Legacy Nursing And Rehabilitation Of Morgan City
Inspection history, citations, penalties and survey trends for this long-term care facility in Morgan City, Louisiana.
- Location
- 740 Justa Street, Morgan City, Louisiana 70380
- CMS Provider Number
- 195386
- Inspections on file
- 23
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Morgan City during CMS and state inspections, most recent first.
A resident who required staff assistance for all ADLs had multiple instances where care provided or refusals were not documented in the electronic medical record. Staff interviews revealed that system limitations prevented CNAs from recording care when it was provided by someone other than the assigned staff or outside of scheduled bath days, resulting in incomplete records. Supervisory staff confirmed the missing documentation and acknowledged no alternative records were available.
The facility did not consistently provide the required number of nursing staff, as shown by staffing records and confirmed by resident and staff interviews. On multiple days, actual LPN and CNA hours fell short of the facility's own staffing requirements, leading to delays in care and reports of staff burnout. Residents and staff reported unmet care needs, especially on the skilled unit, and the administrator could not provide evidence to dispute these findings.
A resident did not receive ordered physical therapy services for a period of time due to the unavailability of a physical therapist following an insurance change. Despite physician orders for PT evaluation and treatment five times per week, the services were not provided as required.
Two residents with cognitive impairments suffered burns from hot coffee due to inadequate supervision in the dining area. One resident, with severe cognitive impairment, sustained a burn on her hand, while another, with moderate impairment, suffered burns on her abdomen and legs. Despite the presence of staff, the coffee dispenser was unsupervised, and the coffee temperature was dangerously high. Staff interviews confirmed the need for assistance, but no effective measures were implemented to prevent such incidents.
The facility failed to ensure proper hand hygiene and infection control practices, as staff did not perform hand hygiene during resident care, handled medication with ungloved hands, and improperly stored clean items in the laundry room. Additionally, a cluster of bacterial urinary tract infections was not identified or addressed by the facility's infection preventionist.
A resident at high risk for skin breakdown was not provided with a pressure-reducing wheelchair cushion, as required by their care plan. Despite having a history of chronic ulcers and diabetes, the resident was observed multiple times without the cushion, and staff interviews confirmed the oversight. The resident reported discomfort, and the DON acknowledged that all residents should have a cushion on their wheelchair.
An LPN failed to properly dispose of a controlled medication after it was removed from its blister pack but could not be administered due to timing. Instead, the LPN placed the medication back into the blister pack, contrary to the facility's policy. The DON confirmed that the medication should have been disposed of once it was removed.
A facility failed to maintain an updated hospice plan of care and recertification of terminal illness for a resident receiving hospice services. The hospice binder contained only an outdated interim plan, and staff were unaware of the contracted hospice agency's responsibilities and the frequency of updates. The administrator was not aware of the lack of current documentation, and the hospice agency confirmed that updates should occur every 60 days and be provided to the facility biweekly.
The facility failed to transmit MDS assessments within the required 14-day period for three residents. The assessments were completed but not transmitted until several days past the deadline, as confirmed by the S4MDS Corporate Nurse.
Incomplete Documentation of Activities of Daily Living for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required staff assistance with all activities of daily living (ADLs), including toileting, showering, and bathing. The resident was cognitively intact and had a care plan indicating dependence on staff for hygiene and grooming, with specific instructions for staff to assist as needed and to document both care provided and refusals. However, review of the resident's documentation for October and November revealed multiple dates with missing entries for morning and evening care, as well as inconsistencies in recording refusals of baths or showers. Interviews with certified nursing assistants (CNAs) and supervisory staff revealed that the resident frequently refused care from certain staff members but would accept care from others. When care was provided by a CNA not assigned to the resident, that CNA was unable to document the care in the electronic medical record due to system limitations. Additionally, the electronic system only allowed documentation on assigned bath days and for the day shift, preventing accurate recording of care provided at other times or by other staff. As a result, care that was provided or refused was often not documented, leaving gaps in the resident's medical record. Supervisory staff, including the Director of Nursing and Assistant Director of Nursing, confirmed the missing documentation and acknowledged that the only record of ADL care was the electronic medical record, with no alternative documentation available. The administrator and previous Director of Nursing also confirmed the deficiency and noted that a change in computer software had occurred during the period in question, but there was no evidence that the documentation issues were identified or corrected. No further documentation was available to address the missing records.
Failure to Meet Required Nursing Staff Levels
Penalty
Summary
The facility failed to provide the required number of nursing staff members on 22 out of 53 days reviewed, as evidenced by staffing records and interviews. The facility's own Facility Assessment outlined specific daily staffing requirements based on an average census of 83 residents, including required hours for LPNs, CNAs, RNs, and behavioral health staff. On multiple dates, the actual nursing staff hours provided fell short of these requirements, with deficits ranging from just over 2 hours to more than 33 hours on certain days. These shortfalls were documented in the facility's staffing pattern reporting forms, which were signed as complete and accurate by the administrator. Resident Council meeting minutes from January and February indicated that residents experienced delays in receiving care, such as not being changed in a timely manner and not being checked on at night. Residents specifically expressed the need for more CNAs. Multiple interviews with residents, family members, and staff corroborated these concerns, with reports of insufficient staffing, particularly on the skilled nursing unit. Staff members, including CNAs and LPNs, described frequent understaffing, increased workload, burnout, and residents having to wait longer for care. The administrator was unable to provide evidence to dispute the findings of insufficient staffing. The deficiency was further supported by direct statements from residents and staff about the negative impact of inadequate staffing on care delivery, including delays in assistance and unmet care needs. The documentation and interviews consistently indicated that the facility did not meet its own established staffing requirements on numerous occasions.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to ensure that a resident received the required physical therapy (PT) services as ordered by the physician. Physician's orders dated 02/27/2025 and 03/06/2025 specified that the resident was to be evaluated and treated with PT five times per week for eight weeks. However, review of the electronic medical record showed that the resident did not receive any PT services between 02/27/2025 and 03/06/2025. According to the Director of Rehabilitation, this lapse occurred because a physical therapist was not available to evaluate the resident after her insurance changed during the week of 02/23/2025. The Medical Director confirmed that the resident had been admitted specifically to receive therapy services and acknowledged that a physical therapist should have been available to provide the required evaluation and treatment during this period.
Inadequate Supervision Leads to Resident Burns
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent thermal burns for two residents. Resident #19, who had severe cognitive impairment and required supervision with eating, sustained a superficial burn from hot coffee on her fingers and palm. The incident occurred when the coffee pot in the main dining area was left unsupervised, as confirmed by a Licensed Practical Nurse. Similarly, Resident #49, with moderately impaired cognition and requiring assistance with eating, suffered burns on her abdomen and legs after spilling hot coffee on herself. Observations revealed that Resident #49 attempted to fill her coffee cup without staff intervention, despite the presence of a staff member whose back was turned to the coffee dispenser. The coffee temperature was measured at 150.8 degrees Fahrenheit, which is within the range that can cause burns. Interviews with staff, including a CNA and the Dietary Supervisor, indicated that Resident #49 needed assistance with the coffee pot due to her cognitive condition, and that the coffee dispenser was not consistently supervised. The Dietary Supervisor acknowledged that although attempts were made to address the hot coffee issue, no effective measures were implemented, and supervision was not increased. The facility administrator admitted that residents should not be burned, highlighting the lack of adequate supervision and safety protocols in place.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care, leading to multiple deficiencies. A Certified Nursing Assistant (CNA) did not remove gloves or perform hand hygiene after providing incontinence care to a resident, subsequently touching various items in the resident's room with contaminated gloves. Similarly, a Treatment Nurse (TN) failed to perform hand hygiene between handling soiled dressings and applying clean dressings during wound care for two residents, despite using double gloves. A Licensed Practical Nurse (LPN) was observed handling a resident's medication with ungloved hands and failed to perform hand hygiene after removing gloves during medication administration. Additionally, clean items were improperly stored in the contaminated area of the facility's laundry room, with soiled laundry bags leaning against racks of clean clothing. The facility also did not identify or take corrective action when a cluster of bacterial urinary tract infections was found among residents living in close proximity. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) did not recognize the cluster or the common bacteria involved, nor did they conduct audits or provide staff education on infection control practices. This oversight was confirmed by the Director of Nursing (DON), who acknowledged the lack of monitoring and preventative measures.
Failure to Provide Pressure-Reducing Cushion for High-Risk Resident
Penalty
Summary
The facility failed to ensure the use of a pressure-reducing wheelchair cushion for a resident assessed as being at high risk for skin breakdown. Resident #5, who had a history of a non-pressure chronic ulcer, chronic venous hypertension with ulcer and inflammation, and diabetes, was observed multiple times without the necessary cushion in place. The resident's care plan indicated that he remained in his wheelchair all day and often slept in it, which increased his risk for skin breakdown. Despite the special instructions in his care tasks to use a wheelchair cushion, observations on several occasions revealed the absence of the cushion. Interviews with the resident and staff further highlighted the deficiency. Resident #5 reported experiencing discomfort and mentioned it to the CNA during incontinence care. However, the CNA could not recall the last time the cushion was used, and the Director of Nursing confirmed that all residents should have a cushion on their wheelchair. The repeated observations and staff interviews indicate a failure to adhere to the care plan and special instructions, leading to the deficiency in providing appropriate pressure ulcer care for Resident #5.
Improper Disposal of Controlled Medication by LPN
Penalty
Summary
The facility failed to ensure proper disposal of a resident's medication by a Licensed Practical Nurse (LPN), identified as S6LPN, during medication administration. According to the facility's Medication Administration Policy and Procedure, medications should be prepared immediately prior to administration, and if a medication is held, a notation should be made on the resident's medication record. Additionally, wasted controlled drugs must be witnessed and co-signed. However, during an observation, S6LPN assessed a resident who reported a pain level of 8 out of 10 and attempted to administer Oxycodone/Acetaminophen, a controlled medication, but realized it was too early to administer the dose. Instead of disposing of the medication as required, S6LPN placed the tablet back into the blister pack and sealed it with tape. Interviews conducted with S6LPN and the Director of Nursing (DON) confirmed that the medication should have been disposed of once it was removed from the blister pack and could not be administered. The DON indicated that S6LPN's action of placing the medication back into the blister pack was incorrect and not in compliance with the facility's policy. This incident highlights a failure in adhering to medication administration protocols, specifically regarding the handling and disposal of controlled substances.
Failure to Maintain Updated Hospice Plan of Care
Penalty
Summary
The facility failed to ensure that a resident's most recent hospice plan of care and recertification of terminal illness were obtained from the contracted hospice agency. This deficiency was identified for a resident who was receiving hospice services while residing in the facility. The facility's hospice care plan required coordination with the contracted hospice agency, but the only documented hospice plan of care was an interim plan dated several months prior, which did not specify the resident's hospice service needs or the scope and frequency of services. There was no evidence of a current certification of the resident's terminal illness, and the facility was unable to provide any updated hospice information. Additionally, the facility staff were not aware of the contracted hospice agency's responsibilities in implementing the hospice plan of care. Interviews revealed that staff, including the Director of Nursing and a Licensed Practical Nurse, were unsure about the frequency of updates to the resident's hospice binder and the frequency of hospice personnel visits. The facility's administrator, who was responsible for ensuring compliance with the hospice agreement, was unaware that the hospice binder was not up to date. The contracted hospice agency's case manager confirmed that hospice care plans were updated at least every 60 days and should be provided to the facility every two weeks, but this was not reflected in the facility's records.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion for three residents. Resident #28's Quarterly MDS, with an Assessment Reference Date (ARD) of 07/17/2024, was completed on 07/18/2024 but was not transmitted until 08/20/2024, exceeding the 14-day requirement. Similarly, Resident #44's Quarterly MDS, completed on 07/31/2024, and Discharge MDS, completed on 08/01/2024, were both transmitted on 08/20/2024, beyond the 14-day timeframe. Resident #241's Discharge MDS, completed on 08/03/2024, was also transmitted late on 08/20/2024. The deficiency was confirmed during an interview with the S4MDS Corporate Nurse, who acknowledged that the MDS assessments should have been transmitted within 14 days of their completion. The delay in transmission for these residents' assessments was identified through a review of the facility's MDS 3.0 Nursing Home Final Validation Report, which documented the late transmission dates.
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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