Landmark South Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 18180 Jefferson Hwy, Baton Rouge, Louisiana 70817
- CMS Provider Number
- 195480
- Inspections on file
- 26
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Landmark South Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to accurately reflect a resident's code status in their medical records, leading to conflicting information about their DNR wishes. The resident's Advance Directive Consent form indicated a DNR status, but the facility recorded a CPR status in the clinical records. This discrepancy was due to a breakdown in the process of updating and verifying the resident's code status across different records, resulting in a potential risk of the resident receiving unwanted CPR.
The facility failed to maintain sanitary conditions in food storage and ice machine maintenance. Opened food items in the refrigerator were not dated, and the ice machine was found with mold-like particles and a pink sticky substance on its rolling table. Staff confirmed these deficiencies, acknowledging the lack of proper labeling and cleaning.
A facility failed to develop a comprehensive care plan for a resident, neglecting to address the use of antidepressant and psychotropic medications and the resident's suicidal ideations. Despite the resident's diagnoses of Alzheimer's Disease and Anxiety Disorder, and the administration of Seroquel and Lexapro, the care plan did not reflect these treatments or the resident's expressed suicidal thoughts. Staff interviews confirmed the oversight, acknowledging the care plan should have included these critical aspects.
A facility failed to ensure proper PPE use during catheter care for a resident on Enhanced Barrier Precautions (EBP). Despite policy requirements for gown and glove use during high-contact activities, a CNA was observed performing catheter care without a gown. The CNA admitted to the oversight, and both an LPN and the DON confirmed the necessity of gown use for residents under EBP.
A facility failed to monitor the administration of psychotropic medication for a resident, as required by its policy. The resident was prescribed Xanax 0.25 mg as needed for agitation or panic disorder, but there was no documentation of pre-administration screens or reasons for administering the medication on several occasions. Additionally, post-administration screens or responses were not documented on certain dates. The DON confirmed the lack of required documentation, indicating non-compliance with the facility's policy.
The facility failed to lock a medication cart when unattended, as observed by surveyors. An LPN confirmed that Cart F was left unlocked near a resident's room, contrary to the facility's policy. The DON also acknowledged that medication carts should be locked when unattended.
The facility did not post the required daily nurse staffing information, as observed on multiple occasions. The posted information was outdated, and the staff member responsible admitted to not updating it. The administrator confirmed the information was not current.
The facility failed to ensure call lights were within reach for two residents, both at risk for falls and with cognitive deficits. Despite care plans and staff training, observations showed call lights on the floor, inaccessible to the residents. Staff interviews confirmed the expectation for call lights to be within reach, highlighting a lapse in adherence to facility policy.
A resident with cognitive impairment and multiple fractures was found on the floor with significant injuries. The incident was reported internally but not to the state agency within the required timeframe, due to a misunderstanding by the Administrator regarding reporting requirements for unwitnessed falls.
Failure to Accurately Reflect Resident's Code Status
Penalty
Summary
The facility failed to adhere to its policy regarding advance directives, resulting in a discrepancy in the medical records of a resident concerning their code status. The resident had signed an Advance Directive Consent form indicating a Do Not Resuscitate (DNR) status, but the facility inaccurately recorded a status of Cardiopulmonary Resuscitation (CPR) in the resident's clinical records. This inconsistency was discovered when the resident, who had intact cognition, confirmed her wish for a DNR status, yet her physical chart indicated a full code status. The issue arose from a breakdown in the process of updating and verifying the resident's code status across different records. Upon admission, the resident's Advance Directive Consent form was completed, but the information was not accurately reflected in the physician's order or the physical chart. The LPN responsible for updating the electronic health record and physical chart based on the consent form failed to ensure consistency, leading to conflicting information about the resident's code status. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's code status. The LPNs involved in the process did not verify the consistency between the signed consent form, the physician's order, and the physical chart. This oversight created a situation where the resident could have received CPR against her wishes in an emergency, highlighting a significant lapse in following the facility's procedures for managing advance directives.
Sanitation Deficiencies in Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage, preparation, and distribution of food, as observed during a survey. Specifically, the facility did not date food items after opening, which included a gallon of milk, thickener mix, turkey meat, cheese blocks, and salad dressing bottles. These items were found in the walk-in refrigerator without any open dates, contrary to the facility's policy that requires all opened food items to be labeled with the name of the food and the date stored. This oversight was confirmed by S4DM during an interview, who acknowledged that all opened items should be labeled with an open date. Additionally, the facility did not properly clean and sanitize the ice machine and its rolling table. The ice machine's ice dispenser tray was covered with round fuzzy greenish/black particles, and similar particles were floating in standing water inside the machine. A pink sticky substance was also noted on the ice machine rolling table cart. S4DM and S1ADM confirmed that the ice machine and table should be clean and sanitary, which they were not. S5MS, who was responsible for cleaning the ice machines, was also interviewed and acknowledged the responsibility for scheduled cleanings.
Failure to Address Medications and Suicidal Ideations in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, specifically addressing the use of antidepressant and psychotropic medications, as well as the resident's suicidal ideations. The resident, who was admitted with diagnoses including Alzheimer's Disease and Anxiety Disorder, was administered Seroquel and Lexapro over a period of time. Despite these medications being recorded in the Medication Administration Records, the resident's care plan did not reflect their use, nor did it address the resident's expressed suicidal thoughts. Interviews with facility staff, including an LPN, MDS coordinator, and the Director of Nursing, confirmed the oversight. The staff acknowledged that the resident's care plan should have included the use of psychotropic and antidepressant medications and addressed the suicidal ideations reported on specific dates. The failure to update the care plan was confirmed by multiple staff members, indicating a lapse in ensuring the resident's care plan was comprehensive and reflective of their current needs.
Improper PPE Use During Catheter Care for Resident on EBP
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) during catheter care for a resident on Enhanced Barrier Precautions (EBP). The facility's policy on EBP, revised in March 2024, mandates the use of gowns and gloves during high-contact activities for residents with indwelling medical devices, such as urinary catheters. Resident #80, who had a history of urinary tract infections and was on EBP since August 30, 2024, required such precautions during catheter care. On November 12, 2024, a Certified Nursing Assistant (CNA) was observed performing catheter care for Resident #80 without wearing a gown, despite the EBP sign on the resident's door indicating the necessity of gown and glove use. The CNA admitted to not wearing a gown due to being busy with other tasks. Subsequent interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the CNA should have worn a gown while providing care to the resident under EBP.
Failure to Monitor Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure adequate monitoring for the effectiveness and side effects of psychotropic medication for one of the residents reviewed. The facility's policy on psychotropic medications requires a pre and post-administration screen for each use of PRN psychotropic medications, including documentation of the behavior the drug is intended to reduce, physiological, environmental, and pharmacological interventions, as well as post-administration behavior and side effects. However, the facility did not adhere to this policy for a resident who was prescribed Xanax 0.25 mg as needed for agitation or panic disorder. The medication was administered multiple times over several days, but there was no documentation of a pre-administration screen or reason for administering the medication on several occasions. Additionally, there was a lack of documentation of a post-administration screen or response to the medication on certain dates. The Director of Nursing (DON) confirmed the absence of required documentation after reviewing the resident's Medication Administration Record (MAR) and nurse's notes. This oversight indicates a failure to comply with the facility's policy on monitoring psychotropic medication, which is crucial for ensuring the safety and well-being of residents receiving such medications.
Medication Cart Security Deficiency
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as required by their policy. During an observation on July 17, 2024, at 8:01 a.m., Cart F was found unlocked and unattended near a resident's room. This was confirmed during an interview with an LPN, who acknowledged that the cart should have been locked at all times when not attended. Additionally, the Director of Nursing confirmed that the medication carts should be locked when left unattended and acknowledged that the surveyor should not have observed Cart F unlocked.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis, as observed on multiple occasions on 07/18/2024. At 8:15 a.m., 10:00 a.m., and 12:30 p.m., the posted staffing information was dated 07/17/2024, indicating it was not updated for the current day. During an interview at 12:55 p.m., S3WC, who was responsible for posting the daily staffing information, admitted that she did not post the staffing information for the day and acknowledged that she should have done so. At 1:03 p.m., S1ADM confirmed that the daily staffing information was not current and was still dated 07/17/2024.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, R1 and R2, as observed during a survey. Resident R1, who has Alzheimer's disease, urinary tract infections, and a cognitive communication deficit, was found with her call light on the floor and out of reach while resting in bed. Her care plan, which has been in place since May 2019, specifically includes the intervention of placing the call light within reach to mitigate her risk of falls. Similarly, Resident R2, diagnosed with systemic lupus, cognitive communication deficit, and dementia, was observed in her wheelchair with the call light behind her on the floor, making it inaccessible. Despite being educated on the importance of using the call light and having staff in-serviced on keeping it within reach, the call light was not accessible to her. Interviews with staff, including LPNs and ADONs, confirmed that the call lights should have been within reach, but they were not, indicating a failure to adhere to the facility's policy and the residents' care plans.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframe, as mandated by state and federal regulations. A resident, who was admitted with multiple diagnoses including Parkinson's Disease, Dementia, and fractures, was found on the floor with significant injuries, including a protruding knot above the left eyebrow, bruising, abrasions, and fractures. The resident was assessed as having moderate cognitive impairment and required total dependence for all activities of daily living and transfers. Despite the severity of the injuries and the unwitnessed nature of the fall, the incident was not reported to the state agency within the required two-hour window. Interviews with facility staff revealed that the incident was reported internally to the Assistant Director of Nursing immediately, but the Administrator was only informed within 24 hours. The Administrator confirmed that the incident, which resulted in fractures, was not reported to the state agency, under the mistaken belief that unwitnessed falls did not require reporting. This oversight represents a failure to adhere to the facility's policy on incident investigation and reporting, which mandates immediate reporting of such incidents to the appropriate authorities.
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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