Legacy Nursing And Rehabilitation Of Pollock
Inspection history, citations, penalties and survey trends for this long-term care facility in Pollock, Louisiana.
- Location
- 8275 Highway 165, Pollock, Louisiana 71467
- CMS Provider Number
- 195249
- Inspections on file
- 22
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Pollock during CMS and state inspections, most recent first.
A resident with severe dementia and behavioral symptoms, including wandering and hypersexuality, was not provided with the ordered 1:1 observation during night shifts. Despite physician orders and care plan directives, staff confirmed that the required supervision was not consistently implemented, resulting in a failure to deliver appropriate treatment and services.
A resident with severe cognitive impairment and a history of falls did not have their care plan updated with new fall interventions after multiple incidents. Despite staff acknowledging that care plans should be revised after each fall, no new interventions were added, and existing interventions remained unchanged.
Two residents with severe cognitive impairment and multiple comorbidities experienced unwitnessed falls or falls with head injury, but neurological checks were not completed for the required 72 hours as per facility policy. Instead, checks were only performed for significantly shorter periods, as confirmed by the DON through record review and interview.
Two residents did not receive wound care as ordered on multiple occasions, and weekly wound assessments were not performed as required by facility policy. The DON and Wound Care Nurse confirmed that wound care was missed on several dates and that a deep tissue injury was not assessed for two weeks after discovery.
A resident with severe cognitive impairment and depression did not receive prescribed Trazodone on multiple days because the medication was not available in the facility. An LPN confirmed the medication was missing and did not follow up with the pharmacy, and the DON acknowledged the missed doses and lack of follow-up.
A resident with COPD and other health issues did not receive proper respiratory care as the facility failed to maintain cleanliness of the oxygen concentrator. The nasal cannula was found uncovered and unlabeled, and the concentrator had brown stains and a dusty filter, contrary to the facility's policy.
The facility failed to administer controlled medications at the time they were signed out, affecting multiple residents, and did not conduct lab work as per physician orders for a resident with severe cognitive impairment. Discrepancies were found between medication records and actual counts, and monthly Depakote levels were missed for a resident with specific medical needs.
The facility did not meet the nutritional needs of residents by failing to follow the menu's portion sizes for pureed diets. During a lunch service, dietary staff used a 3 oz scoop instead of the required 4 oz scoop for pureed meatloaf, affecting nine residents. The dietary manager confirmed the error, admitting to forgetting to check scoop sizes before serving.
The facility failed to ensure pureed foods were prepared by methods conserving nutritional value for nine residents on pureed diets. The dietary cook did not follow the approved menu recipe, using unmeasured ingredients and relying on experience instead. The dietary manager confirmed the absence of recipe adherence, and the RD emphasized the importance of following recipes for adequate caloric intake.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely incontinent care, as confirmed by observations and family grievances. The resident was often found in soiled briefs for extended periods, despite facility policies and recent measures to ensure proper care. Staff interviews revealed inconsistencies in care, and management acknowledged past issues and ineffective processes.
The facility did not include the Medical Director or a designee in the Quality Assessment and Assurance (QAA) process, as required by their policy. The QAA committee must include the Medical Director, Administrator, DON, and three other staff members. The Medical Director's absence was confirmed for meetings in March and June 2024, with no documented evidence of attendance.
A facility failed to maintain proper infection control during wound care for a resident with stage 4 pressure injuries. A treatment nurse did not change gloves or sanitize hands after handling contaminated materials, contrary to the facility's policy. The staff were unaware of the need for hand hygiene between glove changes, as the policy did not specify this requirement.
The facility failed to ensure that residents who were unable to carry out ADLs received necessary services for grooming and hygiene due to staffing shortages. Multiple residents reported not receiving scheduled baths, and staff interviews confirmed the facility was frequently short-staffed, leading to missed care.
The facility failed to provide adequate care due to staffing shortages, resulting in residents not receiving scheduled baths and supervision for smoking. Multiple residents reported not receiving necessary ADL assistance, and staff confirmed the lack of sufficient CNAs to meet care needs.
Failure to Provide Ordered 1:1 Observation for Resident with Dementia
Penalty
Summary
A resident with diagnoses of dementia, anxiety, and psychosis was admitted to the facility and exhibited severe cognitive impairment, as indicated by a BIMS score of 3. The resident displayed behavioral symptoms that interfered with activities, intruded on the privacy of others, and disrupted the living environment, including hypersexual behaviors and significant wandering. Due to these behaviors, a physician's order was in place for 1:1 observation every shift, and the care plan included this intervention to address the resident's needs. Despite the physician's order and care plan, the facility failed to provide 1:1 observation for the resident during the night shifts from 6:00 p.m. to 6:00 a.m. on multiple occasions. Staff interviews confirmed that the required 1:1 observation was not consistently implemented during these hours. This lapse in following the ordered intervention resulted in the resident not receiving the appropriate treatment and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Update Care Plan with New Fall Interventions After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan for a resident after multiple falls, as required. Record review showed that a resident with severe cognitive impairment and multiple diagnoses, including Parkinsonism, dementia, and a history of falls, experienced several falls on specific dates. Despite these incidents, the care plan did not reflect any new or individualized fall interventions after each event. The interventions listed in the care plan were all initiated prior to the first fall and remained unchanged throughout subsequent falls. Interviews with facility staff confirmed that new interventions should have been added to the care plan after each fall, regardless of whether incident reports had been closed. The MDS nurse acknowledged that no new interventions were care planned following the resident's falls and attributed this to waiting for the DON to close out incident reports. The DON also confirmed that the care plan should have been updated after each fall, even if the incident reports were still open.
Failure to Complete Required Neurological Checks After Falls
Penalty
Summary
The facility failed to provide services that meet professional standards of quality by not completing neurological checks for the required 72 hours following unwitnessed falls or falls with head injury for two residents. According to the facility's policy, neurological checks should be implemented for 72 hours in such cases. For one resident with severe cognitive impairment and multiple diagnoses including dementia, depression, and diabetes, neurological checks were only completed for 21, 32, and 33 hours after three separate falls, rather than the required 72 hours. The Director of Nursing (DON) confirmed that the checks were not completed as required. Another resident, also with severe cognitive impairment and multiple diagnoses such as Parkinsonism, major depressive disorder, and dementia, experienced falls resulting in head injury. For this resident, neurological checks were only completed for 9 and 21 hours after two separate falls. The DON acknowledged that neurological checks should have been completed for 72 hours in both cases but were not. These findings were based on record review and staff interviews.
Failure to Provide Timely Wound Care and Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for two residents with skin issues. For one resident with multiple diagnoses including diabetes, malnutrition, and dementia, physician orders were in place for daily wound care to several sites, including diabetic ulcers, abrasions, and skin tears. However, review of the Treatment Administration Record (TAR) revealed that wound care was not completed on several specified dates for all affected areas. The Director of Nursing confirmed that wound care was not performed on the weekends as required. For another resident with a history of fractures, heart failure, and anemia, physician orders were in place for daily wound care to a stage 3 pressure injury and an unstageable pressure injury. The TAR indicated that wound care was not performed on multiple dates for the sacral wound and a deep tissue injury (DTI) to the right ankle. Additionally, after the DTI was discovered, there was no wound assessment or measurement completed until two weeks later, despite facility policy requiring weekly wound assessments and documentation. The Wound Care Nurse acknowledged that the assessment was missed, and the Director of Nursing confirmed the lapses in wound care provision. Facility policy required that skin and wounds be documented upon admission, readmission, weekly, and as needed, with detailed assessments at least weekly or with each dressing change. The failure to perform wound care as ordered and to complete timely and thorough wound assessments for both residents constituted a lack of adherence to professional standards of practice and facility policy.
Failure to Administer Antidepressant as Ordered
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including depression and dementia, did not receive their prescribed antidepressant medication, Trazodone, on four separate days. The resident's care plan specifically included the intervention to administer medications as ordered by the physician. However, review of the Medication Administration Record showed missed doses, and progress notes indicated the medication was not available in the facility on those dates. Interviews with facility staff confirmed that the medication was not administered because it was not present in the medication cart or medication room, despite being ordered. The LPN responsible was aware of the missing medication but did not follow up with the pharmacy to resolve the issue. The DON also confirmed the missed doses and acknowledged that the nurse should have contacted the pharmacy when the medication was unavailable.
Failure to Maintain Cleanliness of Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of Chronic Obstructive Pulmonary Disease, cardiac pacemaker, and cerebral infarction. The resident had an active physician order for oxygen therapy to maintain oxygen saturation levels above 90% during episodes of shortness of breath. However, during an observation, it was noted that the resident's oxygen concentrator was not maintained according to the facility's policy. The nasal cannula was found uncovered and unlabeled on top of the concentrator, which had brown stains and a filter heavily covered with dust. The Assistant Director of Nursing (ADON) confirmed the deficiencies during an interview, acknowledging that the nasal cannula should have been covered and labeled, and the concentrator should have been clean. The facility's policy required that all surface areas of the oxygen concentrator be cleaned with disinfectant wipes or spray as needed, and that the oxygen tubing, cannula, and mask be stored in a plastic bag when not in use. Additionally, the policy stated that the oxygen concentrator filter should be washed weekly. These procedures were not followed, leading to the observed deficiencies in the resident's respiratory care.
Medication Administration and Lab Work Deficiencies
Penalty
Summary
The facility failed to ensure that controlled medications were administered at the time they were signed out by the nurse, affecting nine residents. During a narcotic reconciliation, discrepancies were found between the Individual Controlled Substance Record and the actual number of tablets on hand for several residents. For instance, one resident's record indicated that a tablet of Norco was administered, but the medication card showed an extra tablet remaining. Similar discrepancies were observed for other residents with medications such as Xanax, Oxycodone, Ativan, Lorazepam, and Clonazepam. The LPN involved admitted to signing out medications ahead of time, rather than at the time of administration. Additionally, the facility failed to conduct lab work in accordance with physician orders for one resident. This resident, who had severe cognitive impairment and multiple diagnoses including Schizoaffective Disorder and Epilepsy, had a physician's order for monthly Depakote level checks. However, the records showed that these levels were only checked in April and July, missing the required checks for May and June. The ADON confirmed that the monthly Depakote levels were not conducted as ordered. These deficiencies highlight a failure in the facility's medication administration and lab work processes, as evidenced by the discrepancies in controlled substance records and the missed lab work for a resident with specific medical needs. The observations and interviews conducted during the survey revealed these lapses in adhering to professional standards of quality care.
Failure to Adhere to Menu Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the established menu guidelines for portion sizes. On 07/22/2024, during the lunch service for residents on a pureed diet, the facility's dietary staff used a 3 oz scoop instead of the required 4 oz scoop for serving pureed meatloaf. This discrepancy was observed by surveyors and confirmed through an interview with the dietary manager, who acknowledged the error and admitted to forgetting to check the scoop sizes prior to meal service. This oversight affected the nutritional adequacy of meals for nine residents receiving mechanically altered diets.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods that conserved nutritional value for nine residents who were ordered and served pureed diets. On 07/22/2024, the facility's approved menu indicated that the pureed diet lunch should include specific serving sizes of beef meatloaf, black-eyed peas, cauliflower with cheese mix, and pound cake. However, during an observation, the dietary cook was seen using eight 3oz meat patties, an unmeasured amount of bread crumbs, and three cups of water in a blender without following a recipe. The dietary cook admitted to not using a recipe due to her experience, believing the added water and breadcrumbs would suffice for the nine residents. The dietary manager confirmed that the recipes for pureed meals were not followed because they could not be located, although they should have been used. Additionally, the registered dietitian stated that recipes should be followed to ensure residents receive adequate caloric intake. This lack of adherence to recipes potentially compromised the nutritional value of the meals served to the residents on pureed diets.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary incontinent care for a resident with severe cognitive impairment and multiple medical conditions, including Type 2 Diabetes Mellitus and Unspecified Dementia. The resident was dependent on staff for all activities of daily living, including toileting and personal hygiene. Despite the facility's policy to maintain skin cleanliness and prevent breakdown, the resident's family filed multiple grievances over several months, reporting that the resident was often found saturated with urine and feces. The family marked the resident's diapers to track changes, revealing that the resident remained in soiled briefs for extended periods. During an observation, the Director of Nursing (DON) confirmed the resident was wearing a soiled brief marked from hours earlier, indicating a lack of timely care. Interviews with staff revealed inconsistencies in care, with a CNA unable to recall the last time the resident was changed and conflicting reports about care provided by a hospice aide. The DON acknowledged past issues with timely incontinent care for the resident and admitted that recent measures, such as ambassador rounds by management, were not implemented on the day of the survey.
Medical Director Exclusion from QAA Meetings
Penalty
Summary
The facility failed to include the Medical Director or a designee in the Quality Assessment and Assurance (QAA) process, as required by their policy. The policy specifies that the QAA committee must consist of at least the Medical Director, Administrator, Director of Nursing (DON), and three other staff members designated by the facility. During an interview and record review, it was revealed that the Medical Director or a designee had not been included in the QAA process sign-in sheets for the meetings held in March 2024 and June 2024. The Director of Nursing confirmed the absence of documented evidence of the Medical Director's attendance at these quarterly meetings.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper wound care practices observed during a survey. Specifically, a treatment nurse did not change gloves or perform hand hygiene after handling contaminated materials while providing wound care to a resident with stage 4 pressure injuries on both ischium areas. The nurse removed the old dressing and, without changing gloves or sanitizing hands, reached over the clean field to obtain new supplies and cleanse the wound. This action was contrary to the facility's policy and procedure for dressing changes, which aims to protect the wound, prevent irritation and infection, and promote healing. During an interview, the treatment nurse acknowledged the failure to follow proper hand hygiene protocols. Further investigation revealed that the staff were not aware of the need to sanitize hands between glove changes during wound care, as the existing wound care policy did not explicitly state this requirement. The Assistant Director of Nursing (ADON) confirmed the oversight and recognized the need for policy updates to ensure compliance with infection control regulations.
Failure to Provide Necessary ADL Services Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Resident #1, who has multiple diagnoses including quadriplegia and chronic obstructive pulmonary disease, did not receive a scheduled bed bath due to a shortage of Certified Nursing Assistants (CNAs). This was confirmed by both the resident and the Assistant Director of Nursing (ADON), who acknowledged that the bed bath was neither provided nor documented on the specified date. Similarly, Resident #3, who requires partial assistance with bathing, did not receive a bath as requested due to insufficient staffing, as confirmed by both the resident and a Licensed Practical Nurse (LPN) on duty. The LPN admitted that only one CNA was available on the hall, which led to the resident not receiving the bath on that shift. Additional residents, including #R1, #R2, #R3, and #R4, also reported not receiving scheduled baths due to staff shortages. Interviews with various CNAs and the CNA Supervisor confirmed that the facility was frequently short-staffed, leading to missed baths and inadequate care. The Resident Council Meeting minutes further corroborated the ongoing issue of insufficient CNA staffing during specific shifts. The facility's Administrator also confirmed the shortage of CNAs, which directly impacted the residents' ability to receive necessary ADL care, including bathing and hygiene. This consistent lack of adequate staffing and failure to provide essential care services resulted in the identified deficiencies in the facility's operations.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to have sufficient staff to meet the needs of residents, resulting in inadequate care for several individuals. Resident #1, who has multiple diagnoses including quadriplegia and chronic obstructive pulmonary disease, did not receive a scheduled bed bath due to a lack of CNAs. This was confirmed by both the resident and the Assistant Director of Nursing (ADON), who noted that the care was not documented as provided on the specified date. Resident #3, who requires partial assistance with activities of daily living (ADLs) and has a Foley catheter, also did not receive a bath as requested due to insufficient staffing. The resident expressed frustration over not receiving a bath for two days, and this was corroborated by an LPN who acknowledged the staffing shortage on the hall. Similar issues were observed with other residents, including #R1, #R2, #R3, and #R4, who all reported not receiving scheduled baths due to the facility's staffing issues. Additionally, residents #R5 and #R6, who require supervision while smoking, were unable to smoke at their appointed times because there was only one CNA available on their unit. This was confirmed by the CNA on duty, who stated that she had to wait for additional help before she could supervise the residents' smoke breaks. The facility's staffing shortages were further highlighted in Resident Council Meeting minutes and interviews with various staff members, including the CNA Supervisor and the Administrator, who confirmed the ongoing staffing challenges.
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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