Legacy Nursing And Rehabilitation Of Tallulah
Inspection history, citations, penalties and survey trends for this long-term care facility in Tallulah, Louisiana.
- Location
- 32 Crothers Drive, Tallulah, Louisiana 71282
- CMS Provider Number
- 195443
- Inspections on file
- 24
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Tallulah during CMS and state inspections, most recent first.
The facility failed to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by its abuse reporting policy and state law. A cognitively impaired resident with multiple diagnoses, including dementia and a history of repeated falls, was found with bruising and swelling to the lower leg and later diagnosed by x-ray with acute fractures of the tibia and fibula. The resident could not explain the cause of the injury, and the facility’s investigation did not identify a cause, meeting the policy’s definition of an injury of unknown origin. Despite this, the Administrator, who was responsible for such notifications, did not report the incident to the State Survey Agency.
A resident with moderate cognitive impairment and multiple diagnoses underwent an x-ray of the right shoulder/arm, which was reviewed and signed by an LPN. However, there was no documented evidence that the responsible party was notified of the x-ray results in a timely manner, as confirmed by the DON.
A facility failed to assess the effectiveness and necessity of a safety device for a resident with cognitive impairment and multiple diagnoses. The resident was observed on a mattress with raised edges, but the safety device assessment did not include this intervention. Interviews with the DON and an LPN confirmed the omission.
A facility failed to provide adequate activities for a resident with blindness, who reported not being informed of upcoming activities and expressed dissatisfaction with the activities provided. Despite having a monthly activity calendar and attending some events, the resident rated their satisfaction as a 2 out of 10. The Activity Director confirmed the resident was not individually informed of activities.
The facility failed to follow proper procedures for bed rail use for four residents, lacking physician's orders, informed consent, and risk assessments. Residents with cognitive and physical impairments were observed with bed rails installed without necessary documentation, confirmed by the DON.
A facility failed to monitor a resident's medication regimen for bleeding while on anticoagulant therapy. The resident, with a history of cerebral and heart conditions, was prescribed Eliquis and Aspirin. Despite a care plan indicating a risk for bleeding and the need for monitoring, there was no documentation of such monitoring. Interviews with the DON and an LPN confirmed the absence of documentation.
The facility was found to have several food safety and storage deficiencies, including storing clean pots on a shelf with old food particles, a buildup of an unknown substance in the ice machine, improperly sealed food items in the freezer, and bottled water stored directly on the floor. These issues were confirmed by the Dietary Manager and reported to the administrator, affecting the 84 residents receiving meal trays.
The facility failed to maintain a sanitary environment in the kitchen, as personal belongings were improperly stored near food preparation areas, risking cross-contamination. Observations revealed a purse and jacket in contact with food items, and additional personal items in a storage room. The Dietary Manager confirmed these practices were against protocol, affecting meal service for 84 residents.
The facility failed to maintain safe mechanical equipment in the kitchen, with metal shavings on the can opener and grease buildup in the deep fryer. The Dietary Manager confirmed these conditions, which could affect the 84 residents receiving meal trays. The Administrator was notified of these findings.
A resident with a wedge compression fracture of the T11-T12 vertebra was unable to activate his call light due to physical disabilities, as he could not move his left arm or right fingers. This deficiency was confirmed during an interview and a room visit by the DON and a surveyor.
A resident with severe cognitive impairment and high elopement risk left the facility unnoticed after a sitter mistakenly opened an emergency exit door. The resident was found outside by an LPN and returned safely without injuries. The facility failed to report the incident to the State Survey Agency as required by policy.
A resident with dementia and high elopement risk exited a facility unnoticed due to a sitter's mistake and lack of an alert system on an exit door. The resident, wearing a wander guard, was mistaken for a visitor and allowed to leave. An LPN quickly retrieved the resident with a neighbor's help, and the resident returned unharmed. The facility's staff confirmed the deficiency, noting the absence of a code alert system on the exit door.
Two residents in the facility received medications contrary to physician orders, with nurses failing to adhere to prescribed blood pressure and insulin parameters. One resident with diabetes and hypertension was given Lisinopril and insulin without following the specified hold parameters, while another resident received Metoprolol Tartrate despite vital signs indicating it should be held. These deficiencies were confirmed through MAR reviews and staff interviews.
A resident with multiple health issues, including diabetes and blindness, did not receive adequate personal hygiene care. Observations revealed a buildup of crust and moisture between the toes, an odor from the left foot, and untrimmed nasal hairs. A CNA and LPN confirmed these findings, and the DON acknowledged the need for better hygiene practices.
Failure to Report Injury of Unknown Origin with Fracture to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by state law and the facility’s own Abuse Reporting and Investigation Policy and Procedure. The policy states that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source must be promptly reported to local, state, and federal agencies and thoroughly investigated, and that suspicious injuries of unknown origin, including fractures in cognitively impaired residents when not witnessed, must be reported. The facility’s policy further defines injuries of unknown origin as those not observed by any person, not explainable by the resident, and suspicious due to the extent or location of the injury. Record review showed that a resident with diagnoses including COPD, adult failure to thrive, repeated falls, generalized anxiety disorder, dementia with agitation, and delirium had severe cognitive impairment, with a BIMS score of 7, and required one-person assistance for standing and transfers. An incident report documented that this resident was found with bruising and swelling to the lower left leg in the evening, and an x-ray obtained the next day revealed acute mid and distal fractures of the tibia and fibula. The DON reported that the resident was unable to state the cause of the injury due to dementia and that the facility’s investigation could not determine a cause for the fracture, meeting the criteria for an injury of unknown origin with serious bodily injury. The Administrator, who was responsible for notifying the State Survey Agency, confirmed that the facility did not report this injury as required by the facility’s policy and state reporting requirements.
Failure to Notify Responsible Party of X-ray Results
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident's x-ray results. The resident, who had diagnoses including Alzheimer's disease, psychotic disturbance, mood disturbance, anxiety, and a history of musculoskeletal conditions, was readmitted to the facility and required assistance with activities of daily living. The resident had moderate cognitive impairment, as indicated by a Brief Interview for Mental Status score of 11. On a specific date, the resident was observed resting in bed with a faint pinkish area on her right forearm. A review of the medical record showed that a nurse practitioner ordered an x-ray of the resident's right shoulder/arm, and the x-ray was performed and interpreted on the same day. The LPN signed and dated the report, but there was no documented evidence that the resident's responsible party was notified of the x-ray results. This lack of timely notification was confirmed by the Director of Nursing during an interview.
Failure to Assess Safety Device for a Resident
Penalty
Summary
The facility failed to accurately assess the effectiveness and necessity of safety devices for a resident. The facility's policy on safety and supervision requires documenting interventions and evaluating their effectiveness. However, the medical records for a resident with multiple diagnoses, including muscle weakness, dystonia, mood disorder, altered mental status, and schizophrenia, did not include an assessment of the raised edge mattress being used as a safety device. Observations on two consecutive days confirmed that the resident was lying on a mattress with raised edges, but the safety device assessment did not account for this. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the omission in the assessment.
Failure to Provide Adequate Activities for Blind Resident
Penalty
Summary
The facility failed to provide an ongoing program to support a resident with blindness in their choice of activities. The resident, who had a diagnosis of blindness in both eyes, reported not receiving any activities and not being informed of when activities were going to take place. Despite being provided with a monthly activity calendar and attending some social events, the resident expressed dissatisfaction with the activities provided, rating his satisfaction level as a 2 out of 10. The Activity Director confirmed that the resident was not individually informed of upcoming activities.
Failure to Follow Bed Rail Protocols
Penalty
Summary
The facility failed to ensure proper procedures were followed for the use of bed rails for four residents. Specifically, the facility did not obtain a physician's order, informed consent from the residents or their representatives, or conduct an assessment for the risk of entrapment prior to the installation of bed rails. This deficiency was observed in residents with varying degrees of cognitive and physical impairments, including Parkinson's disease, Alzheimer's disease, and cerebrovascular conditions. Resident #30, who had intact cognition, was observed with loose bed rails, and there was no documentation of a physician's order, informed consent, or risk assessment. Similarly, Resident #23, with severe cognitive impairment, was found with bed rails raised without the necessary documentation or assessments. Resident #34, also severely impaired, and Resident #60, with moderate cognitive impairment, were both observed with bed rails installed without the required procedural steps being documented. The Director of Nursing confirmed the lack of documentation and procedural adherence for all four residents. The facility's policy on restraint devices requires an assessment of the resident's need, informed consent, and a physician's order, none of which were documented for these residents. This oversight indicates a systemic failure to comply with established protocols for bed rail use, potentially compromising resident safety.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring for bleeding in a resident receiving anticoagulant therapy. The medical records for the resident, who had a history of cerebral infarction, transient cerebral ischemic attack, atherosclerotic heart disease, old myocardial infarction, long-term use of anticoagulants, and chronic atrial fibrillation, showed an order for Eliquis and Aspirin. The care plan indicated a risk for bleeding due to anticoagulant therapy, with interventions to monitor for signs and symptoms of bleeding and notify the physician if any were observed. However, there was no documented evidence of monitoring for bleeding in the resident's medical record. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the lack of documentation for monitoring bleeding or bruising when administering the anticoagulants.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. Clean pots and pans were stored on a shelf that had old food particles, indicating improper cleaning and storage practices. Additionally, the ice machine was found to have a significant buildup of an unknown black substance on the inside lid and dust accumulation on the filters, both of which were confirmed by the Dietary Manager as needing cleaning. These conditions suggest a lack of regular maintenance and sanitation in the kitchen area. Further deficiencies were noted in the storage of food items and bottled water. In the walk-in freezer, boxes of beef patties and Churro Bites were left open and exposed to air, which the Dietary Manager acknowledged as improper sealing. Moreover, flats of bottled water were stored directly on the floor in the storage room, contrary to standard storage practices. These findings were reported to the facility's administrator, highlighting the need for improved food safety and storage protocols to ensure the well-being of the 84 residents receiving meal trays from the kitchen.
Sanitation Breach in Kitchen Due to Improper Storage of Personal Items
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, which is crucial for preventing the development and transmission of communicable diseases and infections. During an observation on February 24, 2025, a purse was found on a top shelf next to food preparation items, and a jacket was in direct contact with exposed parchment paper. Additionally, a storage room in the back of the kitchen contained personal belongings, including jackets and a purse, hanging next to a cart with several cans of soup. These observations indicate a lack of adherence to proper storage protocols for personal items in food preparation and storage areas. S9Dietary, who was present during the observations, confirmed that the purse belonged to her but was unaware of the jacket's owner. S8Dietary Manager acknowledged that kitchen staff were not supposed to store personal belongings in the kitchen and storage room due to the risk of cross-contamination. The Diet Type Report indicated that 84 residents received meal trays from the kitchen, highlighting the potential impact of these unsanitary practices. The facility's administrator was informed of these findings on February 26, 2025.
Unsafe Mechanical Equipment in Kitchen
Penalty
Summary
The facility failed to maintain all mechanical equipment in safe operating condition, as evidenced by a buildup of metal shavings on the can opener and a grease buildup inside the deep fryer. During an observation of the kitchen, it was noted that the commercial can opener had a significant accumulation of metal shavings beneath the blade. Additionally, the large gas fryer was observed to have a buildup of grease on its internal components. These observations were confirmed by the Dietary Manager, who was present at the time. The facility's Diet Type Report indicated that a total of 84 residents received meal trays from the kitchen, potentially exposing them to the risks associated with the equipment's condition. The Administrator was informed of these findings two days later.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident who was unable to activate his call light due to physical disabilities. The resident, who was admitted with a diagnosis of wedge compression fracture of the T11-T12 vertebra, demonstrated his inability to move his left arm and right fingers, which prevented him from pressing the call light button. During an interview, the resident confirmed his inability to activate the call light, and this was further verified by the Director of Nursing during a room visit with the surveyor.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident with severe cognitive impairment and a high risk for elopement. The resident, diagnosed with unspecified dementia and wandering behavior, was able to leave the facility without staff awareness. The incident occurred when a sitter, mistaking the resident for a visitor, opened an emergency exit door, allowing the resident to exit the building. The resident was later found walking outside the facility by an LPN, who, with the help of a neighbor, returned the resident to the facility without any observed injuries. The facility's policy required incidents of elopement to be reported to the State Survey Agency within 24 hours, but this was not done. The administrator confirmed that the incident was not reported in the Statewide Incident Management System (SIMS). The resident was assessed as high risk for elopement, and the incident highlighted a lapse in supervision and communication among staff, as the resident was able to leave the facility unnoticed until informed by the sitter.
Resident Elopement Due to Inadequate Supervision and Lack of Alert System
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, diagnosed with unspecified dementia and behavioral disturbances, was assessed as having severe cognitive impairment and was noted to be independent with transfers. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility without staff awareness due to a lapse in supervision. The incident occurred when a private sitter for another resident mistakenly allowed the resident to exit through an emergency door, believing the resident to be a visitor. The resident was observed walking outside the facility by a Licensed Practical Nurse (LPN) who was informed by the sitter. The LPN immediately pursued the resident and, with the assistance of a neighbor, returned the resident to the facility without injury. The resident was found to be in stable condition with no agitation or distress. Interviews with facility staff revealed that the exit door used by the resident did not have a code alert bracelet system to notify staff of the resident's proximity. This lack of an alert system contributed to the staff's unawareness of the resident's exit. The Director of Nursing and the Administrator confirmed the deficiency, acknowledging that the resident was able to elope without staff knowledge until the incident was reported by the sitter.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, specifically for two residents who were reviewed for unnecessary medications. For one resident, the facility did not adhere to the prescribed insulin sliding scale and blood pressure parameters. The resident had a history of type 2 diabetes mellitus, hypertension, and other significant health conditions. Despite having clear physician orders to hold Lisinopril if the diastolic blood pressure was below 75 and to hold insulin if the blood sugar was below 150, the nurses administered these medications multiple times without following the parameters. This oversight was confirmed through interviews with the LPNs and the Director of Nursing. Another resident, who also had a history of hypertension and other health issues, was affected by the facility's failure to follow prescribed blood pressure parameters. The resident's physician orders specified holding Metoprolol Tartrate if the pulse was below 60 or systolic blood pressure was below 110. However, the medication was administered several times despite the resident's vital signs being outside the specified parameters. This was confirmed through a review of the Medication Administration Records and interviews with the nursing staff. The surveyor's findings highlighted a pattern of non-compliance with medication administration protocols, as evidenced by the repeated failure to adhere to physician orders for both residents. The Director of Nursing acknowledged these deficiencies during the surveyor's review, and the facility's administrator was informed of the findings. The report underscores the importance of following physician orders to ensure the safety and well-being of residents in the facility.
Deficiency in Resident Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who was readmitted with multiple diagnoses including type 2 diabetes mellitus with diabetic retinopathy, hemiplegia, hemiparesis, and blindness, required extensive assistance with personal hygiene. During an observation, it was noted that the resident had a thick buildup of black crust between the toes, areas of moisture with a sticky white coating, and an odor emanating from the left foot. Additionally, the resident had long, untrimmed nasal hairs. These findings were confirmed by a CNA and later by an LPN, who acknowledged the need for further attention to the resident's hygiene. The Director of Nursing was informed of the hygiene issues, including the crusty buildup and odor between the resident's toes and the untrimmed nasal hairs. The DON confirmed that the resident's feet should have been cleaned during baths and nasal hairs trimmed. The facility's failure to ensure the resident's personal hygiene needs were met was documented, highlighting a deficiency in the care provided to the resident.
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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