Lexington House
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 16 Heyman Lane, Alexandria, Louisiana 71303
- CMS Provider Number
- 195424
- Inspections on file
- 29
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lexington House during CMS and state inspections, most recent first.
Surveyors found that staff failed to keep call lights within reach for three dependent residents with conditions such as hemiplegia, muscle weakness, gait abnormalities, and a history of falls. In each case, the call light was observed hanging off the side of the bed or lying on the floor, and the resident reported being unable to locate it. CNAs and an LPN acknowledged that call lights were supposed to be on the bed and within residents’ reach at all times, consistent with facility policy, but this was not done for these residents.
A resident with severe cognitive impairment, hemiplegia, and a left AKA reported right lower extremity pain, and imaging confirmed traumatic fractures of the tibia and fibula. The facility classified this as an injury of unknown origin but did not complete a thorough investigation as required by policy: a CNA who had provided care in the 48 hours before the injury was not interviewed or asked for a statement, and the administrator, despite having access to 72 hours of video surveillance, reviewed only the most recent 24 hours prior to discovery of the injury.
A CNA instructed a resident with moderate cognitive impairment and multiple health conditions not to use the call light because she was busy, an action confirmed by both the CNA and the DON as inappropriate and disrespectful. The resident reported this was not the first occurrence, and facility policy requires staff to treat all residents with dignity and respect.
Staff were observed preparing pureed foods without measuring portions or following prescribed recipes, instead relying on visual estimation. The dietary aide and manager both confirmed that recipes were not followed, and the dietician noted this could result in inaccurate nutritional content for residents on pureed diets. This practice had the potential to affect multiple residents receiving pureed diets.
The facility did not maintain a clean and sanitary kitchen, with unlabeled open food items, staff not wearing required hair and beard restraints, unsanitary air conditioner vents, and improper dish sanitization practices. Logs for dishwasher temperatures were also incomplete, and these failures had the potential to affect all residents receiving meals.
A resident with severe cognitive impairment and total care needs was repeatedly observed in bed with the call light on the floor and out of reach, despite facility policy and the care plan requiring it to be accessible. Staff confirmed the call light was not within reach as required.
Two residents were not given the required SNF ABN (CMS-10055) before their Medicare Part A services were discontinued, even though benefit days remained. In both cases, the Accounts Manager stated she was unaware of the need to provide this notice prior to ending skilled services, and both residents continued to reside in the facility after skilled services ended.
Two residents were affected by the facility's failure to follow and develop person-centered care plans. One resident, with moderate cognitive impairment and multiple chronic conditions, was found keeping cigarettes and a lighter in her wheelchair pouch despite a care plan and policy requiring these items to be stored at the nurses' station. Another resident with severe cognitive impairment and a history of eating non-food items was not timely care planned for this behavior, even after multiple incidents of chewing or ingesting non-food items were documented. Staff confirmed these lapses during interviews and record reviews.
The facility did not ensure physician-ordered wound care was provided and documented for three residents with complex medical needs, including pressure ulcers, diabetic ulcers, and skin tears. Wound care was missed or undocumented on multiple occasions, and staff confirmed that treatments were not completed as required.
The facility did not ensure accurate documentation and proper witnessing procedures for controlled medication administration and wasting. An LPN failed to document the administration of a narcotic tablet at the time of administration for a resident, and in a separate case, two narcotic tablets wasted by a nurse lacked the required witness signature. Facility leadership confirmed that staff were aware of these documentation and witnessing requirements.
A resident with multiple medical conditions, including Alzheimer's and a history of UTIs, was observed on several occasions without a water pitcher or fluids at the bedside, despite facility policy and care plan requirements for regular fluid provision. Staff confirmed the resident had no fluid restrictions and should have had fluids available, but documentation showed inconsistent fluid offers.
A resident with a history of UTIs did not receive timely and appropriate treatment due to a breakdown in the facility's process for handling lab results. Despite a culture and sensitivity test indicating resistance to the initially prescribed antibiotic, the resident continued to receive inappropriate treatment until much later, when the correct antibiotic was finally administered.
Failure to Keep Call Lights Within Reach of Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were accessible to multiple residents, contrary to the facility’s own call light policy requiring staff to place the call light within the resident’s reach before leaving the room. For Resident #2, who had hemiplegia, generalized muscle weakness, repeated falls, and was dependent for toileting, hygiene, bathing, dressing, rolling, and transfers, surveyors observed the call light hanging off the left side of the bed, dangling below the bottom of the mattress. Resident #2 stated she was unable to locate the call light. When accompanied by S4LPN, it was confirmed that the call light was not within reach but should have been accessible to the resident at all times. For Resident #3, who had hemiplegia, paroxysmal atrial fibrillation, muscle weakness, syncope and collapse, a history of falling, and severely impaired cognition with a BIMS score of 3, surveyors observed the call light hanging off the left side of the bed near the floor. Resident #3 reported being unable to locate the call light, and S11CNA confirmed that the call light was not within reach and should have been. For Resident R4, who had abnormalities of gait and mobility, generalized muscle weakness, age-related physical debility, and repeated falls, surveyors observed the resident lying in bed with the call light on the floor to the left of the bed. S6CNA confirmed that this call light also was not within reach but should have been. Additional interviews with S10LPN and S3QI confirmed that facility practice and expectations were for call lights to be on the bed, within reach of residents, and in their hand when possible, reinforcing that the observed situations represented failures to follow established procedures.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident had diagnoses including hemiplegia, hemiparesis, dementia, and a left above-knee amputation, and was dependent for hygiene, bathing, dressing, and position changes. A Significant Change MDS showed a BIMS score of 3, indicating severely impaired cognition. On a specified date, the resident complained of pain to the right lower extremity, and x‑rays of the right knee, tibia, and fibula demonstrated traumatic fractures of the proximal tibial and fibular diaphyses and tibial shaft. The facility completed a Critical Incident Report and substantiated an injury of unknown origin based on its policy criteria that the source of the injury was not observed, could not be explained by the resident, and was suspicious due to the extent and location of the injury. Despite policy requirements that the administrator thoroughly investigate all alleged violations and injuries of unknown origin, the investigation was incomplete. Nursing staff who rendered care during the 48 hours prior to discovery of the injury were to provide statements, but a CNA who provided care to the resident from 3:00 p.m. to 11:00 p.m. on the two days before the injury was identified was not interviewed or asked for a statement, even though she confirmed she had provided care during that period. Additionally, the administrator had access to 72 hours of facility video surveillance footage prior to discovery of the injury but reviewed only the previous 24 hours and acknowledged not reviewing the full 72-hour period prior to the injury, despite stating she should have done so.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
Facility staff failed to treat a resident with respect and dignity, as required by facility policy and federal regulations. During an observation, a CNA told a resident not to use the call light anymore because she was busy. The CNA later confirmed to the surveyor that she made this statement and acknowledged it was rude. The resident, who has moderate cognitive impairment and multiple medical conditions including congestive heart failure, diabetes, and dementia, reported that this was not the first time the CNA had told her not to use the call light. At the time of the incident, the resident was observed sitting in her wheelchair with her head down and expressed that she did not want to be told not to use her call light. The Director of Nursing confirmed that it was not the expectation for any staff member to instruct a resident not to use the call light, regardless of how busy they were. The facility's policy on dignity and respect requires staff to display respect when speaking with and caring for residents, and to promote the rights of residents to a dignified existence and self-determination. The actions of the CNA were inconsistent with these requirements and resulted in a failure to ensure the resident was treated with respect and dignity.
Failure to Follow Pureed Diet Recipes During Meal Preparation
Penalty
Summary
The facility failed to ensure that recipes for pureed diets were followed during meal preparation, as observed during a lunch service. A dietary aide was seen preparing pureed foods without measuring portions or adhering to the prescribed recipes, instead relying on visual estimation based on the pan size. The dietary aide confirmed that recipes and measurements were not used when preparing pureed foods. The dietary manager also confirmed that the aide did not follow the required recipes and acknowledged this was not the first occurrence, referencing prior disciplinary action. Additionally, the facility dietician confirmed that failure to follow pureed recipes could result in inaccurate nutritional content for residents receiving pureed diets. This practice had the potential to affect twelve residents who were on pureed diets.
Failure to Maintain Sanitary Kitchen and Adhere to Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not adhere to professional standards for food storage, preparation, and service. Observations revealed that food items in the pantry, such as an open bag of penne pasta, were not labeled with an open date as required. Staff were observed not wearing appropriate hair restraints, including beard restraints, while preparing food, and it was confirmed that beard restraints were unavailable at the time. Additionally, the kitchen's air conditioner vents were found to be unsanitary, covered in a black substance, and there was uncertainty regarding the last time they had been cleaned. Further deficiencies were identified in the dish sanitization process. A dietary aide was observed failing to properly sanitize dishes using the 3-compartment sink, with the sanitization strip being non-reactive on two attempts and the sanitization hose placed in the wrong compartment. The chemical sanitizer was not mixed to the proper concentration, and there was no evidence that water temperature or sanitizer levels were checked or recorded as required. Review of dishwasher temperature logs also revealed missing entries for multiple dates. These failures had the potential to affect all 115 residents who received meals from the kitchen.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's, dementia, and limited mobility, was not provided reasonable accommodation for their needs. The facility's policy and the resident's care plan both required that the call light be placed within the resident's reach to allow communication with staff. However, during multiple observations over two days, the call light was found on the floor next to the resident's bed, out of the resident's reach, while the resident was lying in bed and unable to access it. The resident was non-interviewable and required total care and extensive assistance for bed mobility. Staff confirmed during the survey that the call light was not accessible and acknowledged that it should have been within reach, as per facility policy and the resident's care plan. The repeated failure to ensure the call light was accessible constituted a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Provide Required SNF ABN Prior to Discontinuation of Medicare Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, Form CMS-10055) to residents or their responsible parties prior to discontinuing Medicare Part A services, as observed in the cases of two residents. One resident was discharged from Physical and Occupational Therapy due to non-compliance or refusal to participate, despite having Medicare benefit days remaining. The Accounts Manager confirmed that the SNF ABN was not provided because she was unaware of the form or the requirement to send it before discontinuing skilled services. Similarly, another resident was discharged from Medicare Part A services when benefit days were still available, due to cognitive inability to participate in therapy. The Accounts Manager again confirmed that the SNF ABN was not sent to the resident or their responsible party, citing lack of awareness of the form and its required use prior to discharge from skilled services. Both residents remained in the facility after skilled services were discontinued.
Failure to Implement and Develop Person-Centered Care Plans for Smoking Safety and Pica Behaviors
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, resulting in deficiencies related to smoking safety and management of pica behaviors. For one resident with chronic respiratory failure, COPD, diabetes, and moderate cognitive impairment, the care plan specified that cigarettes and lighters should be kept at the nurses' station and only provided upon request in designated smoking areas. However, observations and interviews revealed that the resident regularly kept a pack of cigarettes and a lighter in her wheelchair pouch, contrary to the care plan and facility policy. Staff confirmed that smoking supplies were not being stored as required. Another resident with severe cognitive impairment, dementia, and a history of eating non-food items was not timely care planned for this behavior. Progress notes documented multiple incidents where the resident chewed or ingested non-food items such as straws, plastics, paper, and cloth. During an observation, the resident was found chewing on string-like material and holding a bib with holes, with staff needing to remove pieces of cloth and food from her mouth. Despite these documented behaviors, the care plan did not initially address the risk of eating non-food items, and staff confirmed the absence of a relevant care plan focus during the review period. These deficiencies were identified through record review, staff and resident interviews, and direct observation, demonstrating a lack of adherence to established care plans and failure to timely address known behavioral risks for the affected residents.
Failure to Provide Wound Care as Ordered for Multiple Residents
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that physician's orders for wound care were implemented as prescribed for three residents. For one resident with chronic respiratory failure, dysphagia, cognitive deficits, and a Stage 3 sacral pressure ulcer, wound care orders were not followed as documented in the Treatment Administration Record (TAR). The wound care was missed on multiple days in April and May, with the Director of Nursing (DON) confirming that documentation was lacking and care was not completed as ordered. Another resident with diabetes, a recent amputation, peripheral vascular disease, and a diabetic foot ulcer also did not receive wound care as ordered. The electronic TAR (eTAR) showed that wound care for the diabetic ulcer and for moisture-associated skin damage (MASD) to the buttocks was not completed on several days in April and May. The DON acknowledged that wound care was not documented or completed as required by the physician's orders. A third resident with chronic respiratory failure, COPD, Parkinson's disease, and dementia had a skin tear to the right eyebrow. The care plan required daily wound care, but there was no evidence of an order to complete this care in the eTAR, and observations revealed the dressing was undated and the wound had dried blood. An LPN confirmed that the treatment should have been performed daily and the dressing should have been dated, but this was not done.
Failure to Accurately Document and Witness Controlled Medication Administration and Wasting
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administration of medications for its residents. Specifically, during a controlled medication reconciliation, it was found that a nurse administered a Clonazepam tablet to a resident but did not document the administration in the clinical record at the time it occurred. The nurse confirmed the omission, and facility leadership acknowledged that all floor nurses were aware of the requirement to document narcotic administration promptly in the clinical record. Additionally, the facility did not follow proper procedures for wasting or destroying narcotic medications. In one instance, two Oxycodone/Acetaminophen tablets were documented as wasted after being dropped, but there was no evidence of a required witness or second signature for either event. The nurse involved confirmed the lack of a witness signature, and the DON verified that all nurses were expected to have a witness and document accordingly when wasting narcotics. These failures were observed on two separate medication carts and involved two different residents.
Failure to Provide Sufficient Fluids for Hydration
Penalty
Summary
The facility failed to provide sufficient fluids to maintain adequate hydration for one resident, as required by facility policy and the resident's care plan. Multiple observations over several days revealed that the resident did not have a water pitcher or any other fluid for hydration at the bedside, despite being awake and alert in the room. The facility's policy mandates that a water pitcher with water and ice be placed at the bedside of all residents unless contraindicated, and that nursing assistants offer fluids every two hours unless restricted. Review of the resident's medical record showed no fluid restrictions, and both the CNA and LPN confirmed that the resident should have had a water pitcher available. The resident in question had a history of Alzheimer's, mild protein-calorie malnutrition, chronic ulcer, peripheral vascular disease, anxiety disorder, dysphagia, osteoarthritis, and a history of urinary tract infections. The care plan included interventions to encourage fluid intake, especially while on antibiotic therapy for a UTI, which required a minimum fluid intake per facility guidelines. Documentation of fluid offers was inconsistent and did not meet the every-two-hour standard. Staff interviews confirmed the absence of a water pitcher and acknowledged that the resident should have had one at the bedside.
Delayed Appropriate Treatment for UTI
Penalty
Summary
The facility failed to provide timely and appropriate treatment for a resident with a urinary tract infection (UTI). The resident, who had a history of UTIs and other medical conditions such as unspecified dementia and overactive bladder, was initially prescribed Bactrim DS after a urinalysis indicated elevated leukocytes and bacteria. However, a subsequent culture and sensitivity test revealed that the pathogen, Escherichia Coli, was resistant to Bactrim DS and other antibiotics, and was susceptible only to Ertapenem. Despite this, the resident continued to receive inappropriate antibiotics until the correct treatment was administered much later. The delay in appropriate treatment was due to a failure in the facility's process for handling lab results. Although the culture and sensitivity results were available and stamped by the facility shortly after being reported, they were not acted upon until much later. Interviews with facility staff revealed that lab results are faxed to the facility and can be accessed via computer, but there was a breakdown in communication and follow-up, leading to the resident not receiving the correct antibiotic in a timely manner.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
