Jefferson Manor Nursing And Rehab Ctr, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 9919 Jefferson Hwy., Baton Rouge, Louisiana 70809
- CMS Provider Number
- 195471
- Inspections on file
- 36
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Jefferson Manor Nursing And Rehab Ctr, Llc during CMS and state inspections, most recent first.
A resident, who was cognitively intact, reported ongoing dissatisfaction with the cleanliness of his room, citing the presence of dead roaches despite daily housekeeping. Direct observation confirmed multiple dead roaches in the room, and staff acknowledged that cleaning was not thorough, resulting in a failure to provide a clean and comfortable environment as required by facility policy.
A resident's Quarterly MDS assessment was not completed or transmitted within the required 14-day period after the ARD. Staff responsible for MDS completion and the DON confirmed the delay, resulting in noncompliance with timely assessment and data transmission requirements.
The facility did not post daily nurse staffing data in a prominent location and failed to include the facility name on the staffing data sheets. The responsible staff member had not updated the postings for over two weeks and was unaware of the requirement to include the facility name.
During a period of floor maintenance, nursing staff did not perform required Q2hr visual checks or respond to call lights for residents on one hall. As a result, a resident who depended on staff for mobility was found unresponsive and expired after unsuccessful CPR, while another resident was found on the floor after an extended wait for assistance, expressing feelings of neglect. Staff interviews confirmed that no care was provided during the maintenance period and administration was not notified of the inability to access residents.
The facility did not assess for entrapment risk or obtain informed consent before installing bedrails for four residents with significant mobility impairments, despite physician orders and ongoing use of mobility bars. Staff interviews confirmed that neither risk assessments nor consents were completed prior to bedrail installation, affecting all residents with bedrails in use.
Staff did not provide care or perform rounds for several hours on one hall due to floor maintenance, resulting in two residents being found on the floor, including one unresponsive. The incident and allegations of neglect were not reported to the state agency within the required 2-hour timeframe, affecting all residents on the hall.
A facility failed to accurately code the MDS for a resident with Autistic Disorder regarding their PASRR status. The resident was approved for admission by the state Level II Authority, but the MDS incorrectly indicated no serious mental illness or intellectual disability. Staff interviews confirmed the error, acknowledging the MDS should have reflected the resident's PASRR status accurately.
The facility failed to adhere to its policy for respiratory care by not labeling a resident's oxygen tubing and humidifier bottle with the date they were last changed. This oversight was confirmed by the DON, who acknowledged that the facility's policy requires weekly changes and proper labeling of these items.
A facility failed to provide trauma-informed care for a resident with PTSD, as there was no documentation of a trauma assessment, identification of triggers, or interventions in place. Staff interviews revealed a lack of awareness of the resident's condition, and the care plan did not address the PTSD diagnosis. The administration confirmed the oversight in care planning.
A resident with a pressure ulcer had a medication order for Flagyl 500 mg inaccurately transcribed. The order was meant for the medication to be crushed and applied to the wound bed, but it was documented to be given enterally. This error was confirmed by several staff members, including the wound care nurse and director of nursing, during an observation of wound care.
A facility failed to provide a resident with the correct food portions as ordered by a physician. The resident, with multiple health conditions, had a physician's order for double portions, but the meal tray did not reflect this order. Staff interviews confirmed the oversight, and the meal ticket was not updated to indicate the required double portions.
A facility failed to accurately document the route of medication administration for a resident with a pressure ulcer. The resident was prescribed Flagyl 500 mg to be applied to the wound bed, but the order was incorrectly documented as enteral administration. Staff confirmed the medication was applied to the wound but documented as given enterally, leading to inaccurate records.
A resident with moderate cognitive impairment eloped from a facility after staff failed to perform required visual checks every two hours. The resident was last seen at 4:00 a.m. and was able to climb over a patio fence at 4:32 a.m. without staff noticing. The absence was not realized until 8:00 a.m., and the resident was found four days later by local police. Staff interviews revealed lapses in following the facility's policy on visual checks and missing residents.
A resident with Type 2 Diabetes and Schizophrenia eloped from the facility after staff failed to perform required visual checks every two hours. The resident was missing for four days, and the incident was not reported to the State Survey Agency within the required timeframe, constituting neglect.
The facility failed to provide privacy for three residents during incontinence care. A resident with urinary tract infections and cerebral infarction was exposed due to an open door and unpulled privacy curtain. Another resident with hemiplegia was similarly exposed. A third resident with dementia and Alzheimer's disease received care without a privacy curtain, as it had been removed and not replaced. Staff confirmed these observations, and the facility was in the process of replacing old curtains.
The facility failed to provide timely incontinence care and daily oral hygiene for residents unable to perform these activities themselves. A resident with severe cognitive impairment was found with a wet incontinence brief, while another resident with hemiplegia had a strong urine odor in his room, indicating lapses in care. Additionally, two residents did not receive daily oral care, with one resident's dentures not being cleaned regularly. CNAs admitted to not performing or documenting the required care, and the DON confirmed these deficiencies.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) or perform proper hand hygiene. Staff members did not wear required PPE, such as gowns, while providing care to residents on EBP, and a CNA failed to perform hand hygiene between tasks and resident rooms, handling items with soiled gloves. Interviews confirmed staff awareness of protocols, yet they did not comply, indicating a gap between policy and practice.
A resident with severe cognitive impairment and at risk for skin breakdown did not receive physician-ordered heel protectors, as observed over two days. Staff interviews revealed confusion over responsibility for implementing the order, with CNAs and LPNs providing inconsistent accounts of care practices.
A facility failed to maintain accurate medical records for a resident with a colostomy, as bowel movements were documented retrospectively without verification. The resident was observed managing his colostomy bag with CNA assistance, but the ADL records were updated days later by a CNA without consulting the staff who worked those shifts. The DON confirmed this ongoing documentation issue.
A resident requiring mechanical lift assistance was improperly transferred by a single CNA, resulting in a fall. Despite the resident expressing severe anxiety and stating she felt she was going to die, these symptoms were not reported to the nursing staff. The resident was later found unresponsive and pronounced dead from cardiac arrest. Interviews revealed that CNAs failed to communicate the resident's distress to the nursing staff.
A resident with Guillain-Barre Syndrome and other conditions requiring two-person assistance for mechanical lift transfers was transferred by a CNA without assistance, resulting in a fall and subsequent cardiac arrest. The CNA admitted to not seeking help despite knowing the requirement for two-person assistance. The incident was captured on surveillance video, and the resident was later pronounced dead at the hospital.
The facility failed to report allegations of neglect resulting in serious bodily injury within the required two-hour timeframe. A resident fell from a mechanical lift and became unresponsive, while another resident suffered a fracture after a fall from bed. Both incidents were reported to the state later than required, violating immediate reporting requirements.
A resident with severe cognitive impairment and multiple medical conditions was not transferred according to her care plan, which required a two-person mechanical lift. Instead, staff physically lifted her on two occasions, leading to a skin tear. The DON confirmed the care plan was not followed.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for one resident. The resident, who was cognitively intact according to a recent BIMS assessment, reported dissatisfaction with the cleanliness of his room, specifically noting the presence of dead roaches throughout the area since the last pest control treatment 2-3 weeks prior. Despite daily sweeping and mopping by housekeeping staff, the resident stated that his room remained dirty and that the conditions made him feel uncomfortable. Direct observation of the resident's room confirmed the presence of eight small dead roaches in various locations, including along the baseboards, next to the fridge, near the wardrobe, under the A/C unit, and by the laundry basket. Housekeeping and other facility staff acknowledged that the room had been cleaned that day but agreed that it was not cleaned thoroughly. The facility's policy requires a safe, clean, and comfortable environment, but the observed conditions and staff interviews demonstrated a failure to meet these standards for this resident.
Failure to Complete and Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) assessments for one of three sampled residents reviewed for resident assessment. Specifically, a resident was admitted to the facility and had a Quarterly MDS assessment with an Assessment Reference Date (ARD) that remained incomplete and in 'in progress' status beyond the required 14 days after the ARD. Interviews with the staff member responsible for MDS completion and the Director of Nursing confirmed that the assessment was not completed or transmitted to the State within the mandated timeframe.
Failure to Post and Document Required Nurse Staffing Data
Penalty
Summary
The facility failed to comply with nurse staffing data posting requirements by not documenting all required information on daily postings and not ensuring the data was posted daily in a prominent, accessible location. On observation, the posted staffing data sheet was dated more than two weeks prior and lacked the facility name. Interviews with the Director of Nursing and the staff member responsible for posting confirmed that the staffing data had not been updated daily as required and that the facility name was missing from the documentation. The staff member responsible also stated she was unaware that including the facility name was a requirement.
Failure to Provide Care and Visual Checks During Floor Maintenance Results in Neglect
Penalty
Summary
Nursing staff failed to respond to call lights and provide care or services to all residents residing on Hall A from 11:00 p.m. to 2:30 a.m. on the night in question. During this period, staff did not perform required visual checks or respond to residents' needs, despite physician orders for visual checks every two hours for certain residents. Video surveillance confirmed that no staff entered resident rooms or provided care during this time, and multiple call lights were left unanswered. One resident, who was dependent on staff for bed mobility and transfers and had a physician's order for visual checks every two hours, activated her call light for assistance but received no response. She was later found unresponsive and pulseless on her fall mat beside her bed, and expired after unsuccessful CPR. Another resident, also requiring staff assistance and ordered for two-hour visual checks, was found lying on the floor after sliding out of bed, having called for help and waited a long time without assistance. This resident verbalized feeling aggravated and neglected due to the lack of response from staff. Interviews with staff revealed that they did not provide care or perform rounds on Hall A during the floor maintenance, which blocked access to resident rooms. Staff admitted to not notifying administration about their inability to access residents and confirmed that no care was provided during the maintenance period. The Director of Nursing and Administrator confirmed that staff were expected to perform visual checks and respond to call lights as ordered, and that the failure to do so constituted neglect.
Removal Plan
- Conduct in-service for all CNAs and LPNs regarding Q2hr visual rounds, including instruction to immediately notify the Administrator if anything prevents them from making Q2hr rounds.
- Do not permit staff unable to be in-serviced to work until they are in-serviced. In-service all new employees during their orientation period.
- Reimplement a log of each resident arranged by room to document direct observation checks every two hours on each shift, with designated nursing staff signing off that observations have been made. Review monitoring by the DON/designee.
- Notify the floor maintenance Vendor that company employees will not be allowed to perform floor services in the absence of the Administrator. Ensure a schedule is set for floor service times and the vendor reports directly to the Administrator.
- Reimplement a QAPI monitor to ensure Q2hr rounds are completed. Assign a nurse to complete and document the Q2hr visual rounds on the QA Monitor. Continue the QA Monitor.
- Discuss effectiveness of the corrective actions at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes.
- Implement additional in-services and/or corrective actions as needed.
Failure to Assess Entrapment Risk and Obtain Consent for Bedrail Use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment from bedrails and did not obtain informed consent prior to the installation of bedrails for four sampled residents who had bedrails in use. For each of these residents, clinical record reviews showed that there was no documentation of entrapment risk assessments or informed consent forms related to the use of bedrails, despite physician orders and medication administration records indicating the use of mobility bars for bed mobility and repositioning. Observations confirmed that the bedrails were in use, and interviews with the residents revealed that they had not signed consents when the bedrails were implemented. The residents involved had significant medical conditions affecting mobility, such as muscle weakness, muscle wasting, foot drop, osteoarthritis, abnormal posture, and cognitive communication deficits. All required substantial or maximum assistance with bed mobility and transfers, and some had a history of repeated falls or other mobility impairments. Despite these conditions, there was no evidence in their records that the facility had evaluated the risks and benefits of bedrail use or discussed these with the residents or their representatives prior to installation. Interviews with facility staff, including an LPN and the DON, confirmed that entrapment risk assessments and informed consents were not routinely completed before installing bedrails, particularly when the bedrails were not being used as restraints. Staff acknowledged that no one was assigned to perform these assessments or obtain consents, and that these processes were not in place prior to the survey. This practice had the potential to affect all residents in the facility with bedrails in use.
Failure to Timely Report and Prevent Neglect Due to Interrupted Care
Penalty
Summary
The facility failed to ensure that allegations of neglect were reported to the state agency within the required 2-hour timeframe after the allegations were made for multiple residents on Hall A. According to the facility's own policies, any evidence of neglect must be reported immediately to the administrator and to the appropriate state officials within 2 hours. However, review of incident reports, video surveillance, and staff interviews revealed that from 10:00 p.m. to approximately 2:30 a.m., no care or services were provided to any residents on Hall A due to floor maintenance activities. Staff confirmed that they did not perform rounds or provide care during this period, and video footage corroborated that no staff entered resident rooms or responded to call lights during this time. One resident was found unresponsive on a fall mat and another was found lying on the floor during the period when care was not provided. The administrator was made aware of the situation at approximately 4:00 a.m., but the incident was not reported to the State Survey Agency within the required 2-hour window. The failure to provide care and the delay in reporting the neglect affected all residents on Hall A, as confirmed by staff interviews and video evidence.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for a resident accurately reflected the resident's status concerning the Preadmission Screening and Resident Review (PASRR). The resident, who was admitted with a diagnosis of Autistic Disorder, had an approval for admission by the state Level II Authority for a temporary period. However, the Admission MDS was incorrectly coded in Section A1500, indicating that the resident was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition, when it should have been coded as 'Yes'. Interviews with the staff responsible for completing the MDS assessment confirmed the error. The staff member acknowledged that the resident's Form 142 indicated approval for nursing home admission by Level II authority, and upon review, confirmed that the MDS coding was incorrect. The Director of Nursing also verified the discrepancy, confirming that the MDS should have been coded to reflect the resident's PASRR status accurately.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for a resident who was dependent on supplemental oxygen. The deficiency was identified during observations and interviews, where it was noted that the resident's oxygen tubing and humidifier bottle were not properly labeled with the date they were last changed. According to the facility's policy, these items should be changed weekly and labeled with the date of the last change. The Director of Nursing confirmed that the oxygen tubing was not labeled as required, acknowledging that the facility's policy was not followed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder. The resident's clinical records, including the Quarterly MDS and Physician History, confirmed the PTSD diagnosis, yet there was no documentation of a trauma assessment, identification of triggers, or interventions in place. The resident's care plan lacked any mention of PTSD, and interviews with staff revealed a lack of awareness and understanding of the resident's condition and necessary interventions. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, confirmed the absence of a PTSD assessment and care plan for the resident. The staff acknowledged that they should have been aware of the resident's PTSD and that a care plan should have been developed to identify triggers and implement interventions. The failure to assess and plan for the resident's PTSD was confirmed by the facility's administration, highlighting a significant oversight in providing trauma-informed care in accordance with professional standards of practice.
Medication Order Transcription Error for Wound Care
Penalty
Summary
The facility failed to ensure medications were administered to meet the needs of a resident with a pressure ulcer. Specifically, the medication order for Flagyl 500 mg was inaccurately transcribed. The order was intended for the medication to be crushed and applied to the wound bed, but it was incorrectly documented to be given enterally. This transcription error was confirmed by multiple staff members, including the wound care nurse, nurse practitioner, assistant director of nursing, and director of nursing. The error was discovered during an observation of wound care for the resident, where it was noted that the medication was being applied to the wound bed as intended, despite the incorrect transcription in the medical records. The staff involved acknowledged the discrepancy between the physician's intended order and the documented order, confirming that the medication administration record did not accurately reflect the physician's instructions.
Failure to Provide Correct Food Portions as Ordered
Penalty
Summary
The facility failed to ensure that a resident received the correct food portions as ordered by a physician. The deficiency was identified during observations, record reviews, and interviews. The facility's policy required that new diet orders and changes be communicated in writing to the Dietary Department by the Nursing Staff. However, this process was not followed for a resident who was admitted with diagnoses including Iron Deficiency Anemia, Deficiency of Other Vitamins, Gastrointestinal Hemorrhage, and Chronic Kidney Disease, Stage 3. The resident had a physician's order for a regular diet with mechanical soft texture and double portions for lunch and supper. On the day of the observation, the resident's meal tray did not contain the double portions as ordered. The meal ticket only indicated a regular diet without the specified double portions. Interviews with the CNA and Dietary Manager confirmed that the meal tray did not match the physician's order. The Dietary Manager acknowledged that the resident's meal ticket was not updated to reflect the double portions, and the Administrator confirmed that the resident should have received the double portions as per the doctor's order.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate documentation regarding the route of medication administration for a resident with an unstageable pressure ulcer and osteomyelitis. The resident was prescribed Flagyl 500 mg to be administered by crushing and applying it to the wound bed. However, the order was incorrectly documented as an enteral administration. This discrepancy was confirmed during interviews with the nurse practitioner and the wound care nurse, who acknowledged that the medication was being applied to the wound bed but documented as being given enterally. The Treatment Administration Record (TAR) for the resident showed multiple instances where the medication was signed off as administered enterally by the staff, despite the actual practice of applying it to the wound. The Director of Nursing reviewed the records and confirmed the inaccurate documentation. This failure to document the correct route of administration constitutes a deficiency in maintaining accurate medical records in accordance with professional standards.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a moderately cognitively impaired resident. The resident, who had a physician's order for staff to visually check his location every two hours, was last seen by staff at approximately 4:00 a.m. on the day of the incident. Despite this order, the resident was able to elope from the facility by climbing over the patio fence at 4:32 a.m., as captured on video surveillance. Staff did not realize the resident was missing until approximately 8:00 a.m., and the resident was not found until four days later by local police. Interviews with staff revealed a lack of adherence to the visual check orders. The LPN and CNA assigned to the resident during the night shift confirmed they conducted rounds but failed to notice the resident's absence after 4:00 a.m. The CNA admitted to not notifying other staff when the resident was not observed during her last round. Additionally, staff on the morning shift did not immediately recognize the resident's absence, further delaying the response to the elopement. The facility's policy on wandering or missing residents was not effectively implemented, as staff failed to perform the required visual checks and did not promptly initiate a search when the resident was not found in his room. The deficiency resulted in an Immediate Jeopardy situation, as the resident was missing for an extended period without staff knowledge, posing a risk to his safety and well-being.
Failure to Report Neglect and Supervise Resident
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. This deficiency involved a resident who was admitted with diagnoses including Type 2 Diabetes Mellitus and Schizophrenia. The resident had a physician's order for visual checks every two hours, which was not adhered to. On the morning of the incident, the resident was not found in his room during breakfast time, and staff were unable to locate him after searching the facility. It was later discovered through video footage that the resident had eloped by climbing over a fence at approximately 4:30 a.m. The staff, including the CNA and LPN assigned to the resident, failed to perform the required visual checks, leading to the resident being unaccounted for from the early morning hours. The resident was missing for four days before being found. The facility's Administrator confirmed that the incident was not reported to the State Survey Agency as required by their policy. This lack of timely reporting and failure to provide adequate supervision constituted neglect as defined by the facility's Abuse/Neglect Prevention Program policy.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy for residents during personal care activities, specifically incontinence care, for three residents. Resident #2, who was admitted with diagnoses of urinary tract infections and cerebral infarction, was observed receiving care without the privacy curtain being pulled or the room door closed. This resulted in her being exposed to her roommate and anyone entering the room. Similarly, Resident #R1, diagnosed with hemiplegia and hemiparesis following cerebral infarction, was also observed receiving care with the room door open and privacy curtains not pulled, leaving him exposed to his roommate and anyone in the hallway. Additionally, Resident #R5, who has unspecified dementia and Alzheimer's disease, was provided incontinence care without any privacy curtain in place, as it had been removed for cleaning and not replaced. This left him exposed to his roommate and anyone entering the room. Interviews with the CNAs involved confirmed these observations, and the Director of Nursing and Administrator acknowledged the lack of privacy provided during care. The facility was in the process of replacing old privacy curtains, but this had not been completed, leading to the deficiency.
Deficiencies in Incontinence and Oral Care
Penalty
Summary
The facility failed to provide timely incontinence care and daily oral hygiene for residents who were unable to perform these activities themselves. Resident #2, who was severely cognitively impaired and required substantial assistance for toileting, was found with a wet incontinence brief and pad, indicating a lack of timely care. Similarly, Resident #R1, who was always incontinent of urine and required maximum assistance, was observed with a strong urine odor in his room and soiled clothing, suggesting that incontinence care was not provided every two hours as required. Additionally, the facility did not ensure daily oral care for Resident #2 and Resident #R3. Resident #2, who required moderate assistance for oral hygiene, had no documented oral care on multiple dates, and confirmed that staff did not perform oral care daily. Resident #R3, who was cognitively intact but required assistance with oral care, reported that staff did not clean her dentures daily, and she was observed without dentures in her mouth. The CNAs responsible for these residents admitted to not performing or documenting the oral care as required. Interviews with the Director of Nursing (DON) confirmed that the facility's policy required CNAs to provide oral care as part of their morning routine and to document it accordingly. The DON acknowledged that the care was not documented as performed daily for the residents in question, which should have been done according to the facility's standards.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, staff members did not wear the required personal protective equipment (PPE), such as gowns, while providing care to residents on EBP. For instance, during the care of a resident with a suprapubic catheter, the Director of Nursing (DON) and two Certified Nursing Assistants (CNAs) did not don gowns while performing high-contact care activities, despite the presence of clear signage indicating the need for such precautions. Additionally, the facility's staff did not follow proper infection control practices, including hand hygiene and glove use, during incontinence care for two residents. Observations revealed that a CNA failed to perform hand hygiene between tasks and resident rooms, and handled various items and surfaces with soiled gloves. This included touching a resident's clothing, bed linens, and room fixtures without changing gloves or washing hands, which is contrary to the facility's policy on incontinence care. Interviews with the involved staff confirmed their awareness of the EBP requirements and the necessity of hand hygiene, yet they acknowledged their failure to comply with these protocols. The DON also confirmed the expectations for staff to perform hand hygiene before and after resident care, and not to touch items with soiled gloves, highlighting a gap between policy and practice in the facility's infection control measures.
Failure to Implement Physician-Ordered Heel Protectors
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, as evidenced by the lack of implementation of physician-ordered heel protectors. The resident, who was admitted with diagnoses of UTIs and cerebral infarction, was severely cognitively impaired with a BIMS score of 6. Despite having a physician's order dated 07/01/2024 for heel protectors to be applied to both heels, observations on multiple occasions over two days revealed that the resident did not have heel protectors in place, nor were her heels floated off the bed as required. Interviews with staff members, including CNAs and LPNs, indicated a lack of clarity and responsibility regarding the implementation of the heel protectors. One CNA admitted to not having seen the heel protectors and typically used a pillow to float the resident's heels, which was not observed during the survey. LPNs expressed that it was either the responsibility of wound care or CNAs to ensure the heel protectors were in place. The Director of Nursing confirmed that the staff should have ensured the heel protectors were applied, as per the physician's order, acknowledging the resident's risk for skin breakdown.
Inaccurate Documentation of Bowel Movements for Resident with Colostomy
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of bowel movements. The resident, who has a colostomy, was observed and interviewed, revealing that he emptied his colostomy bag with the assistance of a CNA. However, the ADL Resident Care Details for the resident showed that bowel movements were documented for several days after the fact, without verification from the CNAs who worked those shifts. This discrepancy was confirmed by S2CNAS, who admitted to adding the missing documentation without consulting the CNAs responsible for the shifts in question. The Director of Nursing (S1DON) also confirmed the issue, stating that CNAs are expected to complete ADL documentation, including bowel movements and colostomy output, before the end of each shift. The DON acknowledged that documentation had been an ongoing issue with the CNAs and confirmed that the documentation for the resident's bowel movements was added retrospectively by S2CNAS without verification. This failure to accurately document the resident's bowel movements in a timely and verified manner constitutes a deficiency in maintaining medical records according to accepted professional standards.
Failure to Report Resident's Change in Condition Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident's significant change in status was reported to the physician, which resulted in an Immediate Jeopardy situation. A resident, who required mechanical lift assistance with two staff members for transfers, was transferred by a single CNA using the mechanical lift. This improper transfer led to the resident falling from the lift and sustaining injuries. Despite the resident expressing severe anxiety and stating that she felt she was going to die, these symptoms were not reported to the nursing staff by the CNAs who interacted with her after the fall. The resident, who had a history of Guillain-Barre Syndrome, heart disease, and several mental health disorders, was found unresponsive approximately 40 minutes after the fall. The CNAs who checked on the resident after the fall observed her expressing distress and anxiety, but failed to communicate these observations to the nursing staff. The resident was later found unresponsive by the Director of Nursing, who initiated CPR. The resident was transported to the hospital, where she was pronounced dead from cardiac arrest. Interviews with the CNAs revealed that they did not report the resident's statements or her anxious demeanor to the nurse, which was a critical oversight. The nursing staff, including the RN and LPN, confirmed that they were not informed of the resident's increased anxiety or her statements about feeling like she was going to die. This lack of communication and failure to report significant changes in the resident's condition contributed to the severity of the incident.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident who required two-person assistance with mechanical lift transfers remained free from accident hazards. This deficiency involved a resident with Guillain-Barre Syndrome, lack of coordination, contractures, and muscle wasting, who was dependent on staff for transfers. The resident's care plan and physician orders specified the need for a mechanical lift with two-person assistance for transfers. On the day of the incident, a CNA transported the resident to her room and attempted to transfer her using a mechanical lift without the assistance of another staff member. During the transfer, the resident slipped out of the lift pad and fell onto the legs of the lift, hitting her right flank. The CNA admitted to not asking for help and acknowledged knowing the requirement for two-person assistance. The incident was captured on surveillance video, showing the CNA entering the resident's room alone with the lift and later calling for assistance after the fall. The resident was initially responsive but later became unresponsive, leading to CPR being initiated and the resident being transferred to the hospital, where she was pronounced dead from cardiac arrest.
Delayed Reporting of Neglect Incidents
Penalty
Summary
The facility failed to report allegations of neglect resulting in serious bodily injury within the required two-hour timeframe to the facility Administrator and the State Survey Agency. In the case of Resident #1, the incident occurred when a CNA attempted to transfer the resident alone using a mechanical lift, resulting in the resident falling and becoming unresponsive. CPR was initiated, and the resident was transported to a hospital for evaluation and treatment. The Director of Nursing was informed of the incident shortly after it occurred, but the report to the state was delayed until later that afternoon. For Resident #2, the incident involved a witnessed fall from the bed during care by a CNA, which resulted in a skin tear and later a proximal fracture to the tibia/fibula. The resident was eventually sent to the hospital for evaluation and treatment. The Administrator was aware of the incident and the resulting injury but did not report the allegation of neglect to the state until the following day. These delays in reporting are in violation of the requirement to report such incidents immediately, but no later than two hours after the allegation is made if it involves abuse or results in bodily harm.
Failure to Implement Care Plan for Resident Transfers
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who required two-person assistance with a mechanical lift for transfers. The resident, who was severely cognitively impaired and had multiple medical conditions including dysphagia, hemiplegia, muscle wasting, and an acquired absence of the left leg, was not transferred according to her care plan. On two occasions, staff members physically lifted the resident without using the mechanical lift, contrary to the care plan that specified a two-person mechanical lift for transfers. Interviews with staff members revealed that the resident was physically lifted by a CNA and an LPN after a fall from her bed, and again by a CNA during a shower transfer, without the use of the mechanical lift. The Director of Nursing confirmed that the resident's care plan required a two-person mechanical lift for transfers and acknowledged that the proper procedure was not followed on these occasions. This failure to adhere to the care plan resulted in the resident sustaining a skin tear to her right shin.
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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