Lakeshore Manor Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Slidell, Louisiana.
- Location
- 1400 Lindberg Drive, Slidell, Louisiana 70458
- CMS Provider Number
- 195177
- Inspections on file
- 47
- Latest survey
- March 14, 2026
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at Lakeshore Manor Nursing & Rehab during CMS and state inspections, most recent first.
An unverified individual who was not employed by the facility or its staffing agency was allowed to enter the building, represent herself as agency CNA staff, and was handwritten onto the daily assignment sheet to provide direct care to ten residents with complex medical conditions. Multiple LPNs accepted her statement that she was agency staff without confirming her identity, employment status, or credentials, and there was no process in place to screen, orient, or assess the competency of agency personnel upon arrival. The individual reported and staff confirmed that she answered call lights, rounded on residents, obtained snacks, and initiated incontinence care for a resident on barrier precautions before leaving the room and not returning to complete care. Review of logs and personnel records showed she was neither a visitor nor an employee, and leadership acknowledged that required registry, background, and credential checks were not performed and that agency staff generally did not receive facility orientation or abuse/neglect training before being assigned to residents, resulting in an Immediate Jeopardy situation.
An unverified individual entered the building after asking about job openings, was allowed access by staff, and then presented herself to several LPNs as agency CNA staff. Without confirming her identity, employment with the agency, or CNA credentials, an LPN issued her a temporary ID badge and assigned her to provide direct care to multiple residents with complex conditions, including hemiplegia, COPD exacerbation, gastrostomy malfunction, atrial fibrillation, subarachnoid hemorrhage, hypertensive urgency, spinal cord infarction, and encephalopathy. The individual reported answering call lights, rounding on residents, obtaining snacks, and providing in-room care to a resident on barrier precautions. Interviews with administrative nursing staff and the DON confirmed there was no process to verify non-employee identity or credentials, no requirement for agency staff orientation, abuse/neglect training, or competency checks before assignment, and no effective entry logging system, resulting in an Immediate Jeopardy determination for all residents receiving direct care from nursing personnel.
A resident with moderate cognitive impairment and dependence on staff for ADLs did not receive necessary nail care, resulting in long, yellow, and dirty fingernails. Despite the resident's repeated requests and staff observations of the issue, no assistance was provided, and the need was not reported or addressed, contrary to facility policy.
A resident readmitted after surgery with a cardiac loop recorder did not receive appropriate care due to the facility's failure to transcribe and clarify hospital discharge orders. Staff did not assess, monitor, or document the resident's surgical incision or loop recorder equipment, leading to a lack of necessary treatment for 26 days.
A resident's records were not maintained accurately, with missing readmission assessments, undocumented blood pressure readings despite hypertension medication, and incomplete weekly skin assessments. The LPNs and DON confirmed these documentation lapses, which did not meet professional standards.
A resident's MDS assessment failed to accurately reflect their status due to an oversight by an LPN, who did not code for a surgical wound following a loop recorder placement. The NP's progress notes documented the condition, but it was not included in the MDS, as confirmed by both the LPN and the DON.
A resident's care plan was not updated to include medical and nursing needs for a surgical incision and loop recorder monitoring after a hospital readmission for a stroke. The oversight was due to the Care Plan nurse overlooking discharge instructions and progress notes, which should have prompted an update. The deficiency was confirmed through observations and interviews with the resident and staff.
A cognitively impaired and legally blind resident in an LTC facility was subjected to sexual and psychosocial abuse by a staff member. The staff member was observed sitting on the resident's bed, rubbing her shoulder, and kissing her on the cheek. Despite witnessing this behavior, a CNA failed to report the incident, allowing the staff member to continue working. The resident's roommate later reported the incident, revealing inappropriate comments and physical contact. The facility's administration was notified, but the staff member was not immediately removed, and the incident was not reported to the police.
A cognitively impaired blind resident was subjected to inappropriate behavior by a staff member, which was witnessed by a CNA but not reported immediately. The incident involved the staff member sitting on the resident's bed, rubbing her shoulder, and kissing her. Despite multiple staff members being aware of the situation, the administration was only informed days later, and the allegations were not reported to law enforcement, resulting in an Immediate Jeopardy situation.
The facility failed to store food according to professional standards, with observations revealing expired milk, unlabeled fruit, and improperly sealed cheese and bread in refrigerators. Staff confirmed that food should be labeled, dated, and sealed, and expired items should be removed.
A resident with cerebral infarction and right-sided hemiplegia was unable to reach the call pad due to improper placement, despite being able to use it when accessible. Observations showed the call pad was often out of reach, and staff confirmed it should have been placed at the mid-chest area. The DON acknowledged the deficiency, confirming the call pad was not within reach as required.
A facility failed to accurately assess a resident's status in the MDS, incorrectly coding the use of a Geri chair as a restraint. The resident, with multiple diagnoses including dementia and poor trunk control, used the chair for support and safety. Staff interviews confirmed the error, as the chair was not intended as a restraint.
A resident with multiple diagnoses, including Dementia and Difficulty Walking, consistently used a geri chair for support and safety due to poor trunk control. However, the resident's care plan did not document this use. Interviews with CNAs and the MDS coordinator confirmed the oversight, and the DON was unaware of the need to include the geri chair in the care plan.
The facility failed to maintain an effective infection control program, as an LPN did not change PPE between assisting two residents on Enhanced Barrier Precautions. Additionally, the facility's infection control policy lacked an annual review, with no documentation of recent updates, potentially affecting all residents.
The facility failed to ensure a sanitary environment in Hall A, with multiple stains observed on the floor around the nurse's station and throughout the hallway. Staff interviews revealed that the floors were expected to be mopped daily, but S7HSK, responsible for mopping, confirmed he did not mop Hall A on the day the stains were noted. S6HSUP acknowledged the stains should have been cleaned the previous day, and S8RD stated the floors were cleaned the day before, despite the stains being present.
The facility failed to maintain ongoing communication and documentation for two residents receiving dialysis, as required by their policy. An LPN and the DON confirmed that Pre Dialysis Assessment & Communication forms were incomplete or missing, indicating a lack of adherence to professional standards of practice.
A facility failed to maintain accurate records for a resident's baths, as required by professional standards. The resident's bath/shower logs showed no documentation for a two-week period. A CNA responsible for the resident's baths admitted to not documenting the baths given or refused. The DON confirmed the lack of documentation.
A facility failed to complete a resident's ordered laboratory tests, specifically a CBC and CMP, as per the physician's instructions. Despite the order, there was no documented evidence of the tests being conducted, and staff interviews confirmed the oversight.
A resident's representative was not informed of new wounds identified on the resident's body, contrary to the facility's policy requiring notification of significant health changes. The wounds were discovered during a skin assessment, but the notification was not documented in the nurse's notes, and the representative only learned of the wounds upon the resident's hospital admission.
A facility failed to maintain accurate medical records for a resident with a wound on the right upper thigh. Despite providing wound care treatment, the wound care nurse and two LPNs did not document the treatment in the Treatment Administration Record (TAR) on multiple occasions. This lack of documentation indicates non-compliance with the facility's policy on pressure ulcer documentation.
The facility failed to ensure accurate MDS assessments for two residents, leading to documentation errors. One resident with a serious mental illness was incorrectly coded as not having such a condition, while another resident's discharge status was inaccurately recorded as a hospital discharge instead of a home discharge. These errors were confirmed by the MDS coordinator and reviewed by the DON.
The facility failed to ensure insulin pen needles were primed before administration for two residents, as required by the manufacturer's guidelines. Observations revealed that LPNs administered insulin without priming the pen needles, leading to potential dosing inaccuracies. The DON confirmed the necessity of priming after reviewing the manufacturer's instructions.
The facility failed to properly label and store medications, including insulin pens and multi-dose vials, leading to potential medication errors. Insulin pens were found unlabeled and without open dates, and multi-dose vials were not discarded within 28 days of opening. Additionally, Med Cart B contained loose pills, violating the facility's medication storage policy.
A resident, who was cognitively intact, requested chef salads for supper on specific days, but the facility failed to provide them, serving chicken tenders and fries instead. The dietary manager confirmed the oversight, as the resident's preferences were not properly documented in the system, leading to a deficiency in personalized dietary care.
A facility failed to implement a comprehensive care plan for a resident with cancer, as lab results were not consistently faxed to the oncologist as ordered. Interviews revealed a lack of clarity and accountability among staff regarding who was responsible for sending the results, leading to a deficiency in care plan implementation.
A resident with a history of myocardial infarction did not attend a scheduled follow-up appointment with a cardiothoracic surgeon due to hospitalization. The appointment was not rescheduled upon the resident's return, and a subsequent physician's order to schedule the appointment was overlooked. The staff responsible for scheduling was unaware of the order, leading to a lapse in the resident's post-operative care.
A resident with cancer diagnoses did not receive the prescribed double portions and snacks BID as ordered by a physician. Despite recommendations from the RD, the facility failed to update dietary orders in the system and communicate changes to the dietary department, resulting in the resident receiving regular portions and no snacks. Interviews with staff revealed a breakdown in protocol adherence and communication.
The facility failed to conduct a scheduled audit, resulting in expired and unlabeled insulin being available for resident use in medication carts and the storage room. Observations revealed multiple instances of opened, unlabeled, and undated insulin pens and vials. Staff interviews confirmed the deficiencies and acknowledged the ineffectiveness of the facility's QA/QAPI system.
The facility did not post daily nurse staffing data as required by their policy, which mandates posting the facility name, current date, total number and actual hours worked, and resident census at the beginning of each shift. An observation found no staffing data sheets, and interviews confirmed the last posting was several days prior. This affected the facility's 80 residents.
Unverified Individual Allowed to Provide Direct Care Without Screening or Credential Verification
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse, neglect, exploitation, and misappropriation prevention policy by not ensuring employment screening and verification for an individual who presented as agency staff. On the morning in question, an individual identified as S12 entered the locked building after being allowed in by a CNA and initially inquired about job openings. She was directed to the back nurses’ station to speak with LPNs. After briefly leaving to change footwear at the request of an LPN, she re-entered the facility and then represented herself to multiple LPNs as an agency CNA arriving to cover an open shift. Facility staff did not verify her identity, employment with the staffing agency, or credentials before assigning her to resident care. S12 was handwritten onto the daily assignment sheet and assigned to provide direct care to ten residents, all of whom had significant medical conditions, including hemiplegia and hemiparesis following cerebrovascular events, COPD with acute exacerbation, gastrostomy malfunction, atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning a gown and gloves, entering the room, rolling the resident to remove his brief, and becoming soiled with feces on her gloved hand and gown sleeve. She then requested assistance from two CNAs, removed her PPE, left the room, and did not return to complete care. Interviews with the two CNAs confirmed that S12 had been present in the resident’s room, had begun incontinence care, and then left after removing her gloves and gown, without returning, leaving them to complete the care. Both CNAs stated they did not know whether she was facility or agency staff. The resident involved confirmed that a female aide, who did not identify herself, answered his call light, called two male CNAs to assist with changing his brief, donned a gown and gloves, became soiled, and then left the room without removing his brief or returning. Review of the visitor log and personnel list showed S12 was not listed as a visitor and was not a current employee. The benefits coordinator, DON, and administrator all confirmed that S12 was not employed by the facility or the staffing agency, that no registry or background checks or credential verification had been completed for her, and that there was no existing process to screen, orient, or complete competency evaluations for agency staff upon entry before they began resident care. This failure to verify and screen S12 before assigning her to direct resident care led to an Immediate Jeopardy situation for the residents under her care. Additional interviews with nursing staff further demonstrated that the facility lacked an operational process to ensure agency staff were verified and oriented before working. One LPN stated that S12 was asked if she was agency staff and, upon her affirmative response, no further verification of agency employment or credentials was performed before she was placed on the assignment sheet. Another LPN acknowledged assigning S12 to care for the ten residents without confirming her agency status, screening, orientation, or competency. The DON confirmed that neither she nor other administrative staff had verified S12’s credentials or screening before S12 was allowed to provide care for approximately two hours. Staff also reported that agency personnel were generally expected to report to any hall, clock in through their agency on their phones, and check the daily assignment sheet, and that agency staff did not receive facility orientation, abuse/neglect training, or competency evaluations prior to being assigned resident care. These actions and inactions collectively demonstrate the facility’s failure to follow its own abuse prevention policy requiring screening of employees and contracted staff, resulting in an Immediate Jeopardy situation.
Removal Plan
- Conduct an immediate search of the facility to locate the unidentified individual and confirm she is no longer present in the building.
- Verify with the staffing agency that the individual is not employed by the agency and confirm through the facility staffing system that she is neither an active nor former employee.
- Instruct receptionist and front desk staff not to allow the individual entry should she return.
- Search the parking lot to ensure the individual has left the premises.
- Contact the Police Department to document the incident and obtain identifying information.
- Print and display a photograph of the individual throughout the facility with instructions to contact law enforcement if she returns.
- Establish a door monitor to ensure all individuals entering the facility are identified, verified, and logged prior to entering the building.
- Evaluate residents who could have potentially been affected by the unidentified individual.
- Interview residents residing in the area where the individual's name had been placed on the assignment sheet to determine whether the individual provided care or engaged in any abusive behavior.
- Interview all residents with a BIMS score of 8 or greater regarding any concerns related to abuse, neglect, or mistreatment.
- For residents with a BIMS score of less than 8, complete a head-to-toe assessment by a licensed nurse to evaluate any signs or symptoms of abuse.
- Implement a system for verification of employee and agency staff credentialing prior to working, including completing required pre-employment screening for facility employees consistent with the facility abuse policy.
- Verify active license/certification prior to the staff member's first shift and maintain documentation.
- Require final clearance by designated facility leadership before marking any employee as cleared for scheduling.
- For agency/contract staff, verify with the staffing agency that the individual has been screened to the same or substantially similar standards and maintain documentation prior to scheduling.
- Prohibit placement of any employee or agency staff member on the daily work schedule until required credentialing and screening verification is completed and documented.
- Conduct a daily schedule review prior to each shift to confirm all scheduled staff have been cleared to work and that any replacements/changes are verified prior to working.
- Validate facility entry at the start of each shift by reviewing identification, confirming the person matches the daily schedule/approved list, and requiring sign-in on the daily staff log.
- Prevent any unverified individual from providing resident care and require immediate follow-up by designated leadership to re-check records, contact the agency, validate licensure/certification, determine eligibility, and remove/replace if verification cannot be confirmed.
- Maintain an ongoing system to monitor employee and agency credentials for expirations/status changes and remove staff from assignment if credentials are expired or unverifiable until resolved.
- Maintain documentation of credentialing verification activities with Administrator and DON oversight and corrective action for failures.
- Have regional staff routinely audit the verification process and trend/correct variances through QAPI.
- Require all people, including staff, entering the facility to sign in and out at the front desk.
- Ensure the front desk is not left unattended by arranging staff coverage for continuous monitoring.
- Change keypad door codes throughout the facility, delete previously stored codes, and input new codes to prevent unauthorized access.
- Provide education for all staff in all departments on abuse/neglect/exploitation prevention, responsibility to identify and report unknown individuals, verification of agency staff prior to resident care, facility entry procedures, and sign-in requirements.
- Verify abuse training requirements for agency staff by obtaining a copy of the training from the agency and providing facility abuse training at the beginning of the agency staff member's first scheduled shift.
- Validate staff competency following abuse prevention education via verbal return demonstration and staff interviews and provide re-education before returning to resident care duties if needed.
- Conduct random staff interviews during supervisory rounds to confirm ongoing staff knowledge of abuse reporting requirements and monitor results through QAPI.
- Monitor the entry log and door monitoring process to ensure all individuals entering the facility are properly verified.
- Conduct random audits of the sign-in log and staffing assignments to ensure only verified staff are providing resident care.
- Complete verification of agency staff credentials and employment status prior to any agency staff member providing resident care, with assigned responsibility.
- Ensure the Manager on Duty and Nurse Supervisor complete abuse training with agency staff secured for nights or weekends.
Unverified Individual Assigned to Provide Direct Resident Care Without Screening or Orientation
Penalty
Summary
The deficiency involves the facility’s failure to administer an effective screening and onboarding system for non-employee staff, which allowed an unknown individual (S12) to be assigned to provide direct resident care without verification of employment, credentials, or required training. On the morning of 03/12/2026, S12 entered the locked building after inquiring about job openings and was allowed entry by a CNA (S14). She was directed to the nurses’ station to speak with LPNs identified as S10 and S13. After briefly leaving to change her footwear at the request of S10, she re-entered the building and was allowed back in by staff member S9R. Upon her return, S12 told S10, S11, and S13 that she was agency staff reporting for an open shift. Without verifying her identity, employment with the staffing agency, or CNA credentials, S11 provided S12 with a temporary ID badge and assigned her to a group of residents (R1 through R10) on the daily assignment sheet, where her name was handwritten. These residents had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction or other cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, gastrostomy malfunction, unspecified atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning gown and gloves, entering the room, rolling the resident to remove a brief, and becoming soiled with feces before calling other CNAs for assistance and then leaving the room. Interviews with administrative nursing staff confirmed that there was no process in place at the time to verify the identity of non-employees upon entry, to confirm agency assignment and credentials, or to provide facility orientation, abuse/neglect training, or competency evaluation before assigning resident care. S13, identified as part of the administrative staff, acknowledged that when S12 presented herself as agency staff, neither she nor S10 verified S12’s agency status or credentials before S11 placed S12 on the assignment sheet for residents R1–R10. S11 confirmed she did not verify that S12 was agency staff and still issued a temporary ID and resident assignment. S10 and the DON (S2) both confirmed that the facility frequently used agency staff but had no existing process to pre-screen non-employees, verify credentials, or ensure completion of orientation and abuse/neglect training prior to allowing them to provide direct care. The administrator (S1) further confirmed that there was no process to verify the identity of non-employees upon entry and that S12 was not employed by the facility or its staffing agency, yet was allowed to provide care to residents for approximately two hours before the issue was discovered. The surveyors determined that this failure to verify and approve agency personnel prior to assignment of resident care created an Immediate Jeopardy situation beginning at 8:00 a.m. on 03/12/2026, when S12 first presented herself as agency staff and was subsequently assigned to provide direct care to residents R1 through R10. The facility’s ineffective administrative system for screening and onboarding agency personnel resulted in residents being placed at a likelihood of serious harm, injury, impairment, or death, as stated in the report. The visitor log for that day did not list S12, further evidencing the lack of a functioning entry and verification process for non-employees.
Removal Plan
- Removed the individual (S12) from the facility and ensured only verified nursing staff were permitted to provide resident care.
- Conducted an immediate search of the facility to locate S12 and confirmed she was no longer present in the building.
- Verified with the staffing agency that S12 was not employed by the agency and confirmed through the facility staffing system that she was not an active employee.
- Ensured S12 was not permitted to provide resident care and confirmed she was no longer present in the building.
- Contacted the Police Department to document the incident and obtain identifying information related to S12.
- Implemented monitoring of the front entrance to ensure all individuals entering are identified, verified, and logged in before entering.
- Interviewed residents assigned to the unit where S12 was listed on the assignment sheet to determine whether she provided care or performed CNA duties.
- Interviewed all residents with a BIMS score of 8 or greater regarding concerns related to care provided by unknown staff.
- Completed head-to-toe assessments for residents with a BIMS score less than 8 to evaluate for signs of injury, neglect, abuse, or improper care.
- Implemented a trained facility staff member as a front desk monitor to verify all individuals entering the facility.
- Required all staff and visitors entering the building to sign in and out at the front desk.
- Continuously monitored the front desk to ensure the entry process is followed and unknown individuals are not allowed entry.
- Changed keypad door codes throughout the facility, deleted previously stored codes, and input new codes to prevent unauthorized access.
- Educated all staff in all departments on verification of agency staff to be completed by the scheduler and/or Payroll Benefits Coordinator and maintained on file prior to placement on the daily schedule; on weekends/holidays verification to be performed by the DON.
- Verified abuse training requirements for agency staff by obtaining documentation from the agency and providing facility abuse training at the beginning of the agency staff member’s first scheduled shift.
- Educated staff on the responsibility to report unknown individuals attempting to provide resident care immediately to the DON or Administrator after ensuring resident safety.
- Educated staff on facility entry procedures and sign-in requirements.
- Educated staff on abuse prevention and resident safety.
- Completed education for staff not present during initial sessions prior to their next scheduled shift.
- Provided education/training for leadership/administrative staff by the Chief Nursing Officer with the Regional Director of Clinical.
- Implemented regional/corporate onsite monitoring of administrative staff compliance with agency staff verification and abuse training, and compliance with sign-in/out and continuous front desk monitoring.
- Restricted resident care assignments to only nursing staff whose employment status, credentials, and agency authorization have been verified by facility leadership prior to assignment.
- Administrator and DON to review the entry sign-in log daily and ongoing to ensure all staff entering are verified.
- Administrator, DON, ADON, and SDC to conduct random audits of staffing assignments and ongoing to confirm only verified employees/agency staff provide resident care.
- Required verification of agency staff credentials and agency confirmation to be completed prior to assigning any agency staff to provide resident care by the Scheduler/Payroll Benefits Coordinator.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for activities of daily living due to a history of a motorcycle accident, neuralgia, and the need for a geri-chair, did not receive necessary assistance with personal hygiene, specifically nail care. The resident had moderate cognitive impairment and required staff support for grooming and hygiene. Observations revealed the resident's fingernails were long, yellow, and had dirt and grime embedded underneath. The resident reported having requested nail trimming for over a month without receiving assistance, and staff interviews confirmed the resident's dependence on staff for nail care. Staff members, including a CNA, the infection prevention nurse, and the DON, all observed and acknowledged the resident's unclean and overgrown fingernails but did not provide the required care or report the need for intervention. The facility's policy required staff to provide necessary care and services to maintain residents' grooming and personal hygiene, but this was not followed for the resident in question, resulting in a failure to meet the resident's needs for nail care.
Failure to Provide Post-Surgical Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services for a newly readmitted resident who required physician orders for immediate care following surgery and the implantation of a cardiac loop recorder. The staff did not accurately transcribe and clarify the hospital discharge recommendations, including wound care and dressing orders, cardiology follow-up for surgical incision care, and monitoring equipment instructions. This oversight resulted in the resident not receiving necessary care and treatment for the surgical incision site or assistance with ensuring the monitoring equipment was functioning for 26 days. The resident was readmitted to the facility after a surgical implantation of a loop recorder, but the facility staff did not ensure that the discharge orders were accurately transcribed and clarified. The resident's hospital records indicated the need for specific wound care instructions and follow-up appointments, which were not addressed by the facility. The staff, including the Admission Nurse, Charge Nurses, Wound Care Nurses, LPNs, and RNs, failed to assess, monitor, document, and treat the resident's surgical incision site and loop recorder monitoring equipment. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's surgical incision and monitoring equipment. The staff did not conduct a full body and skin assessment upon the resident's readmission, and there was no evidence of the surgical incision site being addressed in the resident's clinical records. The facility's failure to provide appropriate care and services created a likelihood of post-surgical complications and delayed treatment of potential arrhythmias identified by the loop recorder.
Deficiencies in Resident Record Maintenance and Documentation
Penalty
Summary
The facility failed to maintain and accurately document resident records in accordance with accepted professional standards for one of the sampled residents. Specifically, the facility did not complete a readmission assessment for a resident who was readmitted from the hospital with diagnoses including Acute Arterial Ischemic Stroke and Hypertension. The Licensed Practical Nurse (LPN) responsible for the readmission confirmed that a complete and accurate physical and skin assessment should have been documented in the Electronic Health Record (EHR) but was not. The Director of Nursing (DON) also confirmed the absence of the required documentation in the resident's records. Additionally, the facility did not document blood pressure readings in conjunction with the administration of Lisinopril, a medication prescribed for hypertension, from the start date of the order until a specified date. The LPNs involved confirmed that blood pressure readings were not documented in the EHR, and one LPN admitted to recording them on personal nursing flowsheets, which were subsequently discarded. The DON verified the lack of documented blood pressure readings in the EHR during this period. Furthermore, the facility failed to accurately document weekly skin assessments for the resident. Despite the presence of a new surgical incision from an implanted loop recorder, the weekly skin observation assessments did not reflect this finding. The LPN acknowledged observing a new dressing but did not document the new wound or incision. The DON confirmed that the nursing staff was expected to document such findings accurately, and the omission was verified upon review of the resident's records.
Inaccurate MDS Assessment for Surgical Wound
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the presence of a surgical wound. The resident, who was admitted with a diagnosis including Cerebral Infarction, had a surgical procedure involving a loop recorder placement, which resulted in a left chest wall dressing with scant bloody drainage. This condition was documented in the Nurse Practitioner (NP) progress notes but was not accurately coded in the resident's Quarterly MDS under Section M: Skin Conditions. The oversight occurred when an LPN, responsible for completing the resident's Quarterly MDS, reviewed the NP's progress notes but overlooked the section indicating the presence of a surgical wound. This error was confirmed during an interview with the LPN, who acknowledged that the MDS did not accurately reflect the resident's status. The Director of Nursing (DON) also reviewed the MDS and confirmed the inaccuracy, acknowledging that the resident should have been coded for a surgical wound.
Failure to Include Surgical Incision Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who had undergone a surgical procedure for a loop recorder placement. The care plan did not include the resident's medical and nursing needs related to the surgical incision and loop recorder monitoring equipment, nor did it have measurable objectives and timeframes. This oversight was identified during a review of the resident's clinical records and after-visit summary discharge instructions from a local hospital, which included specific care instructions for the loop recorder incision. The deficiency was further confirmed through interviews and observations. The resident, who had been readmitted to the facility following a hospital stay for an acute arterial ischemic stroke, had a dressing on his left chest wall with dried drainage, indicating the need for specific care that was not documented in the care plan. The Care Plan nurse admitted to overlooking the discharge instructions and the nurse practitioner's progress notes, which should have prompted an update to the resident's care plan. The Director of Nursing also confirmed the omission in the care plan, acknowledging that it should have included the resident's medical and nursing needs for the surgical wound and loop recorder monitoring.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual and psychosocial abuse, resulting in an Immediate Jeopardy situation. A cognitively impaired and legally blind resident was subjected to inappropriate behavior by a staff member, identified as S5MAIN. The staff member was observed by another CNA sitting on the resident's bed, rubbing her shoulder, and kissing her on the cheek. Despite witnessing this behavior, the CNA did not report the incident, allowing the staff member to continue working in the facility. Further investigation revealed that another resident, who was the roommate of the victim, reported witnessing the staff member making inappropriate comments and physical contact with the resident. The roommate reported that the staff member had previously seen the resident naked in the hallway and made sexually suggestive comments about it. The roommate was initially scared to report the incident but eventually informed a trusted CNA, who then reported it to the LPN and RN on duty. The facility's administration was notified of the situation, and it was discovered that the staff member had a history of inappropriate behavior, including an incident where he pulled down the pants of an LPN without consent. Despite this, the staff member was not immediately removed from duty, and the facility failed to report the incident to the police. The resident involved in the incident was unable to recall the events due to cognitive impairment, but it was determined that a reasonable person would have experienced severe psychosocial harm from such abuse.
Failure to Report Sexual Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of sexual abuse were reported immediately to the administrator and law enforcement authorities. This deficiency involved a cognitively impaired blind resident who was subjected to inappropriate behavior by a staff member. The incident occurred during the Christmas/New Year holiday season when a CNA witnessed a maintenance staff member sitting on the resident's bed, rubbing her shoulder, and kissing her on the cheek. Despite feeling uncomfortable and recognizing the behavior as inappropriate, the CNA did not report the incident to the administration. The situation escalated when another resident reported to a CNA that the same staff member had again engaged in inappropriate behavior with the resident, including kissing her and making inappropriate comments. This report was made several days after the initial incident, and the administration was only made aware of the situation on January 5, 2025. Despite being informed, the administrator failed to report the allegations to local law enforcement, which resulted in an Immediate Jeopardy situation for the resident. Interviews with staff revealed that multiple employees were aware of the inappropriate behavior but failed to report it to their supervisors or the administrator. The facility's policy on abuse, which requires immediate reporting of such incidents, was not followed. The failure to report the abuse in a timely manner left the resident vulnerable to further harm and demonstrated a significant lapse in the facility's responsibility to protect its residents.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not properly storing food items. During an inspection, it was observed that several food items in Refrigerator A and Refrigerator B were not labeled, dated, or sealed as required. Specifically, in Refrigerator A, there were multiple gallons of milk with expired dates, and small containers of fruit and a large container of jelly that were unlabeled and undated. In Refrigerator B, there were loaves of bread, grated parmesan cheese, feta cheese, and a block of margarine that were either unlabeled, undated, or unsealed, exposing them to air. Interviews with staff members, including S17DM and S1ADMIN, confirmed these findings. Both acknowledged that stored foods should be properly labeled, dated, and sealed once opened, and that expired items should be removed and not available for consumption. The failure to follow these guidelines resulted in the presence of expired and improperly stored food items, which were available for consumption, indicating a lapse in maintaining food safety standards.
Failure to Ensure Call Pad Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of needs, as evidenced by the failure to have a call pad within reach for a resident with cerebral infarction and right-sided hemiplegia. The resident, who was moderately cognitively intact and required total dependence for transfers and activities of daily living, was observed multiple times with the call pad out of reach. Despite being able to use the call pad when it was within reach, the resident was unable to access it due to its improper placement. Observations revealed the call pad was often placed at the upper left shoulder area, hanging off the bed, or behind the resident's head, making it inaccessible. Interviews with staff confirmed that the call pad should have been placed at the mid-chest area for the resident to reach it with her left hand. The Director of Nursing acknowledged the deficiency, confirming that the call pad was not within reach and should have been accessible to the resident at all times.
Inaccurate MDS Coding for Resident's Geri Chair Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status, specifically for one resident among those reviewed for the Minimum Data Set (MDS). The resident in question was admitted with multiple diagnoses, including dementia, difficulty walking, dysarthria following a cerebrovascular accident, lack of coordination, depression, and failure to thrive. The quarterly MDS for this resident indicated that a chair preventing rising was used less than daily. However, interviews with staff, including a physical therapy assistant and the MDS coordinator, revealed that the resident used a Geri chair for support and safety due to poor trunk control, not as a restraint. The MDS was incorrectly coded, as confirmed by the Director of Nursing, who stated that the Geri chair was not used as a restraint.
Care Plan Omission for Geri Chair Use
Penalty
Summary
The facility failed to revise the care plan for a resident to include the use of a geri chair. The resident, who was admitted with diagnoses including Dementia, Difficulty Walking, Dysarthria following a CVA, Other lack of Coordination, Depression, and Failure to Thrive, was observed to use a geri chair for support and safety due to poor trunk control. Despite this, the resident's most recent care plan did not document the use of a geri chair. Interviews with multiple CNAs confirmed that the resident consistently used a geri chair when out of bed. The MDS coordinator, responsible for assessments and care plans, acknowledged the omission upon review. The Director of Nursing was unaware that the use of a geri chair needed to be included in the care plan but agreed to update it.
Inadequate Infection Control Practices and Policy Review
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by improper use of Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) by staff. During an observation, an LPN was seen assisting two residents, one with a PEG tube and the other with a left leg wound, both of whom were on EBP. The LPN did not change her gown between assisting the two residents, which involved repositioning one resident and administering medication to the other. This was confirmed by the LPN and the Director of Nursing (DON), who acknowledged that the gown should have been changed between these activities. Additionally, the facility's infection control and prevention policy was not reviewed annually as required. The policy had a published date of 2017 and a revision date of 2022, but there was no evidence of an annual review. The facility administrator was unable to provide documentation of any recent review, indicating a lapse in maintaining up-to-date infection control policies, which could potentially affect all 92 residents in the facility.
Failure to Maintain Sanitary Environment in Hall A
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for residents in Hall A, as evidenced by multiple brown and black stains on the floor around the nurse's station and throughout the hallway. This deficiency was identified during an initial walkthrough of the facility. The facility's policy, titled 'Resident Rights: Safe, Clean and Comfortable Environment,' mandates that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. Interviews with staff revealed that the hallway floors were expected to be mopped daily. However, S7HSK, who was responsible for mopping the hallways, confirmed that he was unable to mop both halls daily and did not mop Hall A on the day the stains were observed. S6HSUP, who was interviewed during an environmental tour, confirmed the presence of the stains and acknowledged that they should have been cleaned the previous day. S8RD, when informed of the observations, stated that the floors were cleaned the day before and needed time to be mopped for the day, despite the stains being present from the previous morning.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility for two residents requiring dialysis services. According to the facility's policy on dialysis care, there should be continuous communication between the nursing home and dialysis staff, including the completion of Pre Dialysis Assessment & Communication forms. However, for two residents, these forms were found to be incomplete or missing for several dates. Specifically, Resident #1 had incomplete communication forms on certain dates and missing forms on others, while Resident #2 had incomplete communication for the entire month of August, with no documentation of post-dialysis weights or code status. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the nurses were expected to fill out these forms completely before the residents left for dialysis treatment. The DON acknowledged the missing and incomplete documentation for both residents and confirmed that continuous documentation between the dialysis center and the facility was not maintained as required. This lack of documentation and communication represents a failure to adhere to the facility's policy and professional standards of practice for dialysis care.
Failure to Document Resident Bathing in Accordance with Professional Standards
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards and practices for one of the sampled residents reviewed for baths. The facility's policy on Activities for Daily Living requires that any decision to refuse care and treatment be documented in the medical record. However, a review of the clinical record for a resident admitted to the facility revealed a lack of documentation for baths or showers from August 1, 2024, through August 14, 2024. During an interview, a CNA responsible for resident baths admitted to giving the resident bed baths and noted that the resident refused the bed bath two or three times upon admission. The CNA acknowledged that she should have documented all baths given or refused on the bath/shower log. The Director of Nursing confirmed the absence of documentation for the specified period.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that a resident's laboratory tests were completed as ordered by the physician. Resident #3 was admitted to the facility and had a physician's order for a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) to be conducted on a specified date. However, upon review of the resident's clinical record, there was no documented evidence that these laboratory tests were completed as ordered. Interviews with staff confirmed that the tests were not conducted as scheduled, indicating a lapse in following the physician's orders for the resident's care.
Failure to Notify Resident's Representative of New Wounds
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's health status, specifically the development of new wounds. The facility's policy, dated March 2023, mandates that the resident's representative be informed of significant changes in health status, such as the deterioration of physical health. However, the facility did not adhere to this policy for a resident who was readmitted with a sacral wound and later developed three new wounds on the right upper thigh, lower abdomen, and right inner thigh. The resident's clinical records and nurse's notes from June 19, 2024, to June 25, 2024, showed no documentation of notification to the resident's representative about these new wounds. Interviews with the resident's representative and the wound care nurse confirmed that the representative was not informed of the new wounds until the resident was admitted to the hospital on June 25, 2024. The wound care nurse acknowledged that the notification should have been documented and confirmed that the representative was not notified as required by the facility's policy.
Failure to Document Wound Care Treatment
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for a resident with a wound on the right upper thigh. The resident was readmitted to the facility with a physician's order to cleanse the wound, apply triad paste, and cover it with a clean dry dressing once daily. However, the Treatment Administration Record (TAR) for the resident showed multiple instances where the documentation of wound care treatment was missing. Specifically, there were blank entries on the TAR from June 18 to June 21 and June 23 to June 25, indicating a lack of documentation for the wound care treatment. Interviews with the wound care nurse and two LPNs revealed that they provided the wound care treatment on the specified dates but failed to document the completion of the treatment in the TAR. The wound care nurse confirmed that the boxes on the TAR for June 18, 20, 21, and 24 were blank, and the LPNs confirmed similar omissions on June 19, 22, and 23. This lack of documentation suggests that the facility did not adhere to its policy on pressure ulcer documentation, which requires recording dressing and treatments, thereby failing to maintain accurate records for the resident's wound care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in the documentation of their statuses. Resident #52, who was admitted with a serious mental illness as indicated by the OBH-Level II Evaluation Summary, was incorrectly coded in the MDS assessment. The assessment, dated 06/04/2024, did not reflect the resident's status as having a serious mental illness, as Section A1500 was marked as 'No' and Section A1510 was left blank. This discrepancy was confirmed during an interview with the MDS coordinator, who acknowledged the error in coding. Similarly, Resident #80's discharge status was inaccurately documented. Although the resident was discharged home with orders for home health and follow-up care, the Discharge MDS incorrectly indicated a discharge to a short-term general hospital. This error was also confirmed by the MDS coordinator after reviewing the nurse's notes and physician orders, which clearly stated the resident's discharge to home. The Director of Nursing reviewed these findings and confirmed that the MDS assessments should have been coded correctly.
Failure to Prime Insulin Pen Needles Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the proper dispensing and administration of insulin, as evidenced by the lack of priming of insulin pen needles before administration. This deficiency was observed in two residents who were receiving insulin injections. The facility's policy on medication administration, which aligns with the manufacturer's guidelines, requires that insulin pen needles be primed to remove air and ensure accurate dosing. However, during observations, it was noted that the Licensed Practical Nurses (LPNs) did not prime the insulin pen needles before administering insulin to the residents. Resident #17 was prescribed insulin lispro to be administered subcutaneously before meals. During an observation, the LPN prepared and administered the insulin without priming the pen needle, contrary to the manufacturer's instructions. Similarly, Resident #42, who had orders for insulin aspart, received insulin without the pen needle being primed. Interviews with the LPNs revealed a misunderstanding of the requirement to prime the insulin pen needles, which was later confirmed by the Director of Nursing (DON) upon reviewing the manufacturer's instructions.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with accepted professional principles. Insulin pens containing multiple doses were found unlabeled and without open dates on Med Cart C and in the medication room's refrigerator. This lack of labeling could lead to the incorrect administration of insulin to residents. Interviews with staff confirmed that insulin pens should be labeled with the resident's name and dated when opened, but this was not consistently done. Additionally, multi-dose vials of insulin were not discarded within the required 28 days after opening on Med Carts B and C. Observations revealed that vials of Lispro and Lantus insulin were past their expiration dates but had not been removed. Furthermore, Med Cart B was found to contain loose pills, which is against the facility's policy for maintaining clean and organized medication storage. Staff interviews confirmed these deficiencies, acknowledging that the vials should have been discarded and the cart should have been free of loose medications.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, leading to a deficiency in providing personalized dietary care. Resident #26, who was cognitively intact with a BIMS score of 15, had expressed a preference for chef salads every Monday, Wednesday, and Friday for supper. Despite this request being communicated to the dietary staff, the resident did not receive the preferred meals. On July 1, 2024, an observation confirmed that the resident was served chicken tenders and French fries instead of the requested chef salad. The meal ticket for that day incorrectly indicated 'No preferences,' highlighting a failure in the communication and documentation process. Interviews with the facility's staff, including the dietary manager and the administrator, revealed that the resident's food preferences were not properly entered into the system, which should have ensured the kitchen staff accommodated the request. The dietary manager confirmed the oversight, acknowledging that the resident should have received a chef salad as per his preference. The administrator also confirmed that the dietary manager is responsible for updating the system with residents' food preferences to ensure accurate meal preparation. This deficiency indicates a lapse in the facility's process for managing and honoring residents' dietary preferences.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident diagnosed with multiple malignant neoplasms, including those of the colon, liver, intrahepatic bile duct, and lung. The resident's physician orders required weekly and monthly laboratory tests, with results to be faxed to the oncologist's office. However, the facility did not ensure these results were consistently faxed as ordered, which was confirmed through interviews with the charge nurse at the oncologist's office and facility staff. Interviews with various staff members, including an LPN, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and a Nurse Practitioner (NP), revealed a lack of clarity and accountability regarding who was responsible for faxing the lab results. The ADON admitted to only faxing results upon request from the oncologist's office, rather than proactively following the physician's orders. This lack of a designated person to ensure the lab results were sent led to the deficiency in the resident's care plan implementation.
Failure to Schedule Follow-Up Appointment for Resident
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by not facilitating a follow-up appointment with a cardiothoracic surgeon. The resident, who was cognitively intact and had been admitted with a diagnosis of Non-ST Elevation Myocardial Infarction, was discharged from the hospital with orders to attend a post-operative appointment. The appointment was initially scheduled for 05/21/2024 but was rescheduled to 05/28/2024 due to a hospitalization. However, the resident did not attend the rescheduled appointment, and no further follow-up was arranged. Interviews revealed that the staff member responsible for scheduling appointments was unaware of a physician's order placed on 06/11/2024 to make a follow-up appointment with the cardiothoracic surgeon. The Director of Nursing confirmed that the follow-up appointment should have been made when the resident returned from the hospital and when the order was placed. The oversight resulted in the resident not receiving the necessary post-operative care as per the discharge instructions and physician's orders.
Failure to Provide Prescribed Diet and Snacks
Penalty
Summary
The facility failed to ensure that a resident received the correct food portions and snacks as ordered by a physician. Resident #73, who was admitted with diagnoses including malignant neoplasm of the colon and secondary malignant neoplasms of the liver, intrahepatic bile duct, and unspecified lung, had a physician's order for a regular/NAS diet with double portions and snacks twice a day (BID) between meals for weight stability. However, observations and interviews revealed that the resident did not receive double portions or the prescribed snacks. The dietary slip for the resident indicated regular portions instead of the required double portions. Interviews with various staff members, including an LPN, CNA, RD, RDM, DON, ADON, NP, and ADM, highlighted a breakdown in communication and protocol adherence. The RD had made dietary recommendations, which were supposed to be reviewed by the MD/NP and then entered into the computer system by the ADON, who was also responsible for communicating these changes to the dietary department. However, these steps were not followed, resulting in the resident not receiving the prescribed diet. Staff members confirmed that they were unaware of the specific dietary orders, and the kitchen staff did not provide the required snacks, indicating a failure in the facility's process for implementing dietary orders.
Medication Storage Deficiency Due to Missed Audit
Penalty
Summary
The facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies in medication storage. Specifically, the facility did not conduct an audit on the scheduled date, which resulted in expired and unlabeled insulin being available for resident use in medication carts and the medication storage room. Observations revealed that Med Cart C contained two Novolog Flex Pens and one Lantus insulin pen that were opened, unlabeled, and undated. Similarly, Med Cart B had a vial of Lantus insulin with an open date that indicated it should have been discarded. Additionally, the medication storage room contained an opened, unlabeled, and undated Novolog Flex Pen. Interviews with staff confirmed the deficiencies. An LPN acknowledged that multi-dose insulin pens and vials expire 28 days after opening and should have been discarded. The Assistant Director of Nursing (ADON) confirmed that insulin pens should be labeled and dated, and the Director of Nursing (DON) admitted that the missed audit led to expired and unlabeled insulin being available for use. The Administrator also confirmed the missed audit and the presence of expired and unlabeled insulin, indicating that the facility's Quality Assurance/Performance Improvement (QA/QAPI) system was ineffective.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location accessible to residents and visitors, as required by their policy. The policy, dated March 2023, mandates that at the beginning of each shift, the facility must post the facility name, current date, total number and actual hours worked, and resident census. However, during an observation on July 1, 2024, at 10:00 a.m., no staffing data sheets were observed. Interviews conducted shortly after with S16HR and S1ADM revealed that the last daily staffing data sheet was completed on June 27, 2024. This lapse in posting staffing information had the potential to affect any of the 80 residents residing in the facility.
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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