitted to the facility and had been there for nearly two months. Despite the care plan indicating that Certified Nursing Assistants (C.N.A.s) were responsible for assisting the resident with daily oral hygiene, observations on two consecutive days revealed a white milky substance between the resident's teeth, indicating a lack of oral care. Interviews with the resident and staff, including a Licensed Practical Nurse (LPN) and a C.N.A., confirmed that the resident required total assistance for oral hygiene, which was not being provided as per the care plan. The Assessment Nurse also acknowledged the resident's need for extensive assistance with ADLs, emphasizing the C.N.A.s' responsibility for daily oral hygiene.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. Resident #31, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Systolic Heart Failure, had a nebulizer mask that was improperly stored. Observations revealed that the mask was left open to air on the bedside table, and interviews confirmed that it was not stored in a bag as required. Similarly, Resident #54, admitted with conditions such as Chronic Obstructive Pulmonary Disorder and Pneumonia, had a BiPAP mask that was not stored correctly. The mask was found on the nightstand, open to air, and had spots of a dried dark red substance inside. An LPN confirmed that the mask should have been cleaned and stored in a bag, indicating a failure to adhere to the prescribed cleaning and storage procedures.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #64, who required such services. Resident #64 was admitted with multiple diagnoses, including pain in the leg, intervertebral disc degeneration, scoliosis, angina pectoris, weakness, and type 2 diabetes mellitus. Her care plan indicated a risk for pain and included orders to administer medication as needed and notify the medical doctor of any unrelieved pain. Despite these orders, the resident did not receive the prescribed Tylenol on two occasions when she reported significant pain levels. On August 26, 2024, Resident #64 reported back pain to a nurse but did not receive the requested Tylenol. The following day, during a skin assessment, she again complained of severe back pain and requested Tylenol, which was not administered. The Treatment Nurse (S22TN) notified the LPN (S7LPN) of the resident's pain, but there was no record of Tylenol being given or any documentation in the nurse's notes regarding the notification or administration of pain relief. Interviews with the LPN and the Director of Nursing confirmed that the resident's pain management was not handled according to the physician's orders.
Deficiencies in Nursing Competency and Safety Practices
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to provide safe and effective care to residents, resulting in two specific deficiencies. The first deficiency involved an LPN who administered insulin using a multi-dose insulin pen intended for a single resident to another resident. This occurred when the LPN, after checking the blood glucose level of a resident, mistakenly used an insulin pen labeled for a different resident. The LPN admitted to not verifying the label on the insulin pen before administration, which was against the facility's policy on safe injection practices. The second deficiency involved the improper application of bed bolsters for a resident at risk of falls. The resident, who had a history of muscle weakness and hemiplegia following a cerebral infarction, was found on the floor due to incorrectly secured bed bolsters. An investigation revealed that a CNA admitted to not knowing how to apply the bolsters correctly, which led to the resident's fall. Further interviews with other CNAs indicated a lack of education on the proper use of bed bolsters, and there was no documentation of staff being educated on this aspect of care. These deficiencies highlight a lack of competency in medication administration and fall prevention measures among the nursing staff. The facility's Director of Nursing confirmed that insulin pens should not be used for multiple residents and acknowledged the absence of comprehensive staff education on the use of bed bolsters. The CNA Supervisor also confirmed that not all CNAs had been in-serviced on the proper use of bolsters, and there was no record of such training being conducted.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that recipes were followed for residents receiving pureed diets, specifically in the preparation of pureed steamed rice. The deficiency was identified through observations, record reviews, and interviews. The facility's policy on the preparation and service of pureed diets, revised in 2018, requires that pureed foods be blended to a consistency that holds its shape, using the smallest amount of liquid possible to maintain nutritional value. However, during an observation, it was noted that the cook, S8Cook, deviated from the recipe by using an excessive amount of milk, which resulted in a mixture that was too thin. The cook was preparing steamed rice for 15 servings but only used 4 cups of rice and added one and a half quarts of milk, contrary to the recipe's instructions of using 11.25 cups of rice, 1 cup of milk, and 1/2 cup of margarine. After realizing the mixture was too thin, the cook added thickener to adjust the consistency. The Dietary Manager, S5DM, confirmed that the recipe was not followed correctly. This oversight had the potential to affect eight residents who were on pureed diets, as the nutritional content of their meals could have been compromised.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to coordinate care for a resident receiving hospice services by not obtaining pertinent information from the contracted hospice agency. The facility's agreement with the hospice agency required both parties to maintain complete and detailed clinical records for patients receiving services. However, a review of the resident's electronic medical record revealed that the hospice certification had expired, and the last hospice nurse visit note was outdated. During interviews, the Director of Nursing admitted to not reviewing hospice documentation and referred the surveyor to the Medical Records Supervisor, who confirmed the lack of updated hospice records for the resident. The resident's diagnoses included dementia, pain, and unspecified protein-calorie malnutrition.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to ensure staff followed the policy and procedures to prevent accidents for a resident who was at high risk for falls. The resident, who was cognitively intact and had a history of multiple falls, was left unattended in the bathroom by a CNA, contrary to the facility's policy that required a nursing assistant to remain with high-risk residents for safety. This resulted in the resident falling while attempting to clean herself, leading to a bruise on her face and a hematoma on her left temple. The incident was observed and reported by various staff members, including the Assistant Director of Nursing, who conducted an investigation but did not initially inquire about how the resident got to the bathroom. The LPN on duty confirmed that the CNA had left the resident alone, and the CNA admitted to leaving the resident unattended despite knowing the resident was a fall risk and had expressed fear of falling. The facility's administration acknowledged the resident's high fall risk and the policy requiring supervision in the bathroom.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that nursing staff immediately notified the Administrator of an injury of unknown origin for a resident. The facility's policy required that any incident involving injuries of unknown origin be reported immediately to the Administrator. However, this protocol was not followed in the case of a resident who was found with blood on his pillow and a laceration on his head. The resident, who had severe cognitive impairment and was unable to communicate how the injury occurred, was sent to the emergency room where he received treatment for a scalp laceration. The nurse responsible for the resident at the time of the incident did not notify the facility's administration about the injury, as she was unaware of the requirement to do so. The Administrator and Director of Nursing were only informed of the incident the following day by the resident's responsible party. This lack of immediate notification was a violation of the facility's policy and had the potential to affect the entire resident census.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. Resident #2, who had a history of osteoarthritis, a displaced fracture of the femur, and vascular dementia, was admitted to the facility with physician's orders for pain medications including Ibuprofen and Acetaminophen. On 03/24/2024, Resident #2 experienced an unobserved fall and subsequently complained of pain in her left leg and hip. Despite displaying nonverbal indicators of pain such as moaning and grunting, the resident did not receive any pain medication on 03/25/2024 as documented in the Medication Administration Record (MAR). The LPN who assessed the resident on the morning of 03/25/2024 acknowledged that the resident was in pain but did not administer the prescribed pain medication and could not provide a reason for this inaction. The Director of Nursing (DON) confirmed that the LPN should have administered pain medication to Resident #2 upon assessing her condition. The failure to administer pain medication as per the resident's care plan and physician's orders resulted in inadequate pain management for the resident. This deficiency highlights a lapse in following professional standards of practice and the comprehensive person-centered care plan designed for Resident #2.
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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