Heritage Manor South
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 9712 Mansfield Road, Shreveport, Louisiana 71118
- CMS Provider Number
- 195408
- Inspections on file
- 22
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Heritage Manor South during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of elopement risk was able to leave the facility through an unlocked office door and an unsecured window, which lacked proper stops to prevent full opening. The resident was found offsite and returned without new injuries. Staff interviews and video review confirmed that the office door was unlocked and windows were not properly secured at the time of the incident.
A resident with multiple medical conditions and a documented DNR order was incorrectly care planned as full code, with interventions for CPR, despite advance directive consent and physician orders specifying DNR. Facility staff confirmed the care plan did not match the resident's documented wishes.
A resident with multiple chronic conditions was the subject of a family member's grievance regarding care issues such as dirty linens, uncertainty about meals, and inadequate hygiene. The complaint was recorded and forwarded to relevant departments, but there was no documentation of an investigation or resolution, nor evidence that the complainant was informed of any outcome, as required by facility policy.
The facility failed to develop a care plan for a resident's diabetic wound and did not obtain a physician order for another resident's oxygen therapy. Despite having physician orders for wound care, the diabetic wound was not included in the care plan. Additionally, a resident using continuous oxygen therapy lacked a documented physician order, which was confirmed by staff interviews.
A resident with severe cognitive impairment and multiple health conditions did not receive a full course of antibiotics as prescribed for a wound infection. The MAR indicated that five doses of Amoxicillin-Pot Clavulanate were missed over several days, which was confirmed by the DON during an interview.
The facility failed to ensure bed rails were securely attached for five residents, leading to potential accident hazards. Observations showed the rails were loose, and residents expressed fear of falling. Staff interviews confirmed the issue, revealing that maintenance checks were only conducted upon request, not routinely.
The facility failed to ensure proper use and maintenance of bed rails for multiple residents, lacking risk assessments, informed consent, and regular maintenance checks. Observations revealed loose bed rails and missing documentation, while interviews with staff highlighted systemic issues in managing bed rail safety.
The facility failed to monitor four residents for edema and bleeding as required, despite their medical conditions and prescribed medications. Residents with conditions such as CHF, COPD, and neurocognitive disorders were not monitored every shift for edema and bleeding, as acknowledged by the DON and ADON.
The facility failed to monitor three residents for side effects and behaviors associated with psychotropic medications. One resident with anxiety and depressive disorders was not monitored for side effects while on Zoloft, Buspirone, Duloxetine, and Bupropion. Another resident with anxiety and depression was not monitored while on Buspirone, Trazadone, and Mirtazapine. A third resident with dyskinesia and neurocognitive disorder was not monitored while on Sertraline, Alprazolam, and Quetiapine. The DON and ADON acknowledged these monitoring lapses.
A facility failed to provide a resident with a written Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN) when discharging them from Medicare Part-A services before benefit days were exhausted. The Account Manager admitted that the resident or their representative should have been notified earlier.
Failure to Prevent Elopement Due to Unsecured Office and Window
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia, Alzheimer's disease, and delusional disorders, was able to elope from the facility. The resident had been assessed as an elopement risk and was care planned for a security bracelet. Despite these interventions, the resident was able to leave the facility through a window in an office that had a malfunctioning door lock. The window did not have a stop to limit how far it could open, and the office door was found to be unlocked at the time of the incident. On the day of the incident, the resident was last seen by a CNA approximately 10-15 minutes before being discovered missing. Video footage showed the resident entering the MDS office and not exiting through the door, indicating the resident left through the window. The resident was later found by staff at a convenience store nearly a mile away and was returned to the facility. Upon assessment, the resident had no new injuries, only pre-existing skin tears. Interviews with staff confirmed that prior to the incident, windows in offices and the therapy gym did not have stops, and the office door lock was not functioning as intended. Staff also confirmed that the system in place for securing office doors and monitoring residents at risk for elopement was not effectively implemented at the time, which allowed the resident to exit the building undetected.
Failure to Update Care Plan to Reflect DNR Status
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's code status as Do Not Resuscitate (DNR), despite having physician orders and an advance directive consent from the resident's responsible party indicating DNR status. Instead, the care plan was initiated for full code, with interventions such as initiating CPR in the event of cardiac arrest, which contradicted the documented wishes and orders. This discrepancy was identified during a review of the resident's medical record and care plan by facility staff, who confirmed that the care plan did not align with the resident's documented DNR status. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), severe protein-calorie malnutrition, anemia, hypertension, anxiety disorder, depression, and pain, and was unable to complete a mental status interview at the time of the deficiency.
Failure to Investigate and Document Grievance Resolution
Penalty
Summary
The facility failed to ensure that a grievance investigation and resolution were conducted and documented according to its own policy for one of three sampled residents. The facility's grievance policy requires that all grievances, including those made by family members, be promptly investigated and resolved, with documentation of the investigation and communication of the resolution to the complainant. In this case, a family member reported concerns regarding a resident's care, including dirty sheets, uncertainty about whether the resident had eaten, and the resident being found soaking wet and in the same clothing as the previous day. The complaint was recorded by the Social Services Director and forwarded to nursing and laundry, but there was no documentation of an investigation or resolution, nor evidence that the complainant was notified of any outcome. The resident involved had multiple diagnoses, including rheumatoid arthritis, type 2 diabetes, Alzheimer's disease, anxiety disorder, bipolar disorder, atherosclerotic heart disease, and mood disorder due to a physiological condition. The resident was rarely or never understood, as indicated by the MDS assessment. Despite the facility's policy outlining specific steps for grievance handling, including investigation and communication of findings, these steps were not followed or documented for the complaint in question. Interviews with the Director of Nursing and Social Services Director confirmed the lack of investigation and resolution documentation.
Failure to Develop Care Plans for Diabetic Wound and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For one resident with a diabetic wound, the facility did not create a care plan addressing the diabetic foot ulcer on the left dorsum-1st digit (Hallux), despite having physician orders for wound care. The resident had severe cognitive impairment, as indicated by a BIMS score of 07, and weekly wound assessments were conducted. However, the care plan did not reflect the necessary interventions for the diabetic wound, which was acknowledged by the MDS Coordinator during an interview. For another resident, the facility did not obtain a physician order for continuous oxygen therapy, despite the resident's dependence on oxygen at 3 liters per minute (LPM) as noted in the Nurse Practitioner Progress Note. Observations confirmed the resident was using oxygen via nasal cannula, and interviews with the resident and staff, including the DON, confirmed the use of oxygen. However, there was no physician order documented for this therapy, which was acknowledged as an oversight by the DON.
Failure to Administer Full Course of Antibiotics
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not administering a full course of antibiotics as ordered by the physician. The resident, who had severe cognitive impairment and multiple diagnoses including type 2 diabetes mellitus, diabetic ulcer, and peripheral vascular disease, was prescribed Amoxicillin-Pot Clavulanate for a wound infection. The physician's order specified a 7-day course of the antibiotic, to be given every 12 hours. However, the Medication Administration Record (MAR) for September 2024 showed that five doses were missed, specifically the 8:00 p.m. doses on three consecutive days and the 8:00 a.m. doses on two consecutive days. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the full course of antibiotics was not administered.
Failure to Secure Bed Rails Poses Accident Hazard
Penalty
Summary
The facility failed to ensure that bed rails were securely attached to the beds for five residents, leading to potential accident hazards. Observations revealed that the bed rails for these residents were loose and moved freely, posing a risk to the residents who relied on them for positioning and support. Interviews with the residents confirmed their awareness of the loose rails, with some expressing fear of falling due to the instability of the rails. The residents involved had various medical conditions, including dementia, bipolar disorder, and muscle weakness, and resided in the facility's secure memory care unit. Their cognitive abilities ranged from moderately impaired to severely impaired, with some residents being unable to communicate effectively. Despite these vulnerabilities, the facility did not ensure the bed rails were securely attached, compromising the safety of these residents. Interviews with facility staff, including CNAs, the ADON, and the DON, confirmed the issue with the bed rails. The maintenance department was identified as responsible for checking the bed rails, but it was revealed that inspections were only conducted when a work order was submitted, rather than on a routine basis. This lack of regular maintenance checks contributed to the deficiency in ensuring a safe environment for the residents.
Deficiencies in Bed Rail Use and Maintenance
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for 12 residents, as identified through record reviews, observations, and interviews. The deficiencies included a lack of assessment for risks associated with bed rail use, failure to obtain informed consent from residents or their representatives, and inadequate documentation of monitoring and supervision during bed rail use. Additionally, the facility did not conduct scheduled maintenance according to the manufacturer's recommendations for the bed rails in use. Several residents were observed with bed rails in use without proper documentation or consent. For instance, one resident with quadriplegia and other severe conditions had bed rails up without any documentation of monitoring or supervision. Another resident with dementia and severe cognitive impairment had loose bed rails, and no consent was obtained for their use. Similar issues were noted for other residents, including incomplete consent forms and missing assessments for the necessity and safety of bed rail use. Interviews with facility staff, including the Director of Nursing (DON) and maintenance personnel, revealed systemic issues in the management of bed rails. The DON confirmed that consents were not obtained, and assessments were not conducted as required. Maintenance staff admitted to only inspecting bed rails when issues were reported, rather than performing regular maintenance checks. The facility lacked the manufacturer's guidelines for bed rail installation and maintenance, contributing to the improper use and potential safety hazards associated with bed rails.
Failure to Monitor Residents for Edema and Bleeding
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not adequately monitoring for edema and bleeding in four out of six residents reviewed. Resident #28, diagnosed with conditions including congestive heart failure and end-stage renal disease, was prescribed Bumetanide for CHF. However, the facility did not monitor for edema every shift on multiple days in October 2024. The Director of Nursing acknowledged this oversight during an interview. Similarly, Resident #34, with diagnoses including chronic obstructive pulmonary disease and CHF, was on diuretic therapy and Apixaban. The facility failed to monitor for edema and bleeding every shift on several days in October 2024. Resident #79, with conditions such as anxiety disorder and acute embolism, was prescribed Eliquis and Furosemide but was not monitored for edema and bleeding every shift on numerous days. Lastly, Resident #87, with neurocognitive disorder and major depressive disorder, was on Eliquis but was not monitored for bleeding every shift on several days. The Assistant Director of Nursing acknowledged these monitoring failures during interviews.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of monitoring for side effects and behaviors in three residents. Resident #34, diagnosed with anxiety disorder, mood disorder, insomnia, and major depressive disorder, was prescribed multiple psychotropic medications, including Zoloft, Buspirone, Duloxetine, and Bupropion. However, the facility did not monitor Resident #34 for side effects and behaviors on numerous days throughout October 2024, as confirmed by the Director of Nursing. Similarly, Resident #79, with diagnoses including anxiety disorder and depression, was prescribed Buspirone, Trazadone, and Mirtazapine. The facility failed to monitor this resident for side effects and behaviors on several days in October 2024. Resident #87, diagnosed with dyskinesia, neurocognitive disorder with Lewy bodies, and major depressive disorder, was prescribed Sertraline, Alprazolam, and Quetiapine. The facility also did not monitor this resident for side effects and behaviors on multiple days in October 2024. The Assistant Director of Nursing acknowledged the lack of monitoring for both Residents #79 and #87.
Failure to Provide Written Notification of Medicare Coverage Changes
Penalty
Summary
The facility failed to provide written notification to a resident regarding changes in their Medicare Part-A coverage and potential financial liability. Specifically, the facility initiated the discharge of a resident from Medicare Part-A services before the benefit days were exhausted, without issuing a Notice of Medicare Non-Coverage (NOMNC) or an Advance Beneficiary Notice (ABN) to the resident or their responsible party. The facility's records indicated that the resident might have to pay out of pocket for care starting on a specified date if no other insurance covered the costs. Despite a phone call made by the Account Manager to the resident's representative to discuss the notice, the required written notifications were not provided. The Account Manager acknowledged during an interview that the resident or their representative should have been notified earlier in the month.
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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