Heritage Manor Of Slidell
Inspection history, citations, penalties and survey trends for this long-term care facility in Slidell, Louisiana.
- Location
- 106 Medical Center Drive, Slidell, Louisiana 70461
- CMS Provider Number
- 195220
- Inspections on file
- 26
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heritage Manor Of Slidell during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses developed a new wound while in the facility. Although documentation indicated that the responsible party was notified, the wound care nurse confirmed that no notification was made. The facility administrator acknowledged the nurse's responsibility to inform the resident's representative, which was not fulfilled.
A resident with severe cognitive impairment was found with a wound on the left inner thigh, initially noted by a CNA and reported to an RN. The resident mentioned spilling hot coffee, but later expressed uncertainty. The wound care RN documented it as a burn, but the facility failed to report the injury to the state agency within the required timeframe.
The facility failed to store food according to professional standards, affecting 93 residents. During a kitchen tour, two open and unlabeled bags of shredded cheddar cheese were found in the refrigerator. This was against the facility's policies, which require labeling of temperature-controlled foods and ensuring no food is left uncovered. Staff confirmed the items should have been sealed and labeled.
The facility failed to maintain proper infection control practices, as staff were observed not wearing PPE correctly for residents with Covid-19 and Enhanced Barrier Precautions. A resident's catheter bag was found on the floor, and staff did not wear gowns during catheter care. Additionally, improper wound care practices were noted, including using a dressing that fell on the floor and not changing gloves after touching contaminated surfaces.
The facility failed to accurately code the MDS for PASRR in two residents with serious mental illnesses. Despite having PASRR Level II Evaluations and state approvals for admission, their MDS assessments were incorrectly marked, with Section A1500 coded as 'No' and Section A1510 left blank. Staff interviews confirmed these errors.
A resident with Neurogenic Bladder had an indwelling catheter, and the care plan required the catheter bag to be positioned below the bladder. However, during an observation, the catheter bag was found secured above waist level, contrary to the care plan. Two CNAs confirmed the incorrect positioning, and the DON stated the expectation was for the bag to hang below the waist.
The facility failed to discard insulin pens 28 days after opening, as required. An LPN confirmed that insulin pens for two residents were still available for use despite being opened on a date beyond the 28-day limit. The DON was informed and acknowledged the oversight.
The facility failed to post daily nurse staffing information as required by their policy. The last completed staffing data sheet was from several days prior, with no documentation for the subsequent days. Interviews with staff confirmed the lapse in posting, acknowledging that the sheets should have been completed daily. This deficiency had the potential to affect any of the 94 residents in the facility.
A CNA transferred a resident without using the required mechanical lift, resulting in the resident sustaining fractures in both the tibia and fibula, as well as a fracture in the great toe. The CNA was aware of the resident's need for a two-person mechanical lift but chose to transfer the resident manually, leading to the injury.
The facility failed to notify a resident's physician and family after identifying a new sacral wound and did not inform the physician when the resident did not have a bowel movement for more than three days, contrary to facility policies.
The facility failed to develop a person-centered care plan for a resident who returned from a hospital stay with a new diagnosis of constipation. Despite being prescribed Senna-docusate for constipation, the resident's care plan was not updated. Staff confirmed that the care plan should have been updated upon the resident's return.
Failure to Notify Resident Representative of Significant Change
Penalty
Summary
The facility failed to ensure that nursing staff notified the resident representative when a resident experienced a significant change in condition. This deficiency was identified for one of the three sampled residents reviewed. The resident in question was admitted with multiple diagnoses, including severe cognitive impairment, and required extensive assistance for mobility and transfers. During a review of the resident's clinical record, it was found that an initial wound assessment was completed, documenting a new open lesion on the resident's left medial thigh. The wound was acquired in-house, and the documentation indicated that the responsible party was notified of the wound. However, upon further investigation, it was revealed that the wound care nurse, S2RN, had documented the notification of the responsible party but confirmed during an interview that she did not actually notify them. The facility's administrator, S1ADM, also confirmed that it was the responsibility of S2RN to notify the resident's responsible party of the change in condition, which did not occur. This lack of communication represents a failure in the facility's protocol to inform the resident's representative of significant changes in the resident's condition.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency within the required 24-hour timeframe. The resident, who was severely cognitively impaired with a BIMS score of 01, was found to have a wound on his left inner thigh. The wound was initially noted by a CNA during incontinent care and reported to an RN. The family of the resident was informed, and the resident himself mentioned spilling hot coffee on his leg, although he later expressed uncertainty about the incident. Despite these findings, the facility did not report the injury to the state agency as required. The wound care RN assessed the lesion initially as a small dry lesion and did not suspect it to be a burn or skin injury. However, upon further assessment, the skin had sloughed off, and the wound was documented as a burn after the family claimed it was due to a coffee spill. The resident's cognitive impairment made it difficult to ascertain the exact cause of the injury. The facility's administrator, responsible for filing self-reported incidents, was aware of the injury but confirmed that no report was filed with the state agency, which constituted a failure to comply with reporting requirements.
Failure to Properly Store and Label Food
Penalty
Summary
The facility failed to adhere to professional standards for food storage, which had the potential to affect 93 residents served from the kitchen. During an initial tour of the kitchen, two open and unlabeled bags of shredded cheddar cheese were found in the facility's refrigerator. This observation was confirmed by S5DS, who acknowledged that the items were unsealed and unlabeled, contrary to the facility's policies. The facility's policy on food storage labeling, dated May 2018, requires all temperature-controlled foods to be labeled with the name of the food and the date of storage. Additionally, the policy on the storage of refrigerated food, dated September 2022, mandates that no food should be left uncovered. S1ADM was informed of these findings and confirmed that opened food items should indeed be sealed and labeled.
Infection Control Deficiencies in PPE and Wound Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper Personal Protective Equipment (PPE) protocols. In the case of two residents diagnosed with Covid-19, staff members were observed removing their PPE, including masks, in the residents' bathrooms and then exiting the rooms without wearing masks. This practice was confirmed by both the staff involved and the facility administrator as the standard procedure, indicating a systemic issue in the facility's infection control practices. Another deficiency was noted with a resident on Enhanced Barrier Precautions due to a urinary catheter. The resident's catheter bag was repeatedly observed on the floor, which is against the facility's policy. Additionally, staff members failed to wear gowns while performing catheter care, despite clear signage indicating the requirement for gown and glove use during such high-contact activities. Interviews with the staff confirmed a lack of awareness and adherence to the Enhanced Barrier Precautions policy. Further infection control lapses were observed during wound care for a resident with multiple diagnoses, including Peripheral Vascular Disease and Type 2 Diabetes Mellitus. The wound care nurse did not change gloves or perform hand hygiene after touching potentially contaminated surfaces before proceeding with wound care. Additionally, a dressing that fell on the floor was used on the resident's wound, and soiled tape was handled improperly. These actions were contrary to the facility's Dressing Change policy, as confirmed by the Director of Nursing.
Inaccurate MDS Coding for PASRR in Two Residents
Penalty
Summary
The facility failed to ensure that residents' assessments accurately reflected their status, specifically in the coding of the Minimum Data Set (MDS) for PASRR (Pre-admission Screening and Resident Review). Two residents, identified as #21 and #54, were affected by this deficiency. Resident #21, who was admitted with diagnoses including Paranoid Schizophrenia, Bipolar Disorder, Schizoaffective Disorder, and Major Depressive Disorder, had a PASRR Level II Evaluation indicating a serious mental illness. However, her Annual MDS assessment was incorrectly coded, with Section A1500 marked as 'No' and Section A1510 left blank, despite her approval for admission by the state Level II Authority. Similarly, Resident #54, admitted with a diagnosis of Schizophrenia, also had a PASRR Level II Evaluation confirming a serious mental illness. His Annual MDS assessment was similarly miscoded, with Section A1500 marked as 'No' and Section A1510 left blank, despite his approval for admission by the state Level II Authority. Interviews with facility staff, including S6MDS and S4DON, confirmed these coding errors, acknowledging that the MDS assessments for both residents should have been coded correctly to reflect their PASRR evaluations.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency. The resident, who was admitted with a diagnosis of Neuromuscular Dysfunction of Bladder, had an indwelling catheter due to Neurogenic Bladder. The care plan for the resident specified that the urine catheter bag should be positioned below the bladder. However, during an observation, it was noted that the catheter bag was secured to the left side of the bed frame above waist level, contrary to the care plan instructions. This was confirmed by two CNAs who acknowledged that the catheter bag should not be positioned above the resident's waist. The Director of Nursing also stated that the expectation was for the catheter bag to hang below the level of the waist.
Failure to Discard Insulin Pens After 28 Days
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, specifically concerning the handling of insulin pens. During an observation of medication Cart A, it was found that insulin pens for two residents were not discarded 28 days after being opened, as required by the NovoLog injection package insert. The insulin pens had an open date of 06/24/2024, but were still available for use on 08/05/2024. An LPN confirmed the oversight, acknowledging that the insulin pens should have been discarded after 28 days. The Director of Nursing was informed of the situation and confirmed that the insulin pens should have been labeled with an open date and discarded accordingly.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted on a daily basis, as required by their policy. The policy, dated June 2024, mandates that the facility must post specific information daily, including the facility name, current date, total number and actual hours worked by RNs, LPNs, and CNAs per shift, and the resident census. This information should be posted at the beginning of each shift. However, a review of the facility's staffing data sheet binder on August 5, 2024, revealed that the last completed staffing data sheet was dated July 29, 2024, with no documentation for the period from July 30, 2024, to August 4, 2024. Interviews conducted on August 5, 2024, with S2AADM and S1ADM confirmed the lapse in posting the staffing data sheets. S2AADM, who was responsible for posting the data sheets, acknowledged that the last fully completed sheet was from July 29, 2024, and confirmed that the sheets should have been completed daily. S1ADM also confirmed awareness of the issue and acknowledged that the staffing data sheets should have been completed daily. This deficiency had the potential to affect any of the 94 residents residing in the facility.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who required transfer by a mechanical lift. Specifically, a CNA transferred a resident from a Geri Chair to her bed without using the required mechanical lift or assistance, despite being aware that the resident required a two-person mechanical lift for transfers. This action resulted in the resident sustaining commuted, displaced, angulated fractures of the distal shafts of both the tibia and fibula, as well as a mildly displaced intra-articular fracture of the distal aspect of the proximal phalanx of the great toe. The incident was reported when the CNA noticed the resident's right foot was deformed after the transfer. The LPN assessed the resident's right foot and found it to be swollen, bruised, and deformed. The resident was then transferred to a local hospital for further evaluation and treatment. Interviews with the CNA, LPN, and DON confirmed that the resident was assessed to require a two-person mechanical lift for transfers, and the CNA admitted to transferring the resident without the mechanical lift or assistance.
Failure to Notify Physician and Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the resident's physician and representative of changes in condition for one resident. Specifically, the facility did not inform the physician and family after identifying a new sacral wound for the resident. The wound was discovered by a CNA and assessed by an RN, but the notification to the family and physician was delayed until the following day. Interviews with staff confirmed that the family and physician should have been notified immediately upon the discovery of the wound, as per the facility's policy on changes in resident medical status. Additionally, the facility did not notify the physician when the resident did not have a bowel movement for more than three days. The resident's records showed no bowel movements between March 8 and March 22, and there was no documentation that the physician had been informed. The Director of Nursing confirmed that the physician should have been notified according to the facility's bowel movement monitoring policy. The physician also verified that he was not informed of the resident's condition during this period.
Failure to Develop Care Plan for New Diagnosis
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who returned from a hospital stay with a new diagnosis of constipation. The resident, who had diagnoses including Traumatic Subdural Hemorrhage, Rhabdomyolysis, and Constipation, was readmitted to the facility and prescribed Senna-docusate for constipation. However, a review of the resident's care plan revealed that no care plan was developed for the new diagnosis. Interviews with facility staff confirmed that the care plan should have been updated to include the new diagnosis upon the resident's return from the hospital.
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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