Legacy Nursing At St. Christina
Inspection history, citations, penalties and survey trends for this long-term care facility in Pineville, Louisiana.
- Location
- 122 Hillsdale Drive, Pineville, Louisiana 71360
- CMS Provider Number
- 195613
- Inspections on file
- 39
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Legacy Nursing At St. Christina during CMS and state inspections, most recent first.
The facility failed to ensure residents were treated with dignity during meal service by not serving all residents at the same table at the same time and by not serving roommates who ate in their room simultaneously. In one instance, multiple residents seated together received their trays at different times while staff served other tables. In another instance, a cognitively intact resident with multiple chronic conditions, including Type 2 DM, bipolar disorder, HTN, and hyperlipidemia, reported that his roommate routinely received breakfast about an hour earlier, and observations confirmed he had not received his tray while his roommate had already been served. Staff and the dietary manager acknowledged that residents seated together or sharing a room should receive their trays at the same time, but this did not occur.
A resident with multiple medical conditions, including hypertension, neuroleptic-induced parkinsonism, protein-calorie malnutrition, and generalized anxiety disorder, had a documented LaPOST-DNR order and DNR status on the face sheet, but the care plan listed the resident as Full Code and described an advance directive for Full Code. The facility’s policy required that each plan of care be consistent with the resident’s documented treatment preferences and/or advance directive. During review and interview, the DON and an LPN/MDS nurse confirmed the resident’s care plan code status was incorrect and should have reflected DNR, not Full Code.
A resident with multiple chronic conditions, moderate cognitive impairment, and a care plan requiring staff assistance with ADLs did not consistently receive scheduled bathing assistance. Review of records showed only three whirlpool baths documented in a 30-day period and a 10-day span with no documentation of a bath or refusal. The resident reported not consistently receiving scheduled baths, and both a CNA and clinical education staff confirmed that there was no bath or refusal documentation for that period, despite the expectation that scheduled baths would be provided.
A resident with anemia, Parkinson’s disease, respiratory symptoms, and a history of pneumonia had physician orders for routine Ipratropium-Albuterol nebulizer treatments. Surveyors observed the resident’s nebulizer machine on the bedside table with the mask lying on top, uncovered and undated, despite a facility policy requiring oxygen-related tubing, cannulas, and masks to be stored in a plastic bag when not in use and changed weekly and as needed. An LPN confirmed the resident received regular breathing treatments, had been treated earlier that day, and acknowledged that the nebulizer mask and tubing should have been covered and dated but were not.
A resident with paraplegia, COPD, essential hypertension, and neuromuscular bladder dysfunction had physician orders and a care plan for a NAS diet with regular texture, thin liquids, and double meat, but the lunch meal ticket omitted the double meat and the resident received only a single meat portion. The resident reported never receiving double portions, and the dietary manager confirmed double meat was part of the ordered diet but was not reflected on the ticket. In addition, RD recommendations to add Boost/Ensure BID between meals for added protein/calories and to monitor weekly weights were provided to the facility but were never transcribed into physician orders or documented in nursing notes, and the DON confirmed there was no order for the supplements.
The facility failed to maintain an effective pest control program as required by its own policy, which mandates that the building be kept free of insects and rodents through an ongoing program. During multiple observations of a resident’s room, surveyors noted numerous gnats on and around a basket of soiled clothes. A NS Adm acknowledged that the gnats were present and should not have been, and an environmental services staff member confirmed these findings. This deficiency meant the facility was not free from insects and had the potential to affect all 131 residents.
Several residents with complex medical needs did not receive scheduled bathing assistance as outlined in their care plans, with documentation and staff interviews confirming that required baths were missed and not properly recorded. Facility staff acknowledged that bathing was not provided routinely as required.
A facility failed to report an allegation of verbal abuse within the required timeframe after a third-party staff member witnessed a staff member curse at a resident in front of others. The administrator did not submit the required report to the Department of Health, citing the delay in notification and the resident's lack of recollection, despite facility policy mandating immediate reporting of such incidents.
A resident with impaired cognition and significant medical history was physically assaulted by a roommate after staff were made aware of escalating threats but failed to intervene or notify appropriate clinical leadership. The incident resulted in facial injuries requiring emergency treatment.
The facility did not report allegations of staff-to-resident sexual abuse and resident-to-resident physical abuse involving two residents with cognitive and physical impairments, as required by policy and regulations. The DON and Administrator were aware of the incidents but did not submit the required reports to the State Survey Agency within the mandated timeframe.
A resident with multiple chronic conditions and a history of UTIs did not receive a prescribed antibiotic in a timely manner after lab results indicated the need for treatment. Although the antibiotic was available in the emergency kit, it was not administered on the day it was ordered, and a subsequent allergy to the medication required a change in therapy. The ADON confirmed the delay in administration.
A resident with severe cognitive impairment and multiple medical conditions did not receive physician-ordered continuous overnight enteral feedings. Observation found the feeding tube disconnected and the pump off, while nursing staff interviews confirmed the feeding was missed and not refused by the resident.
A resident with multiple complex conditions and a pressure ulcer did not have wound care documentation on two days, with no record of care being provided or refused, despite physician orders and facility policy requiring such documentation. Staff confirmed the lack of required entries in the Treatment Administration Record (TAR).
A resident with multiple medical conditions and dependence on staff for ADLs did not receive scheduled bathing assistance, with only three documented baths in a 30-day period despite a care plan requiring three baths per week. Staff interviews and documentation reviews revealed inconsistencies in recording refusals and missed care, and the resident reported not receiving a bath in two weeks.
Surveyors found that the facility failed to maintain a clean and orderly environment, with observations including a resident's room containing hair and a splattered substance on the wall, broken window blinds, a large puddle of urine in another area, and a moldy ceiling tile due to an unresolved leak. Staff and a resident confirmed these unsanitary and disrepaired conditions had persisted for some time.
The facility did not perform weekly weights as ordered for three residents with significant weight loss or at risk for weight changes, and failed to obtain physician orders for wound care for a resident with active wounds. These deficiencies were confirmed by the DON and treatment nurse, and were not in accordance with facility policy or dietician recommendations.
Two residents with significant physical limitations were unable to access or use their call lights, as the devices were repeatedly observed out of reach and not adapted to their needs. Both residents, who required extensive assistance with daily living and had limited mobility, reported having to yell for help due to inaccessible call lights, a fact confirmed by staff and family. Facility policy required call lights to be within reach, but this was not consistently implemented.
A nurse failed to perform hand hygiene when changing gloves and between the treatment of multiple pressure ulcers for a resident who was fully dependent on staff and had several complex medical conditions. The nurse believed hand hygiene was only necessary between residents or if hands were visibly soiled, a misunderstanding confirmed during interviews. The DON acknowledged that proper hand hygiene should have been performed during the wound care process.
A resident with multiple medical and psychiatric conditions was not administered Amiodarone as ordered upon return from the hospital, due to the medication being overlooked during the transition. The omission was confirmed by both the nurse practitioner and DON, and the resident did not experience any reported adverse effects from the error.
A resident with severe cognitive impairment and hemiplegia did not receive ordered wound care for a skin tear on the right elbow, resulting in cellulitis. Despite a physician's order for treatment, the care was not administered on multiple occasions, and documentation was inaccurately completed. Interviews revealed that the treatment nurse was unaware of the wound, and the DON signed off on care that was not provided, leading to harm for the resident.
A resident who fell and sustained a wound to the elbow did not have their wound care order documented or entered by the facility. The DON later entered the order with a backdated start date and inaccurately initialed the TAR for wound care on two dates, despite not performing the care. The DON confirmed providing wound care on a later date but failed to document it, leading to inaccurate medical records.
The facility failed to follow care plans for two residents, missing monthly Trileptal lab tests for one resident with a seizure disorder and not providing daily wound care for another resident with a surgical wound. The lack of communication among nursing staff led to these deficiencies.
The facility failed to ensure a clean and safe environment by not maintaining the cleanliness and repair of wheelchairs for two residents. One resident's wheelchair was repeatedly observed with a soiled cushion, while another's wheelchair had cracked arm pads for about two years. Staff interviews revealed confusion over cleaning responsibilities and a lack of reporting on equipment disrepair.
A resident with a complex medical history requested a transfer to another facility after one night. The facility incorrectly encoded the discharge as unplanned and facility-initiated instead of planned and resident-initiated. Staff interviews confirmed the error in the MDS transmission report.
A resident with complex medical needs did not receive the prescribed continuous tube feeding of Glucerna 1.5 at 55 ml/hr and water at 45 ml/hr. Instead, Jevity 1.5, an incorrect formula, was found hanging and disconnected. Staff confirmed the error and the lapse in following physician's orders.
A resident with Huntington's disease and other conditions requiring assistance with meals was not provided the necessary help during dining services, despite care plan and physician's orders. Observations showed the resident struggling to eat independently, with significant food spillage, and staff interviews confirmed the lack of assistance.
A resident with multiple health conditions, requiring a two-person assist for transfers, was injured when a CNA attempted a solo transfer without a Hoyer lift. The resident hit their head, resulting in a superficial laceration. The incident was due to a lack of adherence to the care plan and poor communication among staff.
The facility failed to manage respiratory equipment properly for two residents, leading to deficiencies. A resident with respiratory conditions had an uncovered and undated nasal cannula, while another resident's nebulizer and suction equipment were similarly mishandled. LPNs confirmed the equipment should have been covered and dated, highlighting lapses in care standards.
The facility did not provide sufficient nursing staff to meet the needs and safety of residents, compromising their well-being. On a specific day, the facility's census was 110 residents, requiring 258.5 staffing hours, but only 256.5 hours were provided, resulting in a 2-hour shortfall. This deficiency was confirmed by the Interim DON.
A resident with cognitive impairments and a history of wandering was physically abused by another resident on two occasions, resulting in a laceration requiring medical attention. The facility failed to manage the aggressive behavior of the second resident, who had a history of delusions and aggression, leading to harm to the first resident.
A facility failed to report a resident-to-resident abuse incident within the required timeframe. A resident with a history of cerebral infarction and other conditions was found on the floor being kicked by another resident with a history of aggressive behavior. Despite the incident being reported to the DON by a CNA, a SIMS report was not completed, resulting in a deficiency in regulatory compliance.
A resident reported being physically and verbally abused by a CNA, but the facility failed to report the allegation to the State Survey Agency within the required 2-hour timeframe. The incident was not entered into the Statewide Incident Management System (SIMS) as mandated.
A facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse. The investigation lacked a timeline and signed statements from staff, despite the resident having intact cognition and reporting the abuse to the nurse and administrator. The administrator confirmed the incomplete documentation.
Failure to Serve Roommates and Tablemates Simultaneously During Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity during meal service, including not serving residents seated at the same table simultaneously. During a dining room observation, three residents were seated together at one table, but only one resident received her meal tray while staff then proceeded to serve residents at other tables. More than 15 minutes later, the remaining residents at that table still had not received their meal trays. The weekend RN supervisor confirmed that residents seated at the same table should be served their meal trays at the same time, but this did not occur. The deficiency also includes the facility’s failure to serve meal trays at the same time to roommates who both received meals in their room. One resident, admitted with diagnoses including Type 2 diabetes without complications, bipolar disorder, hypertension, hyperlipidemia, mild cognitive impairment, and muscle weakness, had an intact cognition (BIMS score of 15) and was independent or required set-up assistance with ADLs. This resident reported that his roommate routinely received breakfast about an hour before he did, and at the time of interview he had not yet received his breakfast tray. Staff interviews revealed that two meal carts were used on the hallway, with the first cart arriving earlier and the second cart arriving after dining room residents were served. Observations confirmed that the resident still had not received his breakfast tray later that morning, while his roommate had received his tray with the first cart. The dietary manager confirmed that roommates who eat in their room should receive their trays at the same time and acknowledged this did not occur for this resident.
Care Plan Code Status Inconsistent With Resident’s DNR Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s plan of care was consistent with the resident’s documented treatment preferences and advance directive. The facility’s Advance Directives Policy stated that each resident’s plan of care would align with their documented treatment preferences and/or advance directive. Review of the medical record for Resident #68, admitted on 12/23/2025 with diagnoses including hypertension, neuroleptic-induced parkinsonism, protein-calorie malnutrition, and generalized anxiety disorder, showed a physician’s order dated 01/16/2026 for LaPOST-DNR (Do Not Resuscitate), and the resident’s face sheet also indicated DNR status. However, review of the resident’s care plan with a target date of 04/11/2026 documented the resident as “Full Code” and included interventions indicating the resident had an advance directive for Full Code. During an interview, the DON and the LPN/MDS nurse confirmed that, despite the DNR physician order and DNR status on the face sheet, the resident was care planned as Full Code and acknowledged the care plan code status should have been DNR instead of Full Code. This discrepancy between the resident’s documented DNR order and the care plan coding constituted a failure to honor and accurately reflect the resident’s advance directive and treatment preferences in the care planning process, as required by facility policy.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
Surveyors identified a failure to provide necessary assistance with activities of daily living, specifically bathing, for one resident. The resident was admitted on 07/10/2025 with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Atrial Fibrillation, Paranoid Schizophrenia, Major Depressive Disorder, Heart Failure, and Lack of Coordination. A Quarterly MDS with an ARD of 01/05/2026 showed a BIMs score of 9, indicating moderate cognitive impairment, and documented that the resident required partial/moderate assistance with bathing. The resident’s care plan also indicated a need for staff assistance with ADL care, including bathing. Review of the bathing task documentation for the prior 30 days showed the resident received whirlpool baths on 02/06/2026, 02/17/2026, and 02/19/2026, but there was a 10-day gap from 02/07/2026 through 02/16/2026 with no evidence that bathing services were provided or refused. During an interview on 02/22/2026, the resident reported not consistently receiving baths as scheduled. On 02/24/2026, a CNA stated that completed baths and refusals are documented in the facility bath log and in the electronic medical record and confirmed there was no documentation of a bath or refusal for this resident during the 10-day gap. The clinical education staff member also confirmed there was no documentation in either the electronic medical record or bath log for that period and acknowledged that the resident should have received scheduled baths but did not.
Failure to Properly Store and Date Nebulizer Equipment
Penalty
Summary
Facility policy titled "Oxygen Concentrator Cleaning Policy and Procedure" directed that oxygen tubing, cannulas, and masks be stored in a plastic bag when not in use and be changed weekly and as needed. Resident #10, admitted on 01/02/2025, had diagnoses including anemia, Parkinson’s disease without dyskinesia, other specified symptoms and signs involving the circulatory and respiratory systems, and a personal history of pneumonia. Physician orders from 11/24/2025 directed that the resident receive Ipratropium-Albuterol inhalation solution via nebulizer every six hours for respiratory symptoms. On 02/22/2026 at 1:55 p.m., surveyor observation revealed a nebulizer machine on the resident’s bedside table with the nebulizer mask lying on top of the machine, uncovered and undated, contrary to the facility’s policy requiring such equipment to be covered and dated. In an interview shortly thereafter, an LPN confirmed that the resident received routine breathing treatments, that she had administered a treatment earlier that day, and that the nebulizer mask and tubing should have been covered and dated but were not. This failure to follow the facility’s oxygen equipment storage and maintenance policy for Resident #10’s nebulizer mask and tubing constituted the cited deficiency.
Failure to Follow Therapeutic Diet and RD Supplement Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with the ordered therapeutic diet and nutritional supplements. The resident, admitted with diagnoses including paraplegia, COPD, essential hypertension, and neuromuscular bladder dysfunction, had a physician’s order dated 10/25/2025 for a no added salt (NAS) diet with regular texture, thin liquids, and double meat, with paper tray setup. The resident’s care plan also specified that the diet should be served as ordered. On observation of a lunch meal on 02/23/2026, the resident’s meal ticket listed NAS, regular texture, and thin liquids but did not include the double meat order, and the tray contained only one piece of fried chicken breast. The resident stated he never receives double portions of meat, and the dietary manager confirmed that the resident’s diet included double meat and that it should have been on the meal ticket but was not. The facility also failed to implement and/or document the registered dietitian’s recommendations for oral nutritional supplements and weight monitoring. RD notes dated 12/23/2025 and 01/23/2026 recommended adding Boost/Ensure twice daily between meals to provide additional protein and calories for wound healing and weight maintenance, along with weekly weights for four weeks. The RD later confirmed she had provided these recommendations to the facility. Review of the record showed no documentation that these recommendations were transcribed into physician orders or, if not approved, documented in nursing notes. The DON confirmed that the resident did not have an order for Boost/Ensure twice daily, despite the RD’s recommendations.
Failure to Maintain Effective Pest Control Resulting in Gnat Infestation in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control environment as required by its Pest Control Policy and Procedure, which states the building shall be kept free of insects and rodents through an ongoing pest control program. During multiple observations of one resident’s room on 02/23/2026 at 7:51 a.m., 8:50 a.m., and 9:20 a.m., surveyors observed multiple gnats on a basket of soiled clothes and flying around on top of the basket. The facility’s Nursing Services Administrator acknowledged that multiple gnats were present in the resident’s room and that they should not have been there, and the Chief Environmental Services staff member later confirmed these findings. This deficient practice resulted in the facility not being free from insects as required by its own pest control policy and had the potential to affect all 131 residents residing in the facility.
Failure to Provide Scheduled Bathing Assistance and Documentation
Penalty
Summary
Multiple residents with significant medical conditions, including Chronic Obstructive Pulmonary Disease, Type II Diabetes, Benign Prostatic Hyperplasia, Morbid Obesity, Cerebral Palsy, Bipolar Disorder, and Severe Intellectual Disabilities, did not receive bathing assistance as required by their care plans. Documentation revealed that residents who required moderate to total assistance with bathing received significantly fewer baths than scheduled, with some receiving only one or two baths in a 30-day period despite care plans specifying three times weekly. Interviews with staff and review of both electronic and handwritten records confirmed insufficient documentation and a lack of routine provision of bathing care. Residents expressed that they had not received baths as expected, and staff, including the DON and CNA Supervisor, acknowledged that the required care was not provided consistently. The facility's policy mandates that residents receive necessary care to maintain their highest practicable well-being, but the failure to provide scheduled bathing and to document care as required led to a deficiency in meeting residents' basic hygiene needs.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. According to the facility's policy, any alleged violation of abuse, neglect, exploitation, or mistreatment must be reported within two hours if it involves abuse or results in serious bodily injury. In this case, a staff member from a third-party company reported to the facility administrator that she had witnessed a facility staff member curse at a resident in front of others after the resident urinated on the floor. The incident was discussed with facility staff, and notes were made regarding the investigation. Despite being informed of the incident, the administrator did not report the allegation to the Department of Health, as required, because he did not believe it was warranted based on his findings, including the delay in reporting and the resident's lack of recollection of the event. The administrator confirmed that no report was made through the Statewide Incident Management System (SIMS) after becoming aware of the alleged verbal abuse. The resident involved had a medical history including Chronic Obstructive Pulmonary Disease, Type II Diabetes, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Obstructive and Reflux Uropathy.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. On the specified date, one resident with a history of cerebral infarction, hemiplegia, diabetes, and schizoaffective disorder, and with moderately impaired cognition, attempted to prevent his roommate from leaving their shared room. This interaction escalated into a physical altercation, during which the resident was struck in the face by his roommate, resulting in facial bruising and a contusion that required emergency department evaluation and treatment. Prior to the incident, multiple staff members, including CNAs, were made aware of escalating threats of physical harm from the aggressor resident, who had a history of bipolar disorder, intellectual disabilities, and severely impaired cognition. These threats were reported to an LPN and subsequently to the DON. Despite these warnings, no new interventions or orders were obtained, and the primary care provider or nurse practitioner was not notified of the threats. The administrator was also not informed of the behavioral issues or threats prior to the altercation. The facility's policy on abuse prevention and prohibition was not followed, as residents must not be subject to abuse by anyone, including other residents. The lack of timely intervention and communication among staff and leadership contributed to the failure to prevent the physical abuse, resulting in actual harm to the resident.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse incidents to the State Survey Agency as required by both facility policy and regulatory guidelines. Specifically, an allegation of staff-to-resident sexual abuse involving a resident with moderate cognitive impairment and multiple psychiatric and medical diagnoses was not reported to the Statewide Incident Management System (SIMS) within the mandated two-hour timeframe, nor was it reported at all. The Director of Nursing (DON) was notified of the allegation and informed the Administrator, who decided not to report the incident, believing it was not necessary. Additionally, an allegation of resident-to-resident physical abuse involving another resident with significant cognitive and physical impairments was also not reported to SIMS. The DON, who was responsible for reporting, did not enter the incident into the system due to lack of administrative approval. The Administrator confirmed awareness of the incident but chose not to initiate a report, stating it was not warranted. These actions resulted in the failure to comply with required abuse reporting protocols for two of four sampled residents.
Failure to Timely Administer Prescribed Antibiotic
Penalty
Summary
A deficiency occurred when the facility failed to provide a prescribed antibiotic in a timely manner to a resident with multiple complex diagnoses, including chronic osteomyelitis, cerebral infarction, hemiplegia, epilepsy, and a history of urinary tract infections. The resident was admitted with these conditions and later developed symptoms of dysuria and altered mental status, prompting a urinalysis with culture and sensitivity. The preliminary lab results were available in the facility's electronic medical record system on the same day the sample was collected. However, the order for the antibiotic Cefdinir was not entered until the following day, with a start date set for yet another day later. Despite the availability of the antibiotic in the facility's emergency kit, the resident did not receive the medication on the day it was ordered. Further complicating the situation, the resident reported an allergy to Cefdinir after the order was placed, leading to a change in the prescribed antibiotic to Macrobid. The Assistant Director of Nursing confirmed that the resident should have received the antibiotic from the emergency kit on the day it was ordered, but this did not occur. The surveyor was unable to reach the nurse responsible for entering the original order during the investigation.
Failure to Administer Ordered Enteral Feedings
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral palsy, aphasia, mild protein calorie malnutrition, gastrostomy status, dysphagia, type 2 diabetes mellitus, and bipolar disorder, did not receive enteral feedings as ordered by the physician. The resident's care plan specified the need for a PEG tube for adequate nutritional intake and required tube feedings to be administered according to physician orders. The physician's orders included continuous Glucerna 1.5 feedings via pump overnight, scheduled bolus feedings, and water flushes. On the morning of the survey, observation revealed that the resident's feeding tube was not connected, and the feeding pump was turned off, despite the presence of a full bag of Glucerna and water hanging on the pole. Interviews with nursing staff confirmed that the overnight continuous feeding had not been administered as ordered, and there was no documentation or report of the resident refusing the feeding. The DON confirmed that the resident should have received the ordered continuous feeding but did not.
Failure to Document Wound Care Administration or Refusal
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that a resident's medical record accurately reflected whether physician-ordered wound care was implemented or refused. Specifically, for one resident with multiple complex diagnoses, including chronic osteomyelitis, hemiplegia, peripheral vascular disease, and an unhealed, unstageable pressure ulcer, there was no documentation on the Treatment Administration Record (TAR) indicating that wound care was provided or refused on two consecutive days, as required by both physician orders and facility policy. Facility policy required that skin and wound care be documented upon admission, readmission, weekly, and as needed, with each dressing change or at least weekly, including the date and time of treatments. Review of the resident's care plan and physician orders confirmed the need for daily wound care to the left lateral foot. During interviews, facility staff confirmed the absence of documentation for the specified dates and acknowledged that, if care had been refused, this should have been recorded on the TAR but was not.
Failure to Provide Scheduled Bathing Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to a resident who was unable to perform these tasks independently. The resident, who had multiple complex medical conditions including chronic osteomyelitis, hemiplegia, and a documented unhealed pressure ulcer, required moderate assistance for bathing and was dependent for all transfers. According to the care plan, the resident was to receive assistance with bathing, hygiene, and grooming. However, a review of the electronic health record and facility documentation revealed that the resident received only three documented baths in the past 30 days, despite being scheduled for three baths per week. Interviews with staff and review of the facility's bath schedule and refusal binder indicated inconsistencies in documentation, with some staff stating the resident did not refuse care, while others noted refusals that were not consistently documented in the medical record. The deficiency was further substantiated by the resident's own report of not having received a bath in two weeks and expressing a desire for daily bathing. The facility's system for tracking refusals and bath schedules was found to be inadequate, as the resident was overlooked in the process and not all refusals or missed baths were properly recorded. The Director of Nursing acknowledged the lack of documentation and the failure to provide the scheduled care, confirming that the resident had not received a bath within the past two weeks as required by their care plan.
Failure to Maintain Sanitary and Orderly Facility Environment
Penalty
Summary
Surveyors observed multiple instances of inadequate housekeeping and maintenance services within the facility, resulting in unsanitary and disordered conditions. In one resident's room, the floor was found to have hair and a dark brown substance near the bed, while the wall near the bed had a moderate amount of a splattered tan and pink substance. The window blinds in the same room were broken and in disrepair. These conditions persisted over several days, as confirmed by repeated observations and interviews with the resident, who stated that the wall and blinds had been in this state for some time and expressed a desire for them to be cleaned and replaced. Additional observations included a large puddle of yellow liquid on the floor in another room, accompanied by a strong urine odor, which was confirmed by a corporate staff member to be unsanitary and in need of cleaning. In a hallway near another room, a ceiling tile was found to have a moderate amount of mold, reportedly due to a leak that had been ongoing for several weeks. Housekeeping and maintenance staff confirmed that the issue had been reported but not resolved, and the ceiling tile required replacement. These findings indicate a failure to maintain a sanitary and orderly environment for residents, staff, and the public.
Failure to Perform Ordered Weights and Obtain Wound Care Orders
Penalty
Summary
The facility failed to provide care and services that meet professional standards of quality by not performing resident weights as ordered and not obtaining physician orders for wound care. Specifically, three residents with significant weight loss or at risk for weight changes were not weighed weekly as required by facility policy and as recommended by the registered dietician. For example, one resident experienced a 5% weight loss over 30 days and was not weighed weekly after this was identified, another resident was not weighed weekly as indicated in their care plan, and a third resident with significant weight loss also missed weekly weights despite dietician recommendations. These lapses were confirmed by the Director of Nursing (DON) during interviews, who acknowledged that the required weekly weights were not performed. Additionally, the facility failed to input physician orders for wound care for a resident with active wounds. Observation revealed bandages on both forearms of the resident, but there were no active treatment orders for these wounds in the medical record. The treatment nurse and DON both confirmed that physician orders should have been in place for all active wounds, but were not obtained for this resident.
Failure to Provide Accessible Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents received reasonable accommodation for their needs and preferences regarding access to call lights. For one resident with a history of spondylolisthesis, neuromuscular dysfunction of the bladder, hemiplegia, and other conditions resulting in total dependence and limited use of fingers and arms, the call bell was repeatedly observed out of reach, placed on the bedside table away from the bed. The resident reported being unable to use the call bell unless it was placed near her fingers and stated she had to yell for help or rely on her roommate. The responsible party also confirmed that the call bell was not consistently within reach during visits. Facility staff, including the DON, confirmed through observation and interview that the resident was physically incapable of using the standard call bell. Another resident, with diagnoses including paroxysmal atrial fibrillation, respiratory failure, heart disease, malnutrition, and psychiatric disorders, was also found to have the call bell inaccessible, clipped to a light over the bed and out of reach. This resident, who required substantial assistance with activities of daily living and had moderately impaired cognition, stated he had to holler for assistance due to the call light not being accessible. Staff confirmed that the call bell was not within reach and that the resident was unable to utilize it due to physical limitations. Facility policy required that call lights be placed on the bed and within reach at all times, but this was not followed for these residents.
Failure to Perform Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a nurse failed to perform proper hand hygiene during the treatment of multiple pressure ulcers for a resident. The resident, who was totally dependent on staff for all activities of daily living and had intact cognition, was admitted with several medical conditions including spondylolisthesis, neuromuscular dysfunction of the bladder, major depressive disorder, hemiplegia, and a history of urinary tract infection. Physician orders required specific wound care for five separate pressure ulcers, including cleansing, application of medihoney and calcium alginate with silver, and covering with dry dressings. During an observed wound care session, the nurse did not perform hand hygiene with alcohol-based hand rub or handwashing when changing gloves or between the care of each of the resident's five pressure ulcers. The nurse later confirmed in an interview that she did not perform hand hygiene during the wound care and believed it was only necessary between residents or if hands were visibly soiled. The Director of Nursing confirmed that hand hygiene should have been performed when changing gloves and between the care of each wound, but it was not done in this instance.
Medication Error: Omission of Prescribed Amiodarone Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident was free from medication errors by not administering a prescribed medication as ordered upon the resident's return from hospitalization. Specifically, the resident, who had multiple diagnoses including Paroxysmal Atrial Fibrillation, heart failure, and psychiatric disorders, was discharged from the hospital with an updated medication list that included Amiodarone HCL 400mg to be taken every morning. Upon review of the resident's medical record, physician orders, and MAR for June 2025, it was found that Amiodarone was not initiated after the resident's re-entry to the facility. Interviews with the nurse practitioner and the Director of Nursing confirmed that the medication was overlooked and not administered as directed in the hospital discharge paperwork. The resident, who had moderately impaired cognition and required substantial assistance with activities of daily living, did not receive the medication as ordered, constituting a medication error. There were no reported adverse reactions related to this omission at the time of the survey.
Failure to Provide Ordered Wound Care Leads to Cellulitis
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the resident's person-centered plan of care for a resident who sustained a skin tear on the right elbow following a fall. The resident, who had severe cognitive impairment and used a manual wheelchair, did not receive the ordered wound care on multiple occasions. Despite a physician's order on 02/23/2025 to clean the wound, apply Triple Antibiotic Ointment, and cover it with a clean dry dressing, the treatment was not administered on 02/23/2025, 02/24/2025, and there was no documentation of care on 02/25/2025. This lack of care led to the development of cellulitis, requiring antibiotic treatment. Interviews with facility staff revealed discrepancies in the documentation and administration of wound care. The Director of Nursing (DON) admitted to signing off on the Treatment Administration Record (TAR) for dates when care was not provided, based on the assumption that it had been done. The Assistant Director of Nursing (ADON) confirmed that no wound care had been provided since the incident. The treatment nurse was unaware of the wound until 02/26/2025, when the resident was diagnosed with cellulitis. This series of inactions and miscommunications resulted in harm to the resident, highlighting a significant deficiency in the facility's care practices.
Inaccurate Documentation of Wound Care for a Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who sustained a fall resulting in a wound to the right elbow. On the day of the incident, a Registered Nurse (RN) notified the provider and received an order for wound care, but this order was not documented or entered into the system. The Director of Nursing (DON) later realized the oversight and entered the order with a backdated start date. Despite the order being received, the wound care was not documented as performed on the specified dates. The DON admitted to initialing the Treatment Administration Report (TAR) for wound care on two dates, even though she did not personally perform the care, because the nurse responsible had not initialed it. This resulted in inaccurate documentation in the resident's medical records. The DON confirmed that she did provide wound care on a subsequent date but failed to document it, further contributing to the inaccuracy of the resident's medical records.
Failure to Follow Care Plans for Lab Tests and Wound Care
Penalty
Summary
The facility failed to provide services according to the residents' care plans for two residents. For one resident, the facility did not follow the physician's orders for monthly Trileptal lab tests, missing results for several months. This resident had a history of Type 2 Diabetes Mellitus, Cerebellar Stroke Syndrome, and a seizure disorder, which required regular monitoring of Trileptal levels as part of their care plan. The Interim Director of Nursing confirmed that the lab tests were not conducted as required. Another resident did not receive wound care as ordered by the physician. This resident, who had a surgical wound, was supposed to have daily wound care, but the treatment was not performed on a specific day when the resident was out for an Intensive Outpatient Program. The nursing staff failed to communicate effectively, resulting in the wound care not being administered upon the resident's return. Interviews with various staff members revealed a lack of communication and coordination, leading to the oversight in wound care treatment.
Failure to Maintain Clean and Safe Equipment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for its residents, specifically concerning the cleanliness and repair of patient care equipment. Resident #52's wheelchair and cushion were observed to be soiled with a brown substance over several days, indicating a lack of proper cleaning and maintenance. Interviews with staff, including a CNA, LPN, and the Housekeeping Supervisor, revealed confusion and lack of clarity regarding responsibility for cleaning the wheelchairs. The Assistant Director of Nursing (ADON) acknowledged that it was everyone's responsibility to clean visibly soiled wheelchairs but was unsure of a scheduled cleaning day, ultimately placing the responsibility on housekeeping. Additionally, Resident #39's wheelchair was found to have cracks and tears in the arm pads, exposing the material underneath. This condition had persisted for about two years, as confirmed by the resident and a CNA who had been working since September 2024. The Maintenance staff was unaware of the disrepair, indicating a failure in reporting and addressing equipment maintenance issues. These deficiencies highlight a lack of adherence to the facility's policy on maintaining reusable medical devices, potentially compromising resident safety and comfort.
Incorrect MDS Discharge Encoding for Resident Transfer
Penalty
Summary
The facility failed to accurately encode and transmit a Discharge MDS Assessment for a resident, leading to a deficiency. The resident, who had a complex medical history including Bipolar Disorder, Sepsis, Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, and Hypertension, was admitted to the facility and requested a transfer to a sister facility after staying only one night. The resident's discharge was incorrectly recorded as an unplanned, facility-initiated discharge instead of a planned, resident-initiated discharge. Interviews with facility staff revealed that the MDS Coordinator, S18, mistakenly input the discharge data as facility-initiated. This error was confirmed by the Assistant Director of Nursing, S3, who acknowledged that the MDS transmission report was completed incorrectly. The discrepancy in the discharge coding was identified during a review of the facility's MDS transmission report, which showed the incorrect Assessment Reference Date and discharge type for the resident.
Failure to Implement Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not implementing physician's orders as prescribed for a resident receiving tube feeding. The resident, who has a complex medical history including cerebral infarction, schizoaffective disorder, and dysphagia, was supposed to receive continuous enteral feeding of Glucerna 1.5 at 55 ml/hr and water at 45 ml/hr via a PEG tube. However, observations on a specific day revealed that the resident was not receiving the prescribed continuous feeding, and instead, a bottle of Jevity 1.5, which was not the ordered formula, was found hanging and disconnected from the resident. Interviews with facility staff, including an LPN and the interim DON, confirmed that the incorrect formula was administered and that the continuous feeding had not been maintained as ordered. The LPN admitted to hanging the last bottle of the correct formula, Glucerna 1.5, on a previous evening, indicating a lapse in following the physician's orders. This deficiency was confirmed by the interim DON and the assistant DON, highlighting a failure in ensuring that the resident's nutritional needs were met according to professional standards and physician directives.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #52, during meal times, which is a violation of their Meal-Time Assistance Policy. Resident #52, who has a history of Huntington's disease, contracture of the right hand, drug-induced subacute dyskinesia, and vitamin deficiency, requires assistance with activities of daily living, including eating. The resident's care plan and physician's orders specify that they need assistance with meals and should be seated at the assist table. However, during observations on two separate days, Resident #52 was not provided with the required assistance during meals, resulting in food being dropped and the resident struggling to eat independently. On the first observation, Resident #52 was seen eating without assistance, dropping food, and struggling due to arm tremors. The CNA interviewed stated that the resident usually feeds himself and does not sit at the assistance table, contradicting the care plan. On the second observation, although seated at the designated assistance table, Resident #52 was again left to eat without help, consuming 80% of the meal but with difficulty and food spillage. The resident expressed a need for assistance, which was not provided until prompted by the surveyor. Interviews with staff confirmed that the resident should have been assisted, highlighting a failure in adhering to the facility's policy and care plan requirements.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure staff followed a resident's person-centered plan of care by not using the required two-person physical assistance during a transfer. This deficiency involved a resident with a history of hypertensive heart disease with heart failure, schizoaffective disorder, major depressive disorder, and peripheral vascular disease. The resident, who had intact cognition and required a two-person assist for bed mobility and transfers, was transferred by a single CNA without the use of a Hoyer lift, contrary to the care plan. During the transfer, the resident tensed and jerked backward, resulting in a head injury. The incident occurred when the CNA attempted to transfer the resident alone after calling for help and receiving no response. The resident hit his head on the wooden headboard, causing a superficial laceration with moderate bleeding. The facility's MD assessed the resident, determined the laceration was superficial, and ordered neuro checks. The incident highlighted a failure in communication and adherence to the care plan, leading to the resident's injury.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents, leading to deficiencies in the handling and storage of respiratory equipment. Resident #81, who has a history of Chronic Obstructive Pulmonary Disease, Asthma, and other respiratory conditions, was observed with a nasal cannula lying uncovered and undated on top of an oxygen concentrator. This observation was confirmed by an LPN, who acknowledged that the equipment should have been properly covered and dated. The resident's care plan indicated the need for oxygen during respiratory crises, yet the equipment was not maintained according to these standards. Similarly, Resident #67, who has multiple diagnoses including Cerebral Infarction and Schizoaffective Disorder, was observed multiple times with a nebulizer concentrator and respiratory suction that were uncovered and undated. Despite the resident's care plan specifying the need for respiratory therapy and monitoring for medication effectiveness, the equipment was not properly managed. An LPN confirmed that the equipment should have been covered and dated, indicating a lapse in adherence to professional standards for respiratory care within the facility.
Insufficient Nursing Staff on Specific Day
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available at all times to meet the needs and safety of residents, which compromised their rights, physical, mental, and psychosocial well-being. On 09/28/2024, the facility's census was 110 residents, and the minimum staffing hours required for that day was 258.5 hours. However, the facility only provided 256.5 nursing hours, falling short by 2 hours. This deficiency was confirmed by the S2 Interim Director of Nursing (DON) during an interview, acknowledging the shortfall in staffing hours necessary to meet the residents' needs and safety.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident on two separate occasions. On the first incident, a resident with a history of wandering and cognitive impairments entered another resident's room, leading to a physical altercation. The resident was found on the floor being kicked by the other resident, resulting in no immediate injuries reported by the Director of Nursing (DON). However, the resident was later involved in another incident where he was pushed from behind by the same resident, causing him to fall and sustain a laceration to his lip that required emergency medical attention. The resident who was abused had a complex medical history, including cerebral infarction, chronic kidney disease, schizoaffective disorder, and a history of traumatic brain injury, which contributed to his cognitive impairments and wandering behavior. His care plan noted the need for increased supervision due to his unsteady gait and history of falls. Despite these precautions, the resident was not adequately protected from the aggressive behavior of another resident, who had a history of physically and verbally aggressive behavior and was known to have delusions and refusal of care. The second resident involved in the incidents had intact cognition but displayed aggressive behaviors, including delusions and a history of pacing and wandering. The facility's failure to effectively manage and separate these residents, despite their known behavioral issues, resulted in physical harm to the first resident. The incidents highlight a deficiency in the facility's ability to ensure the safety and protection of its residents from abuse by others within the facility.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe to the State Survey Agency. The incident involved a resident with a history of cerebral infarction, chronic kidney disease, schizoaffective disorder, and other conditions, who was found on the floor being kicked by another resident. The resident who was the aggressor had a history of schizoaffective disorder, bipolar type, and displayed physically and verbally aggressive behavior. Despite the incident being reported to the Director of Nursing (DON) by a Certified Nursing Assistant (CNA), the DON did not complete a SIMS report for the incident. The incident occurred when a CNA heard a noise from the room of the resident with aggressive behavior and found the other resident on the floor being kicked. The aggressor admitted to the actions when questioned. The facility's failure to report the incident within two hours, as required for allegations involving abuse, constitutes a deficiency in adhering to regulatory requirements for reporting suspected abuse, neglect, or mistreatment.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of staff-to-resident physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Resident #1, who had a BIMS score of 13 indicating intact cognition, reported that approximately two weeks prior, a CNA hit him with a fan on his back and head, and then took him to a shower room where she hit him with a plastic hanger on various parts of his body. Resident #1 also reported verbal abuse, including being called derogatory names. He stated that he reported the incident to a nurse on duty that evening and to the facility administrator the following morning. The facility administrator confirmed that she was notified of the allegation on 02/26/2024, and that the alleged incident occurred on 02/25/2024. Despite this, the allegation was not entered into the Statewide Incident Management System (SIMS) as required. The failure to report the incident within the mandated timeframe constitutes a deficiency in the facility's adherence to its abuse prevention and prohibition policy.
Failure to Thoroughly Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that an allegation of staff-to-resident physical abuse was thoroughly investigated for one of the sampled residents. The facility's policy requires a thorough investigation, including interviews with employees, obtaining signed statements, and interviewing the resident if cognitively able. However, the investigation documentation for the resident in question lacked a timeline of the investigation and signed statements from staff. The resident, who had intact cognition, reported being physically abused by a CNA, including being hit with a fan and a plastic hanger, and subjected to derogatory language. The resident reported the incident to a nurse and the administrator the following morning. The administrator confirmed that she was notified of the allegation and conducted interviews with the resident, the resident's roommate, and the involved CNAs. However, she did not obtain written statements from the staff or the roommate. The administrator acknowledged that the investigation documentation was incomplete, lacking a timeline and signed statements, which is a violation of the facility's policy on abuse prevention and prohibition.
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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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