Legacy Nursing And Rehabilitation Of Winnsboro
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnsboro, Louisiana.
- Location
- 804 Polk Street, Winnsboro, Louisiana 71295
- CMS Provider Number
- 195392
- Inspections on file
- 23
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Winnsboro during CMS and state inspections, most recent first.
Multiple residents were found living in unclean and uncomfortable conditions, including rooms with strong odors, missing linens, dirty medical equipment, and damaged wheelchairs. The laundry area was also unsanitary, with supplies and clothing improperly stored and significant dust and lint buildup. Facility staff, including the DON and Administrator, confirmed these issues and acknowledged ongoing problems with cleanliness and maintenance.
The facility did not complete and transmit MDS Assessments to the state within the required timeframe for four residents. Quarterly and Annual MDS Assessments were delayed in transmission, as confirmed by MDS Coordinators during interviews.
Surveyors identified multiple sanitation and food storage deficiencies, including buildup of grime and old food on kitchen equipment, improper labeling and dating of food containers, dirty or broken storage bin lids, and dented cans. The Dietary Manager confirmed improper food storage and inadequate cleaning, potentially affecting all residents receiving meals from the kitchen.
A resident with severe cognitive impairment and multiple medical conditions was found to have a bed remote with exposed wires in their room. This issue was confirmed by both surveyors and the Maintenance Supervisor, indicating a failure to keep essential electrical equipment in safe working order.
A resident with severe cognitive impairment and multiple medical conditions was repeatedly observed without bed linens and with her brief exposed. Staff, including CNAs and an LPN, were unaware of any reason for the lack of linens and did not attempt to provide them. The DON confirmed that residents should have linens and covers, acknowledging the lapse in maintaining the resident's dignity and privacy.
A resident was discharged from the facility after a one-month stay, but the required discharge summary was not completed as outlined in facility policy. The DON confirmed that there was no documentation of a discharge summary for the resident.
Two residents requiring assistance with ADLs did not receive necessary support for personal hygiene and grooming. One resident with hemiplegia and heart failure was observed with long facial hair despite being care planned for staff assistance, while another resident with diabetes and limited upper extremity mobility had long fingernails and was unable to trim them independently, even after requesting help from staff.
A resident with severe contractures and impaired mobility, as well as physician orders and a care plan for an elbow splint and bilateral hand rolls, was repeatedly observed without these devices in place. Both an LPN and a CNA confirmed the absence of the splints, indicating the facility did not provide the required treatments to maintain or improve the resident's range of motion.
A resident with multiple diagnoses and dependent on staff for bed mobility was found to have a loose half side rail on their bed, as observed on multiple occasions and confirmed by the Maintenance Supervisor. The care plan required the use of side rails for turning and repositioning, but the facility did not ensure the rail was properly secured.
Surveyors found that several residents did not receive respiratory care consistent with physician orders and facility policy. Issues included oxygen concentrators set at incorrect flow rates, dirty oxygen equipment, nasal cannulas not in use as ordered, and nebulizer tubing not changed weekly. Staff confirmed these deficiencies and acknowledged the need for proper cleaning and adherence to orders.
A medication pass observation revealed that an LPN administered a phosphate binder after a resident's meal instead of before, as ordered, and failed to administer Ondansetron at the scheduled time, only giving it after the observation was complete. These two errors out of 37 opportunities resulted in a medication error rate above 5%.
The facility failed to document wound care for two residents with pressure ulcers, despite physician orders for daily treatment. One resident, with a Stage 4 ulcer and cognitive impairment, had missing documentation on specific dates. Another resident, with a Stage 3 ulcer and moderate cognitive impairment, also lacked documentation on a specified date. The DON confirmed these omissions.
A resident admitted with a urinary catheter did not receive necessary treatment and services to prevent infections. The facility failed to assess the medical necessity for the catheter, leading to two UTIs. Observations revealed poor catheter maintenance, and staff confirmed there was no medical justification for the catheter.
The facility failed to provide necessary ADL assistance to three residents, resulting in poor grooming and personal hygiene. One resident consistently had food debris on her clothing and was often barefooted, another had long toenails that needed trimming, and a third had long, jagged fingernails. Staff did not take appropriate actions to address these issues.
The facility failed to ensure nursing staff had the competency to provide appropriate care, as evidenced by the lack of medical justification for a urinary catheter in a resident. The resident, with multiple health conditions, had a catheter without documented necessity, leading to two urinary tract infections. Interviews revealed a lack of awareness and oversight among the DON, LPN/MDS Coordinator, and NP regarding the need for medical justification.
The facility failed to provide adequate supervision and a safe environment for a high-risk resident with severe cognitive impairment, resulting in the resident sustaining a fall and a hematoma. Despite the care plan requiring stand-by assistance and supervision, the resident was observed ambulating unassisted and barefooted, and staff were seen leaving the resident unattended.
The facility failed to ensure a resident maintained acceptable nutritional status, leading to significant weight loss. Despite the resident's need for total assistance with meals, staff only set up meal trays without providing necessary help or supervision, resulting in the resident eating less than 20% of meals and experiencing further nutritional decline.
The facility failed to properly store the oxygen tubing and nasal cannula for a resident with COPD and other health conditions, as required by their policy. Observations revealed the nasal cannula was left uncovered on the mattress or hanging on the side rail, contrary to the procedure of storing it in a plastic bag when not in use. This was confirmed by staff interviews.
A pharmacist failed to report irregularities in the monitoring of a resident receiving Eliquis, an anticoagulant. The resident, with multiple diagnoses including hypertensive heart disease and Alzheimer's, was not monitored for bleeding as required. Drug Regimen Reviews for three months did not identify this issue, and the Director of Nursing confirmed the lack of documentation.
The facility failed to monitor a resident for bleeding while administering an anticoagulant medication, despite a care plan indicating the need for such monitoring. This was confirmed by the DON during an interview.
The facility failed to provide necessary wound care as ordered for two residents, leading to deficiencies in their treatment. One resident with multiple diagnoses developed a stage 2 pressure ulcer, and there was no documentation of treatment on a specific date. Another resident with a diabetic ulcer had delayed updates to wound care orders, resulting in inadequate treatment. Interviews with staff confirmed these lapses in care and documentation.
The facility failed to ensure timely communication of progress notes and lab results by the NP for two residents, impacting their wound care and treatment. Progress notes and lab results were significantly delayed, indicating a lack of competency in providing timely nursing-related services.
A resident with multiple diagnoses, including pressure-induced deep tissue damage, experienced a delay in antibiotic therapy due to the facility's failure to promptly follow up on wound culture results. The resident's sacral ulcer deteriorated, and necessary treatment was delayed by several days, leading to infection.
Failure to Maintain Clean, Safe, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified multiple failures by facility staff to maintain a safe, clean, comfortable, and homelike environment for several residents. Observations revealed that one resident's room was excessively dirty, cluttered, and had a strong urine odor, with liquid resembling urine on the bathroom floor and a wheelchair with damaged armrests and significant debris. Another resident's room lacked bed linens, had a dirty oxygen concentrator, and contained shoes that did not belong to the resident. A third resident's room was found with dirt and grime on medical equipment, unlabeled creams, and a dirty bedside table, with the oxygen concentrator remaining unclean throughout the survey. Additional residents were observed with wheelchairs that had excessive dirt and debris, and cracked or damaged arm padding exposing foam. Interviews with the DON and Administrator confirmed these findings and acknowledged the ongoing issues with cleanliness and equipment maintenance. The facility's laundry area was also found to be unsanitary, with disinfectant supplies stored in sinks, clothing and shoes stacked on washing machines, thick dust and lint buildup on filters and between machines, detergents and empty chemical containers stored on the floor, and random piles of linen and resident care supplies covered in dust. The Housekeeping Supervisor was unable to provide a completed daily cleaning checklist for the laundry area, and an LPN confirmed the unsanitary conditions. These observations and interviews demonstrate a pattern of inaction and insufficient cleaning practices, directly leading to the cited deficiencies.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were completed and transmitted to the state within the required timeframe for four residents. Record reviews showed that three residents had Quarterly MDS Assessments with an Assessment Reference Date (ARD) of 05/27/2025, but these assessments were not transmitted until 07/07/2025. Additionally, one resident had an Annual MDS Assessment with the same ARD, which was also not transmitted until 07/07/2025. Interviews with the MDS Coordinators confirmed that the assessments for these residents were not completed and transmitted in a timely manner as required.
Deficient Food Storage and Sanitation in Kitchen and Dry Storage
Penalty
Summary
The facility failed to store food and discard expired items in accordance with professional standards for food service safety, as observed during a kitchen inspection. Specific findings included dust and grime buildup on the air vent near the kitchen entrance, grime and old food on the base of a large can opener, and a significant amount of old grease in the lower compartment of the deep fryer and on the floor beneath it. Two commercial ovens had dark stains and old food buildup on the doors and interiors, and the microwave contained a large amount of old food splatters on the inside. In the walk-in refrigerator, a large bin containing packages of cheese had a lid with visible dirt and grime, while the walk-in freezer had broken pieces of ice scattered on the floor and an open box of hashbrowns with ice buildup. Further inspection of the dry storage room revealed old foil and food particles under oatmeal and grits containers, with the storage containers for these items lacking dates. Two rolling carts had old food and grime on all shelves, and several large bins containing noodles, salt and pepper packets, and lemonade drink mixes had dirty or broken lids. Multiple large cans were found to be dented, and containers of rice and flour were not labeled with dates. The Dietary Manager confirmed that food was not stored and labeled properly and that the kitchen was not cleaned according to standards. These deficiencies had the potential to affect all 63 residents receiving meals from the facility's kitchen.
Failure to Maintain Bed Control Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain electrical equipment in safe operating condition for one resident. Specifically, a bed remote with exposed wires was observed in the room of a resident who had been admitted with diagnoses including Alzheimer's disease, cerebrovascular disease, aphasia, dysphagia, repeated falls, and transient ischemic attack. The resident was assessed as having severe cognitive impairment. The exposed wires on the bed control were confirmed during observations by both surveyors and the facility's Maintenance Supervisor.
Failure to Maintain Resident Dignity and Privacy Due to Lack of Bed Linens
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, congestive heart failure, metabolic encephalopathy, drug-induced subacute dyskinesia, and aphasia was repeatedly observed lying in bed without bed linens and with her brief exposed. The resident was dependent on staff for all activities of daily living and had limited range of motion in both upper and lower extremities. Multiple observations over several days confirmed the absence of bed linens and lack of coverage for the resident, compromising her privacy and dignity. Interviews with two CNAs and an LPN revealed that none of the staff were aware of any reason for the lack of bed linens, and no attempts were made to provide linens during the observations. The Director of Nursing confirmed that residents are to be provided with linens and covers, and acknowledged the findings related to the resident's dignity. The failure to provide appropriate linens and maintain the resident's privacy constituted a lack of respect and dignity in the care environment.
Failure to Complete Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a discharge summary for one resident who was discharged after a one-month stay. According to the facility's Discharge Transfer of a Resident Policy and Procedure, a discharge summary and post-discharge plan of care form are required to be completed at the time of discharge. Record review showed that the resident was admitted on 03/31/2025 and discharged on 04/30/2025, but there was no documentation of a discharge summary in the resident's file. This was confirmed during an interview with the DON, who acknowledged the absence of the required discharge summary documentation for the resident.
Failure to Provide Necessary ADL Assistance for Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to two residents who were unable to perform these tasks independently. One resident, admitted with cerebral infarction resulting in hemiplegia and hemiparesis, chronic obstructive pulmonary disease, and congestive heart failure, was assessed as having no cognitive impairment and requiring partial to moderate assistance with personal hygiene. Despite being care planned for assistance with all ADLs, repeated observations over several days showed the resident had long facial hair on her chin. Staff confirmed the resident was dependent on staff for ADL care and that she allowed staff to shave her, but her face was not groomed as needed. Another resident, admitted with multiple chronic conditions including diabetes, heart disease, and limited range of motion in one upper extremity, was also assessed as cognitively intact but requiring assistance with ADLs, including nail care. Observations revealed this resident had long fingernails and was unable to trim them independently due to her physical limitations. The resident reported requesting assistance from staff, and staff interviews confirmed that nail care was the responsibility of the nursing staff due to the resident's diabetes. However, the resident's fingernails remained untrimmed during the survey period.
Failure to Provide Prescribed Splints and Hand Rolls for Resident with Contractures
Penalty
Summary
A resident with diagnoses including traumatic hemorrhage of the cerebrum, hemiplegia, aphasia, and bilateral hand contractures was identified as having functional limitations in range of motion (ROM) in both upper and lower extremities, with severely impaired cognitive skills for daily decision making. The resident's care plan and physician orders specified the use of an elbow splint for the right elbow and bilateral hand rolls to address contractures and impaired mobility. Despite these documented orders and care plan interventions, multiple observations over two consecutive days revealed that the resident did not have the prescribed hand rolls or elbow splint in place at any time. Interviews with both an LPN and a CNA confirmed the absence of these devices, with the CNA noting that the splints had not been present during her previous shifts. The DON was notified of these findings, confirming that the facility failed to provide the required splints and hand rolls as ordered and care planned for the resident.
Failure to Secure Bed Rails Creates Accident Hazard
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by not ensuring that bed rails were properly secured for a resident. Record review showed that the resident had chronic obstructive pulmonary disease, bipolar disorder, dementia, and hyperlipidemia, and was dependent on staff for all activities of daily living, including bed mobility. The care plan required the use of half side rails for turning and repositioning. Observations on two consecutive days revealed that the left side rail on the resident's bed was loose. This finding was confirmed by the Maintenance Supervisor during a subsequent observation.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents. For one resident with hemiplegia and a history of traumatic cerebral hemorrhage, physician orders required oxygen therapy to be administered at 2 liters per nasal cannula if oxygen saturation fell below 92%. However, repeated observations showed the oxygen concentrator was set to 3 liters, the nasal cannula was often not in use or was found on the floor or bed, and the concentrator itself was dirty with visible debris and food splatters. Staff interviews confirmed the resident was supposed to have continuous oxygen, but also noted non-compliance by the resident and acknowledged the concentrator was unclean. Another resident with COPD, congestive heart failure, and cerebral infarction had orders for oxygen at 2 liters per nasal cannula and for the concentrator and filter to be kept clean. Observations on multiple occasions revealed dust and grime buildup on both the concentrator and its filter. The DON confirmed the equipment was in need of cleaning during an on-site review. A third resident with COPD, bipolar disorder, dementia, and hyperlipidemia had orders for inhaled ipratropium-albuterol via nebulizer. The nebulizer mask tubing at the bedside was found to be dated nearly a month prior, indicating it had not been changed weekly as required by facility policy. Staff confirmed the tubing had not been replaced in accordance with procedures. These findings demonstrate failures to maintain clean respiratory equipment, ensure correct oxygen flow rates, and timely change of nebulizer tubing as per physician orders and facility policy.
Medication Error Rate Exceeds 5% Due to Improper Administration and Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 5.41% error rate during a medication pass observation. Specifically, an LPN administered Sevelamer Carbonate, a phosphate binder, to a resident after the resident had already eaten breakfast, despite physician orders specifying the medication should be given before meals. Additionally, the same resident was not administered Ondansetron HCl, which was ordered to be given on specific days related to dialysis, during the observed medication pass. The LPN later confirmed that Sevelamer Carbonate was given after the meal and that Ondansetron was administered only after the medication pass observation was completed. The LPN did not notify the DON or the surveyor prior to administering the missed medication. These actions resulted in two medication errors out of 37 opportunities, exceeding the acceptable medication error rate threshold.
Lack of Documented Wound Care for Two Residents
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in providing necessary wound care for two residents. For the first resident, who was admitted with multiple diagnoses including a Stage 4 pressure ulcer, there was no documented evidence of wound care being provided on specific dates in October and November 2024, despite physician orders requiring daily wound care. The resident's medical record indicated cognitive impairment and a need for moderate assistance with activities of daily living. The Director of Nurses confirmed the lack of documentation for the specified dates. Similarly, the second resident, who was admitted with conditions such as hemiplegia, acute respiratory failure, and a Stage 3 pressure ulcer, also did not have documented wound care on a specified date in October 2024. The resident's medical record showed moderate cognitive impairment and dependency on staff for daily living activities. The Director of Nurses confirmed the absence of documentation for the wound care on the specified date.
Failure to Provide Appropriate Catheter Care and Prevent UTIs
Penalty
Summary
The facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services to promote healing and prevent infections. Resident #9, who was admitted on 03/18/2024, had a urinary catheter without medical justification. The facility did not assess the medical necessity for the catheter upon admission, and there was no documentation of the color, clarity, and character of the resident's urine as required by the care plan. This oversight led to the resident developing urinary tract infections (UTIs) on 04/16/2024 and 05/13/2024, both of which required antibiotic treatment. Observations and interviews revealed that the resident's catheter care was inadequate. On 05/13/2024, the resident was found with dark amber urine and cloudy catheter tubing, indicating poor catheter maintenance. The resident reported that the catheter should have been changed already. The facility's records showed that there were only six entries documenting the urine's color and clarity, and none noted the character of the urine. The facility's policy and procedure for catheter care did not provide pertinent guidance on these documentation requirements. Interviews with the facility's staff, including the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator, confirmed that there was no medical justification for the resident's urinary catheter. The resident had no diagnosis that warranted the use of a catheter, and the staff failed to identify this upon admission. The resident's hospital discharge summary also did not include a medical justification for the catheter. The resident's catheter was eventually removed on 05/15/2024 after it was confirmed that there was no medical necessity for its use.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Resident #51, diagnosed with weight loss, dehydration, recent falls, vascular dementia, and a urinary tract infection, required total assistance with ADLs. Observations revealed that Resident #51 consistently had food debris and liquid on her clothing after meals and was often barefooted. Despite these observations, staff did not change her clothing or ensure she had proper footwear. Additionally, Resident #51 was observed with emesis on her clothing, and staff confirmed that she vomited during a meal but did not change her clothing afterward. The Director of Nursing confirmed that staff are responsible for assisting residents with meals, beverages, and changing clothes when necessary, as well as ensuring proper footwear is worn by residents. Resident #55, who had intact cognition and required set-up assistance with personal hygiene, reported that her toenails needed trimming. Observations confirmed that her toenails were long and needed attention, but no action was taken by the staff. The Director of Nursing confirmed that staff should assist Resident #55 with personal hygiene, including toenail trimming. Resident #57, diagnosed with cerebral infarction, Alzheimer's, schizoaffective disorder, hemiplegia, and other conditions, required substantial assistance with ADLs. Observations revealed that Resident #57 had long, jagged fingernails on multiple occasions. The Wound Care Nurse confirmed that Resident #57's fingernails needed trimming, but no action was taken by the staff to address this issue.
Lack of Medical Justification for Urinary Catheter
Penalty
Summary
The facility failed to ensure that nursing staff possessed the competency to provide nursing-related services, as evidenced by the lack of medical justification for the use of a urinary catheter in a resident. The facility's current policy and procedure for catheter care did not include guidance for an admission assessment to determine the medical necessity of a urinary catheter. This deficiency was identified in the case of a resident admitted with a urinary catheter but without a diagnosis that would justify its use. The resident had a history of chronic kidney disease, dehydration, diabetic ulcers, diabetic ketoacidosis, hypertension, and non-pressure chronic ulcers. Despite these conditions, there was no documented medical justification for the urinary catheter, and the resident experienced two urinary tract infections since admission. Interviews with the Director of Nursing (DON), the Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator, and the Nurse Practitioner (NP) revealed a lack of awareness and oversight regarding the need for medical justification for the urinary catheter. The DON confirmed the resident had a urinary catheter since admission and had experienced two urinary tract infections. The LPN/MDS Coordinator admitted to not being aware of the need for justification, and the NP confirmed the absence of medical justification and subsequently ordered the discontinuation of the catheter. This series of actions and inactions led to the deficiency in providing appropriate nursing care for the resident.
Failure to Provide Adequate Supervision and Safe Environment for High-Risk Resident
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and did not provide adequate supervision to prevent accidents for a resident with a high risk of falling. Resident #51, who had diagnoses including closed head injury, dehydration, falls, and urinary tract infection, was admitted to the hospital after sustaining a fall in the secured unit. The resident's Fall Risk assessment indicated a high risk for falling, and the Minimal Data Set (MDS) assessment showed severely impaired cognitive skills. The care plan required the resident to have stand-by assistance when ambulating, wear nonskid socks, and be supervised at all times. However, the resident was observed attempting to ambulate without assistance and was barefooted on multiple occasions. Additionally, staff were observed leaving the resident and other residents unattended in the day room, contrary to the care plan requirements and staff responsibilities confirmed by interviews with the CNA Supervisor and Assistant Director of Nurses (ADON). The resident sustained a hematoma to the forehead from a fall, indicating a failure to provide the necessary supervision and safe environment as outlined in the care plan.
Failure to Provide Adequate Nutritional Assistance
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, leading to significant weight loss. Resident #51, who had diagnoses including weight loss, dehydration, recent falls, vascular dementia, and urinary tract infection, experienced an 11.66% weight loss since admission. The resident's diet order included no added salt, pureed texture, nectar thick fluid consistency, house supplement three times a day, and pudding twice daily. Despite these orders, observations revealed that staff only set up meal trays for the resident without providing the necessary assistance or prompting to consume the meals. The resident was observed eating less than 20% of meals on multiple occasions and was left unattended during meal times, resulting in further nutritional decline and incidents such as spilling drinks and vomiting during meals. Additionally, the resident was found eating inappropriate food (BBQ chips) without staff monitoring, which was against the prescribed diet order. Interviews with staff confirmed that the resident required total assistance with meals and should not be left unattended. The Assistant Director of Nursing (ADON) acknowledged the weight loss and confirmed that CNAs are responsible for notifying floor nurses of any changes in residents' eating habits. The ADON also confirmed that staff should be present to assist residents with meals and beverages at all times. The failure to provide the required assistance and supervision during meals directly contributed to the resident's significant weight loss and overall decline in nutritional status.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care was provided with such care consistent with professional standards of practice. Specifically, the facility did not properly store the oxygen tubing and nasal cannula for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and other health conditions. The facility's policy required that oxygen equipment be stored in a plastic bag when not in use. However, observations on multiple occasions revealed that the resident's nasal cannula was left uncovered on the mattress or hanging on the side rail of the bed. Interviews with the resident and staff confirmed that the nasal cannula should have been stored in a bag when not in use, but this procedure was not followed. The resident, who had moderately impaired cognitive skills, was admitted with several diagnoses including COPD, hypertensive heart disease with heart failure, and severe obesity. The resident's care plan included the use of oxygen therapy at night and as needed due to shortness of breath related to COPD and congestive heart failure. Despite this, the facility did not adhere to its own policy for storing the oxygen equipment, as evidenced by repeated observations of the nasal cannula being improperly stored. This failure was confirmed by both the Licensed Practical Nurse and the Director of Nursing during interviews and observations.
Pharmacist Failed to Report Irregularities in Anticoagulant Monitoring
Penalty
Summary
The pharmacist failed to report any irregularities to the attending physician, medical director, and director of nursing for a resident who was receiving an anticoagulant medication. The pharmacist did not identify that the facility had not monitored the resident for bleeding while on Eliquis. The resident, who had diagnoses including hypertensive heart disease with heart failure, Alzheimer's, and anxiety disorder, required supervision for daily activities and had moderately impaired cognitive skills. Despite the care plan indicating the need for monitoring adverse reactions, there was no documented evidence of staff monitoring for bleeding in the Medication Administration Record and Treatment Administration Record for May 2024. The Drug Regimen Reviews for March, April, and May 2024 did not show any indication that the pharmacist identified the lack of monitoring for bleeding. An interview with the Director of Nursing confirmed the absence of documented evidence that the pharmacist had identified this issue. This failure to monitor and report irregularities represents a significant deficiency in the care provided to the resident.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for bleeding while the resident was administered an anticoagulant medication. The resident, who had diagnoses including hypertensive heart disease with heart failure, Alzheimer's, and anxiety disorder, was prescribed Eliquis. Despite a care plan indicating the need for monitoring adverse reactions, there was no documentation in the Medication Administration Record and Treatment Administration Record for May 2024 that staff monitored the resident for bleeding. This was confirmed by the Director of Nursing during an interview.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide necessary wound care as ordered for two residents, leading to deficiencies in their treatment. Resident #1, who was admitted with multiple diagnoses including encephalopathy, cerebral infarction, and type 2 diabetes mellitus, developed a stage 2 pressure ulcer on the sacrum. Despite having a physician's order for daily wound care, there was no documentation of treatment on 04/04/2024. Additionally, the wound care order was not updated promptly after a nurse practitioner assessed the wound on 04/05/2024, leading to a delay in the application of medihoney and calcium alginate until 04/08/2024. Interviews with the treatment nurse and the Director of Nursing confirmed these lapses in care and documentation. Resident #4, admitted with diagnoses including type 2 diabetes mellitus and congestive heart failure, had a diabetic ulcer on the right heel. The wound care orders were changed by a nurse practitioner on 04/05/2024 to include cleaning with 1/2 strength Dakin's solution and applying medihoney and calcium alginate. However, the treatment nurse did not update the orders until 04/08/2024, and the correct cleansing agent was not used until 04/25/2024. Interviews with the treatment nurse and the Director of Nursing confirmed that the wound care orders were not updated in a timely manner, leading to a delay in appropriate wound care. These deficiencies highlight the facility's failure to ensure that residents received the necessary care and services in accordance with their comprehensive care plans and professional standards of practice. The lapses in documentation and timely updating of wound care orders resulted in inadequate treatment for the residents' pressure ulcers and diabetic ulcers, as confirmed by multiple staff interviews and record reviews.
Delayed Communication of Progress Notes and Lab Results
Penalty
Summary
The facility failed to ensure that nursing staff possessed the competency to provide timely nursing-related services. Specifically, the Nurse Practitioner (NP) did not provide progress notes and laboratory culture results in a timely manner for two residents. Resident #1, who had multiple diagnoses including encephalopathy, cerebral infarction, and pressure-induced deep tissue damage, had a wound culture taken on 04/12/2024. The results were received by the NP on 04/18/2024 but were not sent to the facility until 04/23/2024. Additionally, progress notes for Resident #1 for 04/05/2024, 04/12/2024, and 04/19/2024 were not sent until 04/23/2024 when requested by a state surveyor. Similarly, Resident #4, who had diagnoses including type 2 diabetes mellitus and a diabetic ulcer, had a wound culture taken on 04/05/2024. The NP reviewed the culture results on 04/12/2024 but did not communicate these results or the necessary medication orders to the facility until 05/06/2024. Progress notes for Resident #4 for 04/05/2024, 04/12/2024, and 04/19/2024 were also delayed and not received by the facility until 04/24/2024. These delays in communication and documentation indicate a lack of competency in providing timely nursing-related services, impacting the care of the residents involved.
Delay in Antibiotic Therapy for Pressure Ulcer
Penalty
Summary
The facility failed to ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards to promote healing and prevent infection. Resident #1, who was admitted with multiple diagnoses including encephalopathy, cerebral infarction, morbid obesity, type 2 diabetes, and pressure-induced deep tissue damage, experienced a delay in the initiation of antibiotic therapy. The resident's sacral pressure ulcer deteriorated from a stage 2 to a stage 3 ulcer, with significant slough and exudate, and a wound culture was taken on 04/12/2024 due to odor and deterioration. However, the facility did not follow up on obtaining the culture results in a timely manner, leading to a delay in starting the necessary antibiotic treatment until 04/23/2024, despite the culture revealing multiple infections including Pseudomona aeruginosa, Escherichia coli, and Candida species. Interviews with the Director of Nursing (DON) and the Nurse Practitioner (NP) confirmed that the facility was aware of the wound culture but failed to obtain the results promptly. The NP reported not receiving the final culture results until 04/22/2024, and the resident was not started on antibiotics until 04/23/2024. Further investigation revealed that the lab had received the specimen on 04/18/2024 and had faxed the results the same day, but the facility did not receive or act on these results until five days later. This delay in treatment contributed to the deterioration of the resident's wound and the subsequent infection.
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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