Kaplan Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kaplan, Louisiana.
- Location
- 1300 W. Eighth Street, Kaplan, Louisiana 70548
- CMS Provider Number
- 195315
- Inspections on file
- 23
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Kaplan Healthcare Center during CMS and state inspections, most recent first.
Two residents who required assistance with ADLs did not receive their scheduled showers because CNAs and shower aides were unavailable due to staffing shortages. Both residents, who had intact cognition and documented shower schedules, requested showers but were informed by staff that they could not be accommodated. Staff interviews confirmed that showers were missed when staffing was insufficient, and facility administration was unaware that these residents had not received their scheduled care.
A dumbwaiter cart used to deliver lunch trays was found with dried food residue and had not been cleaned after use, as confirmed by the Dietary Manager. This failure to sanitize the cart between uses was not in accordance with facility policy and professional standards.
Staff did not consistently wear required PPE, such as gowns and gloves, while providing high-contact care to two residents on Enhanced Barrier Precautions for wounds and pressure ulcers. Additionally, shower facilities and equipment were not properly cleaned and disinfected between residents, with visible fecal matter left unaddressed and staff admitting to not using disinfectant after each use, contrary to facility policy.
A resident with a history of atrial fibrillation and cerebral infarction did not receive their prescribed anticoagulant, Eliquis, for 39 days after an IVC filter removal procedure. The facility's nursing staff failed to reconcile and restart the medication, despite hospital discharge orders to resume all previous medications. This oversight led to the resident developing extensive DVT and a large right MCA ischemia, requiring hospitalization and treatment.
A resident suffered harm due to a failure in medication reconciliation at an LTC facility. The resident, with a history of atrial fibrillation, did not receive the anticoagulant Eliquis for 39 days after a procedure, leading to a DVT and stroke. The facility lacked a medication reconciliation policy, and staff failed to verify medications, resulting in significant cognitive decline for the resident.
A facility failed to properly dispose of a contaminated sharp during medication administration. An LPN performed a blood glucose test on a resident and improperly disposed of the used lancet by placing it in her gloved hand and then discarding it in the trash receptacle of the medication cart, instead of the designated sharps container. The LPN confirmed the improper disposal, and the Interim DON verified that used lancets should be discarded in designated sharps containers.
A facility failed to ensure proper hand hygiene during medication administration. An LPN was observed administering insulin to a resident and then documenting without sanitizing her hands, contrary to the facility's policy. The Interim DON confirmed the expectation for staff to sanitize hands after procedures.
A facility failed to notify the physician and NP of a resident's IVC filter removal procedure. The resident, with a history of hemiplegia and thrombosis, underwent the procedure without issue. However, the NP and MD were not informed, and the electronic health record lacked evidence of notification.
A resident with a history of stroke and thrombosis did not receive prescribed Eliquis for 39 days after an IVC filter removal due to a nurse's oversight. This resulted in a deep vein thrombosis and stroke extension. The facility did not report the incident to the state agency, as the administrator believed it was not necessary since an internal report was completed.
A facility inaccurately coded a resident's MDS, indicating antipsychotic use when there was no physician order for such medication. This error was confirmed by the Regional MDS coordinator, who admitted to the coding mistake, leading to an inaccurate assessment.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) and Shower Aides provided scheduled showers and baths to two residents who required assistance with Activities of Daily Living (ADLs). Both residents had care plans indicating the need for assistance with bathing, and their shower schedules were documented as occurring on specific days of the week. Despite these plans, neither resident received their scheduled showers on the designated days. Interviews with the residents confirmed that they requested showers as per their routine, but staff informed them that showers could not be provided due to short staffing. Documentation in the residents' records did not show evidence that showers were given on the scheduled days. Staff interviews corroborated the residents' accounts, with CNAs stating that when shower aides were unavailable and staffing was insufficient, not all showers could be completed as scheduled. The facility's administration confirmed that there were multiple CNA call-ins and absences on the days in question, resulting in a shortage of staff. Although duties were redistributed, the administration was not aware that the affected residents had missed their showers. Both residents involved were noted to have intact cognition, and one resident expressed discomfort due to not receiving a shower after exercising.
Failure to Sanitize Dumbwaiter Cart After Use
Penalty
Summary
The facility failed to maintain clean and sanitary kitchen equipment as required by its own policy and professional standards. During an observation and interview with the Dietary Manager, a dumbwaiter cart used to deliver lunch trays was found outside the kitchen door with multiple dried clumps of yellow and brown food matter, as well as dried thin layers of yellow food residue on several shelves. The Dietary Manager confirmed that the cart had been used to deliver lunch trays that day and acknowledged that it should have been cleaned after each use. She further stated that, based on the condition of the cart, it had not been cleaned after the last meal or the previous night, contrary to facility policy which requires sanitization of the dumbwaiter compartment between transporting soiled dishes and food. No information about specific residents or their medical conditions was provided in the report.
Failure to Adhere to Enhanced Barrier Precautions and Proper Disinfection of Shower Facilities
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) and improper cleaning and disinfection of shower facilities. For two residents on EBP due to wounds and pressure ulcers, staff did not consistently wear the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities. Observations revealed that staff entered rooms and provided care, including transferring residents and changing briefs, without donning the appropriate PPE, despite clear signage and care plans indicating the necessity of EBP for these residents. Interviews with staff confirmed a lack of understanding or adherence to the EBP requirements, with some staff incorrectly believing that gowns were only needed for certain activities or that the signage applied to other residents. Additionally, the facility did not ensure that shower facilities and equipment were properly cleaned and disinfected between residents. In one instance, a shower chair was found with dried brown matter, and a staff member acknowledged that it had not been cleaned after previous use. Another observation documented a strong odor of feces and visible fecal matter on the shower floor after a resident's shower. The staff member removed the feces but did not use any cleaning or disinfectant products before bringing another resident into the same shower stall. The staff member admitted to not using disinfectant after every resident, contrary to facility policy and infection control standards. The facility's own policies required the use of PPE during high-contact care for residents on EBP and mandated cleaning and disinfection of reusable equipment and shower areas between residents. Despite these policies, direct observations and staff interviews demonstrated repeated failures to follow established infection prevention protocols, resulting in deficiencies in both resident care and environmental sanitation.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident received nursing services and care that adhered to accepted standards of quality. Specifically, the nursing staff did not reconcile and administer the resident's prescribed anticoagulant medication, Eliquis, for 39 days following a procedure to remove an inferior vena cava (IVC) filter. This oversight jeopardized the resident's health and safety, as the medication was crucial for preventing blood clots. The resident, who had a history of atrial fibrillation and cerebral infarction, was admitted to the facility with a prescription for Eliquis 5 mg twice daily. After undergoing a procedure to remove an IVC filter, the medication was held and subsequently discontinued by an LPN. Despite discharge orders from the hospital indicating that all previous medications, including Eliquis, should be resumed, the facility's nursing staff failed to restart the medication. This resulted in the resident not receiving Eliquis from the date of the procedure until the resident was observed to be confused and lethargic, with swelling in the left lower extremity. Upon transfer to the hospital, it was discovered that the resident had developed extensive deep vein thrombosis (DVT) in the left lower leg and a large right middle cerebral artery ischemia. The resident required hospitalization and treatment with a Heparin drip before being transferred to another hospital for a higher level of care. The failure to administer the prescribed anticoagulant medication was identified as a significant deficiency in the facility's nursing services.
Medication Reconciliation Failure Leads to Resident Harm
Penalty
Summary
The facility failed to ensure care and services were provided according to professional standards of practice, resulting in harm to a resident. The deficiency occurred when the facility's process for medication reconciliation failed. A Licensed Practical Nurse (LPN) did not reconcile the resident's medications upon readmission to the facility after a procedure, leading to the omission of the anticoagulant Eliquis from the resident's medication regimen. This oversight was compounded by the failure of the Assistant Director of Nursing (ADON) and another LPN to conduct an additional review of the resident's medications, as per the facility's standard practice. The resident, who had a history of atrial fibrillation and cerebral infarction, was supposed to resume Eliquis after the procedure. However, due to the failure in medication reconciliation, the resident did not receive Eliquis for 39 days, missing 78 doses. This resulted in the resident developing a deep vein thrombosis (DVT) and suffering a stroke, leading to significant harm, including a major cognitive decline. The Nurse Practitioner (NP) also failed to verify the resident's medications during rounds, remaining unaware of the medication omission. The facility did not have a policy for medication reconciliation, which contributed to the oversight. The resident's condition deteriorated significantly, as evidenced by a decrease in the Brief Interview for Mental Status (BIMS) score from 12 to 0, indicating severe cognitive impairment. The resident required increased assistance with activities of daily living and experienced a decline in communication and feeding abilities.
Improper Disposal of Contaminated Sharps
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by not properly disposing of a contaminated sharp during medication administration. On November 5, 2024, a review of the facility's policy on sharps disposal, last revised in January 2012, indicated that contaminated sharps should be discarded immediately into designated containers. However, during an observation, an LPN performed a blood glucose test on a resident and placed the used lancet in the palm of her gloved hand. She then removed her gloves and disposed of them, along with the lancet, in the trash receptacle of the medication cart instead of the designated sharps container. In an interview conducted shortly after the observation, the LPN confirmed that she had placed the used lancet inside her gloves and disposed of them improperly. She acknowledged that the lancet should have been discarded in the designated sharps container. The following day, the Interim Director of Nursing and Infection Preventionist confirmed that used lancets should indeed be discarded into designated sharps containers.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that staff performed hand hygiene according to accepted standards during medication administration. On November 5, 2024, a Licensed Practical Nurse (LPN) was observed administering insulin to a resident and then returning to the medication cart to document on her computer without sanitizing her hands. This action was contrary to the facility's Handwashing-Hand Hygiene Policy, which requires hand hygiene before and after direct contact with residents and after contact with objects in the immediate vicinity of the resident. The LPN confirmed in an interview that she did not sanitize her hands as required. Additionally, the Interim Director of Nursing and Infection Preventionist confirmed that staff are expected to sanitize their hands after completing a procedure or during medication pass and before returning to their workstation. This oversight in hand hygiene practice was identified as a deficiency in the facility's infection control and prevention program.
Failure to Notify Physician of IVC Filter Removal
Penalty
Summary
The facility failed to notify the physician and/or nurse practitioner of a resident's invasive procedure for the removal of an Inferior Vena Cava (IVC) filter. This deficiency was identified for one resident who was reviewed for notification of change in a sample of 31 residents. The resident had a medical history that included hemiplegia and hemiparesis following a cerebral infarction, acute embolism and thrombosis of the left femoral vein, and dysphagia following a cerebral infarction. On the day of the procedure, the resident left the facility in stable condition for the procedure, which was completed without issue. However, interviews with the nurse practitioner and medical doctor revealed that they were not informed of the procedure, and a review of the resident's electronic health record showed no evidence that they were made aware of the IVC filter removal.
Failure to Report Medication Error Leading to Resident Harm
Penalty
Summary
The facility failed to report an alleged violation involving a resident who did not receive necessary care to avoid physical harm. The incident involved a resident with a medical history of hemiplegia, hemiparesis following a cerebral infarction, acute embolism, thrombosis of the left femoral vein, and paroxysmal atrial fibrillation. After the removal of the resident's IVC filter, a nurse at the facility failed to restart the prescribed anticoagulant medication, Eliquis, as ordered. This oversight resulted in the resident not receiving Eliquis for 39 days, leading to an extensive left lower leg deep vein thrombosis and an extension of a previous stroke. The facility did not report this medication error to the designated state agency, despite the resident's responsible party notifying the administrator of the error and subsequent harm. The administrator believed the incident was not reportable because an internal Incident/Accident Report was completed. The survey revealed that the facility did not have a policy regarding reportable incidents available for review, and no reports were submitted to the state agency concerning this resident within the past 120 days.
Inaccurate MDS Coding for Antipsychotic Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for antipsychotic use for one resident. Specifically, the quarterly MDS for Resident #42 incorrectly indicated that the resident was taking antipsychotic medications. However, a review of the resident's September 2024 physician orders did not show any order for antipsychotic medication. This discrepancy was confirmed during an interview with the Regional Minimum Data Set (S7RMDS) coordinator, who acknowledged that the resident had not received any antipsychotic medication and admitted to making an error in coding, resulting in an inaccurate assessment.
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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