Hilltop Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pineville, Louisiana.
- Location
- 336 Edgewood Drive, Pineville, Louisiana 71360
- CMS Provider Number
- 195390
- Inspections on file
- 20
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Hilltop Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
The facility did not post up-to-date nurse staffing information, as the displayed staffing sheet was outdated and did not reflect current staffing. The DON and an RN/Charge Nurse confirmed that the staff member responsible for posting this information had quit abruptly, leading to the deficiency.
The facility failed to provide quarterly personal funds statements to three residents, despite holding funds for 52 residents. The residents had authorized the facility to manage their funds and elected to receive statements, but interviews confirmed they never received them. Staff admitted there was no system in place to ensure the distribution of these statements.
The facility did not hold quarterly Quality Assessment and Assurance (QAA) meetings as required, with the last meeting occurring several months ago. The Director of Nursing confirmed that no meetings had been conducted since, and the Medical Director had not reviewed current QAPI data.
A resident was found self-administering Afrin nasal spray without a proper assessment, physician's order, or care plan. The facility's policy requires an interdisciplinary team assessment and specific order for self-administration, which were not in place. Staff confirmed the absence of necessary documentation and approval for the resident's self-administration of the nasal spray.
A facility failed to ensure a resident's call light was accessible, as required by policy. The resident, with severe cognitive impairment and significant physical assistance needs, had their call light positioned out of reach at the foot of the bed. Observations confirmed the call light was not visible or accessible, and staff acknowledged it should have been within reach.
The facility failed to report serious injuries of three residents to the State Survey Agency within the required timeframe. A resident with severe cognitive impairment sustained an avulsion fracture, another had an un-witnessed fall resulting in a femur fracture, and a third resident was found to have a compression fracture. Despite being aware of these injuries, the facility did not report them as mandated by state law.
A facility failed to complete required discharge documentation for a resident with multiple diagnoses, including anxiety disorders and diabetes. The resident's medical record lacked a discharge summary, physician order, and necessary information for the receiving provider. Interviews confirmed the absence of documentation, despite the Administrator's involvement in the transfer.
A resident with severe cognitive impairment and a right hand contracture did not have a required hand roll in place, as observed over several days. Despite care plan and physician orders specifying the use of a hand roll, staff were unable to locate it, indicating a failure to implement the resident's care plan.
The facility failed to update care plans for two residents, one requiring oxygen therapy and another self-administering medications. A resident adjusted her oxygen concentrator against physician orders, and another resident self-administered nasal spray without a care plan or order. Staff confirmed the care plans were not updated to reflect these needs.
The facility failed to document discharge summaries for two residents, one with multiple diagnoses including Alzheimer's and another with moderate cognitive impairment. Both residents were discharged without the necessary documentation, as confirmed by interviews with facility staff.
The facility did not complete annual performance reviews for two CNAs as required by policy. The DON, responsible for conducting and signing off on these evaluations, confirmed that they had not been completed. Personnel records lacked evidence of evaluations for CNAs hired over a year ago.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, were not provided in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing pattern was posted as required. On observation, the posted staffing information was found to be outdated, displaying a date from nearly two weeks prior. During interviews, the Director of Nursing (DON) and an RN/Charge Nurse confirmed that the staff member responsible for posting the daily staffing pattern had quit abruptly, resulting in the failure to update and post current staffing information. The posted sheet did not reflect the current date or actual staffing for the day of the survey, despite a facility census of 89 residents.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly personal funds statements to three residents, despite holding personal funds for a total of 52 residents. The facility's policy, as outlined in the Admission Packet dated February 2023, mandates that individual financial records must be available through quarterly statements and upon request to the resident or their legal representative. However, interviews and record reviews revealed that Residents #44, #67, and #75, who had authorized the facility to manage their funds and elected to receive quarterly statements, did not receive them. Interviews with the residents confirmed that they had never received the required quarterly statements and expressed a desire to receive them. Further interviews with facility staff, including S9 HR and S14 BOM, confirmed the absence of a system to ensure the distribution of these statements. The staff acknowledged that no quarterly statements were provided to any of the 52 residents whose funds were managed by the facility, indicating a systemic issue in the facility's financial management practices.
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 and included the required staff members. The facility's policy on Quality Assurance and Performance Improvement (QAPI) guidelines mandates that the committee should identify issues affecting the quality of care and services provided to residents, with the Medical Director and consultants included in quarterly meetings. However, a review of the facility's QAA committee sign-in sheets revealed that the last meeting was conducted on July 11, 2023. An interview with the Director of Nursing (DON) confirmed that no quarterly QAA meetings had been conducted since that date, and neither the Medical Director nor any governing body member had reviewed current QAPI data since the last meeting.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and determined if a resident was clinically appropriate for self-administration of medication. Specifically, Resident #75 was found to be self-administering Afrin nasal spray without a proper assessment, physician's order, or care plan in place. The facility's policy requires that the interdisciplinary team assess a resident's ability to safely self-administer medications and obtain a specific order if the right is granted. However, Resident #75's clinical record lacked a self-administration assessment for the Afrin nasal spray, and there was no care plan reflecting self-administration. Observations and interviews revealed that Resident #75 had Afrin nasal spray and eye drops at his bedside, which he was self-administering. Interviews with facility staff, including LPNs and RNs, confirmed that there was no self-administration assessment or physician's order for the Afrin nasal spray. The Director of Nursing and another RN also confirmed the absence of a care plan or order for self-administration, acknowledging that the nasal spray should not have been in the resident's room without proper documentation and approval.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for a resident by not providing an accessible call light. The facility's policy requires that each resident have the call light within reach at all times, regardless of their ability to use it. However, observations revealed that the call light for a resident with severe cognitive impairment and significant physical assistance needs was not within reach. The resident, who required extensive assistance with bed mobility and was totally dependent on staff for transfers, had their call light positioned at the foot of the bed, out of reach. Further observations confirmed that the call light was not visible or accessible to the resident, as it was found behind the bed near the foot. Staff members, including an LPN and a CNA, confirmed during an interview that the call light was not within reach and acknowledged that it should have been. The resident's care plan specifically noted the need to keep the call light in reach and respond in a timely manner, highlighting the facility's failure to adhere to its own policies and the resident's care plan requirements.
Failure to Report Resident Injuries Timely
Penalty
Summary
The facility failed to report serious bodily injuries of three residents to the State Survey Agency within the required two-hour timeframe, as mandated by state law. Resident #42, who had severe cognitive impairment and required extensive assistance, sustained an avulsion fracture of the medial femoral condyle. The injury was discovered following an x-ray ordered by a nurse practitioner to rule out osteomyelitis. Despite the facility's awareness of the injury on the day it was discovered, the incident was not reported to the State Survey Agency as required. Resident #93, also with severe cognitive impairment, experienced an un-witnessed fall resulting in a right femur neck fracture with impaction. Initially, x-rays did not reveal any fractures, but subsequent imaging confirmed the injury. The facility was aware of the fracture on the day it was confirmed, yet failed to report it to the State Survey Agency. The resident's fall and subsequent injury were not witnessed, and the resident was known to be at high risk for falls. Resident #96, with moderate cognitive impairment, was found to have a compression fracture of L1 following an MRI. The facility became aware of this major injury of unknown origin on the day the MRI results were received. However, the required report to the State Survey Agency was not initiated. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed for any of the three residents, resulting in a deficiency.
Failure to Complete Required Discharge Documentation
Penalty
Summary
The facility failed to ensure that required discharge documentation was completed for a resident who was reviewed for discharge. The facility's policy on discharge planning emphasizes the importance of a planned program of continuing care to meet each resident's discharge needs. However, the facility did not adhere to its policy, as evidenced by the lack of a completed discharge summary and other necessary documentation in the resident's medical record. This includes the absence of a physician order for discharge, the basis for the discharge, and information provided to the receiving provider, such as contact information, advance directive information, and comprehensive care plan goals. The resident in question had multiple diagnoses, including anxiety disorders, diabetes mellitus, cerebral infarction, aphasia following cerebral infarction, depressive episodes, chronic pain, and chronic obstructive pulmonary disease. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. Interviews with the Director of Nursing (DON) and the Administrator confirmed the absence of the required discharge documentation in the resident's medical record, despite the Administrator's involvement in the resident's transfer to another facility.
Failure to Implement Care Plan for Resident's Hand Contracture
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple medical conditions, including contracture of the right hand. The resident required a hand roll to manage the contracture, as indicated in their care plan and physician orders. However, observations over several days revealed that the hand roll was not in use, and staff were unable to locate it in the resident's room. Interviews with an LPN and a CNA confirmed that the resident was supposed to use a hand roll for the contracted hand, but it was not in place during the observations. The staff acknowledged the absence of the hand roll, which was a necessary intervention for the resident's condition, as outlined in the care plan and medical orders. This oversight indicates a failure to adhere to the established care plan and physician directives for the resident's care.
Failure to Update Care Plans for Oxygen Therapy and Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was reviewed and revised for two residents. For one resident, who required oxygen therapy due to COPD and other conditions, the care plan did not include education for the resident to notify nursing staff if there was a need to increase her oxygen. Observations revealed that the resident was adjusting her oxygen concentrator to 3 liters/minute, contrary to the physician's order of 2 liters/minute. Interviews with staff confirmed that the resident was not care planned to adjust her oxygen level and that the care plan should have been updated to include this information. Another resident, who was cognitively intact and had a history of restlessness and agitation, was found to have nasal sprays and eye drops in his room for self-administration. However, the care plan did not include an order for self-administration of the nasal spray, and there was no self-administration assessment in the resident's medical record. Interviews with staff confirmed that the resident should not have been self-administering the nasal spray at bedside without a proper order and care plan. The deficiencies highlight the facility's failure to update and revise care plans to reflect the residents' current needs and physician orders. This oversight resulted in residents managing their medications and treatments without appropriate guidance and documentation, which could potentially impact their health and safety.
Failure to Document Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to document a discharge summary for two residents, leading to a deficiency in communication of necessary information at the time of discharge. Resident #98, who had multiple diagnoses including Type 2 Diabetes Mellitus with foot ulcer and Alzheimer's Disease, was transferred to a behavioral health hospital due to behaviors and safety concerns. Despite being discharged from the behavioral hospital to another facility, no discharge summary was completed. Interviews with the social worker, Director of Nursing (DON), Assistant Administrator, and Administrator confirmed the absence of a discharge summary for Resident #98. Similarly, Resident #99, who had diagnoses including Anxiety Disorders, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was discharged without a documented discharge summary. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON and Administrator confirmed that a discharge summary should have been completed but was not present in the resident's medical record. This lack of documentation for both residents indicates a failure in the facility's discharge process.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for certified nurse aides (CNAs) as required by their policy. Specifically, the personnel records for two CNAs, hired on 12/01/2022 and 08/19/2021, lacked evidence of completed and signed annual performance evaluations within the past 12 months. The facility's policy mandates that each employee's job performance be reviewed and evaluated annually by the department director and reviewed by management. Interviews revealed that the Director of Nursing (DON) was responsible for conducting these evaluations but had not completed or signed off on any CNA performance evaluations, despite being present during the evaluations. The Human Resources representative confirmed the absence of signed evaluations for the two CNAs in question.
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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