Lacombe Nursing Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Lacombe, Louisiana.
- Location
- 28119 Hwy 190, Lacombe, Louisiana 70445
- CMS Provider Number
- 195348
- Inspections on file
- 22
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Lacombe Nursing Centre during CMS and state inspections, most recent first.
A facility failed to accurately code a resident's fall history in the MDS assessment. The resident, with osteoporosis and a personality disorder, suffered a femur fracture after a fall, requiring hospitalization. The MDS assessment did not reflect this fall, as confirmed by the RN and DON responsible for the assessment.
A resident with osteoporosis experienced an unwitnessed fall, and the facility failed to update the care plan with new interventions. Although bright signs were placed in the resident's room to remind her to ask for assistance, this was not documented in the care plan. The oversight was acknowledged by the responsible RN and confirmed by the DON, indicating non-compliance with the facility's fall policy.
The facility failed to label oxygen tubing and humidifier bottles for residents receiving oxygen therapy, contrary to its policy requiring weekly changes and labeling. Observations showed that residents with conditions like heart failure and COPD had unlabeled equipment, and staff confirmed the oversight.
The facility failed to store and discard expired dietary supplements properly, as observed in Med Storage Room B and the nursing station's refrigerator. Several supplements and a milk carton were found past their expiration dates and not discarded as required. Interviews with the DON and an LPN confirmed these findings, acknowledging the failure to adhere to the facility's policy on food storage and expiration.
A resident with a midline catheter did not receive appropriate site care due to the facility's failure to obtain necessary care orders. The facility's policy required dressing changes every seven days, but there was no documentation of such care, and the dressing was overdue for a change. Staff confirmed the lack of orders and acknowledged the oversight.
A resident's code status was inconsistently documented in a facility's records, with active physician orders indicating CPR LaPOST while the hard chart showed DNR LaPOST. Staff interviews confirmed the discrepancy, highlighting a failure to update the electronic health record to reflect the correct DNR status.
A facility failed to ensure proper PPE use during care for a resident on Enhanced Barrier Precautions. An LPN was observed administering a bolus tube feeding without wearing a gown, despite the requirement for direct care. The resident had diagnoses of Functional Quadriplegia and Gastrostomy Status. The LPN admitted to not wearing the gown, and the DON confirmed the need for gown and gloves during such procedures.
The facility failed to document required nurse staffing data, including the facility census and actual hours worked, on daily postings. This deficiency was confirmed through observations and interviews with staff, who were unaware of the documentation requirements.
A facility failed to complete and transmit a Discharge/Transfer MDS assessment for a resident who was transferred to the hospital and did not return. The RN responsible for MDS assessments confirmed the oversight, and the DON acknowledged that the assessment should have been completed.
A resident with hand contractures was unable to use the standard squeeze bulb call light due to his condition. Despite multiple staff members being aware of the issue, no alternative call light was provided, and the problem was not reported to higher authorities. The resident's call light log showed no usage for a month, indicating he was unable to call for assistance during this period.
A resident with a history of repeated falls experienced two falls, one resulting in skin tears, which were not accurately reflected in the Admission MDS assessment. Interviews confirmed the discrepancy, indicating a failure in the facility's process for accurate resident assessments.
A resident with Hemiplegia and hand contractures experienced multiple falls due to the facility's failure to implement effective interventions and monitor their effectiveness. Despite being unable to use the call light and requiring total assistance, the resident's bed was often found in a high position, and no alternative safety measures were put in place.
Inaccurate MDS Assessment for Fall History
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically in the coding of falls in the Minimum Data Set (MDS) assessment. A resident, who was admitted with diagnoses including age-related osteoporosis and an unspecified disorder of adult personality and behavior, suffered a displaced intertrochanteric fracture of the right femur. This incident occurred after a fall, leading to hospitalization and subsequent return to the facility. However, the resident's Quarterly MDS, with an Assessment Reference Date of December 23, 2024, did not reflect this fall in Section J1700: Fall History, which was left blank. Interviews with the responsible RN and the Director of Nursing confirmed the oversight in coding the fall history, acknowledging that the MDS assessment should have included this information.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised following a fall incident. Specifically, the care plan for a resident with age-related osteoporosis was not updated with new interventions after the resident experienced an unwitnessed fall in the day room. The incident report and nurse's notes from the date of the fall indicated that the resident was found lying on her left side and was unable to explain how the fall occurred. Despite this, the only intervention added to the care plan was to send the resident to the local hospital for evaluation, which did not address the need for preventive measures to mitigate future falls. Interviews with facility staff revealed that the responsibility for updating the care plan lay with a registered nurse, who acknowledged that the care plan was not revised to include new interventions after the fall. The Director of Nursing confirmed that although bright signs were placed in the resident's room to remind her to ask for assistance, this intervention was not documented in the care plan. This oversight indicates a failure to adhere to the facility's policy, which requires the fall care plan to be updated with interventions after each fall to prevent subsequent incidents and reduce the risk of serious injuries.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards by not properly labeling oxygen tubing and humidifier bottles for four residents receiving oxygen therapy. The facility's policy required that oxygen tubing, humidifiers, and nebulizer sets be changed every Sunday night by the night shift nursing staff and labeled with the date of change. However, observations revealed that the oxygen tubing and humidifier bottles for all four residents were not labeled with the date they were last changed. Resident #11, who had a diagnosis of heart failure, was observed wearing oxygen via nasal cannula without a date on the tubing. Similarly, Resident #43, with chronic obstructive pulmonary disease and acute respiratory failure, and Resident #62, with chronic obstructive pulmonary disease and congestive heart failure, were both observed with unlabeled oxygen tubing and humidifier bottles. Resident #64, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, also had unlabeled oxygen tubing. Interviews with nursing staff confirmed the lack of labeling and the failure to adhere to the facility's policy.
Failure to Store and Discard Expired Dietary Supplements
Penalty
Summary
The facility failed to store, prepare, and distribute food and dietary supplements under sanitary conditions, as observed during a survey. The facility's policy requires that all foods stored in the refrigerator or freezer be covered, labeled, and dated with a use-by date. Additionally, food items and snacks kept on nursing units must be maintained at or below 41 degrees Fahrenheit and labeled with a use-by date. Beverages must be dated when opened and discarded after 24 hours. However, during an observation of Med Storage Room B and the nursing station's refrigerator, it was found that several dietary supplements and a milk carton were past their expiration dates and had not been discarded as required. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the observations. The DON acknowledged that the facility failed to store food and dietary supplements properly, and confirmed that all food products and supplements should be used by the expiration date and discarded within 24 hours of opening. The LPN also confirmed the presence of an expired supplement on Med Cart C, which should have been discarded. The facility administrator was informed of these findings and confirmed that the expired items should have been discarded prior to their expiration dates or within 24 hours after opening.
Failure to Obtain Midline Catheter Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not obtaining device site care orders for a midline catheter. The facility's policy required routine care and dressing changes for peripherally inserted central catheter lines every seven days to prevent infection. However, for one resident, there was no documentation of site monitoring or dressing changes for the midline catheter, and no physician's orders were obtained for these necessary procedures. The resident, who was admitted with diagnoses including Dementia, Severe Sepsis without Septic Shock, Bacteremia, and Urinary Tract Infection, had a midline catheter placed. Observations revealed that the dressing on the catheter was overdue for a change, and the date on the dressing was illegible. Interviews with staff confirmed that the necessary orders for site monitoring and care were not obtained, and the responsibility to do so was acknowledged by the Director of Nursing and a Licensed Practical Nurse who was present when the catheter was placed.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently maintained and accurately reflected throughout the clinical record. This deficiency was identified for one resident during an initial screening of 25 residents. The resident in question had conflicting code status orders in their medical records. The active physician orders indicated CPR LaPOST, while the hard chart contained a DNR LaPOST. This discrepancy was confirmed during interviews with facility staff, including an LPN, a social worker, and the Director of Nursing (DON). The LPN and DON both stated that the protocol for verifying a resident's code status involved checking the hard chart or the electronic health record, depending on the resident's location within the facility. However, the electronic health record incorrectly listed the resident's code status as CPR LaPOST, which did not match the DNR LaPOST in the hard chart. The social worker, responsible for updating code statuses in the electronic health record, confirmed that the resident's status should have been updated to DNR but was not. This inconsistency in the resident's code status documentation could lead to inappropriate medical interventions.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff. Specifically, a Licensed Practical Nurse (LPN) was observed administering a bolus tube feeding to a resident without wearing the required gown, despite the resident being on Enhanced Barrier Precautions (EBP). The EBP sign on the resident's door clearly indicated that a gown was necessary for direct, hands-on care. The resident in question was admitted with diagnoses of Functional Quadriplegia and Gastrostomy Status. During an interview, the LPN acknowledged the failure to wear a gown and recognized the requirement to do so. The Director of Nursing (DON) confirmed the necessity of wearing both a gown and gloves for such procedures and expressed the expectation that all staff adhere to these precautions.
Failure to Document Nurse Staffing Data
Penalty
Summary
The facility failed to ensure compliance with nurse staffing data requirements on daily postings, which had the potential to affect any of the 71 residents residing in the facility. On 08/19/2024, an observation of the staffing data sheet revealed that it lacked documentation of the facility census. Further review of staffing data sheets from 08/16/2024 to 08/18/2024 showed no documentation of the facility census or the actual hours worked by nursing staff. Interviews conducted on 08/19/2024 with S8ADON and S1ADM confirmed the absence of required information on the staffing data sheets. S8ADON stated she was unaware that the staffing data sheet required the facility census and actual hours worked for nursing staff, and both she and S1ADM confirmed these details were not documented.
Failure to Complete and Transmit Discharge/Transfer MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of a Discharge/Transfer MDS assessment for a resident who was sent to the hospital and did not return. The resident was admitted to the facility and later transferred to the hospital on March 21, 2024. However, the required MDS assessment was not electronically transmitted as mandated. During an interview, the RN responsible for completing and transmitting MDS assessments confirmed that the assessment for the resident was not completed. Additionally, the Director of Nursing also confirmed the oversight, acknowledging that the assessment should have been completed and transmitted.
Failure to Provide Appropriate Call Light for Resident with Hand Contractures
Penalty
Summary
The facility failed to ensure that a resident with hand contractures had an appropriate call light to notify staff for assistance. Resident #2, who was moderately cognitively impaired and had mild bilateral hand contractures, was observed to be unable to use the standard squeeze bulb call light due to his condition. Despite multiple staff members being aware of the resident's inability to activate the call light, no alternative call light was provided, and the issue was not reported to higher authorities for resolution. Interviews with various staff members, including CNAs and LPNs, confirmed that they were aware of the resident's difficulty but did not take appropriate action to address the problem. The resident's call light log showed no usage from April 1, 2024, to May 1, 2024, further indicating that the resident was unable to call for assistance during this period. Observations and interviews conducted on May 1 and May 2, 2024, revealed that Resident #2's hands were contracted to the extent that he could not squeeze or press the bulb call light. Staff members, including CNAs, LPNs, and the ADON, confirmed the resident's inability to use the call light due to his hand contractures. The DON stated that she expected staff to report when a resident was unable to activate their call light and confirmed that other call lights were available to accommodate residents' needs. However, no action was taken to provide an appropriate call light for Resident #2, resulting in a failure to reasonably accommodate his needs and preferences.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status. Specifically, Resident #1, who was admitted with a diagnosis of repeated falls, experienced two falls on 03/10/2024. The Admission MDS assessment for Resident #1, with an ARD of 03/11/2024, did not accurately reflect these falls. The MDS assessment indicated only one fall without injury, despite the resident having two falls, one of which resulted in skin tears, as documented in the nurse's notes and the facility's incident log. Interviews with the LPN and MDS coordinator confirmed that the resident had two falls on 03/10/2024, and the second fall resulted in skin tears, which should have been coded as an injury on the MDS assessment. The Director of Nursing also verified that the resident's MDS assessment was not accurately coded to reflect the fall with injury. This discrepancy indicates a failure in the facility's process for ensuring accurate resident assessments.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement appropriate interventions, monitor the effectiveness of interventions, and modify interventions following a fall for one resident. The resident, who had a history of Hemiplegia following a Cerebral Infarct and mild contractures to bilateral hands, experienced multiple falls. Despite being instructed to call for assistance, the resident was unable to use the call light due to his condition, and his bed was often found in a high position, contrary to the care plan's instructions to keep it in a low position. Staff interviews confirmed that the resident required total assistance for all activities of daily living (ADLs) and was unable to use the call light effectively, yet no alternative interventions were implemented to address these issues. The resident's care plan included instructions to keep personal items within reach, keep the bed in a low, locked position, and ensure the call button was accessible. However, incident reports revealed that the resident fell multiple times while attempting to reach for items or move without assistance. Immediate actions taken after each fall included educating the resident on the importance of calling for assistance, but these measures were ineffective due to the resident's inability to use the call light. Observations and interviews with staff confirmed that the resident's bed was often in a high position, and the call light was not usable by the resident due to his hand contractures. Interviews with various staff members, including CNAs, LPNs, and the ADON, revealed a lack of communication and failure to implement effective fall prevention measures. The staff were aware of the resident's inability to use the call light and the need for total assistance, yet no alternative safety measures were put in place. The ADON and DON confirmed that they were not notified of the resident's inability to use the call light and acknowledged that the current fall prevention interventions were ineffective. The facility's failure to address these issues resulted in repeated falls and potential injury to the resident.
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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