Lagniappe Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Bastrop, Louisiana.
- Location
- 1408 Summerlin Lane, Bastrop, Louisiana 71220
- CMS Provider Number
- 195593
- Inspections on file
- 19
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Lagniappe Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep medications secured and properly ordered, as required. One resident had three bottles of discontinued miconazole powder stored in the room despite no current physician order or MAR documentation. Another resident, with COPD, cardiac disease, hypertension, hyperlipidemia, dorsalgia, depression, GERD, and moderate cognitive impairment (BIMS 12), had ferrous sulfate tablets, Ofloxacin otic solution, and two inhalers (Albuterol sulfate and Ventolin HFA) on the bedside table, all containing available doses, even though there were no physician orders for these drugs or for them to be kept at bedside. An LPN confirmed the lack of orders, and the DON was notified of the unsecured, unordered medications.
The facility failed to obtain and document informed consent for psychotropic medications for two residents receiving Zoloft and Abilify. One resident with moderate cognitive impairment and multiple complex conditions, including respiratory failure, CKD, dysphagia, hemiplegia, malignancy, and cardiomyopathy, received Zoloft 25 mg daily via PEG for major depressive disorder per physician order, with MARs showing routine administration but no documented consent. Another resident with severe cognitive impairment, post-CVA hemiplegia, T2DM, coronary artery disease, bipolar disorder, and other comorbidities received Abilify 2.5 mg PO daily for bipolar disorder, again with MAR documentation of administration but no record of consent. Nursing staff confirmed during surveyor interviews that there was no documentation supporting that consent for these psychotropic medications had been obtained, indicating residents were not fully informed of their treatment in advance.
Two residents at high risk for falls did not receive care-planned safety interventions. One resident with dementia, Alzheimer’s disease, muscle weakness, and moderate cognitive impairment had a care plan requiring a stand-alone bathroom motion sensor to alert staff when the resident entered the bathroom; surveyors found the sensor on the floor, turned off, and not alarming while the resident was in the room. Another resident with hemiplegia after a cerebral infarction, severe cognitive impairment, and multiple comorbidities had a care plan requiring wheelchair brake extenders after a fall, but was observed seated in a manual wheelchair in the dining area without brake extenders, which was confirmed by an LPN and the DON.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy requiring gown and glove use during high-contact care involving medical devices. A resident on EBP due to a PEG tube received a bolus feeding from an LPN who did not wear a gown, and another resident with an indwelling Foley catheter received catheter care from an LPN who wore gloves but not a gown. The DON later confirmed that gowns should have been used for these high-contact activities, showing that EBP was not consistently implemented during device care.
A resident with multiple medical conditions was improperly restrained with a lap tray on her wheelchair without a physician's order or pre-restraint assessment. The lap tray was not secured correctly, allowing the resident to move it, and staff failed to monitor and document its use as required by facility policy. Observations and staff interviews confirmed these deficiencies.
The facility failed to conduct timely and accurate assessments for residents, leading to deficiencies in care. A resident with an inhaler was not reassessed for self-medication capability, another with a pressure ulcer had inaccurate skin assessments, and a resident with loose dentures was not properly evaluated, affecting her ability to eat. Additionally, records inaccurately showed continued antibiotic treatment for a resident after it was discontinued.
A facility failed to monitor a resident for bleeding risks while on the anticoagulant Xarelto. The resident, diagnosed with atrial fibrillation and bradycardia, had no documented evidence of bleeding risk monitoring. This was confirmed by a nurse during an interview.
A facility failed to follow infection control standards by not using a gown during wound care for a resident under Enhanced Barrier Precaution (EBP). The EBP policy requires gowns and gloves for high-contact activities to prevent the spread of multi-drug resistant organisms. A Wound Care Nurse admitted to forgetting to don a gown during the procedure, contrary to the facility's policy.
Unsecured and Unordered Medications Found in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and that discontinued medications were not kept in resident rooms. For one resident, review of February 2026 physician orders and the medication administration record showed no current order or documentation for miconazole powder, yet surveyors observed three bottles of miconazole powder in the resident’s room. The DON confirmed that the miconazole powder had been discontinued and acknowledged that the medication should not have been stored in the resident’s room. For another resident, admitted with multiple diagnoses including COPD, Takotsubo syndrome, atherosclerotic heart disease, hypertension, hyperlipidemia, dorsalgia, depression, and GERD, the admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment with daily decision-making. Review of physician orders revealed no orders for ferrous sulfate 325 mg tablets, Ofloxacin otic solution 0.3%, Albuterol sulfate inhalation aerosol, or Ventolin HFA 90 mcg/actuation. However, observations of the resident’s room with an LPN showed a labeled bottle of ferrous sulfate tablets on the side table on one day, and Ofloxacin otic solution, Albuterol sulfate inhalation aerosol, and Ventolin HFA inhaler on the side table on another day, all with doses available. The LPN confirmed there were no orders for these medications or for them to be kept at bedside, and the DON was informed of these findings.
Failure to Obtain and Document Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were fully informed about and consented to psychotropic medication treatment. For one resident admitted with multiple complex conditions including acute and chronic respiratory failure, diabetes with chronic kidney disease, dysphagia and hemiplegia following cerebral infarction, secondary malignant neoplasm of the large intestine and rectum, peripheral vascular disease, ischemic cardiomyopathy, and hypertension, the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment with daily decision-making ability. This resident was receiving the psychotropic medication Zoloft 25 mg daily via PEG tube for major depressive disorder, initiated by physician order on 12/08/2025 and administered daily in January 2026 as documented on the MAR. On 02/11/2026, an LPN confirmed there was no documentation in the medical record to support that consent for Zoloft had been obtained. The facility also failed to obtain documented consent for psychotropic medication for another resident admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris, bipolar disorder, hyperlipidemia, and anemia. The annual MDS showed a BIMS score of 6, indicating severe cognitive impairment with daily decision-making. This resident was receiving Abilify 2.5 mg by mouth daily for bipolar disorder, initiated by physician order on 07/21/2025 and administered daily in January 2026, except during hospitalization, as shown on the MAR. On 02/11/2026, an RN confirmed there was no documentation in the medical record to support that consent for Abilify had been obtained. These findings show the facility did not address the residents’ right to be informed in advance of the risks and benefits of psychotropic medication treatment and to provide consent.
Failure to Implement Care-Planned Fall Prevention Devices for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement person-centered care plan interventions for two residents identified as high fall risks. One resident with dementia, Alzheimer’s disease, muscle weakness, lack of coordination, and moderate cognitive impairment used a manual wheelchair and required assistance with ADLs. The resident’s care plan, updated after a fall, specified that therapy would screen the resident and that a stand-alone motion sensor would be placed in the bathroom to notify staff when the resident entered. During an observation, the resident was seated in a wheelchair in the room while the bathroom motion sensor was found lying on the floor and not alarming when someone walked in front of it. A subsequent observation with an LPN confirmed the motion sensor in the bathroom was not turned on while the resident was in the room. The second resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes, atherosclerotic heart disease, bipolar disorder, hyperlipidemia, and anemia, and used a manual wheelchair for mobility. This resident’s fall risk assessments identified a high risk for falls, and the care plan documented risk factors including weakness, history of falls, cognitive impairment, polypharmacy, psychotropic medication use, lack of safety awareness, and loss of mobility with hemiplegia. An approach added to the care plan after a fall required wheelchair brake extenders to be placed on the wheelchair. During observations in the main dining area, the resident was seen seated upright in the wheelchair without brake extenders in place, and both an LPN and the DON confirmed that the wheelchair brake extenders were not present as required by the care plan.
Failure to Implement Enhanced Barrier Precautions During High-Contact Device Care
Penalty
Summary
Facility staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact resident care activities for residents on EBP. The policy specified that high-contact activities, including device care or use such as feeding tubes and urinary catheters, required the use of gown and gloves to prevent the spread of multi-drug resistant organisms. Resident #7 had an order placing the resident under EBP due to a percutaneous endoscopic gastrostomy (PEG) tube, and the care plan identified EBP for high-contact activities, including feeding tube care. During an observation of a bolus feeding via PEG tube at the bedside, an LPN administered the bolus without wearing a gown, despite later confirming that the resident was on EBP precautions due to the PEG. Resident #15 had diagnoses including urinary tract infections and hemiplegia and an order for an indwelling Foley catheter with catheter care to be provided each shift. During an observed catheter care episode, an LPN wore gloves but did not don a gown before performing the catheter care. In a subsequent interview, the DON confirmed that the LPN should have worn a gown prior to performing catheter care. These observations demonstrated that staff did not consistently implement the required EBP measures, specifically the use of gowns during high-contact care involving a PEG tube and an indwelling Foley catheter.
Improper Use of Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. The resident, who was admitted with multiple diagnoses including epilepsy, mild vascular dementia, and chronic kidney disease, was observed with a lap tray on her wheelchair that was not properly secured. The lap tray was intended to be used as a restraint but lacked a physician's order, a pre-restraint assessment, and specific interventions in the care plan. The facility's policy required these steps to ensure restraints were used appropriately and only for medical symptoms. Observations revealed that the lap tray was not fitted securely to the resident's wheelchair, with Velcro straps tied improperly to the wheelchair handles. The resident was able to move the lap tray, indicating it was not functioning as intended. Despite the presence of CNAs and an LPN, the issue was not addressed, and the lap tray remained improperly secured. The facility's policy required that restraints be monitored and released every two hours, but there was no documentation to confirm this was done. Interviews with facility staff, including the Director of Nursing and the MDS Nurse Coordinator, confirmed the lack of a physician's order, pre-restraint assessment, and proper documentation of monitoring and releasing the restraint. The staff acknowledged that the lap tray was not working effectively for the resident, and the necessary procedures outlined in the facility's restraint policy were not followed, leading to the deficiency.
Inaccurate and Untimely Resident Assessments
Penalty
Summary
The facility failed to ensure timely and accurate assessments for several residents, leading to deficiencies in care. One resident, who had an albuterol inhaler at her bedside, had not been reassessed for her ability to self-administer medications since July 2023, despite having chronic obstructive pulmonary disease and anxiety. This oversight was confirmed by the RN/MDS Coordinator, indicating a lapse in the regular evaluation of the resident's capability to manage her medications independently. Another resident, who was at high risk for pressure ulcers, had inaccurate weekly skin assessments documented by an LPN. Despite having a pressure ulcer that was being treated, the LPN's records repeatedly noted the resident's skin as intact, failing to acknowledge the existing condition. This discrepancy was confirmed by the DON, highlighting a significant gap in the monitoring and documentation of the resident's skin condition. Additionally, a resident with loose dentures was not accurately assessed upon admission, as the initial nursing evaluation and subsequent assessments failed to document the poor fit of her dentures. This oversight led to difficulties in chewing and sore gums, which were not addressed in the dietary assessment or communicated to the social services director. The DON later discovered that the dietary manager was aware of the issue but had not acted on it. Furthermore, another resident's records inaccurately reflected the continuation of an antibiotic treatment after it had been discontinued, due to nurses copying and pasting previous notes, as confirmed by the DON.
Failure to Monitor Anticoagulant Risks
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for bleeding risks. Resident #16, who had diagnoses of atrial fibrillation and bradycardia, was prescribed the anticoagulant medication Xarelto at a dosage of 15 milligrams daily. Upon review of the resident's medical record, there was no documented evidence that the facility was monitoring the resident for bleeding risks associated with the anticoagulant. This deficiency was confirmed during an interview with S3Registered Nurse/Minimum Data Set Coordinator, who acknowledged that nurses had not been monitoring resident #16 for bleeding risks.
Failure to Follow Enhanced Barrier Precaution During Wound Care
Penalty
Summary
The facility failed to adhere to infection control prevention standards by not following the Enhanced Barrier Precaution (EBP) policy during wound care for a resident. The EBP policy, dated August 2022, mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the spread of multi-drug resistant organisms. On December 11, 2024, during an observation of wound care, the Wound Care Nurse did not don a gown before performing the procedure on a resident. After completing the wound care, the nurse confirmed in an interview that she had forgotten to wear the gown, acknowledging the oversight in following the EBP policy.
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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