Holly Hill House
Inspection history, citations, penalties and survey trends for this long-term care facility in Sulphur, Louisiana.
- Location
- 100 Kingston Road, Sulphur, Louisiana 70663
- CMS Provider Number
- 195431
- Inspections on file
- 28
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Holly Hill House during CMS and state inspections, most recent first.
A resident with morbid obesity, left AKA, cerebrovascular disease, dementia, and documented dependence for toileting and substantial/maximal assistance for bed mobility had a care plan requiring two or more staff for repositioning and turning in bed. During peri-care, a CNA provided bed mobility alone, turned the resident to the side to change a brief, and the resident grabbed the bed rail and rolled out of bed onto the floor. The resident was found on the floor with a hyperextended right leg, immediate bruising, and skin tears, and was later diagnosed in the hospital with a comminuted periprosthetic proximal tibia fracture, a proximal fibula fracture, and a significant lower-leg hematoma. The CNA admitted not reviewing the Kardex before care and not following the two-person assist requirement.
A resident with dementia and sensory impairment was physically abused by another resident with severe psychiatric and cognitive disorders. Despite a CNA's attempt to intervene, the aggressive resident bypassed staff and struck the victim in the face, causing visible injury. Staff interviews confirmed the incident and acknowledged that the resident was not protected from abuse, in violation of facility policy.
A resident was found with a hematoma and bruising on the right side of the head, but the LPN who was notified of the injury did not immediately report it to administrative staff. As a result, the administrative team and state agency were not notified within the required 2-hour timeframe, in violation of the facility's abuse prevention and reporting policy.
A resident with multiple mental health diagnoses was transferred from the facility to a hospital via stretcher, but the required notification to the State Long-Term Care Ombudsman was not made. Review of the emergency transfer log and staff interviews confirmed the omission.
Two residents with significant behavioral health diagnoses did not receive or have documented 1:1 supervision as ordered by a nurse practitioner following incidents of suicidal ideation and resident-to-resident aggression. Despite clear orders for 1:1 monitoring, the EMR lacked evidence that this supervision was provided prior to their transfers to behavioral hospitals, a deficiency confirmed by facility leadership.
A grievance regarding a resident's odor and soiled brief was not resolved within the facility's policy timeframe of 5 working days, taking 21 days instead. The resident had an acquired absence of the left leg above the knee, dementia, and morbid obesity. Both the DON and Administrator acknowledged the delay.
The facility failed to report and investigate critical incidents involving nine residents in a timely manner. Incidents of abuse, neglect, or injury were not reported within the required time frames, and investigation results were not submitted to the State Survey Agency within five working days. The administrator admitted to not having access to the reporting system and was unaware of pending incidents, leading to deficiencies in incident handling.
A facility failed to accurately complete the MDS for a resident, who was admitted with atrial fibrillation, vascular dementia, and anxiety disorder. The resident's MAR showed they received an anticoagulant and an antidepressant, but no antibiotics. However, the MDS incorrectly documented antibiotic use and omitted the anticoagulant and antidepressant. The MDS coordinator confirmed these discrepancies during a review.
Two residents experienced unwitnessed falls with visible blood, and the facility failed to complete the required neurological checks as per policy. Despite being transferred to the hospital, upon return, the checks were not consistently documented, and there was a lack of documentation regarding the residents' mental status. The ADONs confirmed the incompleteness of the assessments.
A facility failed to ensure up-to-date hospice documentation for a resident with multiple diagnoses, including CHF and Alzheimer's. The hospice nurse's visit notes were outdated, contrary to the hospice services agreement and facility policy. The administrator, responsible for hospice contact, acknowledged the lapse, having not followed up after initially contacting the hospice agency.
A resident with an indwelling catheter experienced a significant decrease in urinary output, which was not reported by the LPN to the physician or charge nurse, as required by facility policy. The resident, who had a history of urinary retention and other conditions, showed a urinary output of only 100 cc over an 8-hour period, significantly lower than usual. This deficiency was confirmed by the DON and ADON during interviews.
A resident with Alzheimer's and mild cognitive impairment was physically abused by another resident with Bipolar Disorder and mild cognitive impairment. The incident occurred when the aggressor accused the victim of gossiping and punched her in the hip. An LPN witnessed the event and confirmed the act was deliberate. The facility's policy defines such actions as abuse, and the DON acknowledged the incident as a willful act of physical abuse.
A resident with severe cognitive impairment and multiple diagnoses did not receive proper monitoring for foley catheter urinary output and anticoagulant side effects as outlined in their care plan. Facility staff confirmed the lack of documentation and absence of a policy for anticoagulant monitoring.
The facility failed to provide sufficient dietary staff, resulting in delayed meal service for 84 residents. Meals were consistently served late, with breakfast and lunch often delayed by up to two hours. Residents and staff reported inconsistent meal times, and snacks were frequently not delivered. These issues highlight the facility's inability to meet scheduled meal and snack times, affecting residents' nutritional needs.
The facility failed to provide meals according to residents' dietary preferences and needs, as observed in five residents. Instances included incorrect milk types being served and missing beverages. A CNA admitted to not checking diet slips before serving, and the Dietary Manager confirmed that substitutions were made without notifying residents.
The facility failed to weigh residents as per physician's orders, impacting 20 residents who were supposed to be monitored weekly for four weeks. The ADON confirmed the oversight, with missing weight records for various weeks across all residents reviewed.
The facility failed to maintain acceptable nutritional parameters for two residents. One resident experienced significant weight loss due to inadequate monitoring and lack of dietary intervention, while another did not receive recommended nutritional supplements. The oversight in implementing dietitian recommendations and monitoring weight changes contributed to these deficiencies.
The facility failed to provide adequate incontinence briefs and linens, affecting resident care. Staff confirmed shortages of large, XL, 2XL, and 3XL briefs, and insufficient towels and washcloths for personal hygiene. The Administrator's budget constraints led to critical supply shortages, impacting 74 incontinent residents and the overall census of 89.
A resident with a history of femur fracture experienced a fall and complained of leg pain. Despite a physician's order for an x-ray, the facility delayed obtaining the x-ray due to a communication lapse with the contracted radiology service. The x-ray, completed four days later, led to a delayed diagnosis of a femur fracture.
The facility failed to store food in accordance with professional standards and did not maintain sanitary conditions in the kitchen. Observations revealed spoiled and expired food items in the refrigerator, freezer, and dry storage, as well as a dirty cart used for food distribution. The Dietary Supervisor confirmed these deficiencies.
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for residents with infections, colonization with MDRO, chronic wounds, and indwelling medical devices. This deficiency affected 8 out of 14 residents who met the criteria for EBP, as confirmed by interviews with key staff members.
The facility failed to implement and maintain infection control practices, specifically Enhanced Barrier Precautions (EBP), for residents with chronic wounds or indwelling medical devices. Staff were unaware of EBP requirements, and multiple residents were observed without necessary signage, PPE, or biohazard bins, leading to potential infection risks.
The facility failed to accurately code the MDS assessment for a resident, incorrectly indicating the use of an antidepressant despite no physician orders for such medication. This error was confirmed by the MDS nurse upon review.
The facility failed to refer a resident with a newly diagnosed Delusional Disorder to the appropriate state-designated authority for a Level II PASARR evaluation. The Assistant Director of Nursing confirmed that the facility was unaware of the requirement to resubmit for a Level II PASARR review.
A resident with multiple diagnoses, including a UTI, was prescribed Bactrim DS. The care plan required monitoring for adverse reactions every shift, but a review of records and staff interviews confirmed that this monitoring was not documented or performed.
The facility failed to protect residents from abuse, resulting in psychosocial harm to a resident who was sexually abused, physical harm to a resident struck with a cane, and another resident who was hit in the eye during an altercation.
The facility failed to provide quarterly statements of personal funds for a resident with Chronic Obstructive Pulmonary Disease and other conditions. The resident, who was cognitively intact, reported not receiving a statement in over two years. The Business Office Manager confirmed the lack of documentation for the quarterly statements in 2023.
The facility failed to develop comprehensive care plans and follow physician orders for three residents, leading to unaddressed sexual behaviors, incorrect medication administration, and missed treatments for respiratory care.
A resident with chronic respiratory conditions had their BiPAP and nebulizer masks improperly stored on the bedside table, with the nebulizer mask also being outdated. Staff confirmed the equipment should have been bagged and replaced weekly, but no policy on respiratory equipment storage was provided.
Failure to Follow Two-Person Assist Care Plan During Bed Mobility Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented an established, individualized care plan requiring two-person assistance for bed mobility for one resident. The resident had been admitted with severe morbid obesity, an above-knee amputation of the left leg, cerebrovascular disease, and unspecified dementia. A quarterly MDS assessment showed the resident had a BIMS score of 8, indicating mild cognitive impairment, required substantial to maximum assistance for bed mobility, and was dependent for toileting hygiene. The resident’s care plan, initiated more than four years earlier, specified that the resident required participation of two or more staff for repositioning and turning in bed due to an ADL self-care performance deficit and impaired mobility. On the day of the incident, the resident was in bed when a CNA (S4CNA) provided peri-care and bed mobility without a second staff member present, contrary to the resident’s care plan. During this care, the CNA turned the resident to the left side in bed to change the resident’s brief. The resident grabbed onto the mobility rail to assist with turning and continued to roll completely out of the bed, falling to the floor on the left side of the bed. The nurse (S3LPN) heard the resident yell out and, upon entering the room, observed the resident lying on her left side on the floor with only the single CNA present. Following the fall, staff observed that the resident’s right leg was hyperextended on the floor, with instant bruising noted to the right ankle and top of the foot, as well as skin tears to the left abdomen and right center chest area. The right leg/ankle was in an unnatural position, and visible bruising was present on the right lower leg. The resident was lifted from the floor using a mechanical lift and returned to bed, and EMS was called for transport for post-fall evaluation. Hospital records later documented that the resident sustained an acute mildly displaced and angulated comminuted periprosthetic fracture of the proximal tibia extending to the distal tip of the tibial prosthesis, an acute mildly displaced fracture of the proximal fibula, and a hematoma of the proximal medial lower leg. In interviews, the CNA acknowledged providing care without a second staff member, not reviewing the Kardex prior to care, and not being aware or not having recently reviewed the resident’s care plan requirements for two-person assistance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the date of the incident, a resident with unspecified dementia, psychotic disturbance, anxiety disorder, and bilateral conductive hearing loss was sitting at a dining room table, feeling his surroundings due to blindness. As he touched a package of graham crackers on the table, another resident with bipolar disorder, severe vascular dementia with psychotic disturbance and agitation, major depressive disorder, and anxiety disorder became upset. The certified nursing assistant (CNA) attempted to intervene by removing the first resident from the table and positioning herself between the two residents. Despite this, the second resident went around the CNA, confronted the first resident, yelled, and slapped him on the left side of the face, resulting in a visible red mark and a reported pain level of 4. Staff interviews confirmed that the CNA and a licensed practical nurse (LPN) were present during the incident. The CNA described her attempt to prevent the altercation by physically intervening, but was unable to stop the aggressive resident from reaching and striking the other resident. The LPN and the assistant director of nursing (ADON) both acknowledged awareness of the incident and confirmed that the resident was not protected from abuse. The facility's own policy states that residents must not be subjected to abuse by anyone, including other residents, but this policy was not effectively implemented in this case.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an allegation of injury of unknown origin was reported immediately to the Administrator or their designated representative, and subsequently to the state agency within the required 2-hour timeframe. According to the facility's abuse prevention and prohibition policy, any employee or agent who becomes aware of abuse, neglect, injuries of unknown origin, or alleged misappropriation of resident property must immediately report the matter to the Administrator. In this case, a resident was found with a hematoma and bruising on the right side of the head. The injury was discovered by a CNA and reported to an LPN on the morning of the incident, but the LPN did not notify administrative staff until later in the day, after lunch. The LPN confirmed during an interview that the injury was not reported immediately as required. Further review and interviews revealed that the administrative staff, including the ADON, DON, and Administrator, were not made aware of the injury until the evening of the same day. The critical incident report was entered nearly two hours after the injury was discovered, and the state agency was not notified within the mandated 2-hour window. The facility's own staff confirmed that the reporting procedures outlined in their policy were not followed, resulting in a delay in both internal and external notification of the incident involving the resident with the head injury.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including depression, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, was admitted on 07/17/2025 and transferred out of the facility to a hospital via stretcher on 07/27/2025. Review of the emergency transfer log for July 2025 showed that the transfer was not documented as having Ombudsman notification. During interviews and record reviews, facility staff confirmed that the required notification to the State Long-Term Care Ombudsman was not made for this transfer.
Failure to Implement and Document 1:1 Supervision for Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan that addressed the need for 1:1 supervision for two out of four sampled residents. One resident, with diagnoses including depression, dementia, psychotic disturbance, mood disturbance, and anxiety, expressed suicidal ideation and was placed on 1:1 supervision per a nurse practitioner's order. However, there was no evidence in the electronic medical record (EMR) of continued 1:1 supervision from the evening until the resident was transferred to a behavioral hospital the following morning. Another resident, with a history of bipolar disorder, vascular dementia with psychotic disturbance and agitation, major depressive disorder, and anxiety, became aggressive and struck another resident. Following this incident, a nurse practitioner ordered 1:1 supervision and a psychiatric consult. Despite this order, there was no documentation in the EMR that 1:1 supervision was implemented for this resident from the time of the incident until the resident was transferred to a behavioral hospital. Facility leadership confirmed the lack of documentation and implementation of the ordered 1:1 supervision for both residents.
Grievance Resolution Delay
Penalty
Summary
The facility failed to resolve a grievance within the stipulated 5 working days as per its grievance policy. A grievance was filed concerning a resident with an acquired absence of the left leg above the knee, dementia, and morbid obesity, regarding odor and a soiled brief. The grievance was filed on 01/07/2025 and was not resolved until 01/28/2025, taking 21 days instead of the required 5 days. Both the Director of Nursing and the Administrator acknowledged the delay in resolving the grievance, which was not in compliance with the facility's policy.
Failure to Timely Report and Investigate Critical Incidents
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, or injury of known origin for nine residents. The incidents were not reported immediately, or within the required time frames of two hours for abuse allegations and 24 hours for non-abuse incidents that do not result in serious bodily injury. Additionally, the results of investigations were not reported to the State Survey Agency within five working days of the incidents. For instance, Resident #1's neglect incident with a head injury occurred on 01/14/2025, but the report was not entered until 02/11/2025. Similarly, Resident #2's fall with a fracture was discovered on 01/08/2025, but the investigation was not completed until 02/04/2025. The facility's administrator, S1ADM, confirmed responsibility for reporting critical incidents but admitted to not having access to the state critical reporting system until recently. S1ADM stated that critical incident information was sent via fax to the state reporting agency but was unaware that the information needed to be entered into the system once access was granted. The administrator also acknowledged being unaware of pending critical incidents, confirming that four incidents were still pending. This lack of timely reporting and investigation completion led to deficiencies in the facility's handling of critical incidents.
Inaccurate MDS Documentation for Resident
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for one resident out of a sample of nine, potentially affecting the entire census of 82 residents. The resident in question was admitted with diagnoses including atrial fibrillation, vascular dementia, and anxiety disorder. A review of the resident's December 2024 Medication Administration Record (MAR) showed that the resident received Eliquis, an anticoagulant, and Trazodone, an antidepressant, but no antibiotics. However, the quarterly MDS dated 12/17/2024 incorrectly indicated that the resident was on antibiotics and failed to note the use of the anticoagulant and antidepressant. During a records review and interview, the MDS coordinator confirmed the discrepancies in the MDS documentation.
Incomplete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, specifically in conducting neurological checks following unwitnessed falls. Resident #1 experienced an unwitnessed fall with visible blood and a facial laceration. Despite the facility's policy requiring neurological assessments every 15 minutes for the first hour, then at decreasing intervals for a total of 72 hours, the checks were incomplete. Resident #1 refused initial checks and was later transferred to the hospital, but upon return, the required checks were not consistently documented. There was also a lack of documentation regarding the resident's mental status for a significant period following the incident. Similarly, Resident #3, who also had an unwitnessed fall with visible blood, did not receive the required neurological checks as per the facility's policy. The resident was found on the floor with right side weakness and was transferred to the hospital. However, upon return, the neurological checks were incomplete, with specific intervals missing documentation. Both incidents were confirmed by the Assistant Directors of Nursing (ADONs) during interviews, acknowledging the failure to complete the required neurological assessments.
Failure to Maintain Up-to-Date Hospice Documentation
Penalty
Summary
The facility failed to ensure that the hospice agency provided services according to the agreement and facility policy, specifically by not collaborating effectively to maintain up-to-date hospice nurse visit notes for a resident. The deficiency was identified during a review of the resident's hospice binder, which revealed that the last hospice nurse visit notes were dated several months prior. This lapse in documentation was contrary to the hospice services agreement and the facility's policy, which required complete, prompt, and accurate documentation of all services provided. The resident involved had multiple diagnoses, including Congestive Heart Failure, Alzheimer's disease, Muscle Wasting and Atrophy, and Unsteadiness on Feet. The facility's administrator, who was the designated hospice contact, acknowledged the issue during an interview, stating that although he had contacted the hospice agency about the missing notes in October, he did not follow up as required. This inaction contributed to the deficiency, as the facility did not ensure that the hospice agency adhered to the agreed-upon documentation standards.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) notified the physician or charge nurse when a resident experienced a significant change in condition. Specifically, the LPN did not report a significant decrease in urinary output for a resident with an indwelling catheter. The facility's policy on catheter care requires that noticeable decreases in urine output be reported to a medical practitioner or charge nurse. However, the LPN, who worked the night shift, observed a urinary output of only 100 cc over an 8-hour period, which was significantly lower than the resident's usual output of 350 cc to 800 cc per shift. The resident involved had a history of urinary retention, benign prostatic hyperplasia, and Parkinsonism, and was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 7. Despite these conditions, the LPN did not notify the resident's physician or the on-call charge nurse about the decreased urinary output. This oversight was confirmed during interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who acknowledged that the low urinary output represented a significant change in the resident's condition that should have been reported.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #2, who was mildly cognitively impaired with a BIMS score of 9, was diagnosed with Alzheimer's disease, Major Depressive Disorder, and Mood Affective Disorder. On the day of the incident, Resident #2 was walking from the dining room when Resident #7, also mildly cognitively impaired with a BIMS score of 9 and diagnosed with Bipolar Disorder, Hallucinations, and Dementia, accused her of being a gossiper and punched her in the right hip. This incident was documented by S6LPN, who witnessed the event and confirmed that Resident #7's actions were deliberate. The facility's policy on abuse and neglect defines abuse as willful actions, which was applicable in this case as Resident #7's actions were intentional. The Director of Nursing, S1DON, confirmed the incident and acknowledged that Resident #7's act was a willful and intentional act of physical abuse. The incident was part of a broader investigation into abuse involving four residents, and the failure to protect Resident #2 from abuse by Resident #7 was identified as a deficiency that had the potential to affect the entire facility census of 78 residents.
Failure to Monitor Foley Catheter Output and Anticoagulant Side Effects
Penalty
Summary
The facility failed to provide services as outlined in the comprehensive care plan for a resident, specifically in monitoring and documenting foley catheter urinary output and side effects of anticoagulant therapy. The resident, who was admitted with diagnoses including urine retention, benign prostatic hyperplasia, and heart failure, had a severely impaired cognitive status. The care plan required monitoring and documentation of urinary output every shift and observation for anticoagulant side effects, such as blood in urine or stools, headaches, and changes in mental status. Upon review, it was found that the facility did not document the resident's urinary output from late April to early May, nor did they monitor or document the side effects of the anticoagulant from late April to mid-May. Interviews with facility staff, including the LPN and ADON, confirmed the lack of documentation and the absence of a policy for anticoagulant monitoring. The ADON acknowledged that the resident's care plan included orders for monitoring these aspects, but the records showed no evidence of compliance with these orders.
Inadequate Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal service for 84 residents. According to the facility's policy, meals and snacks should be served at specific times, with breakfast at 7:30 a.m., lunch at 12:00 p.m., and afternoon snacks at 2:00 p.m. However, interviews and observations revealed that meals were consistently served late. A CNA reported that meal times varied daily, and residents confirmed that breakfast was often delayed. On one occasion, residents in the dining room waited until almost 9:00 a.m. for breakfast due to the absence of a nurse required to observe the meal. Further interviews and observations indicated that lunch trays were also delivered late, with some residents receiving their meals up to two hours past the scheduled time. A family member expressed concern about the frequent delays and potential weight loss of a resident. Additionally, snacks were not consistently delivered, as confirmed by a dietary manager and an LPN, who reported that snacks were often not received on time or at all. These findings highlight the facility's failure to provide adequate dietary staffing to meet the scheduled meal and snack times, impacting the residents' nutritional needs.
Failure to Provide Meals According to Dietary Preferences
Penalty
Summary
The facility failed to ensure that residents received meals according to their dietary preferences and needs as indicated on their diet cards. This deficiency was observed in five residents out of twenty reviewed for nutrition. Specific instances included a resident who was supposed to receive a banana and yogurt daily but had not been receiving them, and another resident who was served whole milk instead of the skimmed milk indicated on their dietary slip. Additionally, several residents were not provided with the beverages listed on their diet slips, such as hot tea and decaf coffee, and were only given water. Interviews and observations revealed that the dietary staff did not consistently follow the diet slips, leading to incorrect meal components being served. A Certified Nursing Assistant admitted to not checking the diet slips before serving meals, resulting in residents receiving the wrong type of milk. The Dietary Manager confirmed that sometimes food items listed on the meal slips were unavailable, and substitutions were made without notifying the residents. This lack of communication and adherence to dietary instructions contributed to an unpleasant dining experience for the residents.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure that residents were weighed according to physician's orders, which was a requirement for monitoring their nutritional status. The deficiency was identified through record reviews and interviews, revealing that none of the 20 residents reviewed had their weights recorded as ordered. The orders specified that residents should be weighed every Tuesday for four weeks, but there was no evidence of compliance with these orders for various weeks across all residents. For instance, Resident #1 was not weighed during weeks 3 and 4, while Resident #2 missed weights for weeks 2, 3, and 4. Similarly, Resident #3 did not have weights recorded for weeks 2, 3, and 4. This pattern of missing weight records was consistent across all residents reviewed, including Resident #R6, who had no weights documented until a specific date, and Resident #R7, who had no weights recorded until a later date. The Assistant Director of Nursing (ADON) confirmed during an interview that the residents' weights were not obtained as ordered. This lack of adherence to physician's orders for weight monitoring was a significant oversight in the care provided to the residents, as it potentially impacted their nutritional management and overall health monitoring.
Failure to Maintain Nutritional Parameters for Residents
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutrition, specifically for two residents. Resident #3 was admitted with diagnoses including muscle wasting, atrophy, adult failure to thrive, and dementia. Despite an order for weekly weight monitoring, there was no evidence that weights were obtained for weeks 2, 3, and 4. A significant weight loss of 9.39% was noted over a month, which had not been addressed. Observations revealed that the resident had difficulty eating due to the food's texture, and the care plan only included serving the diet as ordered without further interventions. Additionally, the resident had not been seen by the registered dietitian as required. For Resident #R18, the facility failed to implement the registered dietitian's recommendation for nutritional supplements twice a day to increase caloric intake. The Assistant Director of Nursing confirmed that the recommendation was not addressed, as the resident was not identified on the list with the recommendation, and the dietitian's assessment was not reviewed in the electronic medical record. This oversight resulted in the resident not receiving the necessary nutritional support as advised by the dietitian.
Deficiency in Supply Management for Resident Care
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring the availability of necessary supplies for incontinence care and personal hygiene. Observations and interviews revealed that the facility ran out of appropriately sized incontinence briefs for 74 incontinent residents. Staff members, including CNAs and LPNs, confirmed the shortage of large, XL, 2XL, and 3XL briefs, which are the most frequently used sizes. The Assistant Director of Nursing and Director of Nursing acknowledged the shortage, and the Medical Records/Central Supply staff indicated that the Administrator removed critical items from supply orders to fit the facility's budget, leading to a lack of necessary supplies. Additionally, the facility did not have a sufficient number of clean linens, such as towels and washcloths, to meet the residents' personal hygiene needs. Observations of the clean linen supply closets showed a shortage of these items across different halls. Staff interviews confirmed that they often ran out of towels and washcloths, which are essential for providing personal hygiene and incontinence care. The Director of Nursing verified the inadequacy of the available linens and noted that the facility did not use disposable wipes, further exacerbating the issue. The facility did not provide policies for the provision of sufficient supplies, including incontinence briefs and linens. The Administrator and Housekeeping/Laundry Manager acknowledged the shortage of supplies and the challenges in maintaining adequate stock. The lack of a structured policy and the removal of critical items from supply orders contributed to the deficiency, affecting the quality of care provided to the residents.
Delay in X-ray Order Fulfillment
Penalty
Summary
The facility failed to follow the physician's orders for a resident, resulting in a delay in obtaining necessary x-rays. The resident, who had a history of a fracture in the neck of the right femur and was admitted to the facility, experienced a fall and subsequently complained of pain in the left leg. Despite the nurse practitioner's order for an x-ray on the day of the fall, the x-ray was not completed until four days later. This delay was due to the contracted radiology service not receiving the order until four days after it was initially made. The resident's medical records showed multiple x-ray orders, but the initial order for the left leg x-ray was not fulfilled in a timely manner. The contracted radiology service confirmed they did not receive the order on the day it was made, and the x-ray was only completed after a follow-up order was sent. The delay in obtaining the x-ray led to a further delay in diagnosing a left femur fracture, which was only identified after additional imaging was conducted several days later.
Failure to Maintain Sanitary Conditions and Proper Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service and did not maintain sanitary conditions in the kitchen. During a tour of the kitchen, it was observed that the deep fryer cooking oil collection area had a thick layer of debris and a large piece of fried food material, which had not been cleaned after its last use. Additionally, the stand-up refrigerator contained spoiled and expired food items, including a plastic gallon bag of lettuce with discoloration and a brown watery substance, and two opened containers of beef base broth past their expiration date. The stand-up freezer also contained expired food items, such as an opened container of English muffins and a plastic gallon bag of fried okra with gray discoloration and frozen chunks of ice. The dry storage room had an expired plastic gallon bag of raisin bran. The Dietary Supervisor confirmed that these items were spoiled or expired and should have been discarded. Furthermore, the food service line was observed to have unsanitary conditions. Cold drinks with lids were placed on a cart for tray distribution, but the cart had multiple areas of red sticky residue and food debris on both sides. The Dietary Supervisor confirmed that the cart had not been cleaned after its previous use, as required. These deficiencies had the potential to affect the 72 residents who consumed food from the kitchen.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for residents with infections or colonization with multi-drug resistant organisms (MDRO) or for residents with chronic wounds and/or indwelling medical devices. This deficiency was observed in 8 out of 14 residents who met the criteria for EBP. Specifically, residents with indwelling urinary catheters, PEG tubes, and chronic wounds were not provided with the necessary precautions as outlined in the facility's policy. The policy, written on 08/21/2023, mandates gown and glove use during high-contact resident care activities for these residents to reduce MDRO transmission. Interviews with the Assistant Director of Nursing (S4ADON), the Administrator (S2ADM), the Regional Director of Operations (S8RDO), and the Interim Medical Director (S9IMD) revealed a lack of awareness and implementation of the EBP policy. S4ADON admitted to being unaware of the EBP requirements until the day before the interview. S2ADM and S8RDO confirmed that the policy had not been implemented despite being aware of its existence. S9IMD also stated he was not aware of the EBP policies and procedures or their lack of implementation for residents meeting the criteria.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain infection control practices to prevent and control the spread of infectious communicable diseases. Specifically, the facility did not ensure that staff adhered to Enhanced Barrier Precautions (EBP) for eight residents who had chronic wounds or indwelling medical devices. The Assistant Director of Nursing (ADON) admitted to being unaware of the EBP requirements until the day before the survey, and none of the residents fitting the criteria were on EBP as required by the facility's policy. This lack of adherence was confirmed through multiple observations and interviews with staff members who were also unaware of EBP protocols. Resident #24, who had a urinary catheter, was observed without any EBP signage, PPE availability, or biohazard bins in the room. Similarly, Resident #232, who had a neurogenic bladder and an indwelling catheter, had no care plan addressing EBP. Staff members, including LPNs, confirmed their lack of knowledge about EBP and the absence of necessary precautions for these residents. Other residents, such as Resident #35 and Resident #68, who had PEG tubes, were also found without EBP signage, PPE, or biohazard bins, and staff admitted to providing care without following EBP protocols. Additional residents, including Resident #17, Resident #30, Resident #48, and Resident #75, all had indwelling catheters but lacked care plans addressing EBP. Observations and interviews revealed that there was no signage, PPE, or biohazard bins in their rooms, and staff were unaware of the EBP requirements. This widespread lack of adherence to infection control practices had the potential to affect 14 out of 74 total residents with chronic wounds or indwelling medical devices, as the facility failed to implement the necessary precautions to prevent the spread of infections.
Incorrect MDS Coding for Antidepressant Use
Penalty
Summary
The facility failed to ensure the residents' assessment accurately reflected the status of one resident by not correctly coding the Minimum Data Set (MDS) assessment for antidepressant use. Specifically, the MDS assessment for a resident with diagnoses including Emphysema, Diabetes Mellitus II, and Legal Blindness was incorrectly coded to indicate the use of an antidepressant. A review of the resident's Electronic Health Record and February 2024 Physician Orders revealed no orders for antidepressants. This discrepancy was confirmed during an interview with the MDS nurse, who acknowledged that the resident should not have been coded as using an antidepressant in the MDS assessment.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Resident #55 was admitted on an unspecified date and was diagnosed with Delusional Disorder on January 19, 2024. A review of the resident's record revealed a Level 1 PASARR dated November 28, 2023, but no Level II PASARR was noted. During an interview on April 24, 2024, the Assistant Director of Nursing confirmed that the resident had received a qualifying diagnosis and that the facility had not resubmitted for a Level II PASARR review, as they were unaware that this was required.
Failure to Monitor Adverse Reactions to Antibiotics
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who was prescribed Bactrim DS for a urinary tract infection. The resident's care plan included monitoring for adverse reactions to the antibiotic every shift, but a review of the Medication Administration Record (MAR) and Nurses Progress Notes revealed no documentation of such monitoring. Interviews with the Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed that there was no order to monitor for adverse reactions and no documentation of monitoring, despite the care plan's requirements. The resident, who had diagnoses including Cerebral Infarction, Retention of Urine, and Urinary Tract Infection, was admitted to the facility and prescribed Bactrim DS. The care plan specified that the resident should be monitored for adverse reactions such as diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions every shift. However, the facility failed to follow through with this monitoring, as confirmed by multiple staff members during interviews and a review of the resident's records.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #1 from sexual abuse by Resident #2. Resident #2, who has diagnoses including Vascular Dementia, Aphasia, Mood Disorder, Sexual Dysfunction, and Disorder of Adult Personality and Behavior, was observed inappropriately touching Resident #1's breast in the dining room. The incident caused psychosocial harm to Resident #1, who was startled and upset. The facility's response included notifying the doctor, increasing Resident #2's medication, and placing him on 1-on-1 observation, but the care plan failed to identify Resident #2's diagnosis of Sexual Dysfunction prior to the incident. Resident #2 was also a victim of physical abuse by Resident #5. Resident #5, who has diagnoses including Cerebral Infarction, Vascular Dementia, and Metabolic Encephalopathy, struck Resident #2 on the head with a cane, resulting in a laceration that required sutures. The incident occurred when Resident #2 bumped into Resident #5's bed, waking him up. The facility's records show that Resident #5 was sent to the hospital for psychological evaluation and was later discharged to home with family. Resident #3 suffered physical harm when Resident #4 hit him in the eye during an altercation in the dining room. Resident #4, who has diagnoses including Unspecified Dementia and Major Depressive Disorder, became aggressive during a bingo game and struck Resident #3, resulting in a contusion and subsequent complaints of headaches and pain. The incident report and witness statements indicate that Resident #3 was defending another resident when the altercation occurred. Resident #3's eye injury required in-house monitoring and further assessment for pain and headaches.
Failure to Provide Quarterly Statements of Personal Funds
Penalty
Summary
The facility failed to provide quarterly statements of personal funds for one resident. Resident #7, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure, had a BIMS score of 15, indicating she was cognitively intact. During an interview, Resident #7 stated that she had not received a statement of her funds in over two years and expressed a desire to know her account balance. The Business Office Manager confirmed that there was no documentation of Resident #7 receiving any quarterly statements for 2023, despite claiming to have provided one in January 2024 for the last quarter of 2023.
Failure to Develop Comprehensive Care Plans and Follow Physician Orders
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for three residents, leading to multiple deficiencies. Resident #2, who was admitted with a diagnosis of Sexual Dysfunction, exhibited numerous inappropriate sexual behaviors that were documented in the nurse's notes. However, the care plan did not identify or address the Sexual Dysfunction diagnosis or the resident's sexual behaviors, as confirmed by the Minimum Data Set (MDS) nurse and the Assistant Director of Nursing (ADON). This oversight resulted in repeated incidents of inappropriate behavior without a tailored intervention plan in place. Resident #4, diagnosed with Unspecified Dementia, Major Depressive Disorder, Anxiety Disorder, and Bipolar Disorder, was not administered the correct dosage of Buspirone as per the physician's updated orders following a hospitalization. The resident's medication was supposed to be increased to three times daily, but the facility continued to administer it only twice daily. This discrepancy was confirmed by both the resident's nurse and the ADON, who acknowledged that the readmission paperwork had not been properly reviewed and updated in the electronic health record (EHR). Resident #7, who had Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, was not care planned for her BiPAP machine and had multiple physician's orders that were not followed. These included the application of antifungal powder, barrier cream, and Triamcinolone cream, as well as the weekly changing of oxygen tubing and cleaning of the oxygen concentrator filter. The resident confirmed that these treatments were not being administered as prescribed, and the ADON verified the lapses in care through a review of the Treatment Administration Record (TAR).
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment for a resident with Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for BiPAP use at bedtime and nebulizer treatments as needed for shortness of breath. During an observation, it was noted that the resident's BiPAP mask and nebulizer mask were left on the bedside table without proper storage. The nebulizer mask was also outdated, with a date of 03/22/2024, and had not been replaced as required. Interviews with the resident, an LPN, and the Assistant Director of Nursing confirmed that the respiratory equipment was not stored properly. The LPN acknowledged that the BiPAP mask should have been bagged and the nebulizer mask should have been changed weekly. Despite requests, the facility was unable to provide a policy on respiratory equipment storage. The Assistant Director of Nursing confirmed that the equipment should have been stored in a bag and labeled, but this was not done.
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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