Maison Du Monde Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Abbeville, Louisiana.
- Location
- 4000 Rodeo Road, Abbeville, Louisiana 70510
- CMS Provider Number
- 195567
- Inspections on file
- 19
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Maison Du Monde Living Center during CMS and state inspections, most recent first.
A resident with moderate hearing impairment and intact cognition, care planned as needing hearing aids, did not receive appropriate assistive devices after the facility failed to follow up with community resources. Social services knew the resident could not afford a hearing program’s application fee and that referrals had been made by an ENT to outside providers for assistance with hearing devices, including an evaluation that was never scheduled. Despite this and the facility policy assigning social services responsibility for obtaining outside services, the Social Services Director did not follow up with the community providers or seek alternative assistance after family involvement lapsed, leaving the resident waiting for hearing aids for months.
Two residents with cognitive and psychiatric conditions engaged in repeated physical altercations on consecutive days after an accusation of stolen soda. On the first day, a resident using a walker accused a wheelchair user of theft, after which the wheelchair user rammed the walker and struck the other resident's leg while a CNA was pushing her away. On the next day, the resident with the walker kicked the wheelchair user in the leg as she passed in the hallway, later admitting she did so in retaliation for the prior day's incident. An LPN documented both events, and the administrator was notified, but the facility did not effectively prevent or protect the residents from physical abuse by each other, contrary to its abuse prevention policy.
A resident was discharged from the facility without a required discharge summary being completed, contrary to the facility’s own policy that mandates a discharge summary and post-discharge plan for anticipated discharges to a private residence or another nursing care facility. Record review showed the absence of any discharge summary in the resident’s medical record, and the SSD confirmed during interview that no discharge summary had been completed.
The facility failed to document and investigate complaints about inconsistent ice distribution voiced during resident council meetings. Despite the facility's policy requiring investigation and reporting of grievances, the Activity Director did not document the complaints, and the CNA Supervisor was unaware of them. Residents expressed dissatisfaction with the inconsistency, highlighting a deficiency in addressing resident concerns.
The facility failed to notify a physician of abnormal CBG levels for a resident with diabetes and did not document a choking incident in another resident's care plan. The first resident had multiple instances of high CBG levels without physician notification, while the second resident, who was cognitively intact, experienced a choking incident that was not addressed in their care plan. Both deficiencies were confirmed by facility staff.
The facility failed to follow recipes for pureed diets, affecting 12 residents. Observations showed cooks preparing pureed meals without measuring ingredients, resulting in improper consistency. Dietary staff lacked training and access to recipes, as confirmed by the RD. This deficiency could impact residents' nutritional intake.
The facility failed to meet professional standards for two residents receiving hospice care. One resident's hospice binder was not updated with current nurse visit notes and certification, and staff were unclear about responsibility for updates. Another resident experienced multiple high blood sugar levels without the hospice agency being informed, as confirmed by the Corporate Nurse and Hospice Agency Director of Nursing.
A facility failed to ensure a resident was safe to self-administer medication, as required by policy. The resident, with moderate cognitive impairment, was observed with medication at her bedside without an assessment or care plan for self-administration. An LPN confirmed leaving the medication, and the DON acknowledged the lack of necessary documentation, indicating a failure to adhere to the facility's policy.
The facility failed to report injuries of unknown source for two residents with severe cognitive impairment. One resident was found on the floor with a left arm fracture and a UTI, while another was found with a head bruise and a left wrist fracture. Both incidents were not reported to the state agency as required.
The facility failed to notify the State LTC Ombudsman of facility-initiated transfers for two residents, as required. A resident with Alzheimer's and another with dementia were transferred to the hospital multiple times, but these transfers were not recorded in the Emergency Transfer Log. The BOM, responsible for the log, was unaware that even short-term transfers needed to be reported, potentially affecting the entire census of 112 residents.
A facility failed to administer enteral feeding at the ordered rate for a resident with Alzheimer's, dementia, and a gastrostomy. The policy required checking the rate against the order, but an LPN confirmed the feeding was running at 45 ml/hour instead of the ordered 44 ml/hour, potentially affecting other residents with tube feedings.
A facility failed to maintain accurate medical records by not ensuring a resident's care plan reflected the need for weekly weight monitoring, despite significant weight loss and a low BMI. The care plan inaccurately documented monthly weighing, which was confirmed by an MDS/LPN during a review. This discrepancy could potentially affect the facility's entire census.
A facility failed to ensure proper use of PPE during biohazard trash removal. A Treatment Nurse was observed handling a soiled glove and biohazard bag without gloves and placed the bag on a treatment cart. The DON confirmed the nurse should have used PPE and not placed the bag on the cart.
A facility failed to ensure proper monitoring and reporting of wound care, leading to an Immediate Jeopardy situation. A resident with multiple health issues, including Peripheral Vascular Disease and Diabetes, experienced a significant deterioration in a right foot wound and developed a new wound on the left foot, both of which became infested with maggots. LPNs conducted assessments without oversight from a registered nurse, resulting in a lack of notification to the physician about the worsening condition.
The facility failed to provide an effective wound prevention program due to the lack of RN oversight in monitoring weekly body/skin assessments and wound evaluations conducted by LPNs. This deficiency led to an Immediate Jeopardy situation when a resident's deteriorating foot wounds were not reported, resulting in maggot infestation.
A facility failed to notify a resident's responsible party and healthcare providers about a worsening right foot wound. The resident had multiple health issues, and the wound significantly increased in size over several weeks. Despite the deterioration, there was no documentation of notification, and interviews confirmed the responsible party and nurse practitioner were not informed. The facility's policy lacked clarity on reporting responsibilities.
Failure to Follow Up on Community Resources for Hearing Aids
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities by not following up with community resources. The resident, who was cognitively intact with a BIMS score of 13 and had moderate hearing difficulty requiring increased volume and distinct speech, had a care plan problem for altered communication related to being hard of hearing and recurrent cerumen impaction, with a noted need for hearing aids. The care plan documented that paperwork for hearing aids had been sent with the family but not returned due to financial issues. In an interview, the resident reported having waited months for hearing aids and stated the facility told her they were waiting on a company to get the devices, while the surveyor had to speak very loudly for the resident to hear. Record review and interviews with the Social Services Director (SSD) showed that the resident had been seen by an ENT specialist and was recommended for a hearing program that required an application fee the resident could not afford. The SSD documented that the ENT office stated the resident could not participate in the program without paying the fee and that the resident was referred to another community provider for assistance with hearing devices. The SSD later learned that this community provider saw the resident and referred her to a second provider for an evaluation to assist with obtaining hearing aids, but the evaluation was never scheduled. The SSD acknowledged she did not follow up with either community provider after communication with the family ceased and did not pursue other assistance or resources for hearing aids from that time until questioned by the surveyor, despite facility policy assigning social services responsibility for making referrals and obtaining needed services from outside entities.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during resident-to-resident altercations on consecutive days. Facility policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse, and that administration will protect residents from abuse by anyone, including other residents, and protect residents during abuse investigations. Despite this policy, one cognitively intact resident with bipolar disorder and depression with psychotic features (Resident #81) and another resident with Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder (Resident #2) engaged in physical aggression toward each other without effective prevention of further contact. On the first day, documentation and interviews showed that Resident #81 was walking in the hallway with a walker when Resident #2, in a wheelchair, passed by. Resident #81 accused Resident #2 of stealing her soda, and Resident #2 then ran her wheelchair into Resident #81's walker. A CNA intervened and began pushing Resident #2 back to her room, during which Resident #2 reached out and hit Resident #81 on the leg. Nursing notes and the facility incident report documented that both residents were then taken to their rooms and that no injuries were observed at that time. The LPN and CNA interviews were consistent in describing that Resident #2 physically struck Resident #81 during the separation. On the following day, the same LPN documented that Resident #2 was again propelling herself in the hallway when Resident #81 came out of her room and kicked Resident #2 in the leg as she passed. Resident #2 yelled out in response, and when questioned, Resident #81 admitted to kicking Resident #2, stating she did so because Resident #2 had hit her the previous day and stolen her soda and that she was not sorry. The LPN assisted Resident #2 back to her room while Resident #81 remained in her room to finish breakfast. The administrator confirmed being notified of both physical altercations at the times they occurred and that there were no injuries, but the incidents demonstrated that the facility did not effectively protect either resident from physical abuse by the other resident as required by its abuse prevention policy.
Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary for one of three closed records reviewed. The facility’s policy, last reviewed on 04/09/2025, states that when a discharge is anticipated to a private residence or another nursing care facility, a discharge summary and post-discharge plan must be developed to assist the resident’s adjustment, and that a copy of the discharge summary must be provided to the resident, the receiving facility, and filed in the resident’s medical record. Record review showed that Resident #123 was admitted on an unspecified date and discharged on 11/07/2025, but the medical record contained no documentation of a completed discharge summary. During a record review and interview on 01/28/2026 at 2:06 p.m., the Social Services Director confirmed that the resident had been discharged on 11/07/2025 and further confirmed that a discharge summary was not completed for this resident. No additional medical history or condition details for the resident at the time of discharge were documented in the report.
Failure to Document and Investigate Resident Complaints
Penalty
Summary
The facility failed to document, investigate, and maintain records of complaints voiced during resident council meetings held in July and October 2024. The facility's policy requires that upon receipt of a grievance or complaint, the designee must review and investigate the allegations and submit a written report of the findings to the administrator within five working days. However, during interviews with residents and staff, it was revealed that complaints about the inconsistency of ice being passed to residents were not documented or investigated as grievances. The Activity Director admitted to not writing up the complaints because only one resident complained in each meeting, and instead, she provided ice and water to the resident and informed the CNA supervisor. Residents expressed dissatisfaction with the inconsistency of ice distribution, stating that while the issue would be temporarily resolved after being reported, it would soon revert to the previous state of neglect. One resident mentioned that having a schedule for ice and water distribution would prevent them from feeling like they were bothering staff. The CNA Supervisor could not recall any complaints about the issue and confirmed there was no documentation of such complaints. This lack of documentation and investigation of grievances is a deficiency in honoring residents' rights to voice concerns and have them addressed appropriately.
Failure to Notify Physician and Document Choking Incident in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For one resident with end-stage heart failure, unspecified dementia, and type 2 diabetes mellitus, the facility did not notify the physician of abnormal capillary blood glucose (CBG) levels as ordered. The resident's medical records showed multiple instances of CBG levels exceeding 401, which required immediate notification to the physician according to the facility's policy. However, there was no documentation indicating that the physician was informed of these abnormal results, as confirmed by the Corporate Nurse during an interview. Another resident, who was cognitively intact and had diagnoses including paraplegia and gastroesophageal reflux disease, experienced a choking incident. The resident choked on food and was subsequently transferred to the emergency room for evaluation due to esophageal obstruction. Despite this significant event, the resident's comprehensive care plan did not include a focus area or interventions related to the choking incident. Both the Minimum Data Set Coordinator and the Director of Nursing confirmed that the incident should have been documented in the care plan with appropriate interventions, but it was not.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that recipes for pureed diets were followed, which had the potential to negatively impact the dining experience and nutritional intake of 12 residents receiving pureed meals. Observations revealed that S4Cook prepared pureed rice without measuring the water or rice, relying on guesswork to achieve the desired consistency. Similarly, S5Cook prepared pureed bread and beans that resulted in a thin liquid consistency, which was not appropriate for a pureed diet. Both cooks demonstrated a lack of adherence to the facility's puree recipe guidelines. Interviews with dietary staff, including S6DS, S8Cook, and S9DS, revealed a lack of training on how to properly puree foods using recipes. S6DS confirmed that the puree recipe liquid addition quick guide was not helpful, as it lacked specific measurements for certain foods. Additionally, S7RD, the registered dietician, confirmed that puree recipes were not available in the main kitchen for cooks to reference. This lack of training and resources contributed to the improper preparation of pureed meals, potentially affecting the nutritional needs of the residents.
Deficiencies in Hospice Care Coordination and Communication
Penalty
Summary
The facility failed to provide services that met professional standards for two residents receiving hospice care. For one resident, the facility did not collaborate effectively with the hospice agency to ensure that the hospice nurse's visit notes and certification were up-to-date in the resident's hospice binder. The last certification period was noted to be outdated, and the last hospice nurse visit notes were several months old. During interviews, facility staff were unclear about who was responsible for ensuring the hospice binder was updated, with the Director of Nursing indicating that it was the hospice agency's responsibility. For the second resident, the facility failed to communicate with the hospice agency regarding the resident's high blood sugar levels. The resident had multiple occurrences of critically high blood glucose levels over several months, yet there was no documentation indicating that the hospice agency was informed of these abnormal levels. The Corporate Nurse confirmed the lack of communication, and the Hospice Agency Director of Nursing stated that the hospice should have been notified of such significant changes in the resident's condition.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as required by their policy. The policy mandates that residents can self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe. However, there was no assessment, physician's order, or care plan for the resident to self-administer medication. The resident, who had a diagnosis of Gastro-Esophageal Reflux Disease and a BIMS score indicating moderate cognitive impairment, was observed with a medicine cup containing medication on her bedside table, which she intended to take herself. An LPN confirmed that she had left the medication, identified as Mylanta, on the resident's bedside table, acknowledging that the resident preferred to take it in intervals. The Director of Nursing confirmed that the resident's record lacked the necessary documentation to support self-administration of medication, and it was inappropriate for the medication to be left at the bedside. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, compromising the safety and care of the resident.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report alleged injuries of unknown source to the State Survey Agency within the required two-hour timeframe for two residents. Resident #84, who has severe cognitive impairment, was found on the floor outside her room with a fracture to her left arm and was diagnosed with a urinary tract infection. The incident was not reported to the state agency as required by the facility's policy. Similarly, Resident #113, also with severe cognitive impairment, was found sitting on the floor with a head bruise and a fracture to his left wrist. This incident was also not reported to the state agency. Both residents were unable to recall the events leading to their injuries, and the Director of Nursing confirmed that these incidents should have been reported but were not.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for two residents, which is a requirement for ensuring proper oversight and resident rights. Resident #84, who had diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder, was transferred to the hospital on multiple occasions, specifically on 10/15/2024, 11/08/2024, and 11/17/2024. However, these transfers were not recorded in the Emergency Transfer Log for October and November 2024, which is used to notify the Ombudsman. Similarly, Resident #113, with diagnoses including dementia, depression, and repeated falls, was transferred to the hospital on several dates, including 08/19/2024, 10/10/2024, 10/12/2024, 11/28/2024, and 12/02/2024, but these were also not documented in the Emergency Transfer Log. The Business Office Manager (BOM), responsible for maintaining the Emergency Transfer Log and notifying the Ombudsman, confirmed the omissions during an interview and record review. The BOM was unaware that facility-initiated transfers, even those lasting less than 24 hours, needed to be included in the log sent to the Ombudsman. This oversight in documentation and notification could potentially affect the facility's entire census of 112 residents, as it undermines the regulatory requirement to inform the Ombudsman of all facility-initiated transfers.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that the enteral feeding for a resident was infused at the ordered rate, which was a deficiency identified during a survey. The facility's policy on enteral feedings required checking the rate of administration against the order before administration. However, an observation and interview with an LPN revealed that the enteral feeding for a resident with Alzheimer's disease, unspecified dementia, dysphagia, chronic systolic heart failure, and a gastrostomy was running at 45 ml/hour, contrary to the ordered rate of 44 ml/hour. This discrepancy was confirmed by the LPN, indicating a failure to adhere to the prescribed feeding rate, which had the potential to affect other residents receiving tube feedings in the facility.
Inaccurate Documentation of Care Plan for Resident
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by not ensuring that the comprehensive care plan for a resident was accurately documented. The resident in question was admitted with diagnoses including paraplegia, spinal stenosis, muscle wasting and atrophy, and ileus. A review of the resident's progress notes revealed significant weight loss over several months, with a current weight of 121.2 pounds and a BMI of 18.4, indicating an underweight status. The resident's weight loss was documented with specific percentage changes compared to previous weights, triggering a need for weekly weight monitoring until stabilization. However, the comprehensive care plan for the resident only included an intervention to weigh the resident monthly, which was inconsistent with the need for weekly monitoring as indicated by the progress notes. This discrepancy was confirmed during a record review and interview with the Minimum Data Set Coordinator/LPN, who acknowledged that the care plan did not accurately reflect the required frequency of weight monitoring. This failure to document the necessary intervention in the care plan represents a deficiency in maintaining accurate medical records, potentially affecting the facility's entire census of 112 residents.
Inadequate Use of PPE During Biohazard Trash Removal
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not ensuring staff used personal protective equipment (PPE) according to accepted standards during biohazard trash removal. During an observation on Hall A, a treatment cart was found with a trash can attached, containing a red biohazard trash bag. A partially discarded blue glove was observed hanging halfway out of the bag. The Treatment Nurse, after completing her treatments, was seen removing the glove and the biohazard bag without wearing gloves, and then placing the biohazard bag on top of the treatment cart. The Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed that the Treatment Nurse should have donned gloves before handling the soiled glove and biohazard materials. Additionally, the biohazard bag should not have been placed on top of the treatment cart. This incident highlights a lapse in following the facility's policy on the use of gloves to prevent the spread of infection and protect staff from potentially infectious materials.
Failure to Monitor and Report Wound Deterioration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not have a registered nurse monitor weekly body/skin assessments and wound care evaluations, which were performed only by Licensed Practical Nurses (LPNs) for ten sampled residents with wounds. This oversight led to an Immediate Jeopardy situation when the facility failed to notify the physician of a deteriorating right foot wound and did not identify and report a new wound on the left foot of Resident #2, resulting in an infestation of maggots in both feet. Resident #2 was admitted to the facility with multiple diagnoses, including Hemiplegia, Schizoaffective Disorder, Peripheral Vascular Disease, and Type 2 Diabetes Mellitus, among others. The resident's comprehensive care plan noted a potential for skin breakdown due to decreased mobility and other factors. Despite having a physician's order for daily wound care on the right foot, the wound evaluations showed significant deterioration from early April to late April, with no documentation of notification to the physician or nurse practitioner. Additionally, body audit/skin assessments failed to identify a new wound on the left foot, which was later discovered to be infested with maggots. Interviews with facility staff revealed that the LPNs were responsible for conducting body audit/skin assessments and reporting any changes to the wound care nurse, who was also an LPN. However, there was no oversight by a registered nurse, and the wound care nurse did not assess the left foot or lower extremity as she was only responsible for active wounds. The Director of Nursing confirmed that the assessments were not conducted properly, and there was a lack of documentation regarding changes in the resident's condition. This failure to monitor and report changes in the resident's wounds led to severe consequences for Resident #2.
Lack of RN Oversight in Wound Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to administer an effective wound prevention program with appropriate professional oversight, leading to a deficiency in the care provided to residents. Specifically, the facility did not ensure that Registered Nurses (RNs) monitored weekly body/skin assessments and wound evaluations performed by Licensed Practical Nurses (LPNs) for ten sampled residents. This lack of oversight had the potential to cause severe harm, injury, or death to 117 residents who received weekly unmonitored body/skin assessments and wound care. The deficiency was highlighted by an Immediate Jeopardy situation when the facility failed to notify a physician of a deteriorating right foot wound and did not identify and report a new wound on a resident's left foot, resulting in an infestation of maggots on both feet. Interviews and record reviews revealed that the facility's LPNs were responsible for conducting all residents' body audits/skin assessments and wound evaluations without RN oversight. The Director of Nursing (DON) confirmed that neither she nor the Assistant Director of Nursing reviewed these assessments. Additionally, the data entry clerk, an LPN, was responsible for ensuring that all assessments and evaluations were documented in the residents' charts. The Corporate Nurse was aware that weekly skin and wound evaluations were conducted by LPNs without RN monitoring, which contributed to the deficiency.
Failure to Notify of Worsening Wound Condition
Penalty
Summary
The facility failed to notify the responsible party, nurse practitioner, and physician of a resident's deteriorating right foot wound in a timely manner. The resident, who was admitted with multiple diagnoses including hemiplegia, schizoaffective disorder, and peripheral vascular disease, had a wound on the right dorsum foot that significantly increased in size over several weeks. Despite the wound's worsening condition, there was no documentation of notification to the resident's responsible party or healthcare providers. Interviews revealed that the resident's responsible party was unaware of the wound's deterioration, and the nurse practitioner was not informed of the worsening condition. The wound care nurse acknowledged the wound's increasing maceration and drainage but confirmed that no notification was made to the responsible party. The facility's policy on wound prevention did not specify which professional discipline should perform assessments or to whom changes should be reported, contributing to the communication breakdown.
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.
