Maison Teche Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jeanerette, Louisiana.
- Location
- 7307 Old Spanish Trail, Jeanerette, Louisiana 70544
- CMS Provider Number
- 195574
- Inspections on file
- 22
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Maison Teche Nursing Center during CMS and state inspections, most recent first.
The facility did not ensure residents received mail on Saturdays, affecting 90 residents. A resident reported the issue during a council meeting, and staff confirmed mail was only delivered Monday to Friday due to the office being closed on weekends. The HR representative was unaware of the regulatory requirement for weekend mail delivery, while the CNA Supervisor acknowledged the requirement but confirmed the ongoing issue.
The facility failed to implement comprehensive care plans for three residents, resulting in deficiencies. A resident did not receive medications before meals as ordered, another did not have compression stockings applied daily, and a third was not monitored for medication side effects. These issues were confirmed through observations and staff interviews, highlighting lapses in adherence to physician orders and care plans.
The facility failed to ensure the privacy of two residents during personal care. A resident with normal cognition reported inappropriate comments from a neighbor about her bathroom activities, which were not addressed by staff. Another resident with moderate cognitive impairment was exposed during personal care due to staff not closing doors, leaving her visible to her roommate and others. Both CNAs involved acknowledged their failure to protect privacy.
A resident with intact cognition reported a hole in the wall of their room that had been present for about a month, despite notifying nurses and maintenance. The Maintenance Director was unaware of the issue, indicating a failure to adhere to the facility's policy of maintaining a homelike environment.
A resident diagnosed with Schizoaffective Disorder did not receive a required Level II PASARR evaluation. The facility failed to refer the resident to the state-designated authority after the new diagnosis, despite the prescription of antipsychotic medication. This was confirmed by the Social Service Director, who acknowledged the oversight.
A resident with a left leg prosthetic experienced a decline in mobility due to a facility-acquired wound on his stump, caused by incorrect application of the prosthetic sleeve during an offsite event. This wound prevented the resident from wearing his prosthetic leg, leading to increased assistance needs and a decline in functional abilities.
A facility failed to adhere to professional standards for respiratory care by improperly storing oxygen tanks and tubing for a resident with chronic respiratory conditions. Oxygen tanks were found in the resident's room and on their wheelchair without proper labeling or storage, contrary to facility policy. Staff interviews revealed a misunderstanding of the facility's oxygen safety guidelines.
A facility's medication error rate exceeded the acceptable threshold of five percent. An LPN administered Carafate and Ferrous Sulfate to a resident after breakfast, contrary to physician orders to give them before meals. This contributed to a 6.67% error rate during a survey of 30 medication pass opportunities.
A resident's family expressed dissatisfaction with the care provided, leading them to call an ambulance to transfer the resident to a hospital. Despite the facility's policy to support residents' rights to voice grievances, the administrator and DON did not document or resolve the family's concerns, citing a lack of understanding of the specific issues. The facility failed to initiate a grievance process, as required.
A facility failed to document as-needed narcotic pain medication on the MAR for a resident, leading to discrepancies between the narcotic record and the MAR. Interviews with an LPN and the DON revealed that the process for documenting narcotic administration was not followed, as medications were not scanned into the computer after administration, resulting in mismatches and illegible entries.
A facility failed to implement a care plan requiring a three-person assist for a resident's transfer using a mechanical lift. The third CNA, who was supposed to observe the transfer, stepped out, resulting in the transfer being conducted without the required observation. This led to the resident being found with a bruise under her left eye. The facility's Administrator and DON confirmed the care plan was not followed.
The facility failed to ensure that nursing aides had the necessary competencies to safely secure a resident in the transportation van. Despite attending training, S3Transportation incorrectly positioned the tiedown hooks and straps, as confirmed during a mock observation by S2DON and S1ADM.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, which had the potential to affect 90 residents. During a resident council meeting, a resident reported that mail was not delivered on Saturdays. Interviews with a Certified Nursing Assistant Supervisor (S12CNASUP) and a Human Resources representative (S11HR) confirmed that mail was only distributed from Monday to Friday, as the office was closed on weekends and no staff were available to deliver mail. S11HR was unaware of the regulatory requirement for weekend mail delivery, while S12CNASUP acknowledged the requirement but confirmed that residents had not been receiving mail on weekends for some time.
Deficiencies in Medication Administration and Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for three residents, leading to deficiencies in medication administration and care practices. Resident #15, diagnosed with Gastro-Esophageal Reflux Disease and Iron Deficiency Anemia, had physician orders for medications to be administered before meals. However, an LPN administered these medications after the resident had already eaten breakfast, contrary to the physician's orders. This oversight was confirmed during an interview with the LPN, who acknowledged the error in medication timing. Resident #39, with diagnoses including Cerebral Infarction and Peripheral Vascular Disease, had physician orders for daily application of compression stockings. Observations revealed that the resident was not wearing compression stockings on multiple occasions, and interviews with the resident and CNAs confirmed that the stockings were not applied as required. One CNA was unaware of the need for daily application, indicating a lack of communication or training regarding the resident's care plan. Resident #76, with conditions such as Atrial Fibrillation and Dementia, was prescribed medications including an anticoagulant, antidepressant, and antipsychotic. The care plan included monitoring for side effects and behaviors related to these medications. However, a review of the MAR showed no documentation of such monitoring, and interviews with an LPN and the DON confirmed the absence of required monitoring records. This lack of documentation and monitoring represents a failure to adhere to the care plan and physician orders.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the personal privacy of two residents during their activities of daily living. Resident #2, who has normal cognition, reported that a neighboring resident, Resident #54, made inappropriate comments about her bathroom activities, such as passing gas and other bodily functions. Despite Resident #2 informing a Licensed Practical Nurse (LPN) about these comments, no action was taken to address the situation. Resident #54 admitted to making these comments, finding them humorous, and confirmed that Resident #2 had not directly confronted him about it. Resident #39, who has moderate cognitive impairment, experienced a lack of privacy during personal care. On two separate occasions, Certified Nursing Assistants (CNAs) failed to close the room and bathroom doors while assisting Resident #39 with personal care, leaving her exposed to her roommate and anyone passing by. Both CNAs acknowledged their failure to protect the resident's privacy, and Resident #39 expressed discomfort with the situation. These incidents highlight the facility's failure to maintain residents' rights to personal privacy.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident, as evidenced by a hole in the sheetrock on the wall of the resident's room. The resident, who had intact cognition as indicated by a BIMS score of 15, reported that the hole had been present for about a month and that both nurses and maintenance had been notified. However, during an interview, the Maintenance Director stated he was not aware of the issue. The facility's policy requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, but this was not adhered to in this instance.
Failure to Submit Level II PASARR for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASARR evaluation. Resident #31 was admitted to the facility and later diagnosed with Schizoaffective Disorder. Despite this new diagnosis, the facility did not submit a Level II PASARR for the resident, as required. The resident's medical record showed a Level I PASARR dated several months prior to the new diagnosis, but no evidence of a subsequent Level II PASARR submission. This oversight was confirmed during an interview with the Social Service Director, who acknowledged that the necessary referral had not been made.
Failure to Prevent Avoidable Reduction in Mobility Due to Incorrect Prosthetic Application
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further avoidable reduction of Range of Motion (ROM) and mobility for a resident, identified as Resident #60. The resident, who was admitted with a diagnosis of acquired absence of the left leg below the knee, developed a facility-acquired non-pressure ulcer on his left stump. This wound, initially an intact blister, deteriorated to 100% slough with bone exposure, preventing the resident from wearing his prosthetic leg. The wound was attributed to the incorrect application of the prosthetic sleeve/stocking, which caused friction and subsequent breakdown during an offsite event where the resident participated in a dance contest. The resident's physical therapy records indicated that prior to the incident, he was mobile and able to walk without assistance using his prosthesis. However, following the event, the resident experienced a functional decline, requiring increased assistance due to the inability to wear his prosthetic leg. The physical therapy evaluation noted recurrent falls and a pressure ulcer on the left residual limb, negatively impacting the resident's functional mobility tasks. The resident's quarterly MDS assessments showed a decline in functional abilities, with increased assistance needed for various activities of daily living. Interviews with facility staff, including the Treatment Registered Nurse and Physical Therapist, confirmed the sequence of events leading to the resident's decline in mobility. The resident himself expressed sadness over his inability to walk and wear his prosthetic leg until the wound healed. The facility's failure to ensure the correct application of the prosthetic leg and to prevent the development of the wound resulted in a significant decline in the resident's mobility and quality of life.
Failure to Properly Store and Label Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. During an observation, two oxygen tanks were found on a rack by the door in the resident's room, and another oxygen tank was attached to the back of the resident's wheelchair with nasal cannula tubing that was not dated or stored in a bag. This was contrary to the facility's policy, which required oxygen delivery devices to be covered in an infection prevention bag when not in use. Interviews with facility staff revealed a lack of adherence to the facility's oxygen safety policies. An LPN stated that oxygen tanks could be stored in the resident's room as long as they were on a rack, and acknowledged that the oxygen tubing should have been labeled and stored in a bag. The Director of Nursing confirmed that the oxygen tanks should not have been stored in the resident's room and should have been placed on a rack in a separate room, indicating a failure to comply with the facility's guidelines for oxygen storage.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations, interviews, and record reviews. During a morning medication pass, an LPN administered Carafate Oral Tablet 1 GM and Ferrous Sulfate Oral Tablet 325 MG to a resident after they had eaten breakfast, contrary to the physician's orders which specified administration before meals. The LPN confirmed the error upon reviewing the resident's electronic health record. This incident was part of a survey where 30 medication pass opportunities were observed, resulting in two errors and a calculated medication error rate of 6.67%.
Failure to Address Family's Grievance Regarding Resident Care
Penalty
Summary
The facility failed to initiate a grievance process for a resident whose family expressed dissatisfaction with the care provided. The resident, who had a severely impaired cognition as indicated by a BIMS score of 06, was admitted with multiple diagnoses including malignant neoplasm of the colon, hemiplegia, type 2 diabetes with diabetic nephropathy, paraplegia, moderate protein-calorie malnutrition, a stage 2 pressure ulcer, and physical debility. On a specific date, the family of the resident called an ambulance to transfer the resident to a local hospital, citing concerns about inadequate care. Despite this, the facility did not document or file a grievance related to the family's concerns. The facility's administrator attempted to contact the family to discuss their concerns but did not receive a response. However, there was no documented evidence of these attempts or any further steps taken to resolve the grievance. During an interview, the administrator and the director of nursing admitted they did not complete a grievance report because they were unsure of the specific nature of the family's dissatisfaction. They acknowledged that they did not make an effort to understand or resolve the family's concerns, resulting in a failure to adhere to the facility's grievance policy.
Failure to Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to ensure that as-needed narcotic pain medication was properly documented on the Medication Administration Record (MAR) for one of the residents reviewed for pain management. The facility's policy requires that the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the MAR. However, discrepancies were found between the resident's Individual Narcotic Record and the MAR. Specifically, doses of Alprazolam and Oxycodone administered to the resident were not consistently documented on the MAR, despite being recorded on the narcotic record. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the process for documenting narcotic administration was not followed as per the facility's policy. The LPN stated that after administering a narcotic, the medication should be scanned into the computer to document it on the MAR, but this step was not completed, leading to mismatches between the narcotic count book and the MAR. The DON confirmed that the MAR and narcotic count sheet should match and acknowledged that some entries on the narcotic count sheets were not legible, further contributing to the documentation discrepancies.
Failure to Implement Care Plan for Resident Transfer
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who required a three-person assist using a mechanical lift for transfers. The care plan specified that a third person should be present for observation during transfers due to the resident's self-care deficit related to decreased mobility, lack of coordination, and muscle weakness. However, during a transfer on October 10, 2024, the third CNA who was supposed to observe the transfer stepped out to get supplies and did not witness the transfer. This resulted in the resident being transferred without the required observation, leading to an incident where the resident was later found with a bruise under her left eye. The incident was captured on video surveillance, which showed several staff members in the vicinity but none witnessing the transfer. Interviews with the CNAs involved revealed that they did not notice any hazards during the transfer. The facility's Administrator and Director of Nursing confirmed that the care plan intervention requiring a third person for observation was not implemented during the transfer, contributing to the deficiency in care provided to the resident.
Inadequate Competency in Securing Residents in Transportation Van
Penalty
Summary
The facility failed to ensure that nursing aides possessed the necessary competencies and skill sets to provide safe nursing services, as evidenced by S3Transportation's incorrect procedure for securing a resident in the facility's transportation van. Despite having signed an attestation and attended an in-service training on the use of the Q-straint Restraint System and wheelchair lifts, S3Transportation did not demonstrate the correct procedure during a mock observation. Specifically, S3Transportation attached the tiedown hooks to the lower portion of the wheelchair, above the wheels, instead of near the seat level, resulting in the tiedown straps being at a 90-degree angle rather than the required 45-degree angle. During the mock observation, S3Transportation confirmed that the tiedown hooks were not positioned correctly, and the straps were not at the proper angle. This deficiency was further corroborated by S2DON and S1ADM, who both confirmed the incorrect positioning of the tiedown hooks and straps. The failure to follow the correct procedure for securing a resident in the transportation van indicates a lack of competency in ensuring the safety and well-being of residents during transportation.
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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