Legacy Nursing And Rehabilitation Of Plaquemine
Inspection history, citations, penalties and survey trends for this long-term care facility in Plaquemine, Louisiana.
- Location
- 59215 River West Drive, Plaquemine, Louisiana 70764
- CMS Provider Number
- 195343
- Inspections on file
- 34
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Plaquemine during CMS and state inspections, most recent first.
A CNA did not pull the privacy curtain while providing incontinence care to a resident with severe cognitive impairment, resulting in the resident's exposed genitalia being visible to her roommate. Facility policy requires privacy during personal care, but this was not followed during the incident.
A CNA did not perform hand hygiene or change gloves after cleaning a resident's perineal area and before applying a clean brief. The CNA also used soiled gloves to obtain additional wipes from a multi-use package, contrary to infection control policy, as confirmed by interviews with the DON and Administrator.
The facility failed to maintain food safety and hygiene standards, with staff not fully containing hair in hairnets, uncovered food items, and improperly labeled and stored food. Personal food items were stored with residents' food, and expired food was available for use. These deficiencies were confirmed by staff interviews.
Two residents were unable to reach their call bells, which were improperly placed, leading to a deficiency in care. An LPN confirmed the issue, and the facility administrator acknowledged that call bells should be accessible.
A resident with severe cognitive impairment was not provided adequate privacy during personal care activities. Staff failed to pull the privacy curtain and fully close the window blinds, exposing the resident's nude body to the outside. Interviews with facility staff confirmed that privacy should have been maintained.
A facility failed to implement a care plan intervention for a resident at risk of falls due to hemiplegia. The care plan required a self-release lap tray while the resident was in a wheelchair, but observations showed the resident without the tray on multiple occasions. Interviews with an LPN and the ADON confirmed the oversight.
A resident with a suprapubic catheter experienced improper care when their catheter bag was repeatedly placed in bed rather than below the bladder, contrary to CDC guidelines. This oversight, acknowledged by a CNA and confirmed by an LPN and the ADON/Infection Preventionist, contributed to the resident's history of UTIs and cystitis.
A facility failed to follow its policy for maintaining respiratory care equipment for a resident. The policy required storing respiratory tubing, mouthpieces, and masks in a plastic bag when not in use. However, observations showed the resident's nasal cannula, nebulizer mask, and oxygen tubing were repeatedly found uncontained and improperly stored on the floor, on the resident's chest, and on the bedside table. The DON confirmed the equipment should have been stored in a clean, labeled plastic bag.
The facility failed to maintain a sanitary environment for two residents, as dried tube feeding formula was observed on their enteral feeding equipment and floors over two days. The administrator confirmed the oversight, acknowledging that the areas should have been cleaned by staff.
The facility failed to accurately complete the MDS for two residents. One resident with bilateral amputations was incorrectly assessed as needing assistance with footwear, while another resident with serious mental illnesses was inaccurately marked as not having such conditions. Staff interviews confirmed these inaccuracies.
The facility failed to designate a licensed nurse as a charge nurse for each shift, as required by regulations. A review of schedules from early December 2024 showed no designated charge nurse for both day and night shifts. Interviews with LPNs confirmed the absence of a charge nurse on the night shift. The DON admitted to not designating a charge nurse, and the administrator confirmed the lack of documentation.
A facility failed to communicate necessary resident information to a receiving facility during a transfer. An LPN did not call the emergency department to provide a report when a resident was transferred, as required by the facility's procedures. Interviews with the LPN, DON, and Administrator confirmed the lapse, and there was no documentation to show that the receiving facility received all required information.
A resident with a history of COVID-19 and displaying symptoms requested a test after developing a fever. Despite the facility's policy for immediate testing, the resident was not tested until the following day, resulting in a positive COVID-19 result. An LPN administered Tylenol and noted the need for testing the next day, leading to a deficiency in infection control.
The facility failed to prevent an altercation between two residents, resulting in physical harm. Both residents had shown increased agitation and aggressive behaviors, but the facility did not increase supervision or take preventive measures. Staff observed one resident pacing with a belt and making delusional statements, but no additional interventions were implemented.
The facility failed to report an altercation between two residents, one of whom sustained injuries, to the State Survey Agency within the required 5 working days. The incident involved residents with mental health diagnoses, and the facility's administrator acknowledged the reporting failure.
The facility failed to develop a crisis intervention plan for a resident with delusional disorder, anxiety disorder, and paranoid personality disorder, as required by the PASRR program. Despite the resident's cognitive intactness and additional diagnoses, no documented evidence of the plan was found, and interviews confirmed its absence.
The facility failed to address signs of pain in a nonverbal resident with a left shoulder fracture. Despite multiple high pain levels documented in the resident's EMAR and standing orders for pain medication, there was no evidence of pain medication being administered. Observations and interviews confirmed the resident's pain and the lack of appropriate pain management.
Failure to Ensure Resident Privacy During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide privacy for a resident with severe cognitive impairment during incontinence care. The CNA did not pull the privacy curtain between the resident and her roommate, resulting in the resident's exposed genitalia being visible to the roommate. This action was observed during incontinence care, and both the CNA and facility leadership acknowledged that the privacy curtain should have been used to ensure the resident's privacy. The resident was dependent on staff for toileting hygiene and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment at the time of the incident. Facility policy states that residents have the right to privacy during treatment and care of personal needs, but this was not followed during the observed event.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow proper hand hygiene protocols during incontinence care for a resident. Specifically, after cleaning the resident's perineal area and removing a soiled brief, the CNA did not sanitize her hands or apply clean gloves before proceeding to put on a clean brief. Additionally, the CNA used soiled gloves to obtain more disposable wipes from a multi-use package multiple times during the care process, and placed the package of wipes on the resident's bed. Interviews with the CNA, the Director of Nursing (DON), and the Administrator confirmed that the CNA should have removed soiled gloves, performed hand hygiene, and donned clean gloves before applying a clean brief. They also acknowledged that obtaining wipes from a multi-use package with soiled gloves was not in accordance with facility policy and infection prevention procedures.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards in food procurement, storage, preparation, and service, as observed during a kitchen inspection. Staff members, identified as S8Dietary Helper and S9Dietary Helper, were found with hair not fully contained in hairnets while in the food preparation area, contrary to the facility's policy. Additionally, individual cups of vanilla pudding were left uncovered on the preparation table. The facility's refrigerator contained several unlabeled and undated food items, including a zip lock bag of cooked cubed chicken, a Styrofoam cup with a pudding-like substance, and a cream cheese Danish, which was later identified as a personal food item belonging to S8Dietary Helper. Furthermore, a bag of chopped cabbage was found with a grayish-black unknown substance, indicating spoilage. The facility's freezer also contained undated and unlabeled food items, such as a half-full bag of frozen fries and an opened package of an unspecified item. Interviews with S8Dietary Helper and S7Dietary Manager confirmed these observations, with S7Dietary Manager acknowledging that all kitchen staff should wear hairnets properly, food items should be labeled and dated, and personal food items should not be stored with residents' food. The presence of expired and improperly stored food items, along with the lack of adherence to hairnet policies, highlights deficiencies in the facility's food safety and hygiene practices.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, leading to a deficiency in resident care. Resident #2 reported being unable to reach his call bell, which was observed to be tangled and located under his bed on multiple occasions. Despite being capable of using the call bell, Resident #2 was unable to access it due to its improper placement. This was confirmed by an LPN who acknowledged that the call bell was not within reach. Similarly, Resident #95 was observed multiple times lying in bed with the call bell placed on top of a dorm-size refrigerator on a nightstand, making it inaccessible. Resident #95 expressed a need for assistance but was unable to call staff due to the call bell's location. An LPN confirmed that Resident #95 was capable of using the call bell and that it should have been within reach. The facility administrator also acknowledged that call bells should be accessible to residents.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to maintain a resident's right to privacy during care for one resident. The resident, who had severe cognitive impairment and was dependent on staff for various personal care tasks, was observed receiving a bed bath and having their bedsheets changed without adequate privacy measures in place. Specifically, the privacy curtain in the room was not pulled, and the window blinds were only halfway down, exposing the resident's nude body to the outside parking lot. Interviews with facility staff, including a CNA Supervisor, the Assistant Director of Nursing, and the Director of Nursing, confirmed that privacy should have been provided during the resident's care. The staff acknowledged that the privacy curtain should have been pulled and the blinds fully closed to ensure the resident's privacy during these personal care activities.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care plan interventions to decrease the risk of falls for Resident #84, who was identified as being at risk for falls due to an unsteady gait related to hemiplegia. The care plan for Resident #84 included an intervention to apply a self-release lap tray while the resident was up in his wheelchair, with a start date of 10/19/2024. However, multiple observations on 01/27/2025 and 01/28/2025 revealed that Resident #84 was sitting in his wheelchair without the self-release lap tray. Interviews with an LPN and the Assistant Director of Nursing confirmed that the resident was supposed to have the lap tray while in the wheelchair, indicating a failure to implement the care plan intervention as required.
Improper Positioning of Catheter Bag Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper positioning of a urinary catheter bag for a resident with a suprapubic catheter, leading to a deficiency in care. Observations revealed that the catheter bag was placed in the resident's bed near their feet, rather than below the level of the bladder, as required by the CDC's guidelines for preventing catheter-associated urinary tract infections. This improper positioning was noted during catheter care provided by a Certified Nursing Assistant (CNA), who acknowledged the mistake in an interview. The resident in question had a history of urinary tract infections (UTIs) and cystitis, with multiple diagnoses recorded over several months. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing/Infection Preventionist, confirmed that the catheter bag should have been maintained below the bladder level to prevent such infections. The repeated failure to adhere to this guideline contributed to the resident's ongoing issues with UTIs and cystitis.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to adhere to its policy and procedure for maintaining respiratory care equipment for a resident. The facility's policy required that respiratory tubing, mouthpieces, and masks be stored in a plastic bag when not in use. However, observations revealed that a resident's nasal cannula, nebulizer mask, and oxygen tubing were repeatedly found uncontained and improperly stored. On multiple occasions, the nebulizer mask was observed lying on the floor, on the resident's chest, and on the bedside table. During an interview, the Director of Nursing confirmed that the nebulizer mask should have been contained in a clean, labeled plastic bag, which was not the case.
Failure to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents, leading to a deficiency in providing a safe, clean, and comfortable living space. Observations revealed that a dried light brown unknown substance was present on the enteral feeding pump poles and floors of two residents' rooms. These observations were made multiple times over two days, indicating a lack of timely cleaning and maintenance by the facility staff. Interviews with the facility's administrator confirmed the presence of the dried substance, which was identified as dried tube feeding formula. The administrator acknowledged that the enteral feeding equipment and floors should have been cleaned by the staff but were not. This oversight in maintaining cleanliness and sanitation in the residents' environment contributed to the deficiency noted in the report.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for two residents. Resident #42, who was admitted with bilateral above-the-knee amputations, had inaccuracies in his MDS assessments. The assessments incorrectly indicated that he was dependent on staff for putting on or taking off footwear, despite his condition making it impossible for him to perform these actions. Interviews with the Director of Rehabilitation and the MDS Nurse confirmed that the MDS assessments for Resident #42 were not completed accurately due to his amputations. Resident #51, who was admitted with diagnoses including Schizophrenia, Bipolar Disorder, and Post Traumatic Stress Disorder, also had an inaccurate MDS assessment. The significant change MDS assessment incorrectly marked that Resident #51 did not have a serious mental illness, despite his documented diagnoses. An interview with the MDS nurse confirmed that the MDS question regarding serious mental illness was not marked correctly, leading to an inaccurate assessment.
Failure to Designate Charge Nurse for Each Shift
Penalty
Summary
The facility failed to ensure a licensed nurse was designated as a charge nurse for each shift, as required by nursing staff regulations. A review of the facility's Nursing Daily Work Schedules from December 2, 2024, through December 11, 2024, revealed the absence of a designated charge nurse for both the 6:00 AM to 6:00 PM shift and the 6:00 PM to 6:00 AM shift. Additionally, the November and December 2024 Nurse Schedules lacked a designated charge nurse for each shift. Interviews with several Licensed Practical Nurses (LPNs) confirmed the absence of a designated charge nurse on the night shift. The Director of Nursing (DON) acknowledged the oversight, admitting that she did not designate a charge nurse on the nursing schedule for each shift, which was a requirement. The facility administrator also confirmed the lack of documented evidence of a designated charge nurse for each shift.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to communicate appropriate resident information to a receiving facility during a transfer, resulting in a deficiency. Specifically, a Licensed Practical Nurse (LPN) was responsible for transferring a resident to the emergency department but did not call the receiving facility to provide a report, as required by the facility's procedures. The resident was discharged to the emergency department without documented evidence that the necessary information was conveyed. Interviews with the LPN, the Director of Nursing (DON), and the Administrator confirmed that the report was not given, and there was no documentation to support that the receiving facility received all required information for the transfer.
Delayed COVID-19 Testing for Symptomatic Resident
Penalty
Summary
The facility failed to test a resident displaying signs and symptoms of COVID-19 in a timely manner, as required by their COVID-19 testing policy. The policy mandates that any resident showing symptoms should be tested as soon as possible. Resident #2, who had a history of COVID-19, requested a temperature check on August 22, 2024, and was found to have a fever of 101.2°F. Despite expressing that he felt similar to when he previously had COVID-19 and requesting a test, the resident was not tested until the following day, August 23, 2024, when he tested positive for COVID-19. Interviews revealed that the delay in testing was due to the actions of an LPN who, upon discovering the resident's fever, administered Tylenol and documented the need for testing in a nurse's note for the following day. This delay in testing did not align with the facility's policy of immediate testing for symptomatic residents, resulting in a deficiency in infection prevention and control.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents remained free from physical abuse, resulting in an altercation between two residents. Resident #4, who had a history of delusional disorder, anxiety disorder, and paranoid personality disorder, attacked Resident #5 with a belt, causing scratches that required daily wound care. Both residents had shown increased agitation and behaviors prior to the incident, but the facility did not increase supervision or take preventive measures despite these warning signs. Staff had observed Resident #4 pacing and making delusional statements, but no additional interventions were implemented to address his escalating behavior. Resident #4 had previously exhibited delusional behavior, including an incident in August 2023 where he believed Resident #5 was trying to kill him. Despite this history, the facility did not separate the two residents or increase supervision. On the day of the incident, Resident #4 was seen walking around with a belt and a lock in his hand, and staff noted his increased agitation. However, no measures were taken to monitor him more closely or to prevent potential harm. Resident #5, who had diagnoses including bipolar disorder and major depressive disorder, also displayed aggressive behavior and had a history of making racial slurs and threats. Despite these behaviors, the facility did not increase supervision or implement new interventions. The staff and administration were not adequately informed about the residents' escalating behaviors, and no actions were taken to prevent the altercation. The facility's failure to address these issues resulted in physical harm to Resident #5.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required 5 working days. Resident #4, who has diagnoses including delusional disorder, anxiety disorder, and paranoid personality disorder, was involved in an altercation with Resident #5. Resident #4's care plan indicated a potential for verbal aggression due to his mental and emotional illnesses. On the day of the incident, Resident #4 was found walking around with a belt and a lock, claiming his roommate, Resident #5, had attacked him. Resident #5, who has diagnoses including bipolar disorder and major depressive disorder, confirmed the altercation, stating that Resident #4 had become aggressive and they had wrestled. Resident #5 sustained scratches to his neck and thumb during the incident, which were documented and treated by the facility's staff. Despite the altercation and the injuries sustained by Resident #5, the facility did not report the incident to the state agency. The administrator acknowledged that the incident should have been reported but was not. The failure to report this incident within the required timeframe constitutes a deficiency in the facility's compliance with regulations regarding the reporting of abuse and neglect.
Failure to Develop Crisis Intervention Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident had a crisis intervention plan developed as required by the pre-admission screening and resident review (PASRR) program. Resident #4, who was admitted with diagnoses including delusional disorder, anxiety disorder, and paranoid personality disorder, did not have a documented crisis intervention plan despite the PASRR Level II Evaluation Summary and Determination Notice specifying the need for such a plan. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 14, showing cognitive intactness, and additional diagnoses of non-traumatic brain dysfunction and paranoid schizophrenia. Upon review, there was no documented evidence of a crisis intervention plan for Resident #4, and the facility was unable to provide such documentation. Interviews with the resident's psychiatric counselor and the Director of Nursing confirmed that no crisis intervention plan had been developed. The psychiatric counselor indicated that the contracted psychiatric services company had not developed or assisted in the development of the plan, and the Director of Nursing acknowledged the facility's inability to present the required evidence to the surveyor.
Failure to Address Pain in Nonverbal Resident
Penalty
Summary
The facility failed to address signs of pain in a nonverbal resident with a left shoulder fracture. The resident's care plan, initiated on 04/02/2024, included goals for minimal to no discomfort and interventions such as administering medications as prescribed and reporting unrelieved pain to the physician. However, a review of the resident's March and April 2024 Electronic Medication Administration Records (EMAR) revealed multiple instances of high pain levels (ranging from 4 to 8) without any documented evidence of pain medication being administered. The facility's standing physician orders included administering 650 milligrams of acetaminophen for mild to moderate pain, but there was no documentation that this was done for the resident's reported pain levels. Observations on 04/02/2024 and 04/04/2024 revealed the resident exhibited facial grimacing during incontinence care, indicating pain. Interviews with CNAs and LPNs confirmed the resident's pain and the lack of pain medication administration. The Director of Nursing (DON) and the resident's Nurse Practitioner also confirmed the resident's high pain ratings and the absence of documented pain medication administration. Despite the standing orders for pain management, the facility did not address the resident's pain, leading to the deficiency noted in the report.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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