Jena Nursing And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jena, Louisiana.
- Location
- 5877 Aimwell Road, Jena, Louisiana 71342
- CMS Provider Number
- 195399
- Inspections on file
- 41
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Jena Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with intact cognition, multiple chronic conditions, and an indwelling urinary catheter had an NP and physician order for Clindamycin 1% topical medication to be applied twice daily to a penile erosion site. Review of the TAR showed repeated missing documentation of the evening dose on numerous days within the ordered treatment period, with no recorded reasons for omission. The DON acknowledged the lack of documentation, and an LPN admitted administering the topical medication without documenting it on the TAR, contrary to facility policy requiring documentation of each administered or omitted dose.
A resident with multiple medical conditions, including acute respiratory failure, UTI, and a stage 3 pressure ulcer, experienced a new onset of elevated heart rate ranging from 130–137 bpm that persisted throughout a shift. An LPN recognized this as a change in condition and discussed possible hospital transfer with the resident and spouse, who declined, but did not notify the NP despite facility policy requiring provider notification for significant changes in vital signs. The NP later reported receiving no notification of this change, and the DON confirmed that increased heart rate constitutes a change in condition that should have been reported.
Surveyors found that the facility failed to obtain and document an updated CNA registry verification before re-hiring a CNA who had previously been terminated. Review of the CNA’s personnel file showed an original registry check from the initial hire but no verification completed at the time of re-hire, and the administrator confirmed that no such documentation existed.
The facility failed to post complete daily nurse staffing information as required. Surveyors observed that Daily Nursing Staff Posting forms for consecutive days were displayed without documenting the resident census at the start of the shift, the daily nursing hours required, or the actual nursing hours worked. An RN responsible for staff development confirmed that these required data elements were not posted for those days and acknowledged that she had routinely posted the forms without the missing information.
Two residents with physician orders and care plans for Enhanced Barrier Precautions (EBP) during wound care did not receive care in accordance with the facility’s infection control policy. During separate wound care procedures, a treatment RN failed to wear a gown and did not change gloves between cleaning the wounds and applying ointments, powder, or clean dressings. The corporate RN confirmed that EBP requires staff to wear a gown and gloves for wound care and to change gloves after cleaning and before applying clean dressings or ointments.
A resident with a history of anoxic brain damage, cardiac arrest, and venous thrombosis was started on Apixaban for deep vein thrombosis, which was identified as a significant change in condition. The facility did not complete the required Significant Change MDS Assessment within 14 days of this change, as confirmed by MDS staff.
Two residents with complex medical histories had MDS assessments that did not accurately reflect their clinical status, including falls and antipsychotic medication use, despite documentation in their records and care plans. Staff confirmed the inaccuracies in the assessments.
A resident with a history of deep vein thrombosis and on Apixaban therapy was not care planned for anticoagulant therapy, despite staff acknowledging this should have been addressed. The resident had intact cognition and multiple significant diagnoses, but the care plan did not reflect the need for anticoagulant management.
The facility did not ensure person-centered care plans were developed and implemented for several residents. One resident with quadriplegia did not have a functioning bed alarm as ordered, with repeated observations showing the alarm was disconnected and improperly placed. Another resident who smoked was not care planned for smoking, despite facility policy and completed evaluation. A third resident with complex medical and psychiatric conditions had only a generalized care plan, lacking comprehensive, individualized interventions. Staff responsible for care planning acknowledged these deficiencies.
The facility did not meet professional standards by failing to properly document and assess a resident's skin condition, neglecting to obtain monthly weights for another resident as required, and administering medication by the wrong route to a resident with a G-tube. These deficiencies involved incomplete assessments, lack of adherence to care plans, and failure to follow physician orders.
A resident with moderately impaired cognition and multiple psychiatric diagnoses was physically assaulted by another resident after refusing a request, resulting in facial lacerations and emergency room evaluation. Both individuals had no prior history of physical aggression, and the incident was confirmed through staff interviews and record review.
A resident with schizophrenia and intact cognition was prescribed Risperdal 1mg twice daily, but there was no evidence that a gradual dose reduction was attempted or that a clinical contraindication was documented. Despite a consultant pharmacist's recommendation for a dose reduction, the physician did not provide a documented response, and the medical record lacked required documentation regarding the use of the antipsychotic medication.
Three residents had MDS assessments that did not accurately reflect their up-to-date COVID-19 vaccination status, despite immunization records showing they had received the required doses. The Infection Preventionist confirmed the discrepancy between the MDS documentation and the actual vaccination records.
The facility did not ensure that residents dependent on staff for ADLs received necessary grooming and hygiene care. A resident with impaired mobility was observed with unkempt hair and unshaven facial hair, while two other residents missed multiple scheduled bed baths, resulting in foul odors and inconsistent hygiene. Staff interviews and documentation confirmed that required care was not consistently provided.
A resident with multiple health conditions and at risk for pressure ulcers was not turned or repositioned as required by her care plan. Staff interviews and observations confirmed the resident remained in the same position for several hours, and necessary interventions were missing from both electronic and paper records. The DON acknowledged these omissions, resulting in a failure to provide necessary services to maintain skin integrity.
A resident who required continuous tube feeding and water flushes did not receive enteral nutrition as ordered by the physician. The feeding pump was found turned off, with both the resident and LPN unaware of the duration. Another LPN reported turning off the feeding due to the resident's stomach pain and later restarting it, but there was no documentation of the interruption. The DON was informed of issues but could not determine the cause or length of the feeding lapse.
The facility did not complete required annual performance reviews or provide regular in-service education for two CNAs, as shown by missing or outdated documentation in their personnel records. Both the administrator and HR confirmed the absence of these evaluations during interviews.
Multiple infection control deficiencies were identified, including an LPN administering medications via PEG tube without wearing a gown as required by EBP policy, a nurse failing to perform hand hygiene during wound care and contaminating supplies, and improper storage of both unused and used resident care items directly on the floor and in shower areas. Additionally, a visibly soiled shower curtain was observed, with staff unaware of cleaning protocols.
Two residents experienced incidents involving suspected abuse or unexplained injuries that were not reported immediately to management as required. In one case, an LPN observed bruising on a resident with severe cognitive impairment but failed to notify management, and in another, an LPN delayed reporting an abuse allegation made by a resident with moderate cognitive impairment. Both staff members later acknowledged the delay in reporting.
A facility failed to ensure controlled medications were administered and documented correctly for multiple residents. An LPN signed out doses of medications at times when she had already clocked out, and there was no documentation in the eMAR. The LPN admitted to pre-pulling medications and administering them early, against physician's orders, leading to false documentation of administration times.
The facility failed to document the effectiveness of pain management for five residents, as required by policy. Residents received pain medication without prior or post-administration assessments, and doses were not recorded on the eMAR. The DON confirmed the lack of documentation, highlighting a systemic issue in pain management practices.
A resident with a history of behavioral issues physically abused another resident by hitting them after an altercation involving a wheelchair. The incident was captured on surveillance, confirming the sequence of events. Both residents were assessed with no injuries reported.
A resident with a history of chronic left hip dislocation did not receive timely care due to a missed orthopedic specialist appointment. The resident, who required substantial assistance and had impaired cognition, was in pain and immobile. The facility failed to ensure transport to the appointment, leading to a delay in necessary medical evaluation and treatment.
A resident with a history of mental health issues physically assaulted another resident in the dayroom, despite staff presence. The altercation began when the aggressive resident attempted to take another resident's food tray, leading to a verbal confrontation and subsequent physical fight. The incident resulted in a skin tear for the aggressor and a reported head injury for the other resident, indicating a failure in the facility's abuse prevention measures.
A resident with a PEG tube did not receive the prescribed nutritional and hydration support due to incorrect feeding and flush rates set by the facility staff. The resident's feeding was set at 40ml/hr instead of the prescribed 50ml/hr, and water flushes were administered at 30ml every 3 hours instead of 50ml/hr. Additionally, the feeding and flush bags were not labeled as required. Staff interviews confirmed these discrepancies, highlighting a failure to follow the registered dietitian's recommendations.
The facility failed to maintain a clean, comfortable, and homelike environment in Rooms a, b, and c, with issues including dust, trash, dead insects, stained and loose ceiling tiles, non-functional lights, and a dirty window pane obstructing the outside view.
The facility failed to meet professional standards of quality by not obtaining required labs for a resident with multiple diagnoses and not notifying a physician of a dietician's recommendations for another resident's tube feeding regimen.
The facility failed to ensure that residents who were unable to carry out ADLs received necessary grooming and personal hygiene services. Several residents were observed with long facial hair and untrimmed, dirty fingernails, despite their care plans indicating they required assistance. Interviews with residents and staff, as well as record reviews, confirmed these deficiencies.
The facility failed to maintain dignity for a female resident by not ensuring she was free of facial hair. The resident, who has multiple diagnoses and requires total assistance with all activities of daily living, was observed with 1/4 inch facial hair on her chin. An RN confirmed that the facial hair should have been shaved but was not.
The facility failed to act promptly on grievances reported by residents during a Resident Council meeting. Concerns about CNA performance were documented and given to the DON, but no follow-up or investigation was conducted.
A resident with multiple diagnoses, including Acute Respiratory Failure and Anoxic Brain Damage, was not provided with the correct tube feeding regimen as recommended by the dietician. Despite the plan of care specifying a different feeding rate and flush schedule, the resident continued to receive inadequate nutrition and hydration.
The facility failed to post daily nurse staffing information. An observation revealed that the posted information was outdated by several days, and the DON confirmed that it should have been updated daily but was not.
The facility failed to ensure that pureed foods were prepared according to standardized recipes, resulting in the use of unmeasured ingredients and methods that did not conserve nutritional value for three residents. Dietary staff admitted to not using recipes and the dietary manager confirmed the lack of adherence to the facility's policy on pureed food preparation.
The facility failed to ensure that all staff adhered to Enhanced Barrier Precautions for a resident with a tracheostomy and mechanical ventilation. A hospice CNA provided direct care without wearing the required PPE, despite signage and equipment indicating the need for such precautions. The CNA admitted to not understanding the signage, and the nurse confirmed that hospice staff were expected to follow the posted instructions.
Failure to Accurately Document Topical Antibiotic on TAR
Penalty
Summary
The facility failed to ensure medications were accurately documented on the Treatment Administration Record (TAR) in accordance with its medication administration policy. The policy required staff to document each medication as it was prepared on the MAR/TAR and to document a reason if a medication was not given as ordered. For one resident with intact cognition, admitted with diagnoses including depression, stage 4 sacral pressure ulcer, paraplegia, presence of urogenital implants, neuromuscular dysfunction of the bladder, and an indwelling urinary catheter, a nurse practitioner ordered Clindamycin 1% topical ointment to be applied to a penile erosion site twice daily for 14 days. The corresponding physician order specified Clindamycin Phosphate External Solution 1% topical, to be applied to the penile erosion site twice daily for infection over the same 14-day period. Review of the resident’s January–February 2026 TAR showed missing documentation for the 6:00 p.m. dose of the Clindamycin topical medication on multiple dates within the treatment period, with no entries indicating administration or reasons for omission. During interview, the DON confirmed there was no documentation on the identified dates and acknowledged that nurses should have documented on the TAR after administering the topical medication. In a separate interview, an LPN stated she remembered the Clindamycin 1% topical order and confirmed she did not document on the TAR after administering the ointment, despite being required to do so.
Failure to Notify NP of Resident’s Elevated Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring notification of the attending physician extender and resident representative when there is a significant change in a resident’s condition, including unstable vital signs such as pulse. The facility’s policy titled "Notification of a Change in a Resident's Status" specifies that the physician/NP and responsible party must be notified for significant changes in or unstable vital signs. Resident #5, admitted with diagnoses including acute respiratory failure, depression, urinary tract infection, a stage 3 pressure ulcer of the left buttock, and infection of the skin and subcutaneous tissue, had a Quarterly MDS indicating moderately intact cognition with a BIMs score of 8. During a morning medication pass, the LPN observed that Resident #5’s heart rate was elevated between 130–137 beats per minute and identified this as a new change in condition. The LPN reported that the elevated heart rate persisted throughout her shift. She asked the resident and the resident’s husband if they wanted to go to the hospital, and both declined. Despite recognizing that facility practice and policy require notifying the physician or NP of a change in condition even when a resident refuses transfer, the LPN did not notify the NP of the elevated heart rate. The NP later stated he expects to be notified of any change from baseline and confirmed he had not been informed of this event. The DON also confirmed that an increased heart rate is a change in condition and that the NP should have been notified, establishing that the required notification did not occur for this resident’s elevated heart rate.
Failure to Obtain CNA Registry Verification Prior to Re-Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) registry verification was obtained prior to the re-hire of one CNA. Record review showed that this CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. The personnel file contained a CNA registry verification dated 10/22/2012, corresponding to the original hire, but there was no documented evidence that a new CNA registry verification was obtained at the time of re-hire. During an interview on 03/18/2026 at 11:50 a.m., the administrator confirmed that the facility did not have documentation showing that a CNA registry verification was completed prior to re-hiring this CNA as required. This deficiency was identified for 1 of 2 CNA personnel records reviewed, specifically for the CNA who had a break in employment and was subsequently re-hired without updated registry verification documentation in the personnel record.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to properly complete and post required daily nurse staffing information. On 03/18/2026 at 8:45 a.m., surveyors observed a Daily Nursing Staff Posting form dated 03/18/2026 on a bulletin board in the middle of the facility that did not include the resident census at the start of the shift, the daily staffing hours required, or the actual hours worked. At the same time, a Daily Nursing Staff Posting form dated 03/17/2026 was also observed without the resident census, daily staffing hours required, or actual hours worked documented or updated from the previous day. In an interview on 03/18/2026 at 9:20 a.m., the Staff Development Coordinator RN confirmed that for both 03/17/2026 and 03/18/2026 the facility did not post the resident census, daily nursing hours required, or the actual nursing hours provided, and acknowledged that she had always posted the forms without this required information but should not have. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves failure to implement the facility’s infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy for high-contact resident care activities such as wound care. The facility’s policy, last reviewed on 03/01/2026, requires staff to use gown and gloves during EBP and to change gloves between cleaning and applying ointments or dressings. Resident #2, admitted on 09/03/2025 with a primary diagnosis of Acute Respiratory Failure with Hypoxia, had an order and care plan in place for EBP in relation to wound care. On 03/16/2026 at 2:25 p.m., during wound care for Resident #2, S6 TXRN did not wear a gown and did not change gloves between cleaning the wounds and applying ointments and powder, contrary to the EBP protocol. Resident #3, admitted on 07/02/2024 with a primary diagnosis of Restless Legs Syndrome, also had an order and care plan for EBP. On 03/16/2026 at 2:45 p.m., during wound care for Resident #3, S6 TXRN again failed to follow EBP protocol by not wearing a gown and not changing gloves between cleaning and redressing the wound. In an interview on 03/16/2026 at 3:15 a.m., S2 CorpRN confirmed that EBP procedures require direct care staff to wear a gown and gloves during wound care and that S6 TXRN should have worn a gown and changed gloves after cleaning a wound and before applying clean dressings or ointments, as required by facility policy.
Failure to Complete Timely Significant Change MDS Assessment After Initiation of Anticoagulant Therapy
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days after a significant change in a resident's condition. Record review showed that a resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a history of venous thrombosis and embolism. The resident was not on anticoagulant therapy at the time of a quarterly MDS assessment, but physician orders later indicated the initiation of Apixaban for a history of deep vein thrombosis. Interview with the MDS staff confirmed that the initiation of anticoagulant therapy constituted a significant change in the resident's status, and acknowledged that the required Significant Change MDS Assessment was not completed within the mandated timeframe.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with a history of seizures, traumatic brain injury, dementia with behavioral disturbance, and delirium, incident reports and electronic medical records documented unwitnessed falls and the administration of antipsychotic medication. However, multiple MDS assessments did not indicate any falls in the relevant periods, nor did they accurately record the use of antipsychotic medication, despite physician orders and medication administration records showing otherwise. Another resident with Parkinson's disease and severely impaired cognition experienced falls, including one with injury, as documented in the care plan and electronic medical record. Despite this, the resident's quarterly MDS assessment failed to accurately reflect the occurrence of these falls. Staff interviews confirmed that the MDS assessments for both residents did not accurately represent their clinical status as required.
Failure to Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident who had a history of deep vein thrombosis and was receiving anticoagulant therapy with Apixaban. The resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a personal history of venous thrombosis and embolism. Despite having intact cognition as indicated by a BIMS score of 15, the resident's care plan did not address the ongoing anticoagulant therapy. This omission was confirmed through interviews with facility staff, who acknowledged that anticoagulant therapy should have been included in the resident's care plan.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for multiple residents, resulting in unmet needs and noncompliance with physician orders and facility policies. For one resident with quadriplegia, seizures, and a PEG tube, staff did not ensure the bed alarm was properly placed, connected, or functioning as ordered. Observations over several days showed the bed alarm control box was detached and not connected, with the alarm mat misplaced in a Geri chair rather than on the bed. The resident was unable to locate her call light and reported a history of falls, while staff confirmed the bed alarm was not in use as required by the physician's order. Another resident who smoked cigarettes was not care planned for smoking, despite a completed Smoking Evaluation Tool and facility policy requiring individualized care plans for smokers. The resident's care plan did not address smoking, and the LPN responsible for care plans acknowledged this omission during review. Facility policy specifies that all smokers must have a care plan based on their evaluation, but this was not implemented for the resident in question. A third resident with multiple complex diagnoses, including schizophrenia, anxiety disorder, and chronic liver disease, had only a single, generalized care plan area focused on disease management. The care plan lacked comprehensive, person-centered interventions and did not address the resident's full range of needs, strengths, preferences, or goals. The LPN responsible for care plans confirmed that a comprehensive care plan had not been developed or implemented in a timely manner for this resident.
Failure to Meet Professional Standards in Skin Audits, Medication Administration, and Weight Monitoring
Penalty
Summary
The facility failed to ensure that care and services provided to residents met professional standards of quality in several instances. For one resident with multiple diagnoses including COPD, heart failure, and impaired mobility, the facility's policy required weekly head-to-toe skin audits with documentation of any identified skin conditions. However, a nurse failed to document observed bruising during a body audit and did not perform a complete assessment, as she did not lift the resident's shirt to check for additional injuries. This resulted in undisclosed bruising being identified only after notification from hospital staff, rather than through the facility's own assessment process. Another resident with schizophrenia and morbid obesity was not weighed monthly as required by facility policy and the resident's care plan. The resident's last recorded weight was several months prior, despite interventions in the care plan specifying monthly weights and provider notification for significant changes. The Director of Nursing confirmed that the resident had not been weighed as required. Additionally, a resident with anoxic brain damage and a tracheostomy did not receive medication as ordered by the physician. The physician's order specified that Baclofen should be administered via G-tube, but an LPN crushed the medication and administered it orally. Both the LPN and the unit manager confirmed that the medication was not given by the correct route, and the physician's order had not been updated to reflect any changes following a swallow study. This resulted in the resident not receiving medication as prescribed.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. On 05/20/2025 at 4:09 p.m., one resident was struck multiple times on the head by another resident after refusing a request for a cigarette. This assault caused lacerations to the victim's left cheek, right cheek, forehead, and chin, requiring evaluation at the emergency room. Both residents involved did not have a prior history of physical aggression toward others, as confirmed by their medical records and staff interviews. The facility's abuse prevention policy states a commitment to protecting residents from abuse, including physical abuse such as hitting. Despite this policy, the incident occurred, and the injured resident, who had moderately impaired cognition and diagnoses including depression, anxiety, mood disorder, and seizures, suffered actual harm. The aggressor had intact cognition and diagnoses of schizoaffective disorder and major depressive disorder with psychotic symptoms. The event was substantiated through interviews, medical record reviews, and the facility's own investigation report.
Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of schizophrenia, who was admitted on 11/06/2020, was found to be receiving Risperdal 1mg twice daily without evidence of a gradual dose reduction (GDR) attempt or documentation that a GDR was clinically contraindicated. The resident's most recent MDS assessment indicated intact cognition and ongoing use of antipsychotic medication, yet there was no record of a GDR being attempted. Additionally, a consultant pharmacist had recommended a GDR for Risperdal, but there was no documented response from the physician to this recommendation. The medical record lacked any documentation supporting either a GDR attempt or a clinical reason for not pursuing one.
Inaccurate MDS Documentation of COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the COVID-19 vaccination status for three out of five residents reviewed for vaccinations. For these residents, the most recent MDS assessments indicated that their COVID-19 vaccinations were not up to date. However, a review of their immunization records showed that they had received the required COVID-19 vaccine doses, with dates documented for each administration. During an interview, the Infection Preventionist confirmed that the residents should have been considered up to date with their vaccinations according to facility policy, and acknowledged that the MDS assessments did not accurately reflect this status.
Failure to Provide Required ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who were unable to perform these tasks independently, resulting in deficiencies in grooming and personal hygiene. One resident with impaired mobility due to Muscular Dystrophy, who was dependent on staff for all ADLs, was observed with unkempt hair, dried sputum, and long facial hair. Staff interviews confirmed that the resident's grooming needs, including shaving and face washing, had not been met as required by facility policy. Two additional residents, both dependent on staff for bathing and personal hygiene, did not receive daily bed baths as specified in their care plans and facility policy. Documentation and staff interviews revealed that these residents missed multiple scheduled bed baths over a period of days. Observations noted foul odors in their rooms, and one resident reported only receiving bed baths upon request, with significant gaps between baths. Review of facility records, care plans, and staff schedules confirmed that the required ADL care, including daily bed baths and grooming, was not consistently provided. Staff acknowledged the missed care and, in one instance, admitted to documenting a bed bath that was not actually performed. The deficiencies were corroborated by direct observation, resident interviews, and review of care documentation.
Failure to Provide Required Turning and Repositioning for At-Risk Resident
Penalty
Summary
Staff failed to provide necessary services to maintain optimal skin integrity for one resident who was at risk for pressure ulcers. The resident, who had multiple diagnoses including spinal stenosis, Alzheimer's disease, morbid obesity, and was always incontinent of bowel and bladder, required moderate assistance for bed mobility and was care planned to be turned and repositioned every two hours and as needed. Observations over several hours showed the resident remained in the same position in bed, and interviews with CNAs confirmed that the resident had not been turned or repositioned during their shifts. The resident also confirmed she was unable to reposition herself and was not routinely turned by staff. Further review revealed that the resident's care plan included the need for regular turning and repositioning, but this intervention was not reflected in the facility's electronic charting system or on the paper kardex. The DON confirmed these omissions and acknowledged that the required tasks were not listed as they should have been. Staff interviews corroborated that the resident was not turned or repositioned as required by her care plan, resulting in a failure to provide necessary services to prevent pressure ulcers.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on tube feeding and water flushes did not receive enteral feedings as ordered by the physician. The resident had diagnoses including acute respiratory failure, hyperlipidemia, hypothyroidism, and insomnia, and was admitted with a care plan indicating the need for tube feeding due to nothing by mouth status. Physician orders specified Glucerna 1.5 at 60ml/hr via pump and water flushes at 250ml every 4 hours. Review of the medication administration record and progress notes for the relevant dates showed no documentation that the tube feeding was held or refused. On observation, the resident's feeding pump was found turned off, and the resident was unaware of how long it had been off. The LPN on duty at the time was also unaware that the pump was off and had not been notified of any issues during shift change. Another LPN from the previous shift reported turning off the tube feeding due to the resident's complaint of stomach pain and turning it back on a few hours later, but could not recall hearing the feeding alarm during the night. The DON was notified of issues with the tube feeding but did not know why or for how long the feeding had been off, despite the resident's orders requiring continuous feeding.
Failure to Complete Annual CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete annual performance reviews and provide regular in-service education based on those reviews for two of three certified nursing assistants (CNAs) reviewed. Personnel records showed that one CNA, hired in November 2023, did not have an annual performance review completed within the past 12 months, with the last documented review dated prior to their hire date. Another CNA, hired in May 2024, also had no evidence of an annual performance review in the past 12 months. During interviews, the administrator acknowledged that annual performance reviews had been requested but not provided, and the HR representative confirmed that the personnel records lacked evidence of completed annual performance evaluations for the affected CNAs. No information about the medical history or condition of any residents was included in the report, and the deficiency was limited to the facility's failure to observe and document CNA job performance and provide related training as required.
Infection Control Lapses in Medication Administration, Wound Care, and Environmental Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff adherence to established protocols. During a medication pass for a resident with quadriplegia and a PEG tube, an LPN administered medications and flushed the tube without wearing a gown, despite the facility's Enhanced Barrier Precautions (EBP) policy requiring both gown and gloves for such procedures. The LPN acknowledged forgetting to don a gown, and the Director of Nursing confirmed this was not in compliance with policy. The resident's medical record indicated ongoing PEG tube care for administration of Baclofen and Gabapentin. Further deficiencies were observed during wound care, where a treatment nurse failed to perform hand hygiene before preparing and applying wound dressings. The nurse handled clean gauze with ungloved hands, placed it into a cup, and then sprayed it with wound cleanser, contaminating the supplies. The nurse admitted to not performing hand hygiene and using the contaminated gauze on the resident's wound, which was inconsistent with the facility's standard precautions policy. Additional observations revealed improper storage of resident care items, with unused supplies such as adult briefs, wash basins, and under-pads stored directly on the floor, and used basins and a soiled urinal left on the shower floor. A shower curtain was also found to be visibly soiled, with staff unable to state the cleaning frequency or protocol. Facility administration confirmed these storage and cleanliness issues were not in accordance with expected standards.
Failure to Immediately Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that incidents of suspected abuse and injuries of unknown origin were reported immediately to management staff for two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including COPD and heart disease, was found to have bruising on the right eye and hip area. Although an LPN observed these bruises while accompanied by the resident's responsible party, she did not notify management at the time, believing the issue had already been addressed. Management only became aware of the bruising after being informed by a marketer who visited the resident in the hospital several days later. In the second case, a resident with moderate cognitive impairment and a history of dementia and anxiety reported to a CNA that two women were trying to harm her. The CNA relayed this to an LPN, who assessed the resident but delayed reporting the allegation of abuse to the administrator, sending a text message several hours later instead of immediately. Both staff members acknowledged during interviews that they should have reported these incidents to management without delay, as required by facility policy.
Controlled Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that controlled medications were administered as ordered and documented correctly for five residents. The deficiencies were identified through a review of medical records and interviews. The facility's policy required that when administering controlled medications, authorized personnel must record the administration on the MAR/eMAR and enter specific information on the Controlled Drug Record, including the date and time of administration, amount administered, signature of the person preparing the dose, and quantity reconciled. However, discrepancies were found in the documentation of medication administration for several residents. For Resident #1, the Controlled Drug Record for Norco 10-325mg showed doses signed out by an LPN at times when the LPN had already clocked out, and there was no documentation of these doses in the eMAR. Similar issues were found for Resident #2, where doses of Norco and Ativan were signed out without proper documentation, and the LPN had clocked out before the recorded administration times. Resident #3's records also showed doses signed out without proper documentation, and the LPN had clocked out before the recorded times. Resident #4's records revealed doses signed out without documenting a time or signature, and the LPN had clocked out before the recorded administration times. Resident #R1's records showed a dose of Tramadol signed out after the LPN had clocked out. Interviews with the Director of Nursing (DON) confirmed that the LPN documented giving controlled medications at times after she had already clocked out. The LPN admitted to pre-pulling medications and administering them early, which was against the physician's orders. The DON confirmed that the LPN did not follow the facility's policies and procedures for medication administration, leading to false documentation of medication administration times.
Failure to Document Pain Management Effectiveness
Penalty
Summary
The facility failed to provide appropriate pain management for five residents by not assessing the effectiveness of pain medication after administration. The facility's policy requires documentation of the date, time, dose, route, and effectiveness of PRN medications, but this was not followed. For each resident, there was no documentation of pain assessment prior to or after administering pain medication, nor were the doses recorded on the electronic Medication Administration Record (eMAR). Resident #1, with diagnoses including heart failure and hip dislocation, received Norco for pain on multiple occasions without documented assessments of pain or effectiveness. Similarly, Resident #2, who has severe cognitive impairment and multiple diagnoses, received Norco without proper documentation or assessment. Resident #3, with chronic heart failure and osteoarthritis, also received pain medication without documented assessments, and the doses were not recorded on the eMAR. Resident #4, who is cognitively intact and has spinal stenosis, received Norco without documented pain assessments or nurse signatures. Lastly, Resident #R1, with anemia and hypertension, received Tramadol without documentation of pain assessment or effectiveness. The Director of Nursing confirmed the lack of documentation for all residents, indicating a systemic issue in pain management practices at the facility.
Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #11, who has a history of Schizoaffective Disorder, Bipolar Type, and Traumatic Brain Injury, was involved in an altercation with Resident #12, who also has Schizoaffective Disorder and a history of behavioral issues. The incident occurred when Resident #12, while propelling himself in a wheelchair, unknowingly rolled over Resident #11's foot. In response, Resident #11 pushed the wheelchair away, leading Resident #12 to stand up and hit Resident #11 in the shoulder. The altercation escalated as both residents stood up and swung their arms at each other, although no further physical contact was made. Resident #12 lost his balance and fell to the floor. Staff members, including S9 Central Supply and S8 LPN, intervened shortly after the incident. Both residents were assessed and found to have no physical injuries, and neither resident reported any pain. The facility's surveillance footage confirmed the sequence of events, showing that Resident #11 was not the aggressor. The incident was reported to the facility's administration, and it was noted that Resident #12 had a history of behavioral issues. The facility's failure to prevent this altercation highlights a deficiency in ensuring residents' safety from abuse by other residents.
Failure to Ensure Timely Specialist Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who had a history of chronic recurrent spontaneous left hip dislocation, was referred to an orthopedic specialist following a hospital admission. Despite the referral, the resident did not attend the scheduled appointment with the orthopedic specialist due to a missed ambulance transport, which was not noticed by the facility staff. The resident, who had moderately impaired cognition and was dependent on assistance for mobility and hygiene, expressed ongoing pain and immobility due to the dislocated hip. The resident's medical records indicated a need for urgent orthopedic consultation and potential surgical intervention. However, the facility's failure to ensure the resident's transport to the specialist appointment resulted in a delay in receiving necessary medical evaluation and treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. Resident #3, who has a history of mental health issues including Schizoaffective Disorder and Major Depressive Disorder, was involved in an altercation with Resident #4. Resident #3's care plan noted a risk for altered mental status and behaviors, including outbursts and aggression. Despite these known risks, Resident #3 was able to engage in a physical altercation with Resident #4 in the dayroom. Resident #4, who has Parkinson's Disease, Major Depressive Disorder, and moderate cognitive impairment, was involved in the incident when Resident #3 attempted to take another resident's food tray. Resident #4 verbally intervened, which led to Resident #3 approaching and physically assaulting Resident #4. The altercation escalated to both residents hitting each other and falling to the floor, resulting in a skin tear for Resident #3 and a reported knot on Resident #4's head. The incident was witnessed by S2 CNA, who was present in the dayroom and attempted to intervene by verbally instructing Resident #3 to stop. Despite these efforts, the altercation occurred, highlighting a failure in the facility's ability to prevent resident-to-resident abuse. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents, but this policy was not effectively implemented in this case.
Failure to Maintain Prescribed Nutritional and Hydration Status for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident with a PEG tube maintained acceptable nutritional and hydration status as per the resident's comprehensive assessment. The resident, who had multiple diagnoses including chronic kidney disease, cerebrovascular disease, and dependence on a ventilator, was observed receiving tube feeding at a rate lower than prescribed. The prescribed rate was 50ml/hr for both Glucerna 1.5 and water flush, but the actual rate was set at 40ml/hr for the feeding and 30ml every 3 hours for the water flush. Additionally, the feeding and flush bags were not labeled with the resident's name, date, and time as required by the facility's policy. Interviews with facility staff confirmed the discrepancies in the feeding and flush rates. An LPN acknowledged that the rates were not set according to the physician's orders and that the bags were not labeled as they should have been. The Director of Nursing also confirmed that staff failed to implement the recommended changes to the feeding and flush rates made by the registered dietitian. This oversight in following the prescribed nutritional and hydration regimen for the resident led to the deficiency noted in the report.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in several resident rooms. Specifically, Rooms a, b, and c were observed to have a large amount of dust, trash, and dead insects in the corners between the beds and windows. Additionally, the window pane in Room a was covered with mildew and a green and brown substance, obstructing the outside view. The ceiling tiles in Rooms a and b were loose, had exposed insulation, and were stained brown. Furthermore, the over bed wall-mounted lights in Room b were not operational over both beds. These deficiencies were confirmed during observations on two separate days and were corroborated by S10 Maintenance, who acknowledged that the rooms had not been properly cleaned and that the ceiling tiles needed to be replaced, repaired, or painted. S10 Maintenance also confirmed that the light bulbs in Room b needed replacement and that the window pane in Room a should have been cleaned to allow the resident an outside view.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of quality for Resident #43 and Resident #268. For Resident #43, who had diagnoses including Chronic Respiratory Failure, Type 2 Diabetes Mellitus, and Paroxysmal Atrial Fibrillation, the facility did not obtain the required quarterly labs in December 2023 as ordered by the physician. This was confirmed by the Director of Nursing during an interview, acknowledging that the labs should have been collected but were not present in the medical record or Echart. For Resident #268, who had diagnoses including Acute Respiratory Failure, Anoxic Brain Damage, and Tracheostomy status, the facility failed to notify the physician of the dietician's recommendations to adjust the tube feeding regimen. Despite the dietician's assessment recommending changes to the enteral feeding to meet the resident's nutritional needs, there was no documentation that the primary care physician had been informed. This was confirmed by both the Corporate RN and the primary care physician, who expressed concern over not being notified and indicated the need for immediate action to assess the resident's hydration status.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that Residents #1 and #4 were free from facial hair and failed to provide nail care to dependent residents, including Residents #11, #17, #21, #38, #48, and #62. These deficiencies were observed during various times and confirmed through interviews with the residents and staff members, as well as through record reviews of the residents' care plans and medical records. Resident #1, who has diagnoses including cerebral infarction and dementia, was observed with long facial hair despite his care plan indicating he required assistance with grooming. Resident #1 reported asking several staff members to shave him but had not been shaved. Similarly, Resident #4, who has diagnoses including diabetes and COPD, was observed with thick gray facial hair and long, dirty fingernails. Resident #4 confirmed that it had been weeks since his nails were trimmed and over a week since he had been shaved. Other residents, such as Resident #17, #21, #38, #48, and #62, were observed with long, untrimmed fingernails, some with dark substances underneath. These residents required assistance with ADLs due to various medical conditions, including dementia, hemiplegia, and schizophrenia. Interviews with the residents and staff confirmed that the necessary grooming and nail care had not been provided, despite being outlined in their care plans. The Director of Nursing (DON) also confirmed these observations during the survey.
Failure to Maintain Resident Dignity by Ensuring Removal of Facial Hair
Penalty
Summary
The facility failed to maintain dignity for a female resident by not ensuring she was free of facial hair. The facility's policy states that both male and female residents should be free of facial hair unless otherwise noted in the care plan. The resident, who has diagnoses including Unspecified Dementia, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Anxiety Disorder, and Dysphagia, requires total assistance with all activities of daily living. An observation revealed that the resident had 1/4 inch facial hair on her chin. An interview with an RN confirmed the presence of the facial hair and acknowledged that it should have been shaved but was not.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting. Specifically, during the 02/13/2024 meeting, residents raised concerns about not being able to lay down when they wanted to when agency CNAs were working, not receiving baths, and CNAs not passing out ice. The concerns were documented and given to the Director of Nursing (DON) on 02/14/2024, with a response due by 02/23/2024. However, there was no documented evidence of an investigation into these concerns, and no follow-up was provided to the Resident Council. Interviews with the Activity Director and members of the Resident Council confirmed that the DON had not provided a follow-up or spoken to the Resident Council about the documented concerns. The Activity Director, who was responsible for assisting the Resident Council with setting up meetings and keeping minutes, confirmed that the concerns were given to the DON but no action was taken. The DON also confirmed that a follow-up should have been provided but was not. This failure to address and investigate the grievances reported by the residents constitutes a deficiency in the facility's grievance handling process.
Failure to Meet Nutritional Needs for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure services were provided according to the resident's Comprehensive Plan of Care for a resident who required tube feeding. The resident, who had multiple diagnoses including Acute Respiratory Failure, Anoxic Brain Damage, and Hypertension, was observed on multiple occasions receiving Jevity 1.5 at 50ml per hour with 50ml H20 flushes every 6 hours. However, the Registered Dietician's assessment recommended a different regimen of Jevity 1.5 at 62ml per hour with 42ml/hour flush continuous every hour to meet the resident's nutritional needs. Despite the dietician's recommendations, the resident continued to receive the incorrect tube feeding settings, as confirmed by observations and an interview with the Corporate RN. This discrepancy resulted in the resident not receiving adequate nutrition and hydration as per the Comprehensive Plan of Care, highlighting a failure in the facility's adherence to the prescribed nutritional plan for the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily. On 04/02/2024 at 9:30 a.m., an observation revealed that the daily nurse staffing information posted was dated 03/29/2024. During an interview on the same day at 11:56 a.m., the Director of Nursing (DON) confirmed that the nurse staffing information should have been updated daily but was not.
Failure to Follow Standardized Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for three residents who were ordered and served pureed diets. The facility's approved recipes for pureed roast turkey and pureed turnip greens were not followed. Instead, dietary staff prepared these items without referring to the standardized recipes, resulting in the use of unmeasured ingredients and methods that did not align with the facility's policy on pureed food preparation. Specifically, one dietary staff member admitted to adding milk and bread to the turkey without measuring or using a recipe, while another staff member also failed to follow the recipe when preparing the pureed turkey and turnip greens for serving. This was confirmed through interviews and observations with the dietary manager and staff, who acknowledged the lack of adherence to the recipes and the absence of recipe references during food preparation. The deficiency was identified during a review of the facility's approved 2024 Lunch Menu and the corresponding recipes for pureed foods. The facility's policy on pureed food preparation emphasized the use of standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. However, the dietary staff did not follow these guidelines, leading to the preparation of pureed foods that did not meet the required standards. This failure was observed and confirmed by the dietary manager, who acknowledged that the staff should have referred to the recipes but did not. The dietary manager also attempted to correct the issue by printing the recipes and preparing the pureed food items herself, but still did not adhere to the recipe instructions.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain infection control practices to prevent and control the spread of an infectious communicable disease. Specifically, the facility did not ensure that all staff adhered to Enhanced Barrier Precautions for a resident who was colonized or infected with a multidrug-resistant organism (MDRO). The facility's policy required the use of gowns and gloves during high-contact resident care activities for such residents. However, an observation revealed that a hospice CNA was providing direct care to a resident with a tracheostomy and mechanical ventilation without wearing the required PPE, despite the presence of signage and equipment indicating the need for Enhanced Barrier Precautions. The hospice CNA admitted to seeing the signage but did not understand its purpose and had not read it. The CNA was informed by facility staff that the sign and equipment were placed because state surveyors were in the building. Further interviews with the respiratory therapist and the resident's nurse confirmed that the hospice CNA was not wearing the appropriate PPE and that hospice staff were expected to follow the posted instructions. The nurse was unsure if all hospice staff had been made aware of the new precautions, although they should have been informed.
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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