Magnolia Manor Nursing And Rehab Ctr, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 1411 Claiborne Avenue, Shreveport, Louisiana 71103
- CMS Provider Number
- 195406
- Inspections on file
- 25
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Magnolia Manor Nursing And Rehab Ctr, Llc during CMS and state inspections, most recent first.
A resident with multiple medical and psychiatric diagnoses, including schizoaffective disorder and a moderately impaired BIMS score, was started on Depakote 125 mg BID for mood stabilization. The MAR showed the medication was administered as ordered, but the resident’s responsible party reported she was not informed of the new medication and only learned of it when the resident later refused a blood draw for a Depakote level. Review of the medical record, including progress notes, showed no documentation of notification to the responsible party, and the DON confirmed that notification should have occurred and that there was no evidence it had been done.
A resident with severe cognitive and physical impairments was physically and verbally abused by a CNA during care, as captured on surveillance video. The CNA forcefully handled the resident's limbs, used profane language, and expressed refusal to continue care, causing the resident distress. The incident was not immediately reported by staff, and was only brought to administration's attention after the resident's family provided video evidence.
A CNA provided care to a resident in a hurried and disrespectful manner, making dismissive comments and speaking about the resident to other staff during care. The resident, who had impaired mobility and was resistive to care, expressed discomfort during the interaction. Leadership confirmed that the care provided did not promote dignity or quality of life.
A CNA failed to recognize and report physical and verbal abuse by another CNA during incontinent care for a resident with significant cognitive and physical impairments. The abuse, which included rough handling and use of profane language, was not reported to administration as required by facility policy, and was only discovered after a family member provided video evidence. The deficiency involved a breakdown in timely internal reporting of suspected abuse.
A facility failed to monitor a resident's edema while the resident was receiving Furosemide, a diuretic, for chronic pulmonary edema and heart failure. Despite the prescription, there was no documentation of edema monitoring, as confirmed by an LPN and the DON.
A facility failed to provide necessary respiratory care by not cleaning a resident's oxygen concentrator filter weekly as required. The resident, who required continuous oxygen due to conditions like pneumonia and COPD, was observed with a concentrator filter containing a gray film. An LPN admitted to being unaware of the cleaning requirement, indicating a lapse in following the facility's policy.
A resident with cognitive impairments was physically abused by a staff member in a LTC facility. The incident involved the resident, who was in a wheelchair, and a staff member identified as S7 Sunshine Aide. Surveillance video showed the aide hitting the resident with a plastic cup during an altercation. The resident, known for aggressive behaviors, was assessed with no physical injuries but experienced severe psychosocial harm.
Failure to Notify Responsible Party of New Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a new medication order. The resident was admitted with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, bipolar II disorder, type 2 diabetes mellitus, schizoaffective disorder bipolar type, generalized anxiety disorder, unspecified convulsions, unspecified conjunctivitis, a left hip contracture, and a sacral pressure ulcer. The resident’s MDS showed a BIMS score of 9, indicating moderately impaired cognition. In June 2025, the physician ordered Depakote 125 mg by mouth twice daily for mood stabilization related to schizoaffective disorder, bipolar type, with a start date of 06/30/2025, and the June 2025 MAR documented that Depakote administration began on that date. During a telephone interview, the resident’s responsible party reported she was not notified when Depakote was started and only became aware of the medication on 07/24/2025 when the resident refused a blood draw for a Depakote level. Review of the resident’s medical record, including progress notes, did not reveal any documentation that the responsible party had been informed of the initiation of Depakote in June 2025. In an interview, the DON confirmed that the responsible party should have been notified of the Depakote order and acknowledged she could not provide any evidence that such notification occurred.
Failure to Protect Resident from Physical and Verbal Abuse by CNA
Penalty
Summary
A cognitively impaired resident with multiple neurological and psychiatric diagnoses, including hemiplegia, dementia, anxiety disorder, bipolar disorder, and schizophrenia, was subjected to physical and verbal abuse by a Certified Nurse Assistant (CNA) during morning care. The resident required extensive two-person assistance for all activities of daily living except feeding and was always incontinent of urine and bowel. The incident was captured on a surveillance video, which showed the CNA pulling down on the resident's contracted leg, forcefully snatching the resident's arm from the side rail, and aggressively removing the resident's diaper. The resident verbally expressed pain during the incident. In addition to the physical actions, the CNA was heard cursing at the resident and making statements indicating frustration and refusal to continue care. The resident responded by apologizing repeatedly, suggesting distress and possible psychosocial harm. The facility's policy clearly prohibits any form of abuse, including physical and verbal abuse, and outlines specific procedures for the detection, prevention, and reporting of such incidents. Interviews with staff and the resident's family confirmed the abusive behavior observed in the video. The CNA involved was not the resident's primary caregiver but was assisting another CNA at the time. The second CNA present acknowledged that the actions observed constituted abuse and should have been reported immediately. The incident was not reported until the resident's sister brought it to the attention of facility administration, indicating a failure in immediate identification and reporting of abuse as required by facility policy.
Failure to Provide Dignified and Respectful Care During Resident Assistance
Penalty
Summary
A deficiency occurred when a CNA provided care to a resident in a hurried and disrespectful manner, as captured on a surveillance video. The CNA made dismissive comments, such as 'Just nothing else better to do' and 'waste it; I don't care; I don't have nothing to do with that,' while attempting to remove a cup of juice from the resident's hand. The resident, who had impaired physical mobility, a self-care deficit, and was known to be resistive to care due to anxiety, moved their hand away, and later expressed discomfort by hollering 'you're hurting me' as linens were removed forcefully from under their leg. The CNA also spoke about the resident to other staff during care, further compromising the resident's dignity. The resident's care plan included specific interventions, such as using a draw sheet for turning and repositioning per family request, and required turning and repositioning every two hours, as well as incontinence care. Despite these documented needs, the care provided was not consistent with promoting the resident's dignity or quality of life. The CNA's actions included rushing through care, speaking disrespectfully, and engaging in conversations about the resident with other staff in the resident's presence. Interviews with facility leadership confirmed that care should be provided at the resident's eye level, without hurried actions or staff conversations unrelated to the resident's care. The Director of Nursing and other administrators acknowledged that the CNA's behavior was inappropriate and did not uphold the resident's right to dignity during care.
Failure to Timely Report and Recognize Resident Abuse During Care
Penalty
Summary
A deficiency occurred when the facility failed to implement its policies and procedures to ensure that an allegation of abuse was reported to administration in a timely manner. During incontinent care, a Certified Nurse Assistant (CNA) engaged in both physical and verbal abuse toward a resident, which was not immediately recognized or reported by another CNA present during the incident. The facility's policy required that any abuse or suspicion of abuse be reported immediately to the Administrator or designee, but this did not occur as required. The resident involved had significant medical conditions, including neurological disorders, hemiplegia, dementia, anxiety, bipolar disorder, schizophrenia, muscle wasting, and cognitive decline. The resident was dependent on staff for bed mobility and transfers, and was always incontinent of bladder and bowel. During the incident, surveillance video captured the CNA pulling on the resident's contracted leg, causing the resident to express pain, and forcefully removing the resident's arm from a side rail. The CNA also used profane language and expressed frustration during care, while the resident repeatedly apologized. The other CNA present did not intervene or report the abuse at the time. The failure to report the abuse was later acknowledged by the second CNA after receiving in-service training on identifying and reporting abuse. The incident was only brought to the attention of administration after the resident's sister presented video evidence. The delay in reporting and failure to follow internal reporting procedures constituted the deficiency cited in the report.
Failure to Monitor Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically in the case of a resident with chronic pulmonary edema and chronic diastolic heart failure. The resident was prescribed Furosemide, a diuretic, to be taken twice daily. However, the facility did not monitor the resident's edema as required. This lack of monitoring was confirmed during an interview with an LPN, who acknowledged the absence of documentation for edema monitoring. The Director of Nursing also confirmed that the resident was not monitored for edema, which should have been done.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards for a resident who required continuous oxygen support. The deficiency was identified during a review of the facility's practices and an observation of the resident's oxygen concentrator. The facility's policy mandates that humidifier bottles, cannulas, and oxygen tubing be changed at least once weekly and dated, and that the concentrator filter should be cleaned weekly or as needed. However, observations revealed that the filter on the resident's oxygen concentrator contained a fine gray film, indicating it had not been cleaned as required. The resident, who was admitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and dependence on supplemental oxygen, was observed wearing continuous oxygen at 2 liters via nasal cannula. Despite the resident's continuous use of oxygen, the filter remained uncleaned over multiple observations. An LPN interviewed during the survey acknowledged the dirty condition of the filter and was unaware of the requirement to clean it, highlighting a lapse in adherence to the facility's respiratory care policy.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse and psychosocial harm by a staff member. The incident involved a cognitively impaired resident who was observed on surveillance video being physically abused by a staff member, identified as S7 Sunshine Aide. The aide was seen hitting the resident on her hands and forearm with a hard plastic kitchenware cup. This incident occurred when the resident, who was in a wheelchair, approached a coffee cart and picked up cups, leading to an altercation with the aide. The resident involved had a history of cognitive impairments, including vascular dementia with behavioral disturbances, and was known to exhibit aggressive behaviors. The resident's medical record indicated severe cognitive impairment with a BIMS score of 5 out of 15. The resident's care plan included interventions for managing aggressive behavior, such as using a calm voice and avoiding arguments. Despite these measures, the resident engaged in a physical altercation with the aide, who reacted by hitting the resident. The incident was captured on surveillance video, which showed the aide and the resident swinging at each other, with the aide making contact with the resident's arm. Interviews with staff members confirmed the altercation, and the aide was subsequently sent home. The facility's investigation revealed that the aide's actions constituted physical abuse, and the resident was assessed with no physical injuries but was determined to have experienced severe psychosocial harm due to the incident.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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