Legacy Nursing And Rehabilitation Of Port Allen
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Allen, Louisiana.
- Location
- 403 15th Street, Port Allen, Louisiana 70767
- CMS Provider Number
- 195599
- Inspections on file
- 29
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Port Allen during CMS and state inspections, most recent first.
A wheelchair‑dependent resident with ataxia, who required staff assistance for all ADLs, was transported to an appointment by a trained transport driver. The driver believed proper wheelchair restraints were not available in the van and, instead of reporting this, placed the resident’s wheelchair between seats and attempted to secure the resident with a regular van seat belt, despite knowing this was not the correct method. As the van exited the parking lot and hit a pothole, the rear door opened, the ramp deployed, and the resident rolled out of the van onto a gravel surface. The driver then assisted the resident back into a regular van seat and left the premises without notifying the ADM, DON, or other staff, contrary to facility policy requiring immediate reporting of all incidents and accidents during transport.
A resident with ataxia fell from a facility van when the rear door opened during transport, after the transport driver failed to properly secure the resident. The driver did not immediately notify the DON or administrator, despite facility policy requiring all incidents and accidents to be reported at once. The DON learned of the event later and informed the administrator, who was responsible for reporting alleged neglect to the state agency within 24 hours. The administrator initially did not consider the event neglect and did not report it, although she later acknowledged that the failure to secure the resident in the van, resulting in the fall, met the facility’s definition of neglect and should have been reported within the required timeframe.
A resident with CHF, type 2 DM with circulatory complications, vitamin deficiency, and generalized muscle weakness received a house nutritional supplement multiple times without a documented provider order. An LPN reported obtaining a verbal order from an NP to give 4 oz of house supplement when the resident refused meals but failed to enter the order and could not recall specific administration times. Another LPN later administered the same supplement with morning meds despite no order in the chart and was unsure if it should have been given. The NP confirmed giving a verbal order that should have been entered, and the DON verified there was no documented order, while nurses acknowledged the supplement should not have been administered without it.
A resident with severe cognitive impairment, CHF, type 2 DM with circulatory complications, morbid obesity, impaired mobility, and wheelchair use had physician orders and a care plan intervention for a pressure-reducing seat cushion every shift due to high risk for pressure ulcers. On the survey day, the resident was observed twice seated in a wheelchair without the ordered cushion. A CNA and an LPN both stated the resident required two-person assistance, was at risk for pressure ulcers, and had an order for a pressure-reducing cushion, yet confirmed no cushion was present in the wheelchair or the room. The DON verified that the cushion should have been in use whenever the resident was out of bed in the wheelchair.
A resident with dementia and high fall risk experienced multiple unwitnessed falls, but the facility did not update the care plan to reflect these incidents or implement new fall prevention interventions as required by policy. Documentation and interviews confirmed that no new strategies were identified or added to the care plan after each fall.
The facility failed to ensure safe and appropriate respiratory care for three residents by not implementing protocols for cleaning or replacing non-invasive ventilation equipment and by not changing or labeling oxygen tubing and humidification bottles in a timely manner, as required by facility policy. Staff interviews and record reviews confirmed that these actions were not performed or documented.
The facility did not document risk assessments or obtain informed consent before installing bed rails for several residents with complex medical conditions. Staff confirmed the use of bed rails and the lack of required documentation regarding entrapment risk and consent.
A resident with respiratory and cardiac diagnoses was provided oxygen therapy without a physician's order, contrary to facility policy. Nursing staff confirmed the resident used oxygen as needed, and the DON verified no order was present in the clinical record.
A resident who was dependent on staff for bathing and had multiple chronic conditions did not have scheduled baths documented in their medical record, despite staff confirming the care was provided. This failure to document resulted in an incomplete and inaccurate record of the resident's care.
A resident with paraplegia and intact cognition did not have a working call light in his room, despite informing staff of the issue. Multiple staff confirmed the call light was nonfunctional, and the problem was not documented in the maintenance log as required by facility policy. The resident had to self-transfer and seek staff assistance in person due to the lack of a functioning call system.
A facility failed to report an alleged verbal abuse incident involving a moderately cognitively impaired resident to the state agency within the required 2-hour timeframe. The resident's representative reported overhearing a CNA use derogatory language and refuse assistance. The facility's policy requires prompt reporting of abuse, but the DON and Administrator confirmed the incident was not reported as required.
The facility failed to maintain a safe and clean environment in two rooms. In Room A, the window unit cover was missing, leaving the filter exposed. In Room C, the bathroom door did not close completely, and a tile was lifted up. These issues were confirmed by the facility administrator.
The facility failed to transmit MDS assessments within the required timeframe for eight residents. Assessments opened in July 2024 were not transmitted by their due dates, as confirmed by staff responsible for entering the data. The Director of Nursing was informed of these findings, indicating a lapse in regulatory compliance.
The facility failed to ensure accurate MDS assessments for two residents, both of whom had Level II PASARR approvals that were not reflected in their assessments. This discrepancy was confirmed by staff responsible for entering MDS data, impacting the residents' plans of care.
The facility failed to incorporate PASARR Level II recommendations into the care plans of four residents with mental disorders or intellectual disabilities. The residents' care plans lacked documentation and implementation of recommended services such as crisis intervention plans, therapy evaluations, and specialized services. Staff interviews revealed a lack of awareness and implementation of these recommendations, contrary to facility policy.
A resident with Left Sided Hemiplegia following a CVA, who was cognitively intact and required assistance for ADLs, reported that a CNA instructed him not to press the call light again after he requested help to get back into bed. The CNA admitted to prioritizing her task over the resident's request, and the DON confirmed that staff should prioritize responding to call lights. This incident reflects a failure to uphold the resident's right to dignity and self-determination.
The facility failed to ensure call lights were within reach for two residents, one with severe cognitive and visual impairments and another with limb impairments. Both residents were unable to access their call lights, leading to unmet needs. Staff confirmed the call lights were not positioned correctly.
A facility failed to support a resident's choice regarding their bedtime, leading to a deficiency. The resident, who was cognitively intact and required assistance due to hemiplegia, had to wait up to an hour for help to get into bed after requesting it. A CNA confirmed the delay was due to other tasks, and the DON acknowledged the resident's right to choose their bedtime.
A resident requiring substantial assistance with ADLs did not receive necessary nail care, resulting in long, jagged fingernails with a black substance underneath. Despite the facility's policy that nail care is part of the bathing routine, the resident's nails were not trimmed or cleaned during his shower. Interviews with staff revealed confusion over nail care responsibilities, and the resident lacked documented orders for nail care.
A resident with severe cognitive impairment and multiple medical conditions was at risk due to improperly secured padding on a wall next to his bed. The padding, intended as a safety measure, was attached with screws that were protruding, posing a potential injury risk. Staff confirmed the hazard during observations and interviews, acknowledging the risk due to the resident's involuntary movements.
The facility failed to notify physicians of significant changes in two residents' conditions. One resident, with a history of dementia and other health issues, showed no urine output and worsening symptoms, but the physician was not informed. Another resident, with diabetes and COPD, did not receive ordered IV fluids due to access issues, and the physician was not notified. These communication lapses led to deficiencies in care.
A resident receiving IV therapy for dehydration was not properly monitored for intake and output, leading to an Immediate Jeopardy situation. Despite orders for IV fluids, staff failed to document the resident's fluid status, resulting in the resident being transferred to the hospital with acute metabolic encephalopathy and other conditions. Interviews revealed that staff were not consistently tracking or documenting intake and output, contrary to facility policy.
A resident receiving IV therapy experienced a significant change in condition, including no urine output, which was not communicated to the physician by the nursing staff. This led to an Immediate Jeopardy situation, as the resident was later diagnosed with acute metabolic encephalopathy and other conditions. The facility failed to monitor and document the resident's intake and output accurately, despite having policies in place.
The facility did not post daily nurse staffing data in a prominent location accessible to residents and visitors. Observations showed that the data was either missing or outdated on several occasions. Interviews with the DON and Administrator confirmed the requirement for daily updates. This deficiency could potentially affect any of the 118 residents in the facility.
The facility failed to develop and implement care plans for several residents who had IV fluids ordered for hydration. Despite physician orders addressing dehydration or fluid depletion, the care plans lacked any related problems or approaches. Staff confirmed that care plans should be updated with new diagnoses or changes in condition, which was not done for these residents.
The facility failed to document completed care correctly for three residents, resulting in missing toileting hygiene records. Despite requirements for CNAs to document ADLs every shift, records showed incomplete entries for residents with conditions like dementia, schizophrenia, and diabetes. Staff interviews confirmed the documentation lapses, indicating a deficiency in maintaining accurate medical records.
Neglect During Resident Van Transport and Failure to Report Incident
Penalty
Summary
The deficiency involves the neglect of a wheelchair‑dependent resident during transport by a facility van. The resident had ataxia, required a wheelchair for mobility, and was care planned to need staff assistance for all ADLs due to an unsteady ataxic gait. On the date of the incident, the transport driver was responsible for taking the resident to a medical appointment using the facility’s transport van. The driver had previously received training on how to safely transport and secure wheelchair‑bound residents in the van. The driver reported that when loading the resident, he believed he did not have the appropriate wheelchair seat belt or safety straps available in the van. Instead of reporting this to administration or refusing to transport without proper equipment, he placed the resident in his wheelchair in the back of the van between two seats and attempted to secure the resident by using a regular van seat belt. He attached the seat belt from a van seat to the side of the wheelchair, wrapped it around the resident, and fastened it to the seat belt buckle, despite knowing this was not the correct method and that it did not properly secure or lock the resident in place. The facility’s vehicle safety checklist completed earlier in the month documented that all doors, seat belts, and wheelchair straps were present and working properly, and subsequent inspection after the incident confirmed that wheelchair seat belts and safety straps were in the van and in good repair. As the driver exited the facility parking lot with the resident in the wheelchair, the van hit a pothole, causing the back door to open, the ramp to deploy, and the resident to roll backwards out of the van onto the gravel driveway. Video surveillance reviewed by the administrator and DON showed the van exiting, hitting the pothole, the back door opening, the ramp coming down, and the resident rolling down the ramp onto the gravel. The driver stopped, assisted the resident back into the van, and placed the resident into a regular van seat. He then drove away from the facility without notifying the administrator, DON, or other facility staff of the incident, despite facility policy requiring immediate reporting of all incidents and accidents during transport. The facility only became aware of the event when a passerby who witnessed the fall came into the building and reported what they had seen. The driver later acknowledged that he knew he should have reported the incident at the time it occurred.
Removal Plan
- S2DON drove S3TD back to the facility and S8TD drove Resident #1 back to the facility using a regular van seat and the van seatbelt; S3TD was suspended pending investigation.
- S9NP assessed Resident #1 and noted no injuries and no complaints of pain.
- Van keys were locked in S1ADM’s office and the van was not used again.
- Corporate Maintenance Coordinator, Maintenance Supervisor, and S1ADM inspected the van; found missing screws on the back door latch; confirmed wheelchair straps and regular seatbelts were available and working; confirmed wheelchair ramp and latches were in good working order.
- The van was taken out of service and removed from site.
- S1ADM in-serviced transportation staff on proper restraint/securement for residents transported via wheelchair (demonstration) and on notifying the Administrator and/or DON immediately of any issues/incidents and reviewing van forms/binder; clarified that residents who can safely transfer to a van seat may ride in a traditional seat.
- S3TD was terminated.
- The Administrator completed a ride-along with S8TD and S7TD and completed the Driver In-service Checklist and the Transportation Policy Acknowledgement Form.
- A 3rd party consultant provided training on wheelchair securement and lift operations and issued certificates of completion (S7TD, S8TD, S1ADM, S21ESS).
- Administrator ordered additional transport safety items discussed during the 3rd party training: a seatbelt lock and Q-straint loops; items were placed into the van.
- Transportation monitoring was initiated weekly for 6 weeks via Administrator/designee ride-alongs to ensure resident safety, proper securement, and safe driving.
- Facility borrowed a van from a sister facility to continue resident transports and completed Driver In-service Checklists.
- Facility rented vans so bariatric residents could be safely transported and completed Driver In-service Checklists.
- Facility scheduled ambulance transfers as needed.
- Administrator/designee planned ongoing ride-alongs/training with each approved van driver approximately every 6 months.
Failure to Timely Report Neglect After Resident Falls From Transport Van
Penalty
Summary
The facility failed to timely report an allegation of neglect to the administrator and to the State Survey Agency within 24 hours as required by its abuse reporting and transportation policies. The facility’s Abuse Reporting and Investigation Policy required all alleged violations involving neglect to be reported immediately, but not later than 24 hours, to the state licensing/certification agency, and defined neglect to include failure to provide timely, consistent, safe, adequate, and appropriate care and services. The Transportation Policy required all incidents and accidents, no matter how minor or major, to be reported immediately to the administrator. Resident #1, admitted with diagnoses including ataxia, was being transported in the facility van when the rear door opened and the resident rolled or fell out into the parking lot. An incident report documented that this occurred outside at 12:30 p.m., with no injuries noted. The transport driver (S3TD) acknowledged that he was responsible for transporting residents and that Resident #1 fell out of the van while he was driving. He admitted he did not notify administration at the time because the resident did not complain of pain or injuries, despite knowing he should have reported the incident. The DON (S2DON) stated he became aware of the fall at 12:45 p.m. the same day, and that the driver had not notified him when it occurred; he later informed the administrator (S1ADM) after a passerby notified the facility that the resident had fallen from the van. The administrator stated she was responsible for reporting neglect to the state agency and that she was informed of the incident by the DON, but she did not consider it neglect at the time and did not report it to the state agency. She later confirmed that the driver’s failure to secure the resident in the van, resulting in the resident falling out, was neglect and should have been reported within the 24-hour timeframe.
Unauthorized Administration of Nutritional Supplement Without Documented Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided matched physician orders and met professional standards, specifically regarding administration of a nutritional house supplement. Resident #2 was admitted with chronic combined systolic and diastolic congestive heart failure, type 2 diabetes mellitus with circulatory complications, vitamin deficiency, and generalized muscle weakness. Review of the resident’s clinical record on 03/16/2026 showed no current physician order for a house supplement. An LPN reported that on 03/09/2026 she notified the nurse practitioner that the resident was not eating, and she received a verbal order to administer 4 ounces of house supplement whenever the resident refused meals. She admitted she forgot to enter this verbal order into the record and stated she administered the supplement at least four times between 03/09/2026 and 03/16/2026, but could not recall the specific dates or times. She confirmed she should not have administered the supplement without entering the order. The nurse practitioner confirmed she had given a verbal order the prior week for the house supplement to be given if the resident refused to eat and would accept it, and stated that if the supplement was administered, it should have been entered as an order. Another LPN, assigned to the resident from 6:00 a.m. to 6:00 p.m. on 03/17/2026, stated she administered 4 ounces of the house supplement that morning with the resident’s medications, then confirmed upon review of the record that there was no order for the supplement and expressed uncertainty about whether she should have given it without an order. The DON reviewed the clinical record and confirmed there was no documented evidence that the house supplement had been ordered for the resident and acknowledged that nurses should not have administered the supplement without an order in the clinical record.
Failure to Implement Ordered Pressure-Reducing Seat Cushion for High-Risk Resident
Penalty
Summary
A resident with chronic combined systolic and diastolic congestive heart failure, type 2 diabetes mellitus with circulatory complications, morbid obesity due to excess calories, and generalized muscle weakness was admitted with significant risk factors for pressure ulcer development. The resident’s quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, dependence on staff for chair/bed-to-chair transfers, and a need for a pressure-reducing device for the wheelchair. Physician orders, in place since 07/23/2025, directed use of a pressure-reducing seat cushion every shift, and the care plan documented an intervention for a pressure-reducing seat cushion due to the resident’s obesity, diabetes, occasional incontinence, impaired mobility, and wheelchair use. On the survey date, observations at 8:13 a.m. and 11:10 a.m. found the resident seated in a wheelchair without a pressure-reducing seat cushion. The resident could not be interviewed due to cognitive status. A CNA reported that the resident required two-person total assistance with transfers and incontinent care, was at risk for pressure ulcers, and had been out of bed in the wheelchair at the start of her shift; she confirmed there was no pressure-relieving cushion in the wheelchair or in the room. An LPN likewise confirmed the resident was at risk for pressure ulcer development, had a physician order for a pressure-reducing seat cushion when in the wheelchair, and that no cushion was present in the wheelchair or room when she assisted with transferring the resident back to bed. The DON reviewed the physician orders and confirmed that a pressure-reducing seat cushion should have been used any time the resident was out of bed in the wheelchair.
Failure to Update Care Plan and Implement New Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls remained as free from accident hazards as possible. Specifically, after the resident experienced two unwitnessed falls, there was no evidence that the resident's care plan was updated to reflect the dates and circumstances of these incidents. Facility policy required that care plans be updated following any significant change in condition, including falls, and that such incidents be discussed with the interdisciplinary team for the implementation of preventative strategies. However, documentation review showed that the care plan did not include information about the falls that occurred. Additionally, the facility did not identify or implement any new fall prevention interventions in response to the resident's falls. There was no documentation in the care plan, physician's orders, progress notes, or nurse's notes indicating that a new, resident-specific intervention was considered or put in place after each fall. This was confirmed by both the Assistant Director of Nursing and the Director of Nursing, who acknowledged that the care plan should have been updated with new interventions following each incident. The resident involved had multiple diagnoses, including senile degeneration of the brain, unspecified dementia, unsteadiness on feet, and movement disorder, and was classified as high risk for falls. The lack of timely care plan updates and absence of new interventions following repeated falls constituted a failure to implement an effective fall prevention program as required by facility policy.
Failure to Provide Safe and Timely Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for three residents who required respiratory support. For one resident with a history of morbid obesity, acute pulmonary edema, chronic congestive heart failure, cardiomegaly, and sleep apnea, there was no protocol or physician order in place for cleaning or replacing the non-invasive ventilation support tubing and mask. The resident's care plan and medical records lacked documentation of any cleaning or replacement of this equipment, despite regular use. Multiple LPNs assigned to the resident confirmed that they only cleaned the mask if visibly soiled and never cleaned or replaced the tubing, and there was no documentation of these actions. The DON and CNO acknowledged the absence of orders and documentation for cleaning or replacing the equipment, and the nurse practitioner confirmed that a protocol should have been implemented. For two other residents receiving oxygen therapy, the facility did not ensure timely changing and labeling of oxygen tubing and humidification bottles. One resident, who used oxygen as needed, had a humidifier bottle that was not changed according to the weekly schedule, as confirmed by both observation and staff interviews. The DON verified that the bottle should have been changed and was not. The second resident, with diagnoses including acute respiratory failure with hypoxia and emphysema, had an empty and undated humidifier bottle and nasal cannula tubing. Staff confirmed that both the tubing and bottle should have been changed weekly and labeled with the date, but this was not done. Interviews with staff, including LPNs and the DON, consistently revealed a lack of adherence to facility policy and procedure regarding the cleaning, replacement, and documentation of respiratory care equipment. The facility's own policies required regular cleaning and replacement of respiratory equipment, but these protocols were not followed or documented for the residents reviewed.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for multiple residents. Specifically, there was no documentation that the risks and benefits of bed rails were reviewed with the residents or their representatives, nor was informed consent obtained prior to bed rail installation for one resident. Additionally, for four residents who had bed rails in use, there was no evidence that an entrapment risk assessment was completed prior to installation. These deficiencies were identified through observations of residents in their beds with bed rails raised, interviews with CNAs and the DON, and reviews of clinical records that lacked the required documentation. The residents involved had significant medical conditions, including polyneuropathy, diabetes, morbid obesity, congestive heart failure, hemiplegia, paraplegia, and cerebral infarction. Despite these complex diagnoses and the presence of bed rails on their beds, the facility did not document the necessary assessments or obtain informed consent as required. Staff interviews confirmed the ongoing use of bed rails and the absence of documentation related to risk assessment and consent.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering oxygen therapy to a resident without a physician's order. According to the facility's own policy, a physician's order specifying the liter flow and method of administration is required before oxygen therapy can be provided. Review of the resident's clinical record showed no physician's order for oxygen therapy, despite the resident having diagnoses including acute respiratory failure with hypoxia, emphysema, and unspecified heart failure. Observations confirmed that an oxygen concentrator was present and in use in the resident's room, set at 2 liters per minute. Interviews with nursing staff verified that the resident had been using oxygen as needed, including the night prior to the survey, without a physician's order. The Director of Nursing also confirmed the absence of an order for oxygen therapy in the resident's clinical record, acknowledging that such an order was required before administration.
Failure to Document Scheduled Baths in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate by not documenting the provision of scheduled baths. According to the facility's policy, documentation and charting are required to provide a complete account of resident care. Review of one resident's clinical record showed that the resident, who was dependent on staff for bathing and had multiple diagnoses including polyneuropathy, type 2 diabetes mellitus, morbid obesity, chronic congestive heart failure, and cardiomegaly, was scheduled to receive baths on specific days. However, there was no documentation indicating that baths were provided on several scheduled dates. Interviews with the CNA assigned to the resident confirmed that the baths were provided on the scheduled days, but the CNA acknowledged that these were not documented in the resident's bath documentation. The Chief Nursing Officer also confirmed that if a bath was provided, it should have been documented. The lack of documentation resulted in an incomplete and inaccurate medical record for the resident.
Failure to Provide Functioning Call Light System for Resident with Mobility Impairment
Penalty
Summary
A deficiency was identified when a resident with paraplegia and other mobility limitations did not have access to a functioning call light system in his room. The resident, who was cognitively intact and at risk for falls, reported that his call light had not worked since he moved into his current room. He stated that he informed staff about the issue when he first moved in, but the problem was never addressed. As a result, the resident had to self-transfer to his wheelchair and go down the hall to find staff whenever he needed assistance. Multiple staff members, including a CNA, LPN, and maintenance staff, confirmed through observation that the call light did not function or illuminate outside the room as required. A review of the facility's maintenance log showed no entries regarding the malfunctioning call light for this resident, despite facility policy requiring staff to notify maintenance and document such issues. The Director of Nursing confirmed that staff should have documented the problem and notified maintenance, and acknowledged that the resident was capable of using the call light. The lack of a functioning call system in the resident's room was not addressed according to facility procedures, resulting in the deficiency.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the state agency within the required 2-hour timeframe. The incident involved a resident who was moderately cognitively impaired, as indicated by a BIMS score of 12, and had a medical history of Cerebral Vascular Accident with Hemiplegia and Hemiparesis, and Contracture of Muscle. The resident's representative reported that during a phone call with the resident, she overheard an unknown CNA refuse to assist the resident for breakfast and use derogatory language. The facility's policy mandates that all reports of resident abuse be promptly reported to local, state, and federal agencies as defined by current regulations. However, the Director of Nursing (DON) and the Administrator confirmed that the incident, which met the definition of verbal abuse, was not reported to the state agency within the required timeframe. This oversight was acknowledged during interviews with the DON and the Administrator, who confirmed the failure to adhere to the reporting policy.
Deficiencies in Room Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents in two of the six rooms reviewed. In Room A, the window unit cover was found lying on the floor with the filter exposed during an observation. This issue persisted over several days, as confirmed by the facility administrator, who acknowledged that the cover should have been in place to protect the filter. In Room C, maintenance issues were identified, including a bathroom door that did not close completely, leaving a one-inch gap from the bottom to midway of the door. Additionally, a piece of tile measuring 4 inches by 4 inches was lifted up in the corner next to the closet dresser. These issues were confirmed by the facility administrator, who noted that the door should close properly and the tile should not be lifted.
Failure to Transmit MDS Assessments on Time
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required timeframe for eight residents. The assessments for these residents were opened on various dates in July 2024 but remained in progress and were not transmitted by their respective due dates in July 2024. This deficiency was identified through interviews and record reviews conducted on August 13, 2024. The residents affected included those with both annual and quarterly MDS assessments, indicating a systemic issue in the timely processing and transmission of these assessments. Interviews with staff members responsible for entering MDS assessments confirmed the failure to meet the transmission deadlines. Both S4MDSN and S5MDSN acknowledged their responsibility for entering the assessments and confirmed that they should have been transmitted within 14 days of completion. The Director of Nursing (S2DON) was also informed of these findings and confirmed the expectation that all resident assessments should be transmitted on time. The report highlights a clear lapse in the facility's adherence to regulatory requirements for MDS assessment transmission.
Inaccurate MDS Assessments for PASARR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the Pre-Admission Screening and Resident Review (PASARR) status for two residents. Resident #22, who was admitted with diagnoses including Schizoaffective Disorder - Bipolar Type, Psychotic Disorder with Hallucinations, and Mild Intellectual Disabilities, had a Level II PASARR approved for admission. However, the Annual MDS assessment inaccurately indicated that the resident had not been evaluated for PASARR. This discrepancy was confirmed by S4MDSN during an interview, who acknowledged that the resident's plan of care was based on the incorrect MDS coding. Similarly, Resident #108, admitted with diagnoses such as Unspecified Psychosis, Schizoaffective Disorder, Generalized Anxiety Disorder, and Major Depressive Disorder, also had a Level II PASARR approved. Yet, the Annual MDS assessment failed to reflect this, marking the PASARR evaluation as 'no.' S4MDSN, responsible for entering MDS assessments along with S5MDSN, confirmed the error during an interview. The Director of Nursing (S2DON) also confirmed that Level II PASARRs should have been accurately coded in each resident's MDS assessment.
Failure to Implement PASARR Level II Recommendations
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) Level II determinations and recommendations for four residents. The facility's policy requires incorporating PASARR Level II recommendations into the resident's assessment and care plan, but this was not done for residents with mental disorders or intellectual disabilities. The residents involved had various diagnoses, including Major Depressive Disorder, Bipolar Disorder, Anxiety Disorder, Schizoaffective Disorder, and Mild Intellectual Disabilities. For Resident #13, the facility did not document or implement the PASARR Level II recommendations, which included short-term counseling, crisis intervention, and therapy evaluations. Similarly, Resident #22's care plan lacked documentation of a crisis intervention plan and specialized services like CPST and PSR-group. Resident #24's care plan also did not include a crisis intervention plan or therapy evaluations, and Resident #108's care plan failed to document or offer recommended outpatient services and PSR. Interviews with staff members revealed a lack of awareness and implementation of PASARR Level II recommendations. The social worker responsible for reviewing and implementing these recommendations admitted to not reviewing or implementing the recommended services. Additionally, the staff responsible for care planning confirmed that they had not been incorporating PASARR Level II recommendations into the residents' care plans, which was expected by the Director of Nursing.
Failure to Respect Resident's Right to Dignity and Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by regulations. Resident #61, who was admitted with a diagnosis of Left Sided Hemiplegia following a Cerebral Vascular Accident (CVA), was cognitively intact with a BIMS score of 14 and required substantial assistance for activities of daily living (ADLs). The resident reported an incident where, after pressing the call light for assistance to get back into bed, a CNA (S13CNA) entered the room and instructed him not to press the call light again. This was corroborated by the resident's roommate, who witnessed the interaction. Further investigation revealed that S13CNA admitted to telling Resident #61 not to press the call light again after he had done so while she was passing ice. The CNA stated that she needed to finish her task before attending to the resident's request. The Director of Nursing (S2DON) confirmed that CNAs should prioritize responding to call lights and that staff should not instruct residents not to use the call light. This incident highlights a failure in maintaining the resident's right to a dignified existence and self-determination, as the resident's needs were not promptly addressed, and he was discouraged from seeking assistance.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to unmet needs and preferences. Resident #1, who was severely cognitively and visually impaired, was observed on multiple occasions with her call light out of reach at the foot of her bed. Despite her attempts to locate the call light, she was unable to do so due to her visual impairment. Interviews with CNAs confirmed that Resident #1's call light was not within reach and should have been clipped to her sheet next to her pillow for easy access. Similarly, Resident #16, who was cognitively intact but had bilateral upper and lower limb impairment and was dependent on staff for mobility, was observed seated in a chair with his call light lying on his bed, 8 feet away. He confirmed his inability to reach the call light and expressed that he could not notify staff for assistance. The Director of Nursing acknowledged that the call light was not within reach and confirmed that it should have been accessible to the resident.
Failure to Support Resident's Choice in Bedtime
Penalty
Summary
The facility failed to promote and facilitate a resident's self-determination by not supporting their choice regarding significant aspects of their life, specifically the time they wished to go to bed. The deficiency was identified for one resident who was cognitively intact, as indicated by a BIMS score of 14, and required substantial assistance for activities of daily living due to left-sided hemiplegia following a cerebral vascular accident. The resident reported having to wait 45 minutes to an hour for assistance to get back into bed after pressing the call light at around 7:00 p.m. During an interview, a CNA confirmed that the resident had to wait because she was occupied with other tasks, such as passing ice and ensuring the resident received a snack before going to bed. The Director of Nursing acknowledged that residents have the right to choose when they want to go to bed, indicating a failure in adhering to the facility's policy on resident rights and quality of life, which emphasizes the importance of self-determination and individuality.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary services for maintaining good grooming and personal hygiene for a resident who was unable to perform activities of daily living (ADLs) independently. Specifically, the facility did not trim and clean the fingernails of a resident who required substantial assistance with ADLs. The resident, who was cognitively intact with a BIMS score of 14, expressed a desire for his fingernails to be trimmed and cleaned, which was not done during his shower. Observations revealed that the resident's fingernails were long, jagged, and had a black substance underneath four of them. Interviews with facility staff, including a CNA, an RN, and the Director of Nursing (DON), revealed a lack of clarity and execution regarding nail care responsibilities. The CNA stated that the wound care nurse was responsible for nail care, while the RN and DON confirmed that all residents should have monthly nail care orders documented in the Treatment Assessment Record (TAR). However, the resident in question did not have any such orders, and the staff confirmed the oversight. The facility's policy indicated that nail care should be part of the bathing routine, but this was not adhered to in the case of the resident.
Improperly Secured Padded Wall Poses Hazard
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, specifically by not properly securing a padded wall for a resident with severe cognitive impairment and multiple medical conditions. The resident, who had a history of cerebrovascular accident, epilepsy, and anoxic brain injury, was observed in a room where the padding on the wall next to his bed was secured with screws. Several of these screws were protruding from the wall, posing a potential risk for injury. The resident's care plan included padding on the wall as a safety measure due to his high risk for falls and injury. Multiple observations and interviews with staff confirmed the presence of the hazard. The resident was seen moving his limbs involuntarily, making contact with the exposed screws during incontinence care. Staff members, including an LPN, a CNA, and the Director of Nursing, acknowledged the safety hazard posed by the protruding screws. They confirmed that the screws should not have been extending from the padding and recognized the risk of injury to the resident due to his involuntary movements.
Failure to Notify Physicians of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to ensure proper communication of significant changes in residents' conditions to their physicians, resulting in a deficiency. Specifically, for Resident #3, the nursing staff did not notify the physician when the resident exhibited no urine output, despite being lethargic and weak. On the morning of 05/31/2024, an LPN attempted to collect urine using an in-and-out catheter but found no urine output, and the resident's brief was dry. This significant change was not communicated to the resident's physician or nurse practitioner, which was a critical oversight given the resident's deteriorating condition. Resident #3 had a medical history that included unspecified dementia, schizophrenia, benign prostatic hyperplasia, metabolic encephalopathy, sepsis, and acute embolism. On 05/30/2024, the resident was noted to be weak and lethargic, prompting a nurse practitioner to order intravenous fluids and lab work. However, the lack of urine output was not reported, and by 7:00 a.m. on 05/31/2024, the resident's condition had worsened, with symptoms of lethargy, body rigidity, and twitching extremities. The resident was eventually transferred to the hospital, where they were diagnosed with acute metabolic encephalopathy, hypernatremia, and acute cystitis with hematuria. Additionally, the facility failed to notify the physician for Resident #R4 when an IV could not be started as ordered. Resident #R4, who had diagnoses including type 2 diabetes mellitus with diabetic nephropathy and chronic obstructive pulmonary disease, was ordered to receive IV fluids due to confusion and lethargy. However, the LPN was unable to access a vein and did not inform the nurse practitioner of this issue, which was another instance of inadequate communication regarding significant changes in a resident's condition.
Failure to Monitor IV Therapy Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident receiving IV therapy, which resulted in an Immediate Jeopardy situation. The resident, who had a history of unspecified dementia, benign prostatic hyperplasia, metabolic encephalopathy, and sepsis, was ordered to receive IV fluids for dehydration due to lethargy and weakness. However, the facility did not consistently assess, monitor, or document the resident's intake and output, which is a critical component of care for residents receiving IV therapy. On the night of the incident, a Licensed Practical Nurse (LPN) attempted to collect urine from the resident using an in-and-out catheter but found no urine output, and the resident's brief was dry. Despite these findings, there was no documentation of the resident's intake and output for each shift, and the nurse practitioner was not notified of the resident's condition. The following morning, the resident was found to be lethargic, with rigid body and twitching extremities, and was subsequently transferred to the hospital, where they were diagnosed with acute metabolic encephalopathy, hypernatremia, and acute cystitis with hematuria. Interviews with facility staff revealed a lack of monitoring and documentation of intake and output for residents receiving IV therapy. Several staff members, including LPNs and CNAs, admitted to not tracking or documenting the intake and output, and there was confusion about the procedures for monitoring residents' fluid status. The Director of Nursing confirmed that the facility's policy required tracking intake and output for residents on IV therapy, but this was not followed in the case of the resident in question.
Failure to Communicate Change in Condition and Monitor IV Therapy
Penalty
Summary
The facility failed to administer care effectively and efficiently, leading to a significant deficiency in the care of a resident receiving IV therapy. The nursing staff did not communicate a significant change in the resident's condition to the physician, despite the resident having no urine output while on IV therapy. This lack of communication occurred for one of the five residents reviewed for IV therapy, resulting in an Immediate Jeopardy situation. The resident was observed to be lethargic and weak, and despite attempts to collect urine, there was no output, which was not reported to the physician. The facility also failed to ensure that the resident received treatment and care in accordance with professional standards of practice. There was a lack of accurate assessment, monitoring, and recording of the resident's intake and output, which is crucial for residents receiving IV therapy. The resident, who had a history of unspecified dementia, benign prostatic hyperplasia, metabolic encephalopathy, and sepsis, was diagnosed with acute metabolic encephalopathy, hypernatremia, and acute cystitis with hematuria after being transferred to the hospital. Interviews with staff revealed that the nurse practitioner was not notified of the resident's lack of urine output, which was a significant change in condition. The Director of Nursing confirmed that intake and output should have been tracked for all residents receiving IV therapy, as per the facility's policy. Despite previous in-service training on notifying physicians of incidents and hydration policies, compliance with these trainings was not monitored, contributing to the deficiency.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data, including resident census and total number and actual hours worked for licensed and unlicensed nursing staff, was posted daily in a prominent location accessible to residents and visitors. Observations on multiple dates revealed that the nurse staffing data was either not posted or outdated. Specifically, on June 18 and June 20, 2024, no nurse staffing data was posted. On June 22 and June 23, 2024, the posted data was dated June 21, 2024, indicating it was not updated daily. Interviews with the Director of Nursing (S2DON) and the Administrator (S1ADM) confirmed that the staffing data should have been updated and posted daily. This deficiency had the potential to affect any of the 118 residents residing in the facility.
Failure to Implement Care Plans for Residents with IV Hydration Orders
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents who had intravenous fluids ordered for hydration purposes. These residents included individuals with various medical conditions such as dementia, diabetes, dysphagia, and infections. Despite having physician orders for IV fluids to address dehydration or fluid depletion, the comprehensive care plans for these residents did not include any problems or approaches related to their hydration needs. Interviews with facility staff, including the MDS coordinator and the Director of Nursing, confirmed that care plans should be updated with any new diagnoses or changes in condition. The staff acknowledged that residents with IV fluids ordered for hydration should have had a dehydration care plan developed, which was not done for the affected residents. This oversight indicates a failure in the facility's process for updating and implementing care plans in response to changes in residents' medical conditions.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that completed care was documented correctly in the medical records of three residents. Resident #3, who was admitted with multiple diagnoses including Unspecified Dementia and Schizophrenia, was found to have incomplete documentation of toileting hygiene. The records showed that toileting was documented only once on several days throughout April and May 2024, despite the requirement for documentation on each shift. Similarly, Resident #R1, with diagnoses including Cerebral Infarction and Type 2 Diabetes Mellitus, had incomplete toileting documentation for several days in June 2024. Resident #R2, who required partial assistance with toileting due to conditions like Unspecified Psychosis and Dysphagia, also had missing documentation for several days between May and June 2024. Interviews with facility staff, including the MDS coordinator, ADON, and DON, confirmed the missing documentation. The staff acknowledged that CNAs were required to document ADLs, including toileting, every shift, and that the missing entries indicated a failure to document as required. The absence of complete documentation for these residents was confirmed by the staff, highlighting a deficiency in maintaining accurate and complete medical records in accordance with professional standards.
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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