Jefferson Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson, Louisiana.
- Location
- 2200 Jefferson Hwy, Jefferson, Louisiana 70121
- CMS Provider Number
- 195272
- Inspections on file
- 42
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Jefferson Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis, requiring substantial assistance with dressing, was observed wearing the same stained hospital gown for multiple days. Despite receiving a bed bath, the resident was redressed in the same soiled gown, and staff confirmed that clothing should have been changed daily.
Nine staff members, including CNAs and a CNA Supervisor, did not follow proper mechanical lift procedures as outlined by facility policy and the manufacturer's guidelines. Staff were observed and reported locking the caster brakes during resident transfers, instead of leaving them unlocked as required, demonstrating a lack of competency in safe lift operation.
Staff failed to maintain accurate medical records by sharing EMR credentials and documenting care activities under the wrong staff accounts. Multiple CNAs admitted to using each other's logins to record ADLs and other care tasks for several residents, resulting in documentation that did not accurately reflect who provided care or when it was delivered.
A resident with physician orders for insulin and specific blood glucose monitoring experienced multiple episodes of elevated blood glucose. Despite orders to notify the physician for high readings, there was no documentation that the physician was informed of these elevated levels, as confirmed by review of records and interviews with the DON.
A resident with a history of atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers did not receive daily wound care as ordered on multiple occasions. Documentation and staff interviews confirmed that wound care was missed, especially on days when the resident attended dialysis, with no evidence of refusal or physician orders to hold care. Nursing staff and the DON acknowledged the lapses in following wound care orders.
The facility did not consistently ensure that LPNs reconciled and documented controlled substances on all medication carts at shift changes, as required by policy. Multiple shifts lacked signatures from either the off-going or oncoming nurse, and some records were incomplete regarding the total number of controlled medication packages. Staff interviews confirmed awareness of the policy but acknowledged lapses in following it, and the DON verified the documentation was not completed as required.
The facility did not ensure its QA Committee followed through on a corrective action plan to address ongoing deficiencies in narcotic count documentation. Despite a QAPI plan requiring weekly audits and nurse signatures, recurring issues with incomplete and inaccurate narcotic reconciliation persisted, and no disciplinary actions were taken against staff for noncompliance.
The facility did not ensure its QAA committee consistently included the required members, such as the MD, Administrator, DON, and three additional staff, during quarterly meetings. Documentation showed that on multiple occasions, either some required members were absent or not enough staff were present, and the facility could not provide evidence to confirm proper attendance.
Three residents, including those with intact and moderate cognitive status, were unable to access their personal funds on weekends due to limited business office hours and lack of communication about alternative access through the DON. Facility policy required reasonable access, but there was no documentation that residents were informed of weekend procedures or that funds were accessed during that time.
A resident was discharged from Medicare Part A skilled services before benefit days were exhausted, but the required Notice of Medicare Non-Coverage (NOMNC) was not provided to the resident or their responsible party. Facility records and staff interviews confirmed the absence of the NOMNC prior to discontinuation of covered services.
A resident's room was not kept in a sanitary condition, as an unknown dried brown substance remained on the wall next to the bed for several days despite housekeeping staff being responsible for cleaning and disinfecting the area. Multiple staff confirmed the deficiency during surveyor observations and interviews.
The facility did not report an injury of unknown origin involving a resident with severe cognitive impairment, nor did it report an incident of resident-to-resident physical aggression, both of which were required by policy. Leadership interviews confirmed that neither event was reported to the State Survey Agency, and there was a lack of clarity among staff regarding reporting requirements.
A resident with severe cognitive impairment was found with a bruise of unknown origin near the eye, and the facility failed to conduct a thorough investigation as required by policy. The administrator did not document security footage reviews or obtain written staff statements, and key staff were not interviewed about the incident. The lack of documentation and incomplete investigation resulted in a failure to properly address the injury.
A resident was discharged without receiving the required 30-day written notification. Review of records and staff interviews confirmed that the mandated notice was not provided prior to the resident's discharge.
The facility did not make required referrals to the Louisiana PASRR program for two residents—one admitted with Major Depressive Disorder and Bipolar II Disorder, and another who developed Major Depressive Disorder after admission. Staff interviews and record reviews confirmed that PASRR Level II evaluations were not completed or referred for these residents, despite their qualifying mental health diagnoses.
A resident admitted with major depressive disorder and bipolar II disorder did not have these psychiatric diagnoses reflected on their Level I PASRR, which was found to be incomplete and undated. Facility staff confirmed the PASRR was inaccurate and not verified for accuracy or completeness, and no documentation was provided to show a complete PASRR was ever done.
A resident who required total assistance with ADLs did not receive necessary nail care, as evidenced by long, yellowed fingernails with visible debris underneath. Staff confirmed the resident's dependence and acknowledged the need for nail care, but documentation and repeated observations showed the care was not provided.
A carton of Med Plus 2.0 nutritional supplement was left opened and unrefrigerated on a medication cart, remaining available for resident use beyond the manufacturer's recommended 4-hour window. An LPN was unaware of the storage requirement, and the DON confirmed the supplement should have been discarded.
Two residents had inaccurate entries in their electronic Medication Administration Records (eMAR), including documentation of wound care assessments and medication administration that did not actually occur. Staff and leadership confirmed that these records were not truthful or accurate, as required by facility policy and professional standards.
A resident did not receive Nystatin powder as prescribed, due to a misunderstanding by the treatment nurse who thought it was ordered as needed. The medication was not applied on multiple occasions, as confirmed by the DON after reviewing the eMAR.
A resident's insulin order was changed by an LPN from once daily to twice daily without a physician's order. The LPN had not completed the required medication competency assessment, which was overlooked during orientation. The facility failed to ensure the LPN demonstrated competency in clarifying physician orders.
The facility failed to ensure complete and accurate documentation of medication administration records for two residents. One resident's eMAR lacked documentation for medications like Gabapentin and eye drops, while another resident's eMAR was missing records for multiple medications, including Aspirin and Insulin. The DON confirmed these omissions, emphasizing the need for proper documentation.
A facility failed to assess a resident for self-administration of medications, as a cognitively intact resident was found with a medicine cup containing nine pills on their bedside table. The facility's policy requires nurses to ensure residents take their medications and not leave them unattended. An LPN left the medications for the resident to self-administer later, assuming they were taken. The DON confirmed this was against policy, and the resident was not care planned for self-administration.
A resident, who was cognitively intact but required assistance with bathing due to limited range of motion, did not receive scheduled baths over several periods from August to October. Despite being scheduled for baths three times a week, documentation showed gaps in care, and the facility could not provide evidence of bathing during these times. The DON confirmed the oversight.
A resident, who required assistance with bathing, was inaccurately documented as receiving showers, while staff and the resident confirmed only bed baths were provided. The DON acknowledged the documentation error, highlighting a failure to maintain accurate medical records.
The facility failed to ensure fall prevention measures for two high-risk residents. One resident did not have a fall mat or dycem as required, and another did not have a fall mat despite a physician's order. Observations and staff interviews confirmed the absence of these safety measures.
The facility failed to sanitize the thermometer when measuring food temperatures and did not perform hand hygiene during meal service. A culinary cook did not sanitize the thermometer between uses, and a CNA did not wash hands or change gloves while assisting residents with meals. Both actions were confirmed as unacceptable by the culinary manager and the DON.
The facility failed to ensure a resident's room and equipment were kept clean. Observations revealed dried substances on the floor and tube feeding pole, and the resident's wheelchair had labels covered in a dark brown substance. Staff confirmed the unsanitary conditions.
The facility failed to check a resident's PEG tube placement before administering enteral nutritional therapy. An LPN did not auscultate the tube placement as required by the facility's policy, and the Quality Assurance Nurse confirmed this procedure should have been followed.
The facility failed to complete quarterly assessments in a timely manner for seven residents, with assessments completed more than 14 days after the ARD. Staff confirmed the late completion, and validation reports corroborated the findings.
The facility failed to submit resident assessments to CMS in a timely manner for nine residents. The assessments were completed but not transmitted within the required 14-day period, and one assessment was rejected due to an invalid date and not resubmitted promptly. This issue was confirmed through record reviews and staff interviews.
Failure to Provide Assistance with Dressing for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with hemiplegia and hemiparesis, who required substantial to maximal assistance with dressing, was not provided appropriate assistance with changing clothes. The resident was observed on three consecutive mornings lying in bed wearing the same hospital gown, which had a visible red stain on the left upper chest area. The resident reported that no staff member had changed her clothes since the initial observation and expressed a desire to have her clothes changed. Further investigation revealed that a Certified Nursing Assistant provided a bed bath to the resident but dressed her in the same soiled hospital gown afterward. The Corporate Nurse acknowledged that residents' clothes should be changed daily and that it was inappropriate to redress a resident in the same clothing after a bath. These findings were based on observations, interviews, and record review, confirming that the facility failed to provide necessary assistance with dressing and changing clothes for a dependent resident.
Staff Lacked Competency in Mechanical Lift Operation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides were competent in the operation of mechanical lifts, as required by both facility policy and the manufacturer's guidelines. Specifically, 9 out of 14 staff members investigated, including CNAs and a CNA Supervisor, demonstrated incorrect procedures during resident transfers using the mechanical lift. The facility's policy and the manufacturer's operating manual both specify that the caster brakes of the mechanical lift should remain unlocked when raising a resident from a bed to allow the lift to center itself and increase stability. However, multiple staff members reported and were observed locking the caster brakes during this process. During an observed transfer, staff locked the caster brakes before raising a resident from the bed, contrary to the required procedure. Interviews with several CNAs confirmed their practice of locking the brakes when lifting or lowering residents, indicating a widespread lack of competency in the correct use of the mechanical lift. Supervisory staff and a corporate nurse acknowledged that staff should be following the manufacturer's guidelines, which were not adhered to during the observed and reported incidents.
Inaccurate Resident Records Due to Shared EMR Credentials
Penalty
Summary
Staff failed to ensure the accuracy and integrity of resident medical records for six out of nine residents reviewed. Documentation in the electronic medical record (EMR) showed that staff members recorded care activities such as bed mobility, toileting, bowel and bladder elimination, turning and positioning, and meal consumption for multiple residents. However, interviews revealed that the staff who documented these activities were not always the ones who provided the care. For example, one CNA's credentials were used by others to document care provided to residents, and another CNA admitted to using a colleague's credentials because she had forgotten her own. Additionally, a CNA was documented as providing a bed bath to a resident on a specific date, but in an interview, she stated she did not care for that resident on that day, and another CNA confirmed she had provided the care but used someone else's credentials to document it. Further interviews with staff, including CNAs and supervisory personnel, confirmed that sharing EMR credentials and documenting under another staff member's login was occurring. The corporate nurse and CNA supervisor both acknowledged that staff credentials should remain confidential and that staff should not document in the EMR using another person's credentials. These actions resulted in inaccurate and unreliable resident records, as the documentation did not accurately reflect who provided care or when it was provided.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels as required by the resident's physician orders. The orders specified that the physician should be called if the resident's blood glucose level was between a certain range, but review of the electronic Medication Administration Record (eMAR) showed several instances where the resident's blood glucose levels were significantly elevated, ranging from 360 mg/dL to 433 mg/dL. Despite these elevated readings, there was no documented evidence that the physician was notified as directed by the orders. Interviews with the Director of Nursing confirmed that nursing staff were expected to notify the physician for any blood glucose level above 352 mg/dL, but the facility was unable to provide documentation that such notifications occurred for the elevated readings identified. This deficiency was identified for one resident out of five sampled for unnecessary medications, based on both record review and staff interviews.
Failure to Provide Ordered Daily Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow physician's orders to provide daily wound care for a resident with unhealed pressure ulcers. Review of the resident's medical record and electronic Medication Administration Record (eMAR) showed that wound care orders, including cleaning and dressing of wounds on the left heel, left great toe, left hip, and sacrum, were not performed on multiple documented dates. There was no evidence in the progress notes that wound care was provided or refused on these dates, and no documentation was available to justify the missed care, such as holding wound care due to dialysis appointments. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident did not receive wound care as ordered on several days, particularly when the resident was out of the facility for dialysis. The staff acknowledged that there were no orders to hold wound care and that care should have been provided before or after dialysis. The resident's medical history included conditions such as atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers, and the Braden Scale assessment indicated a risk for skin breakdown.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an accurate and complete system for reconciling controlled substances across all five medication carts reviewed. According to the facility's policy, both the off-going and oncoming nurses are required to count and document the controlled substances at each shift change, with signatures from both parties on the Controlled Drug Count Record and Package Inventory form. However, multiple instances were identified where either the off-going or oncoming nurse, or both, did not sign the required documentation for various shifts and dates across all medication carts (a through e). In some cases, the total number of controlled medication packages reconciled was also not documented. Record reviews revealed that for numerous shifts, there was no documented evidence that the required reconciliation and documentation of controlled substances occurred. This included missing signatures and incomplete records for both the receipt and disposition of controlled drugs. The facility was unable to provide any additional documentation to demonstrate that the reconciliation process was completed as required by their policy. Interviews with nursing staff confirmed that they were aware of the requirement to reconcile and document controlled substances at each shift change, but admitted to not completing the process as required on specific occasions. The Director of Nursing also confirmed that the Controlled Drug Count Record and Package Inventory sheets were not completed with the necessary signatures at the beginning and/or end of shifts as required.
Failure to Implement QA Plan for Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee effectively implemented a developed plan of action to address identified quality deficiencies related to accurate narcotic count documentation. Despite creating a Quality Assurance Performance Improvement (QAPI) plan that included weekly audits of medication carts and required nurse signatures, recurring problems with incomplete and inaccurate narcotic reconciliation documentation persisted. The Director of Nursing confirmed that, although the issue was identified and interventions such as staff discipline were outlined, no disciplinary actions were taken against nursing staff for ongoing noncompliance, and the documentation issues continued to be observed during the survey.
QAA Committee Lacked Required Members and Attendance at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee was composed of all required members and met at least quarterly, as outlined in its own policy and procedure. According to the facility's policy, the QAA committee should include the Medical Director (MD), the Administrator, the Director of Nursing (DON), and three other staff members designated by the facility. Review of the QAA meeting minutes and sign-in sheets for three separate quarterly meetings revealed that the required composition of the committee was not consistently met. On one occasion, only the DON, Administrator, Dietary Manager, and MD were present, with no evidence of additional staff. On another occasion, the MD and Administrator were absent, and on a third occasion, only the DON, Administrator, and MD were present, again lacking additional staff members. The facility was unable to provide any additional documentation to demonstrate that the required members attended the QAA meetings on the reviewed dates. An interview with the DON confirmed that no further evidence was available to show compliance with the committee composition requirements for those meetings. No information about residents or their medical conditions was included in the report.
Failure to Ensure Resident Access to Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents were able to access and manage their personal funds at all times, as required by policy. Three residents, including two who were cognitively intact and one with moderate cognitive impairment, reported being unable to access their funds on weekends. The facility's policy stated that residents should have reasonable access to their funds and that requests for fifty dollars or less would be honored the same day. However, interviews revealed that the business office was only open for banking hours Monday through Friday, and while a petty cash box was left with the weekend DON, this information was not communicated to residents. There was no documented evidence that residents were informed about how to access their funds on weekends, nor was there documentation that any residents had actually accessed their funds during that time. Staff interviews confirmed that the process for weekend access was not publicized, and the facility lacked records showing that residents were notified of banking hours or that this was discussed during care plan meetings or resident council meetings. The administrator acknowledged that while funds were technically available on weekends, there was no documentation to support this or to show that residents were aware of the process.
Failure to Provide Required Medicare Non-Coverage Notice Prior to Discharge
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from Medicare Part A skilled services before exhausting their benefit days. The resident began receiving Medicare Part A skilled services on 09/23/2024, with the last covered day being 11/03/2024. The facility initiated the discharge from Medicare Part A services, but there was no documented evidence that the required NOMNC was given to the resident or their responsible party prior to the discontinuation of covered services and discharge home. Record review and staff interviews confirmed that the NOMNC was not located or completed for the resident, and the facility was unable to provide documentation that the notice was issued as required. The Social Services Director acknowledged the absence of the NOMNC, and the Administrator confirmed that the facility had identified issues with beneficiary notifications but had not yet implemented a quality assurance process to address the problem.
Failure to Maintain Sanitary Resident Room Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in a resident's room, as evidenced by repeated observations of an unknown dried brown substance on two areas of the wall next to the resident's bed. This substance was noted on four consecutive days during surveyor observations, indicating that the issue persisted over time and was not addressed despite ongoing housekeeping responsibilities. Interviews with the housekeeper responsible for the room revealed that she claimed to have cleaned and wiped all unclean areas, yet the substance remained present during a joint observation. Additional staff, including a business office specialist and the facility administrator, confirmed that the wall was not maintained in a sanitary manner at the time of the observations. The facility's own housekeeping job description required cleaning and disinfecting walls, but this standard was not met in this instance.
Failure to Report Injury of Unknown Origin and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report two separate incidents as required by its Abuse Prevention and Prohibition policy. In the first incident, a resident with severe cognitive impairment was found with a bruise of unknown origin to the right periorbital area. The resident was unable to provide a history of the injury, and there was no documented evidence of a witnessed fall or explanation for the bruise. Despite the lack of a known cause, the administrator and regional administrator did not submit a report to the State Survey Agency, as required for injuries of unknown origin. In the second incident, another resident with severe cognitive impairment was physically pulled from a wheelchair and yelled at by another resident. This event was documented in the facility's incident log and nurse's notes, but there was no evidence that the incident was reported to the State Survey Agency as an allegation of resident-to-resident abuse. Interviews with facility leadership confirmed that the incident was not reported, and there was uncertainty among staff about whether the event constituted a reportable allegation of abuse.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a reddish-blue bruise around the right eye, and was unable to provide a history of the injury. The facility's abuse prevention policy required a comprehensive investigation, including interviews and signed statements from all staff involved, as well as interviews with the resident or their roommate if the resident was unable to communicate. However, the administrator only spot-checked security footage without documenting the review, and did not obtain or document written statements from staff. The CNA Supervisor reported conducting only verbal interviews with two CNAs, but did not document these interviews, and both CNAs later stated they were not interviewed or asked for statements. Additionally, an LPN who was notified of the bruise was not interviewed about the incident. The administrator assumed the injury was caused by a fall, despite no documented falls for the resident, and did not interview staff from other shifts or obtain further evidence. There was no documented evidence to show that a thorough investigation, as required by facility policy, was completed regarding the resident's injury. The lack of documentation and incomplete staff interviews resulted in a failure to properly respond to and investigate the injury of unknown origin.
Failure to Provide 30-Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30-day written notice prior to the discharge of a resident. Review of the electronic medical record showed that the resident was discharged on 02/05/2025 at 3:33PM, but there was no documented evidence that the resident received the mandated 30-day notification before discharge. Interviews with the Social Service Director and the Administrator confirmed that the resident did not receive the 30-day written notification prior to being discharged.
Failure to Refer Residents with Mental Illness for PASRR Evaluation
Penalty
Summary
The facility failed to ensure that referrals were made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for two residents with mental illness diagnoses. One resident was admitted with diagnoses of Major Depressive Disorder and Bipolar II Disorder, but there was no documented evidence that a PASRR Level II evaluation was completed or a referral was made to the PASRR program. Another resident developed a diagnosis of moderate, recurrent Major Depressive Disorder after admission, yet there was also no documentation of a PASRR Level II evaluation or referral for this new diagnosis. Interviews with facility staff confirmed that both residents met criteria requiring a PASRR Level II referral, either due to admission with a mental illness or the onset of a qualifying diagnosis after admission. Record reviews and staff statements indicated that these referrals were not identified or completed during routine audits or at the time of diagnosis, resulting in a failure to coordinate necessary assessments and referrals as required.
Failure to Accurately Complete PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a complete and accurate Level I Pre-Admission Screening and Resident Review (PASRR) was conducted for a resident admitted with diagnoses of major depressive disorder and bipolar II disorder. Record review showed that the resident's Level I PASRR was incomplete, undated, and did not identify any mental illness diagnosis, despite the resident's documented psychiatric conditions. Interviews with facility staff confirmed that the PASRR was inaccurate and incomplete, and there was no documented evidence that a complete Level I PASRR was ever completed or verified for accuracy and completeness for this resident.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A dependent resident who required total assistance with activities of daily living (ADLs) did not receive appropriate nail care. Review of the care task log showed that the resident's nail care was marked as not applicable on the morning of the observed date. Multiple observations throughout the day revealed that all ten of the resident's fingernails were yellowed, extended one-fourth to one-half inch beyond the fingertips, and had an unknown gray substance visible underneath. The resident expressed a desire to have his fingernails cut. Staff interviews confirmed that the resident required total assistance with ADLs, and the Assistant Director of Nursing acknowledged that the resident's nails needed to be cut and cleaned. The repeated observations and documentation review indicated that the facility failed to provide necessary nail care and assistance for this dependent resident.
Improper Storage and Availability of Nutritional Supplement
Penalty
Summary
A carton of Med Plus 2.0 nutritional supplement was found opened and unrefrigerated on a medication cart, with the opened date marked as the previous day. According to the manufacturer's guidelines, the supplement should be used within 4 hours of opening if not refrigerated. Observation confirmed that the supplement was still available for resident consumption well beyond the recommended time frame. An LPN acknowledged not knowing the requirement to discard the supplement after 4 hours if not refrigerated, and the DON confirmed that the supplement should not have been available for use under these conditions.
Inaccurate Documentation in eMAR for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic Medication Administration Record (eMAR) for two residents. For one resident with a history of unhealed pressure ulcers and who was cognitively intact, the eMAR and wound care assessment indicated that a wound care nurse evaluated and treated the resident's wounds on a specific date. However, both the resident and the nurse confirmed that no such evaluation or treatment occurred on that date, and the nurse could not explain why the documentation was inaccurate. Facility leadership, including the Director of Nursing and a corporate nurse, confirmed the documentation was incorrect and should not have been entered as such. For another resident who was admitted to a hospital and later returned to the facility, the eMAR showed that multiple medications and care tasks were documented as completed during the resident's absence from the facility. These included administration of eye drops, tube feedings, repositioning, and other nursing interventions, all recorded as performed by specific LPNs. Interviews with staff confirmed that medications and tasks should only be documented if actually performed, and the Director of Nursing acknowledged that the eMARs should have been accurate and not indicated completion of tasks that did not occur.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident, leading to a deficiency in pharmaceutical services. The resident was prescribed Nystatin powder to be applied to the right abdominal fold twice daily and as needed. However, a review of the electronic Medication Administration Record (eMAR) for September 2024 revealed multiple instances where the medication was not applied as scheduled. Specifically, the Nystatin powder was not administered at 8:00 a.m. on one occasion and at 4:00 p.m. on numerous dates throughout the month. Interviews conducted with the treatment nurse and the Director of Nursing (DON) confirmed the oversight. The treatment nurse mistakenly believed the Nystatin powder was ordered only as needed, which led to the medication not being applied as per the physician's orders. The DON verified that the medication was indeed ordered to be applied twice daily and as needed, acknowledging the failure to adhere to the prescribed regimen on the documented dates.
LPN Changes Insulin Order Without Physician's Approval
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) demonstrated competency in clarifying a physician's order for a medication change. Specifically, an LPN altered a resident's Tresiba insulin order from 30 units once daily to 30 units twice daily without obtaining a physician's order. This change was made despite the resident's care plan indicating that medications should be administered as ordered by the physician. The lack of documented evidence of a physician's order for this change was confirmed through record reviews and interviews. The deficiency was further compounded by the fact that the LPN responsible for the medication change had not completed the competency assessment for medications during their orientation. This oversight was acknowledged by the Assistant Director of Nursing, who admitted to overlooking the completion of the medication competency. The Director of Nursing confirmed that the medication order should not have been changed without a physician's order and acknowledged the incomplete competency assessment for the LPN involved.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to ensure that medication administration records were complete and accurately documented for two of the three residents sampled. For Resident #1, the October 2024 Physician's Orders included medications such as Gabapentin, artificial tears, and Prednisolone-Moxifloxacin-Bromfenac eye drops. However, the electronic Medication Administration Record (eMAR) lacked documented evidence of administration for these medications on specific dates. The Director of Nursing (DON) confirmed these omissions and stated that all medications should have been documented as administered or noted with the appropriate chart code if not administered. Similarly, for Resident #2, the October 2024 Physician Orders included multiple medications such as Aspirin, Ferrous Sulfate, Folic Acid, Insulin Glargine, Levothyroxine Sodium, Norvasc, Zoloft, Fluoxetine HCl, Senna, and Insulin Aspart. The eMAR did not show documented evidence of administration for these medications on specified dates. The DON confirmed these omissions as well, indicating that all medications should have been documented when administered or as applicable.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as evidenced by an incident involving a cognitively intact resident with a Brief Interview for Mental Status score of 15. The facility's Med Pass Guidelines policy, dated 12/04/2017, stipulates that nurses should not leave medications with residents in a cup and must ensure that residents take their medications. However, during an observation, a medicine cup containing nine pills was found on the resident's bedside table. The resident confirmed that an LPN left the pills for self-administration later. The LPN admitted to assuming the resident took the medications while she was present and acknowledged that she should have ensured the medications were taken before leaving the room. The Director of Nursing confirmed that the LPN should not have left medications at the resident's bedside, and the resident was not care planned to have medications at the bedside.
Failure to Provide Scheduled Baths to Resident
Penalty
Summary
The facility failed to provide a dependent resident with scheduled baths, as required by their care plan and the facility's Bed Bath Policy and Procedure. The resident, who was cognitively intact but had limitations in range of motion in both upper and lower extremities, required partial to moderate staff assistance with bathing. Despite being scheduled for baths on Mondays, Wednesdays, and Fridays, the resident reported not receiving a bath for weeks. Documentation from August to October 2024 revealed multiple periods where the resident was not provided a bath, specifically from August 5 to August 9, August 17 to August 26, August 29 to September 3, and October 3 to October 6. The facility was unable to provide any documented evidence that the resident received a bath during these times. The Director of Nursing confirmed the lack of documentation and acknowledged that the resident should have been provided baths according to the schedule.
Inaccurate Bath Documentation for Resident
Penalty
Summary
The facility failed to accurately document the type of bath provided to a resident, leading to a deficiency in maintaining accurate medical records. The resident, who was cognitively intact and required partial to moderate staff assistance with bathing due to limitations in range of motion, was documented as having received showers on multiple occasions in August 2024. However, interviews with the resident and staff, including CNAs and the shower aide, confirmed that the resident only received bed baths and did not take showers. The discrepancy in documentation was acknowledged by the Director of Nursing, who confirmed that the bath records should have accurately reflected the type of bath the resident received. This inaccuracy in documentation was identified during a review of the resident's care plan and bath log, highlighting a failure to adhere to accepted professional standards in maintaining medical records.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall prevention measures were in place for two residents identified as high risk for falls. Resident #44, who had moderate cognitive impairment and a history of unwitnessed falls, did not have a fall mat at his bedside or a dycem in his wheelchair as required by his care plan. Multiple observations confirmed the absence of these safety measures, and interviews with staff revealed a lack of awareness or adherence to the resident's fall prevention interventions. Similarly, Resident #98, diagnosed with Parkinsonism, lack of coordination, and muscle weakness, did not have a fall mat at the bedside despite a physician's order and a high fall risk assessment. Observations over several days confirmed the absence of the fall mat, and staff interviews indicated that the fall mat was not consistently in place. The Director of Nursing confirmed that both residents should have had the specified fall prevention measures in place at all times.
Failure to Sanitize Thermometer and Perform Hand Hygiene
Penalty
Summary
The facility failed to sanitize the thermometer when measuring internal food temperatures and did not perform hand hygiene during meal service. Specifically, a culinary cook did not sanitize the thermometer before and between measuring the temperatures of various foods, including pureed cauliflower, lasagna, broccoli, brown gravy, and chicken noodle soup. The cook used a dishtowel and paper towels to wipe the thermometer instead of sanitizing it, and even dropped the thermometer into the chicken noodle soup without disposing of the contaminated soup. The culinary manager confirmed that the cook's actions were not acceptable and did not follow proper sanitization procedures. Additionally, a CNA failed to perform hand hygiene while assisting residents with meal distribution. The CNA did not wash hands before or after handling food trays, opening drinks, unwrapping utensils, or assisting residents in various rooms. The CNA also used the same gloves to handle multiple food trays and residents without changing them or performing hand hygiene. Both the CNA and the Director of Nursing acknowledged that the observed practices did not adhere to the facility's hand hygiene policy and were unacceptable.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to ensure a resident's room and equipment were kept clean for one of the four residents reviewed for environment. Observations on three consecutive days revealed large areas of a dried tan substance on the floor near the resident's tube feeding pole and on the base of the tube feeding pole. Additionally, the resident's wheelchair had two law labels covered in a dark brown substance. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the resident's floor, tube feeding pole, and wheelchair were not sanitary and should have been kept clean.
Failure to Check PEG Tube Placement Before Feeding
Penalty
Summary
The facility failed to check the placement of a resident's PEG tube prior to administering enteral nutritional therapy. Specifically, an LPN did not auscultate the tube placement before administering a bolus feeding to a resident diagnosed with dysphagia and gastrostomy status. The facility's policy required checking the tube's position by listening for air movement in the stomach, but this step was not followed. The deficiency was observed during an inspection, where the LPN admitted to not performing the required auscultation before administering the feeding. The resident's care plan also specified the need to check the tube placement before feedings, which was not adhered to. The Quality Assurance Nurse confirmed that the procedure should have been followed as per the facility's policy.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to complete quarterly assessments in a timely manner for seven residents. The assessments for these residents were completed more than 14 days after the Assessment Reference Date (ARD), which is not in compliance with the required timeline. Specifically, the assessments for Resident #45, Resident #56, Resident #74, Resident #88, Resident #132, Resident #149, and Resident #164 were all completed late, with completion dates ranging from 18 to 39 days after the ARD. During interviews, both the MDS Nurse and the Director of Nursing confirmed that the assessments were completed late and acknowledged that they should have been completed within the required timeframe. The facility's Final Validation Reports also confirmed the late completion of these assessments. This deficiency was identified through record reviews and staff interviews, highlighting a failure in the facility's process for timely resident assessments.
Failure to Submit Resident Assessments Timely
Penalty
Summary
The facility failed to submit resident assessments to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for nine residents. The assessments for these residents were completed but not transmitted within the required 14-day period. Specifically, the assessments for Resident #6, Resident #20, Resident #92, Resident #103, Resident #120, Resident #130, Resident #147, Resident #162, and Resident #170 were all submitted late, with delays ranging from several days to over a month past the completion date. Additionally, Resident #130's assessment was rejected by CMS due to an invalid date and was not resubmitted in a timely manner. This issue was confirmed through record reviews and interviews with facility staff, including the MDS Nurse and the Director of Nursing, who acknowledged the delays and the failure to meet the submission requirements. The deficiencies were identified during a review of the facility's Final Validation Reports and interviews with staff members. The MDS Nurse was unaware of the rejection of Resident #130's assessment and confirmed that the other assessments were submitted late. The Director of Nursing also confirmed the late submissions. These findings indicate a systemic issue with the timely submission of resident assessments, which is a critical regulatory requirement for ensuring accurate and up-to-date resident information is available to CMS.
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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