Highland Place Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 1736 Irving Place, Shreveport, Louisiana 71101
- CMS Provider Number
- 195350
- Inspections on file
- 30
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Highland Place Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with chronic pain did not receive scheduled Morphine due to failures in medication refill and communication processes. Nursing staff did not follow up with the pharmacy or escalate the issue when the medication ran out, resulting in the resident missing three consecutive doses, experiencing severe pain, and requiring transfer to the ER after alternative pain medications proved ineffective.
Two residents with PICC lines did not have care plans addressing their IV antibiotic administration, and one resident did not receive IV antibiotics as ordered, with missed doses confirmed by the DON. Another resident did not receive restorative nursing services as ordered, as staff failed to place the resident on the restorative schedule.
A resident with a PEG tube was observed receiving continuous enteral feeding while lying flat, despite physician orders and facility policy requiring the head of bed to be elevated 30-45 degrees during feeding. Facility leadership confirmed the resident was not positioned correctly at the time of observation.
A resident with a documented preference for white meat chicken was served dark meat during a meal, despite staff being aware of this preference and it being clearly listed on the meal card. Staff and dietary management acknowledged the error and confirmed the resident's preference was not honored.
A resident with Type 2 diabetes did not receive care according to physician orders, including missed blood glucose rechecks after high readings, failure to perform required glucose checks before insulin administration, lack of physician notification for elevated glucose levels, and missed doses of prescribed Lantus insulin. These deficiencies were confirmed through record review and by the DON.
A resident with a gluteal cleft pressure injury did not receive wound care as recommended by a wound NP, as the new treatment orders were not started until more than two weeks after being documented. The delay was due to a misunderstanding by the treatment nurse, who did not initiate the updated care regimen as ordered.
A resident's grievance about delayed call light response was not resolved by the facility. The resident, with intact cognition but physical limitations, experienced long waits for assistance after being incontinent. Despite filing a grievance, neither the resident nor their responsible party received a review of the grievance. Observations confirmed the call light was ignored, and staff interviews revealed the grievance was not communicated back, indicating a failure in the grievance resolution process.
A resident with PTSD was subjected to sexual abuse by another resident who exposed himself and made unwanted advances. The facility failed to separate the perpetrator from the victim and other residents, and staff did not provide immediate protection or support. The incident was not reported to the administration until hours later, indicating a failure in communication and adherence to abuse prevention policies.
A resident was subjected to inappropriate behavior by another resident, including exposure and physical contact, without immediate intervention from facility staff. The administration was not informed until hours later, and the aggressor remained in the shared room without supervision. Interviews revealed a lack of documentation and adherence to the abuse/neglect policy, highlighting a significant lapse in procedures.
A resident with a post-surgical wound experienced unmanaged pain due to the facility's failure to provide appropriate pain management. Despite requesting Tylenol, the LPN on duty informed the resident that no pain medication could be administered due to prescription issues. The resident, experiencing significant pain, called 911 and was admitted to the hospital ER, where she received Dilaudid for acute pain. The facility's pain management policy did not adequately address the administration of pain medication, leading to this deficiency.
A resident with paraplegia and PTSD reported an incident of sexual abuse by another resident, which was captured on video. The facility's ADON was informed but failed to report the incident to the Administrator or state agency within the required timeframe, violating the facility's abuse prevention policy.
A facility failed to thoroughly investigate a sexual abuse allegation involving two residents. A resident reported inappropriate behavior by another resident, supported by video evidence. The investigation was insufficient as the administrator only interviewed staff not present during the incident, contrary to the facility's policy.
A facility failed to document a physician's discharge order for a resident with severe cognitive impairment and multiple diagnoses, including chronic viral hepatitis C. The ADON admitted to misplacing the verbal order and acknowledged the lack of a system for handling verbal orders.
A facility failed to provide transportation for a resident with metastatic cancer to attend scheduled medical appointments, including a lab, oncology visit, and chemotherapy infusion. Despite the facility's policy requiring transportation arrangements, there was no documentation of the resident being transported or attending the appointments, nor any record of refusal. Interviews with staff confirmed the absence of documentation and transportation.
A resident admitted with multiple fractures and hemorrhages had a care plan that was not updated to reflect their improved condition. Despite a July MDS assessment showing cognitive intactness and reduced need for assistance, the care plan still included outdated interventions. Interviews in October revealed the resident was independently performing tasks and had stopped using prescribed devices. The MDS Director acknowledged the care plan should have been revised.
A facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers. Despite being care planned for potential skin integrity issues, the facility did not perform an accurate assessment or notify the MD/NP of the resident's skin condition. Inconsistent assessments by staff led to a lack of attention to the resident's sacral area, potentially worsening the condition.
The facility failed to implement a comprehensive care plan for two residents. One resident did not receive prescribed doses of Keflex due to a lack of communication with the pharmacy, while another resident's care plan was not updated after multiple falls, despite requiring extensive assistance. The DON acknowledged these oversights.
A facility failed to notify a resident's responsible party about a change in medical condition, specifically the initiation of antibiotics for a urinary tract infection. The facility's policy mandates prompt notification of changes, but records lacked documentation of such communication. Interviews with staff, including an LPN and the DON, confirmed the oversight.
A resident with multiple health conditions, including quadriplegia and acute kidney failure, was observed with a urinary catheter drainage bag improperly positioned, with the drain port tubing touching the floor. This was against the facility's CAUTI prevention guidelines, which require the drainage bag to be kept below the bladder level and off the floor. An LPN confirmed the improper positioning, highlighting a failure in adhering to catheter care protocols.
A facility failed to obtain informed consent and a physician's order for bed rail use for a resident with severe cognitive impairment and multiple diagnoses. Despite the facility's policy requiring these steps, the resident's medical records lacked the necessary documentation. Interviews with staff confirmed the presence of bed rails without the required consent and order, highlighting a breach in protocol.
The facility did not ensure that a CNA completed the required annual training on abuse and dementia care. The CNA's personnel record showed the last training was completed over a year ago, contrary to the facility's policy requiring annual training. This was confirmed during an interview with the Staff Development Coordinator, who acknowledged the lack of documentation for the required training.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to request assistance. One resident's call light was found on the ground, inaccessible, while another's was wrapped around a bed wheel, also out of reach. The DON confirmed these deficiencies during interviews.
The facility failed to address ongoing concerns about the laundry service, as reported by residents over several months. Multiple residents experienced issues with missing or incorrectly returned clothing, leading some to have their families handle laundry instead. Staff interviews revealed a lack of a structured laundry schedule and issues with clothing being returned to incorrect rooms, contributing to the problem. Despite acknowledging these issues, the facility did not take prompt action to resolve the concerns.
The facility failed to develop and implement care plans for two residents diagnosed with UTIs. One resident, with a history of chronic conditions, did not have a care plan for their UTI despite having a physician's order for Keflex. Another resident, with multiple health issues, also lacked a care plan for their UTI and was not administered Doxycycline and Acidophilus as ordered. These deficiencies were confirmed by facility staff.
A resident experienced a 13.32% weight loss over three months while being NPO and on PEG tube feedings. The facility failed to revise the care plan to include a dietician consult and weekly weight monitoring, despite the DON acknowledging the weight loss exceeded concern thresholds.
The facility failed to maintain grooming and hygiene for several residents, including untrimmed nails and missed baths. A resident with diabetes had long fingernails despite a care plan for podiatrist monitoring. Another resident with Alzheimer's had dirty nails not cleaned during bathing. A resident with cerebral infarction had jagged nails, and a resident with depressive disorder had a cracked nail unaddressed for days. A resident with mobility issues had long toenails causing discomfort, and another resident reported not receiving scheduled baths, confirmed by missing records.
A resident with a history of blood clots and cellulitis did not receive prescribed ted hose for edema, as they had not arrived from the supplier. Observations confirmed the absence of ted hose on the resident's swollen legs. Additionally, the facility failed to monitor the resident for edema while on diuretics, and the care plan did not address edema. Staff interviews confirmed these oversights, highlighting a failure to adhere to physician orders and care planning.
A resident with a complex medical history and multiple pressure ulcers was readmitted to the facility without timely wound care treatment orders. The facility delayed obtaining and implementing these orders for several days, as confirmed by interviews with the RN/Unit Manager and DON.
The facility failed to conduct quarterly Registered Dietician assessments for a resident receiving tube feeding, with the last documented assessment being in 2021. Additionally, another resident's monthly weights were not recorded in the EHR for two months, despite a policy requiring monthly documentation. The resident had a history of cerebrovascular disease and was on enteral feeding, with a potential weight loss noted.
The facility failed to properly label tube feeding formulas for two residents, omitting the time the feeding was hung, as required by their procedure. This deficiency was confirmed by an LPN during observations.
The facility failed to maintain proper respiratory care and equipment maintenance for residents, as observed in four cases. Equipment such as oxygen concentrators, nebulizers, and masks were not cleaned, labeled, or stored according to facility policy, affecting residents with chronic respiratory conditions. These deficiencies were confirmed by staff interviews.
The facility did not meet the required staffing levels on three weekends during the first fiscal quarter of 2024. On two specific dates, the facility provided fewer hours than required, as confirmed by the Interim Administrator/Regional MDS.
The facility failed to monitor two residents for adverse effects related to their medications. A resident on Lasix and Eliquis was not monitored for edema, bleeding, or bruising, while another resident on Lasix was not monitored for edema. Staff acknowledged the lack of required documentation for these conditions.
The facility failed to ensure the QAA Committee met quarterly, as required. A review of meeting records showed no evidence of quarterly meetings since the last annual survey. During an interview, the Administrator and Regional Director of Clinical Operations admitted they could not provide documentation of the required meetings. This deficiency potentially affected 189 residents.
The facility failed to ensure proper infection control practices and program maintenance. A resident on contact isolation for C-diff was not properly identified, and a CNA did not use the required PPE during care. Additionally, the facility did not maintain infection control tracking and trending for several months, as confirmed by the Infection Preventionist.
The facility did not ensure secure handrails on Hall W, affecting 31 residents. Observations showed a handrail near the exit door lacked an end cap, exposing a sharp edge and a crack. A CNA noted the handrail had been broken for months, and the Maintenance Supervisor confirmed it should have been repaired.
A facility failed to accurately document a resident's discharge status in the MDS assessment. The resident was discharged to another LTC facility, but the MDS incorrectly indicated a discharge to a hospital. This error was confirmed by the RN/MDS Director during a record review.
Failure to Provide Scheduled Pain Medication Resulting in Uncontrolled Pain and Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with chronic pain and multiple medical conditions, including spinal cord injury and chronic pain syndrome, did not receive scheduled Morphine Sulfate as ordered for pain management. The resident's physician had prescribed Morphine 30 mg, two tablets by mouth every eight hours, but the facility ran out of this medication. The last documented dose was administered in the afternoon, after which three consecutive scheduled doses were missed. During this period, the resident experienced severe pain, including a headache and nausea, and reported that alternative pain medications such as oxycodone-acetaminophen and Tylenol were ineffective. The breakdown in medication administration was due to failures in the facility's refill and communication processes. Nursing staff identified that the resident was running low on Morphine and faxed refill requests to the physician. Although the physician indicated that a hard copy prescription was sent to the pharmacy, there was no confirmation that the pharmacy received the request, and the medication was not delivered. Nursing staff did not follow up with the pharmacy as instructed, nor did they escalate the issue to the Unit Manager, DON, or Administrator in a timely manner. The Unit Manager and other staff were aware that the resident was out of Morphine but did not take further action to resolve the situation or notify higher-level staff. As a result, the resident missed three consecutive doses of scheduled Morphine, experienced uncontrolled pain, and ultimately required transfer to the emergency room for severe headache, nausea, and ineffective pain control. Interviews with staff and review of documentation confirmed that the facility failed to ensure the resident received pain medication as ordered, and that communication and follow-up procedures were not properly executed, directly resulting in actual harm to the resident.
Failure to Develop and Implement Care Plans for PICC Line Management and Physician-Ordered Services
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the use of PICC lines for two residents who were admitted with these devices for IV antibiotic administration. Record reviews showed that neither resident had a care plan problem or approaches documented for the management of their PICC lines, as confirmed by the MDS Director. One resident had a PICC line in the left arm, while the other had a PICC line initially in the left jugular vein, later replaced in the right upper inner arm. Both residents' care plans lacked documentation regarding the use and management of these lines for IV antibiotics. Additionally, the facility failed to administer IV antibiotics as ordered for one resident, with medication administration records missing documentation for specific doses. The resident reported not receiving the antibiotics as prescribed, and the DON confirmed the missed doses. Another resident did not receive restorative nursing services as ordered by the physician, with staff interviews revealing that the resident was not placed on the restorative schedule, resulting in the omission of required care. These failures were confirmed through staff interviews and record reviews.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube was observed receiving enteral feeding while lying flat in bed, contrary to physician orders and facility policy. The facility's policy and the resident's care plan both required the head of the bed to be elevated 30-45 degrees during tube feeding and for one hour after feeding. The resident, who had a history of traumatic brain injury and was rarely or never understood, was found supine with the feeding pump infusing, and the head of the bed was not elevated as required. Record review confirmed that the physician's orders specified continuous enteral feeding with the head of bed elevated, and this was also documented in the care plan. During the observation, facility leadership, including the DON and Administrator, acknowledged that the resident was not positioned correctly during the feeding process. The failure to elevate the head of the bed during tube feeding was directly observed and confirmed by staff interviews.
Failure to Honor Resident's Dietary Preference for White Meat
Penalty
Summary
The facility failed to honor a resident's documented dietary preference for white meat chicken during a lunch meal service. On the day of observation, the resident was served two baked chicken legs, which are dark meat, despite their meal card clearly indicating a preference for white meat. Staff interviews confirmed awareness of the resident's dislike for dark meat and acknowledged that the meal provided did not align with the resident's stated preference. The dietary manager also confirmed that the resident's preference should have been followed but was not in this instance.
Failure to Follow Physician Orders and Medication Administration Standards for Diabetic Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident with Type 2 diabetes mellitus and hyperglycemia. Specifically, the facility did not ensure that high blood glucose levels were rechecked as ordered after administering sliding scale insulin for glucose readings greater than 400. Multiple instances were identified where blood glucose levels exceeded 400, insulin was administered per sliding scale, but no evidence was found that glucose was rechecked after three hours as required by the physician's orders. Additionally, the facility did not consistently perform blood glucose checks to determine if sliding scale insulin was needed, as ordered, on certain mornings. There were also multiple occasions where the resident's blood glucose levels were above the threshold requiring physician notification, but there was no documentation that the physician had been notified as ordered. These failures were confirmed through review of the electronic medication administration records (eMAR) and nursing notes, as well as by the Director of Nursing during an interview. Furthermore, the facility did not administer the resident's prescribed morning doses of Lantus insulin on specific dates, as indicated by the absence of documentation in the eMAR. The Director of Nursing confirmed that there was no evidence these doses were given or documented. The facility's medication administration policy requires medications to be administered and documented as ordered, including timely administration, proper documentation, and physician notification when required, but these standards were not met in the care of this resident.
Failure to Timely Implement Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure ulcers for a resident with a gluteal cleft pressure injury. The resident, who had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, muscle weakness, and a nontraumatic intracerebral hemorrhage, was under the care of a wound nurse practitioner (NP) who recommended a specific wound care regimen. The NP's recommendations, which included cleaning the wound with cleanser, applying honey and a dry dressing, and changing the dressing three times per week or as needed, were documented in the resident's record. Despite these recommendations, the treatment administration record showed that the NP's wound care orders were not implemented until more than two weeks after they were made. Interviews with the treatment nurse revealed a misunderstanding regarding whether to continue the previous treatment until supplies were exhausted, despite no such instruction being documented. The NP confirmed that the new wound care orders should have been started as soon as they were given, and the treatment nurse acknowledged that the recommended care was not initiated as ordered.
Failure to Resolve Grievance Regarding Call Light Response
Penalty
Summary
The facility failed to adhere to its Grievance Policy by not resolving a grievance filed by a resident's responsible party regarding the resident's call light not being answered. The grievance, filed on January 31, 2025, highlighted incidents on January 25 and January 31, 2025, where the resident had to wait excessively long for assistance, specifically to be changed after being incontinent. Despite the grievance being filed, the facility did not provide a completed review of the grievance in writing or verbally to the resident or their responsible party. The resident involved had an intact cognitive status with a BIMS score of 15, indicating full cognitive function, but had physical limitations due to cardiopulmonary arrest and was on diuretic therapy. During a surveyor's visit, the resident confirmed that their call light was not answered, and the surveyor observed the call light being ignored. Interviews with staff confirmed that the grievance was not communicated back to the resident or their responsible party, indicating a failure in the facility's grievance resolution process.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse and psychosocial harm, resulting in an Immediate Jeopardy situation. A resident with intact cognition was approached in his bed by another resident who exposed himself and made unwanted sexual advances. Despite the incident being reported, the perpetrator was not immediately separated from the victim or other residents in the shared room, and no one-on-one supervision was provided. The incident involved multiple residents, including a paraplegic resident with PTSD, who reported the abuse to the facility administrator. The staff's response was inadequate, as they did not believe the victim and failed to provide immediate protection or support. The resident was left in the same room with the perpetrator and other residents until later in the day, exacerbating his PTSD symptoms. Interviews with staff revealed a lack of immediate action and documentation regarding the incident. The RN on duty did not witness the abuse but heard the victim's distress and failed to ensure the perpetrator was monitored or separated. The facility's administration was not informed until hours after the incident, highlighting a breakdown in communication and adherence to abuse prevention policies.
Failure to Ensure Resident Safety and Proper Response to Abuse Allegation
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency that affected the well-being of a resident. The incident involved a resident who was approached at his bedside by another resident with inappropriate behavior, including exposure and physical contact. Despite the resident's intact cognition and ability to report the incident, the facility staff did not take immediate action to separate the aggressor from the other residents in the shared room. The deficiency was further compounded by the lack of immediate response from the facility's administration. The administrator was not informed of the incident until the resident reported it directly to her office hours later. During this time, the aggressor remained in the shared room with the victim and other residents, without any one-on-one supervision or monitoring, which was a critical oversight in ensuring the safety and well-being of all residents involved. Interviews with facility staff revealed a lack of documentation and adherence to the abuse/neglect policy, particularly in terms of providing one-on-one care and monitoring for the aggressor. The Director of Nursing acknowledged the failure to implement necessary measures following the incident, and the administrator confirmed the absence of documentation for one-on-one supervision. This deficiency highlights a significant lapse in the facility's procedures for handling allegations of abuse and ensuring resident safety.
Failure in Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, resulting in actual harm. Resident #4, who had undergone surgery for the removal of metatarsals, reported pain at her surgical site and requested pain medication. Despite her request for Tylenol, the LPN on duty, S3, informed her that she could not administer any pain medication due to issues with the medication prescription. This led to Resident #4 experiencing unmanaged pain, which she rated as a 6 on a scale of 0-10. The facility's pain management policy, dated April 2022, outlines procedures for evaluating and managing pain, including both pharmacological and non-pharmacological interventions. However, the policy did not address the administration of pain medication as ordered. On the evening of the incident, S3 LPN did not conduct a pain assessment for Resident #4, as she was focused on arranging for the resident's transfer to the hospital. The lack of pain management led Resident #4 to call 911, resulting in her being admitted to the hospital ER, where she received Dilaudid for acute pain. Interviews with the staff and Resident #4 revealed that the resident was aware of the staff's attempts to resolve the prescription issue but was dissatisfied with the lack of immediate pain relief. The Director of Nursing acknowledged that Resident #4 should have received pain medication. The incident highlights a failure in the facility's pain management practices, as the resident did not receive any pain relief during the shift, leading to her hospitalization.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents within the required timeframe. Resident #1, who has diagnoses including unspecified paraplegia, anxiety disorder, depression, and PTSD, reported that Resident #2 approached him inappropriately during the early hours of 12/27/2024. Resident #1 captured the incident on video, showing Resident #2 with his genitals exposed and making inappropriate advances. Despite the incident being reported to the Assistant Director of Nursing (ADON) shortly after it occurred, it was not communicated to the facility's Administrator or the state agency within the mandated two-hour window. The facility's policy requires immediate reporting of such incidents to the Administrator and the state agency, but this protocol was not followed. The ADON acknowledged awareness of the incident but did not report it to the Administrator. The incident was not officially documented until several hours later, and the Administrator confirmed that the incident report was not submitted to the state agency as required. This delay in reporting constitutes a failure to adhere to the facility's abuse prevention policy and state regulations.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents. Resident #1 reported that Resident #2 approached him inappropriately during the early hours of 12/27/2024. Resident #1, who has diagnoses including unspecified paraplegia, anxiety disorder, depression, and post-traumatic stress disorder, stated that Resident #2 grabbed him by the arms and shoulders and exposed himself while making inappropriate comments. Video evidence from Resident #1's cell phone corroborated his account, showing Resident #2 with his genitals exposed and engaging in inappropriate behavior. The facility's investigation into the incident was inadequate. The administrator, who is the designated abuse coordinator, only interviewed two employees who were not present during the incident. The investigation did not include interviews with all staff members who were on duty at the time of the incident, as required by the facility's Abuse Prevention Policy. The administrator acknowledged that a thorough investigation was not conducted, failing to adhere to the policy's standards for addressing and investigating allegations of abuse.
Lack of Documentation for Physician's Discharge Order
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one of the sampled residents. Specifically, there was no documentation of a physician's discharge order for a resident who was discharged to the hospital. The resident had multiple diagnoses, including pain in the left wrist, chronic viral hepatitis C, cognitive communication deficit, and unspecified cannabis use. The resident's Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of 06, reflecting severely impaired cognition. During an interview, the Assistant Director of Nursing (ADON) admitted to misplacing the verbal discharge order from the physician and acknowledged the absence of a system for taking verbal orders.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure that a resident had access to necessary medical services outside the facility, as evidenced by the lack of transportation provided for scheduled medical appointments. The facility's Transportation to Appointments Policy outlines that the Transportation Supervisor or designee is responsible for scheduling and ensuring transportation for residents' medical appointments. However, for a resident with a diagnosis of colon cancer with metastatic cancer to bone, there was no documentation indicating that the resident was transported to or attended their scheduled appointments on November 7, 2024. These appointments included a non-fasting lab, a hematology oncology visit, and a chemotherapy infusion. Interviews with facility staff, including the Director of Nursing and the CNA Supervisor, confirmed that there was no documentation of the resident being transported or attending the scheduled appointments. Additionally, there was no record of the resident refusing to attend these appointments. The lack of documentation and transportation for the resident's critical medical appointments represents a failure to adhere to the facility's policy and ensure the resident's right to access necessary medical care.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to revise the care plan for one of the nine sampled residents, identified as Resident #4. Resident #4 was admitted with multiple serious injuries, including fractures and hemorrhages, and initially required significant assistance with mobility and activities of daily living (ADLs). The care plan, initiated in April and June 2024, included interventions for impaired physical mobility and ADL self-care performance deficits, such as partial weight-bearing instructions and the use of a Miami J-Collar and cam boot. Despite a quarterly MDS assessment in July 2024 indicating that Resident #4 was cognitively intact and required only supervision and setup help for mobility and ADLs, the care plan was not updated to reflect the resident's improved condition. Interviews conducted in October 2024 revealed that Resident #4 was independently performing tasks such as getting out of bed, dressing, and bathing, and had stopped using the prescribed collar and boot. The MDS Director confirmed that the care plan should have been updated following the July assessment.
Failure to Accurately Assess and Report Pressure Ulcer Risk
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers, consistent with professional standards of practice. The resident, who had a history of Spastic Diplegic Cerebral Palsy, Type 2 Diabetes, and other conditions, was totally dependent on staff for bed mobility and transfers. Despite being care planned for potential skin integrity issues, the facility did not perform an accurate assessment or notify the MD/NP of the resident's skin condition. On 09/14/2024, a Licensed Practical Nurse noted a pinkish/red area on the resident's buttock, indicating a stage I and II pressure ulcer, but failed to successfully notify the NP. Subsequent assessments by the treatment nurse and unit manager revealed inconsistencies in the documentation and recognition of the resident's skin condition. The treatment nurse initially reported no skin issues, while the unit manager later identified Moisture Associated Skin Damage (MASD) to the resident's sacrum. The Director of Nursing acknowledged that the MD should have been notified of the initial assessment and that the treatment nurse's assessment was inaccurate, potentially leading to a worsening of the resident's condition.
Deficiencies in Care Plan Implementation and Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their medical and care needs. For one resident, the facility did not follow physician orders for administering Keflex, an antibiotic, via PEG tube. The medication was not administered on specific dates, and there was no activity recorded in the facility's automated medication dispensing system, indicating missed doses. The Director of Nursing acknowledged the oversight, which was due to a failure in communication and verification with the pharmacy. Another resident experienced multiple falls, but the facility did not revise the resident's care plan to include interventions for falls that occurred on two specific dates. Despite the resident being cognitively intact and requiring extensive assistance with mobility and transfers, the care plan was not updated to address the falls. The Director of Nursing confirmed that the care plan should have been revised following these incidents.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident when there was a change in the resident's medical condition. Specifically, the responsible party was not informed about the initiation of antibiotic treatment for a urinary tract infection. The facility's policy requires that the resident, their attending physician, and the responsible party be promptly notified of any changes in the resident's medical or mental condition. However, in this case, the responsible party was not notified when the resident was prescribed Keflex, an antibiotic, to be administered via PEG tube three times a day for seven days. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The records did not show any documentation that the responsible party was informed about the antibiotic order. During interviews, an LPN acknowledged making a progress note entry regarding the new order but could not recall notifying the family. The Director of Nursing also confirmed that the responsible party should have been notified about the antibiotics ordered for the urinary tract infection, indicating a lapse in following the facility's notification policy.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate care to prevent urinary tract infections. The deficiency was identified during a review of the facility's policy and procedure for preventing Catheter-Associated Urinary Tract Infections (CAUTIs), which mandates maintaining unobstructed urine flow and keeping the drainage bag below the level of the bladder without placing it on the floor. However, an observation revealed that the urinary catheter drainage bag of a resident was hanging from the bedframe with the drain port tubing touching the floor, which is against the facility's guidelines. The resident involved had multiple diagnoses, including acute respiratory failure with hypoxia, acute kidney failure, quadriplegia, and essential hypertension. The resident's physician's orders included specific instructions for the care of a suprapubic catheter, which required sterile procedures and monthly changes. Despite these orders, the improper positioning of the catheter drainage bag was noted during an observation, and an LPN confirmed that the bag should not have been touching the floor, indicating a lapse in following the established CAUTI prevention strategies.
Failure to Obtain Consent and Physician's Order for Bed Rails
Penalty
Summary
The facility failed to obtain a written order from a physician and informed consent for the use of bed rails for one of the sampled residents. According to the facility's Bed Rail Policy, it is essential to assess residents for safety risks, review these risks and benefits with the resident or their representative, obtain informed consent, and secure a physician's order before installing bed rails. However, the review of Resident #2's medical records did not reveal any informed consent or physician's order for the use of bed rails, which is a violation of the facility's policy. Resident #2, who was admitted with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage, and severe cognitive impairment, was found to have grab bars on their bed. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the presence of mobility bars on the resident's bed and acknowledged the absence of the required informed consent and physician's order. This oversight indicates a failure to adhere to the established procedures for ensuring the safe and appropriate use of bed rails, as outlined in the facility's policy.
Failure to Complete Required Annual Training for CNA
Penalty
Summary
The facility failed to ensure that required annual training on abuse and dementia care was completed for one direct care staff member, a Certified Nursing Assistant (CNA), out of six direct care staff personnel records reviewed. According to the facility's Abuse Prevention Policy, all staff, including contractors and volunteers, are required to receive annual education and training on abuse, neglect, and exploitation. The personnel record of the CNA in question showed a hire date of September 25, 2018, and indicated that the last documented training on abuse and dementia was completed on June 1, 2023. During an interview conducted on August 13, 2024, the Staff Development Coordinator reviewed the CNA's personnel record and acknowledged the absence of documentation for the required annual training. This oversight highlights a lapse in adherence to the facility's policy on mandatory training, which is crucial for ensuring staff are equipped to handle situations involving abuse, neglect, and exploitation.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, as required by the facility's procedure. Resident #39 reported not having a call light during an interview, and observations confirmed that the call light was on the ground, wedged between the wall and a piece of furniture, making it inaccessible. This issue persisted over multiple days, as observed on June 3rd and June 5th, 2024. The Director of Nursing (DON) confirmed the deficiency during an interview, acknowledging that the call light should have been within the resident's reach. Similarly, Resident #67, who was at risk for falls due to decreased mobility and a history of falls, also had an inaccessible call light. Observations on June 3rd and June 4th, 2024, revealed that the call light cord was wrapped around and wedged in the bed wheel at the foot of the bed, making it unreachable for the resident. The DON acknowledged this issue during an interview, confirming that the call light was not within the resident's reach, contrary to the care plan's interventions to anticipate and meet the resident's needs.
Failure to Address Laundry Service Concerns
Penalty
Summary
The facility failed to adequately address and act upon the concerns raised by the resident council regarding issues with the laundry service. Over several months, multiple residents reported missing or incorrectly returned clothing items during resident council meetings. These grievances were documented from January to May 2024, with residents expressing dissatisfaction with the slow return of laundry, missing items, and receiving clothes that did not belong to them. Some residents, due to these ongoing issues, opted to have their families handle their laundry instead. The facility's grievance log for May 2024 also recorded complaints about missing clothing, with delayed responses from the facility. Interviews with staff revealed a lack of a structured laundry schedule and issues with clothing being returned to incorrect rooms or floors, contributing to the problem. The Activity Director and Housekeeping/Laundry Supervisor acknowledged the issues, with the latter noting that the return of clothes depended on various factors, including the absence of names on clothing and room changes by residents. Despite these acknowledgments, the facility did not take prompt action to resolve the residents' concerns, leading to continued dissatisfaction and potential impact on all 189 residents.
Failure to Develop and Implement Care Plans for UTIs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents diagnosed with urinary tract infections (UTIs). Resident #25, who has a history of chronic congestive heart failure, primary hypertension, type 2 diabetes, and a UTI, did not have a care plan addressing the UTI despite having a physician's order for Keflex. The resident's electronic health record and comprehensive plan of care lacked any mention of the UTI diagnosis or treatment plan. This oversight was confirmed by an LPN/MDS Nurse during an interview. Similarly, Resident #98, with a medical history including UTI, generalized epilepsy, type 2 diabetes, cerebral infarction, essential hypertension, and aphasia, also lacked a care plan for their UTI. Although there was a physician's order for Macrobid, the care plan did not reflect this diagnosis. Additionally, Resident #98 was not administered Doxycycline and Acidophilus as ordered by the nurse practitioner, as these medications were not entered into the electronic health record or the medication administration record. This failure was confirmed by the Director of Nurses during an interview.
Failure to Revise Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced significant weight loss. The resident, who was NPO and receiving enteral feedings through a PEG tube, showed a weight decrease from 112.6 lbs to 97.6 lbs over a period of approximately three months, indicating a 13.32% weight loss. Despite this significant weight loss, the resident's care plan was not updated to include a dietician consult or the implementation of weekly weight monitoring. During an interview, the Director of Nursing (DON) acknowledged that the resident's weight loss exceeded the thresholds for concern, which should have triggered a dietician consult and weekly weight checks. However, these actions were not documented in the resident's care plan. The DON confirmed that the facility's protocol involves reviewing residents with significant weight loss in monthly meetings and implementing necessary interventions, but these steps were not taken for this resident.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in maintaining grooming and hygiene for several residents. Resident #25, who has a diagnosis of diabetes mellitus and other health issues, was observed with long fingernails despite a care plan that included monitoring by a podiatrist. The resident expressed a need for nail trimming, which was confirmed by staff as not being performed. Similarly, Resident #57, with Alzheimer's disease and other conditions, was found with long, dirty fingernails, which were not cleaned or trimmed during bathing as required. Resident #98, with a history of cerebral infarction and diabetes, was observed with long, jagged fingernails, indicating a failure to follow the care plan that required nail care on bath days. Staff acknowledged the need for frequent trimming due to fast nail growth. Resident #141, with major depressive disorder, had a cracked thumbnail that had not been addressed for several days, despite the resident's request for trimming. This oversight was confirmed by staff, highlighting a lapse in the care plan's execution. Additionally, Resident #120, with multiple fractures and mobility issues, had long, thick toenails causing discomfort, and had not been seen by a podiatrist for about a year, contrary to the care plan. Resident #174 reported not receiving scheduled baths, confirmed by a review of the electronic health record, which showed no record of bathing since admission. The resident had to wash herself at the sink, indicating a failure in the facility's scheduling and documentation processes.
Failure to Follow Physician Orders for Edema Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema, as per physician orders and professional standards of practice. The resident, who had a medical history of blood clots and cellulitis, reported not wearing ted hose despite having a physician's order for them. Observations confirmed the absence of ted hose on the resident's swollen lower extremities on multiple occasions. The resident's medical records indicated a diagnosis of embolism and thrombosis, and orders for ted hose application during the day, as well as medication for DVT and CHF with edema. However, the facility did not ensure the resident received the prescribed ted hose, as they had not arrived from the medical supply company. Additionally, the facility failed to monitor the resident for edema while on diuretics, as required by the physician's orders. The resident's care plan did not address the issue of edema, and the EMAR did not include monitoring tasks for edema related to diuretic use. Interviews with facility staff, including an LPN and the DON, confirmed the oversight in monitoring and the lack of documentation regarding the order and follow-up for the ted hose. This lack of adherence to physician orders and care planning resulted in the resident not receiving the necessary treatment for their condition.
Failure to Timely Implement Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. Upon readmission to the facility, the resident, who had a complex medical history including anoxic brain damage, cardiac arrest, and severe hypoxic ischemic encephalopathy, was not given appropriate wound care treatment orders. The resident was assessed to have a stage IV pressure ulcer on the sacrum, and stage II pressure ulcers on the right arm and left foot. However, the facility did not obtain or implement wound care treatment orders until several days after the resident's readmission. Interviews with facility staff, including a Registered Nurse/Unit Manager and the Director of Nursing, confirmed the delay in obtaining and implementing wound care treatment orders. The staff acknowledged that the orders were not put in place until four days after the resident's readmission, indicating a lapse in the facility's protocol for managing pressure ulcers and ensuring timely care for residents with such conditions.
Failure to Conduct Regular Dietician Assessments and Document Monthly Weights
Penalty
Summary
The facility failed to ensure that Resident #85 received at least quarterly Registered Dietician (RD) assessments as per the facility's policy. The policy required the RD to review all new admissions, tube feedings, and residents on dialysis at least quarterly. However, Resident #85, who was receiving Glucerna via a feeding pump and had multiple diagnoses including hemiplegia, diabetes, and malnutrition, did not have a documented RD assessment since 07/15/2021 until a mini assessment on 06/06/2024. The RD reported that the last assessment was on 03/21/2023, but could not provide documentation, and the mini assessment was conducted without seeing the resident, relying solely on the resident's record. Additionally, the facility did not document monthly weights for Resident #135 in the electronic health record (EHR) as required by the facility's weight management policy. Resident #135, who had a history of cerebrovascular disease and was on enteral feeding, had a recorded weight of 164.4 pounds on 03/01/2024, but no weights were documented for April and May 2024. A handwritten weight of 158.9 pounds was found for May 7, 2024, indicating a potential weight loss. The Director of Nursing confirmed that the weights were not recorded in the EHR for the specified months, which was against the facility's policy.
Failure to Properly Label Tube Feeding Formulas
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents who were receiving tube feeding. The deficiency was identified during a review of the facility's procedures and observations of the residents. The facility's procedure for enteral tube feeding via pump requires that the feeding bag or bottle be labeled with specific information, including the resident's name, room number, type of formula, date and time the formula is hung, and the rate of administration. However, during observations, it was found that the tube feeding formula labels for two residents did not include the time the feeding was hung. Resident #85, who was admitted with diagnoses including hemiplegia, hemiparesis, and Type 2 diabetes mellitus, was observed receiving Glucerna via feeding pump. The label on the feeding formula did not include the time it was hung. Similarly, Resident #161, who had diagnoses including hemiplegia, aphasia, dysphagia, and severe protein-calorie malnutrition, was observed receiving Jevity 1.5 via feeding pump, and the label also lacked the time the feeding was hung. An LPN confirmed that the labels for both residents were incomplete and should have included the time the feeding was hung.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring such care, as evidenced by observations, record reviews, and interviews. Specifically, the facility did not maintain cleanliness and proper labeling of respiratory equipment for four residents. Resident #79's oxygen concentrator and filter were observed with a thick layer of dust, and the oxygen tubing was not dated, contrary to the physician's orders and facility policy. The Director of Nursing confirmed these deficiencies during an interview. For Resident #120, the nebulizer and mask were found on the overbed table without proper labeling or dating, and they were not stored correctly when not in use. This was confirmed by an LPN during an interview. Similarly, Resident #136's nebulizer mask was dated from several weeks prior and was not stored in a plastic bag when not in use, as required by the facility's policy. The LPN confirmed these observations and acknowledged the improper storage and labeling. Resident #139's respiratory care was also deficient, with oxygen tubing and humidifier bottles not labeled or dated, and the nebulizer mask not stored properly. These issues were confirmed by both an LPN and a respiratory therapist, who stated that respiratory supplies should be changed weekly and properly labeled. The facility's failure to adhere to its own respiratory therapy equipment policy resulted in these deficiencies, affecting the care provided to residents with significant respiratory needs.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of residents, specifically on three weekend days during the first fiscal quarter of 2024. A review of the facility's Payroll Based Journal (PBJ) Staffing Data Report indicated that the facility did not meet the minimum required staffing hours on October 21, 2023, and December 16, 2023. On these dates, the facility provided 375.38 hours and 366.9 hours, respectively, while the required hours were 378.35 and 376. Additionally, on October 1, 2023, the facility provided 275.75 hours, exceeding the required 254.85 hours, but this was not the case for the other two dates. During an interview, the Interim Administrator/Regional MDS confirmed the facility's failure to meet the required staffing hours on the specified dates.
Failure to Monitor Residents on Diuretics and Anticoagulants
Penalty
Summary
The facility failed to adequately monitor two residents for potential adverse effects related to their medication regimens, resulting in a deficiency. Resident #27 was prescribed Lasix, a diuretic, to manage peripheral vascular disease and was required to be monitored for edema. Additionally, the resident was on Eliquis, an anticoagulant, necessitating monitoring for abnormal bleeding or bruising. However, a review of Resident #27's medical records revealed a lack of documentation for monitoring these conditions. During an interview, an LPN acknowledged that the necessary monitoring for bleeding and edema was not conducted as required. Similarly, Resident #106 was prescribed Lasix for edema associated with hypertension. The medical records for this resident also lacked documentation of monitoring for edema, which was confirmed during interviews with both an LPN and the Director of Nursing. Both staff members acknowledged the absence of necessary monitoring documentation for the administration of the diuretic, indicating a failure to adhere to the prescribed monitoring protocols for these residents.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee met at least quarterly, as required. This deficiency was identified through a review of the QAA meeting information, which did not provide evidence of any quarterly meetings since the last annual survey conducted on June 8, 2023. During an interview on June 6, 2024, the facility's Administrator and the Regional Director of Clinical Operations acknowledged their inability to provide documentation of the required quarterly QAA meetings. This failure had the potential to affect the 189 residents residing in the facility, as documented by the facility's Long-Term Care Facility Application for Medicare and Medicaid form dated June 3, 2024.
Inadequate Infection Control Practices and Program Maintenance
Penalty
Summary
The facility failed to ensure staff practices were consistent with current infection control principles, specifically in the use of appropriate PPE during resident care. A resident on contact isolation for C-diff was observed without proper signage indicating isolation status, and a CNA was seen providing care without wearing the required PPE, such as a gown and shoe covers. The CNA confirmed the oversight, and the Director of Nursing acknowledged the failure to adhere to the facility's contact isolation policy. Additionally, the facility did not maintain an infection prevention and control program as required. There was no written evidence of implemented infection control policies and procedures for surveillance, tracking, and trending of infections. The Infection Preventionist confirmed that monthly infection control tracking and trending had not been completed for several months, which was a requirement according to the facility's policy.
Insecure Handrails on Hall W
Penalty
Summary
The facility failed to ensure that hallway handrails were securely affixed to the walls, specifically on Hall W, which could potentially affect 31 residents residing there. Observations revealed that the handrail near the exit door on Hall W lacked an end cap, leaving a sharp edge exposed and a crack in the handrail. During an interview, a CNA reported that the handrail had been broken for a couple of months. Further observation with the Maintenance Supervisor confirmed the deficiency, acknowledging that the handrail should have been repaired.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the discharge status of a resident. Specifically, the MDS assessment for a resident who was discharged to another long-term care facility incorrectly indicated that the resident was discharged to a short-term general hospital. This discrepancy was identified during a review of the resident's records and was acknowledged by the Registered Nurse/MDS Director during an interview. The error in the MDS assessment was not aligned with the actual discharge destination as documented in the resident's progress notes.
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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