Many Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Many, Louisiana.
- Location
- 120 Natchitoches Hwy 6 East, Many, Louisiana 71449
- CMS Provider Number
- 195310
- Inspections on file
- 27
- Latest survey
- February 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Many Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident's medications were left unattended at the bedside, contrary to the facility's policy requiring safe and timely administration. The resident, with intact cognition, fell asleep before taking the medications. An LPN admitted to not ensuring the medications were taken, and the DON confirmed this was against nursing standards.
The facility did not complete annual performance reviews for four CNAs within the required 12-month period. Personnel records for these CNAs lacked evidence of a completed and signed review by the department head. Interviews with the administrator and corporate HR confirmed the requirement for annual evaluations, which were not conducted for the CNAs involved.
The facility did not post daily nurse staffing information, including the resident census and hours worked by RNs, LPNs, and CNAs. Observations showed outdated staffing data, and interviews revealed uncertainty about responsibility for updates over the weekend. The administrator confirmed the information should have been posted daily but was not.
The facility failed to meet the nutritional needs of residents on pureed diets by not following recipes and portion sizes. An employee prepared meals without using the recipe binder, resulting in incorrect consistency and portion sizes. During meal service, incorrect serving utensils were used, leading to improper portion sizes. The Dietary Manager confirmed these deficiencies.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with undated and improperly stored food items, lack of temperature monitoring, and inadequate hygiene practices among staff. Observations revealed dirty equipment, uncovered food, and incomplete documentation of sanitizing procedures, leading to unsanitary conditions and a hair found in food served to residents.
A facility failed to notify the Ombudsman in writing of a resident's discharge, as required by policy. The resident was discharged to a behavioral hospital, but the Business Office Manager did not send the necessary notification. Interviews with staff confirmed the oversight, and the Corporate RN acknowledged the failure to comply with notification requirements.
A facility failed to refer a resident with a new diagnosis of Schizoaffective Disorder for a Level II PASARR evaluation. The Social Services Director initially believed the resident did not meet the criteria, but later confirmed the need for the evaluation after reviewing the resident's diagnoses. This oversight resulted in a deficiency.
A facility failed to implement a comprehensive care plan for a resident on NPO status due to severe cognitive impairment and medical conditions. Despite orders for tube feeding, a water pitcher was found in the resident's room, and a CNA admitted to giving the resident sips of water. Interviews revealed a lack of staff understanding and communication regarding the resident's NPO status.
A facility failed to document a discharge summary for a resident with a complex medical history, including a femur fracture and osteoarthritis, upon their discharge. Although the resident was discharged in stable condition and notifications were made to relevant parties, the absence of a discharge summary was confirmed by the DON and a Corporate RN, violating the facility's policy.
A facility failed to implement Enhanced Barrier Precautions for a resident with complex medical needs, as PPE was not available despite policy requirements. An LPN did not wear a gown during medication administration via PEG tube, confirmed as necessary by the DON, indicating a lapse in infection control practices.
A resident with severe cognitive impairment was physically abused by another resident with a history of aggression in a common area. Despite the aggressor's care plan noting potential for physical aggression, the incident occurred, resulting in a bruise to the victim's ear. Staff intervened to separate the residents.
The facility failed to report resident-to-resident sexual abuse within the required timeframe. An LPN witnessed two incidents over a weekend but did not file an incident report immediately. The DON and Administrator were informed the following Monday, and a SIMS report was filed, confirming the delay in reporting.
A resident with a history of falls and cognitive impairment did not have a fall mat at their bedside, as required by their care plan. Despite being at high risk for falls and having previously sustained a hip fracture, the necessary safety intervention was not in place. The absence of the fall mat was confirmed by the DON during an observation.
A resident's wheelchair was improperly secured with only three of the four required anchors in a transport van, leading to the wheelchair tipping over and the resident sustaining a head injury. The incident occurred due to incomplete weekly safety inspections and untrained staff securing the wheelchair.
A facility failed to ensure a CNA was competent in securing a resident's wheelchair in a van, leading to an accident where the resident sustained a head injury. The CNA used only three of the required four anchors, one of which was a broken makeshift strap. The facility's policy on vehicle safety inspections was also not followed.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered safely and timely to a resident, identified as Resident #46. The incident involved leaving the resident's morning medications at her bedside, which is against the facility's policy that requires medications to be administered in a safe and timely manner. Resident #46, who has intact cognition as indicated by a BIMS score of 15, was found with a cup of medicine on her bedside table. The resident reported that the nurse had left the medications for her to take, but she fell back asleep before doing so. The medications left at the bedside included several critical prescriptions such as Effexor XR, Eliquis, and Lasix, among others. An LPN confirmed during an interview that she did not ensure the resident had swallowed her medications before leaving the room, acknowledging that she should have done so. The Director of Nursing also confirmed that it is the expectation for nurses to ensure residents swallow their medications and not leave them unattended at the bedside. This oversight in medication administration represents a failure to meet professional standards of practice for the resident involved.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete an annual performance review for four certified nurse aides (CNAs) within the required 12-month period. The personnel records for CNAs S11, S12, S13, and S14 did not contain evidence of a completed and signed annual performance review by the department head. S11 was hired on September 15, 2023, S12 on November 21, 2023, S13 on February 1, 2023, and S14 on April 26, 2023. Interviews with the facility's administrator and corporate HR confirmed that annual performance evaluations are required for all employees, but these were not conducted for the CNAs in question.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the resident census and the total number and actual hours worked by RNs, LPNs, and CNAs responsible for resident care per shift. Observations on January 12, 2025, at 8:40 a.m. and 9:06 a.m. revealed that the staffing information posted was outdated, showing data from January 10, 2025, and missing updates for January 11 and 12, 2025. Interviews with an RN and an LPN indicated uncertainty about who was responsible for updating the staffing information over the weekend. The facility's administrator confirmed that the required staffing information should have been posted daily but was not.
Failure to Follow Pureed Diet Recipes and Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents on pureed diets by not following established recipes and portion sizes. During the preparation of a pureed lunch meal, an employee, S18, was observed adding unmeasured amounts of ingredients to the food processor without following a recipe. S18 was unaware of the recipe binder for pureed food preparation and was instructed to make the food look like baby food. This resulted in the preparation of meals that did not adhere to the required consistency and portion sizes as outlined in the facility's recipe book. Additionally, during the lunch meal service, the pureed diet of beef meatballs was not served with the correct serving utensil. S18 initially used a scoop that measured 1 and 5/8 oz. instead of the required #8 scoop, which measures 1/2 cup or 4 ounces. After being informed by the Dietary Manager, S18 switched to a different scoop, but it still did not meet the required portion size. The Dietary Manager confirmed that the incorrect serving size utensil was used, which did not comply with the posted serving measurements.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions, as evidenced by multiple observations and interviews. During an initial tour of the kitchen, it was noted that several food items in the refrigerator and freezer were not properly dated or sealed. This included undated butter, sausage links, turkey sandwich meat, and various frozen items such as spinach, potatoes, and chicken wings. Additionally, there was a lack of proper labeling and dating for dry foods and opened packages, which is a violation of the facility's policies on food storage and safety. Further observations revealed unsanitary conditions in the kitchen and dining areas. Pan lids were found dirty with food particles, and food items such as hamburger buns and apple juice were left uncovered. The black refrigerator in the dining area lacked a thermometer, and there was no temperature log for the entire month, which is against the facility's policy of monitoring and recording refrigerator temperatures. These lapses in maintaining sanitary conditions and proper documentation were confirmed by the Dietary Manager during interviews. The facility also failed to ensure proper hygiene practices among dietary staff. During a lunch meal service, hair was found in the corndogs, and it was observed that the staff member serving the food wore an inadequate hair covering. Additionally, the Kitchen Aide was unaware of how to document the dishwasher's sanitizer solution concentration, and logs for the dishwasher's sanitizing solution were incomplete. These deficiencies highlight a significant lapse in adhering to professional standards of food service safety and hygiene within the facility.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman in writing of a resident's transfer or discharge, as required by their policy. The policy mandates that residents and their representatives receive written notification of a transfer or discharge at least thirty days in advance, and a copy of this notice must also be sent to the Office of the State Long Term Care Ombudsman. However, a review of Resident #71's electronic health record revealed no documentation that the Ombudsman was notified of the resident's discharge to another facility. Interviews with facility staff confirmed the oversight. The Social Services Director indicated that the Business Office Manager was responsible for sending notifications to the Ombudsman. The Business Office Manager admitted to not submitting the required notification for Resident #71's discharge. Additionally, the Corporate RN confirmed that the facility should have submitted a written notification to the Ombudsman, but failed to do so.
Failure to Refer Resident for Level II PASARR Evaluation
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. The resident, who was admitted with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Vascular Dementia, was later diagnosed with Schizoaffective Disorder. Despite this new diagnosis, there was no evidence that a Level II PASARR evaluation was submitted to the state authority, as required. The Social Services Director, responsible for sending referrals for Level II PASARR evaluations, initially stated that the resident did not meet the criteria for such an evaluation. However, upon reviewing the resident's diagnoses, the Social Services Director acknowledged that the form submitted was incorrect and confirmed that a Level II PASARR evaluation should have been conducted but was not. This oversight led to the deficiency identified in the report.
Failure to Implement NPO Status for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #44, who was on NPO (nothing by mouth) status due to severe cognitive impairment and multiple medical conditions, including dysphagia and hemiplegia. Despite the physician's order and care plan indicating that the resident required tube feeding and should not receive anything by mouth, a water pitcher with a straw was observed on the resident's bedside table. This indicates a lack of adherence to the care plan. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's NPO status. An LPN stated that if the resident requested anything by mouth, she would explain the NPO status, while a CNA admitted to providing the resident with small sips of water, using the water pitcher in the room. The Director of Nursing confirmed that the resident should not have been given water and that the presence of the water pitcher was inappropriate, highlighting a failure in ensuring staff awareness and compliance with the resident's care plan.
Failure to Document Discharge Summary for Resident
Penalty
Summary
The facility failed to document a discharge summary for a resident who was discharged, as required by their policy. The policy, titled 'Transfer or Discharge Documentation and Notice,' mandates that details of a transfer or discharge be documented in the medical record and communicated to the receiving health care provider. However, upon review of the resident's electronic health record and paper medical record, no discharge summary was found. This oversight was confirmed during an interview with the Director of Nursing and a Corporate Registered Nurse. The resident in question had a complex medical history, including a displaced comminuted fracture of the right femur, muscle weakness, osteoarthritis, cognitive communication deficit, age-related osteoporosis, and anxiety disorder. The resident was discharged in stable condition via ambulance, and the necessary notifications were made to the responsible party and physician. Despite these actions, the absence of a documented discharge summary represents a failure to comply with the facility's discharge documentation policy.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of Enhanced Barrier Precautions (EBP) for a resident. The facility's policy, dated April 1, 2024, outlined the need for EBP, which includes the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that the necessary personal protective equipment (PPE) was not available at the resident's room, despite the presence of an EBP sign. This oversight was noted on multiple occasions, indicating a lapse in adherence to the facility's infection control policy. The resident involved had a complex medical history, including dysphagia, hemiplegia, dementia, and required tube feeding, making them particularly vulnerable to infections. During a medication administration via PEG tube, an LPN failed to wear a gown, which was confirmed as a requirement by the Director of Nursing. This incident highlights a specific instance where staff practices did not align with the established infection control protocols, potentially increasing the risk of cross-contamination and infection transmission within the facility.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #6, who has severe cognitive impairment, was physically abused by Resident #8, who also has severe cognitive impairment and a history of behavioral problems, including potential physical aggression. On the day of the incident, Resident #8 approached Resident #6 in a common area and physically assaulted her by grabbing her hair and ear. This incident occurred despite Resident #8's care plan noting his potential for aggression. The incident was witnessed by another resident and staff members, who intervened to separate the two residents. Resident #6 sustained a bruise to her left ear as a result of the altercation. The facility's failure to prevent this incident highlights a deficiency in ensuring residents' rights to be free from abuse, as outlined in their Abuse Prohibition Policy.
Failure to Timely Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency within the required timeframe. The incidents involved two residents and occurred over a weekend. The facility's policy mandates that any employee aware of such allegations must report them immediately to the Abuse Coordinator, who is then responsible for reporting to the state agency within two hours if serious bodily injury is involved. However, the Licensed Practical Nurse (LPN) who witnessed the incidents did not file an incident report immediately, as required by the facility's policy. The Director of Nursing (DON) and the Administrator were not informed of the incidents until the following Monday during a morning meeting. Upon learning of the incidents, the DON initiated the Statewide Incident Management System (SIMS) report. The Administrator confirmed that the facility substantiated the allegations but acknowledged that the report was not filed within the required two-hour window after the incidents were discovered. This delay in reporting constitutes a deficiency in the facility's adherence to its abuse reporting policy.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was at high risk for falls. The resident, who had a history of repeated falls and various medical conditions including Alzheimer's disease and schizoaffective disorder, was admitted with a diagnosis of a displaced fracture of the right femur. The resident's care plan included the use of a fall mat at the bedside as an intervention to prevent further falls. However, during an observation, it was noted that there was no fall mat present at the resident's bedside or anywhere in the room. The resident, who had a moderate cognitive impairment with a BIMS score of 11, was able to propel himself in a wheelchair and stated that he did not require assistance for transfers. Despite this, the resident had previously fallen and sustained a hip fracture, requiring surgical intervention. An interview with the Director of Nursing confirmed the absence of the fall mat, which was a required intervention according to the resident's care plan. This oversight indicates a failure to adhere to the prescribed safety measures for the resident, potentially compromising their safety and well-being.
Failure to Properly Secure Wheelchair in Transport Van
Penalty
Summary
The facility failed to ensure residents remained as free of accident hazards as possible, specifically failing to properly secure a resident's wheelchair prior to transporting the resident in one of the facility's vans. This resulted in an immediate jeopardy situation when the resident's wheelchair was anchored with only three of the four required anchors. While the van was in motion, the wheelchair fell backwards, causing the resident to hit the back of her head on the lift, sustaining an abrasion with bleeding noted to the back of her head. The incident occurred because the weekly safety inspections on the transportation van had not been completed by the van driver as directed by the facility's policy. The resident involved had a medical history that included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes mellitus, contracture of the left hand, bipolar disorder, and pain. The resident was cognitively intact and used a manual wheelchair, requiring substantial assistance with transfers. On the day of the incident, the resident was being transported back from a doctor's appointment when the wheelchair, which was improperly secured with only three anchors, tipped over after the van hit a bump. The resident sustained a head injury and complained of a headache following the incident. Interviews with staff revealed that the front right anchor of the wheelchair securement system had been replaced with a manual ratchet strap by the maintenance director, who did not report this change to the administrator. The CNA who secured the wheelchair was not trained to do so and was unaware that the manual ratchet strap was not functioning properly. The transportation driver and CNA both acknowledged that they had been using the van with only three working anchors for some time. The facility's administrator confirmed that the drivers had not been completing the required weekly safety inspections of the van, contributing to the incident.
Failure to Ensure CNA Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was competent in the skills and techniques necessary to assure resident safety during transportation. Specifically, an untrained CNA was allowed to secure a wheelchair-bound resident in a facility van, which led to an accident. The CNA used only three of the required four anchors to secure the resident's wheelchair, and one of the anchors was a makeshift ratchet strap that had been broken for an unspecified period. This resulted in the resident's wheelchair tipping backward when the van hit a bump, causing the resident to sustain an abrasion to the back of the head and experience a headache for several days. The resident was cognitively intact and required substantial assistance with transfers and mobility due to conditions such as cerebral infarction, hemiplegia, and hemiparesis. The incident report and interviews revealed that the CNA had not been trained to secure wheelchairs in the van and was unaware that this task was outside her responsibilities. The CNA who was driving the van admitted to knowing about the broken anchor and had reported it to maintenance, but no action had been taken to repair it. The facility's policy required drivers to complete a weekly vehicle safety inspection, but this had not been done consistently. The administrator confirmed that only drivers were trained to secure wheelchairs and acknowledged that the required safety inspections had not been completed as mandated. The administrator also confirmed that the resident's wheelchair had not been properly secured on the day of the accident.
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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