Mary Anna Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wisner, Louisiana.
- Location
- 125 Turner Street, Wisner, Louisiana 71378
- CMS Provider Number
- 195605
- Inspections on file
- 16
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Mary Anna Nursing Home during CMS and state inspections, most recent first.
A resident with hemiplegia, multiple chronic conditions, and wheelchair dependence was transported by a CNA who failed to apply the van’s restraining lap belt, did not stop to reposition the resident after being told she was sliding, and left her unattended in the van while stopping at a personal residence. During this time, the resident slid from her wheelchair onto the floor of the van. The CNA returned, did not call the facility or seek assistance, and drove the resident back while she remained on the floor, without reporting when the fall occurred or how long the resident had been on the floor. The facility’s investigation, referencing existing abuse/neglect, fall management, and transportation safety policies and prior staff training, substantiated neglect and the situation was cited as Immediate Jeopardy.
A wheelchair-dependent, cognitively intact resident with multiple comorbidities, including hemiplegia, CHF, DM with neuropathy, chronic pain, cervical spinal stenosis, and COPD, was transported in the facility van by a CNA who had been trained on transportation safety policies requiring use of restraints and seat belts. The CNA did not apply the van’s restraining lap belt and did not reposition the resident after the resident reported sliding down in the wheelchair. The CNA then stopped at her personal residence, left the resident unattended in the van, and during this time the resident slid from the wheelchair onto the van floor. On returning to the van, the CNA found the resident on the floor but did not call the facility for assistance and drove back with the resident still on the floor, where staff later assessed and lifted the resident from the van floor. Surveyors determined this constituted an Immediate Jeopardy situation.
The facility failed to ensure residents were free from physical restraints used for convenience, as bolsters were applied without consent, physician's orders, or assessments. This affected four residents with cognitive impairments and mobility issues, highlighting a systemic issue in following restraint policies.
A resident with Alzheimer's and a history of falls experienced multiple falls due to inadequate interventions. Despite being dependent on staff and having severely impaired cognitive skills, the facility's interventions, such as reminders to balance and wear well-fitted shoes, were confirmed as inappropriate by the DON. The resident's falls included incidents with a walker and slipping in urine.
The facility failed to assess the risk of entrapment from bed rails for three residents before installation, despite their severe cognitive impairments and medical conditions. The facility's policy requires such assessments and informed consent, but documentation was lacking, as confirmed by the administrator.
Resident Neglect During Unsafe Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during transportation in the facility van. A CNA responsible for transport did not follow the facility’s transportation safety policies and procedures, including the requirement to properly secure residents with restraining seatbelts. The resident involved had multiple medical diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic heart failure, type 2 diabetes with autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. The resident was cognitively intact with a BIMS score of 15 and was dependent on a wheelchair for mobility and staff assistance for transfers using a lift. During a return trip from a physician appointment, the CNA failed to attach the van’s restraining lap belt across the resident’s lap. While en route, the resident told the CNA that she felt like she was sliding down in her wheelchair. Despite this verbal report, the CNA did not stop the van to reposition the resident or correct the lack of restraint. Instead, the CNA continued driving until reaching her personal residence. The CNA then went inside her residence, leaving the resident unattended in the van and still not properly secured or repositioned. While the CNA was inside her personal residence, the resident slid out of her wheelchair onto the floor of the transportation van. When the CNA returned to the van, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. The CNA then drove approximately 15.3 miles back to the facility with the resident remaining on the floor of the van. Upon arrival, the CNA did not inform facility staff when the fall had occurred or how long the resident had been on the floor. The resident was later assessed with no injuries, and the facility’s investigation substantiated neglect based on these events and the CNA’s failure to follow established policies on abuse, neglect, fall management, and transportation safety. The facility’s policies in place at the time defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The transportation policy required adequate training of personnel transporting residents, including safe wheelchair transportation, proper use of restraints, and procedures for what to do if someone falls. The CNA had completed annual abuse and neglect training and had acknowledged the transportation training checklist and passenger assistive techniques, which included always using seat belts and ensuring passenger restraints fit securely. Despite this training and policy framework, the CNA did not secure the resident with the lap belt, did not respond appropriately when the resident reported sliding, left the resident unattended in the van, failed to seek assistance after the fall, and transported the resident back to the facility while she remained on the floor of the van. These actions and inactions led to the substantiated neglect and the Immediate Jeopardy determination.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers regarding policy changes and performed competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee 3 times per week, including checks on arrival/departure to ensure residents are safely anchored and properly seated, quizzing drivers on who to call in the event of a fall, and speaking with residents about their trip.
- Monitor transportation compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Failure to Secure Wheelchair-Dependent Resident and Provide Supervision During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of the transportation van’s restraining seatbelt for a wheelchair-dependent resident during transport. The facility had a written Transportation Policy and Passenger Assistive Techniques procedure requiring that residents who use wheelchairs be safely secured with passenger restraints and that seat belts be used for all passengers. The CNA responsible for transport had completed the Transportation Training Checklist and acknowledged the transportation policy and passenger assistive procedures, which included guidance on safe wheelchair transportation, use of restraints, and what to do if someone falls. The resident involved was admitted with multiple significant diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. A quarterly MDS assessment documented that the resident was cognitively intact with a BIMS score of 15, was dependent on a wheelchair for mobility, and required staff assistance with transfers using a lift. Despite this dependence on staff for safe mobility and transfers, the resident was transported in the facility van without the restraining lap belt being applied. During the return trip from a medical appointment, the resident reported to the CNA driver that she felt she was sliding down in her wheelchair. The CNA did not stop the van to reposition or secure the resident with the restraining seatbelt and continued driving until reaching her own personal residence. The CNA then left the resident unattended in the van while she went inside her residence. While unsupervised and not secured by a seatbelt, the resident slid out of the wheelchair onto the floor of the van. When the CNA returned, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. Instead, the CNA drove the resident back to the facility while the resident remained sitting on the floor of the van. Upon arrival, staff, including an LPN, observed the resident on the van floor and assisted with assessment and lifting the resident from the floor. The incident was determined by surveyors to constitute an Immediate Jeopardy situation on the date of occurrence.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers to communicate policy changes and perform competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee: checks upon arrival and departure 3 times per week to ensure residents are safely anchored in the van and properly seated; quiz transport drivers at each departure/arrival on who to call in the event of a fall; counsel on notifying nursing immediately in the event of a fall.
- Monitor compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Failure to Obtain Consent and Physician's Order for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, the facility did not obtain consent, secure a physician's order, or conduct appropriate assessments before using roll control bolsters on residents' beds. This deficiency was observed in four out of five residents reviewed for restraints, indicating a systemic issue in the facility's adherence to its own policies and regulatory requirements. Resident #20, who had severe cognitive impairment and was dependent on staff for mobility, was observed with bolsters on the bed without prior assessment, consent, or a physician's order. Similarly, Resident #24, with cognitive impairment and extensive assistance needs, was also found with bolsters without the necessary documentation and approvals. Both residents had care plans indicating a potential for falls, but the facility did not follow the required procedures for restraint use. Residents #11 and #29 were also subjected to the use of bolsters without documented assessments, consents, or physician's orders. Resident #11 had a history of falls and severe cognitive impairment, while Resident #29 had multiple diagnoses including dementia and was dependent on staff for daily living activities. Interviews with the facility's administrator confirmed these failures, highlighting a lack of compliance with the facility's policies and regulatory standards regarding restraint use.
Inadequate Fall Prevention Interventions for Resident
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards by not implementing appropriate interventions after each fall. The resident, who had a history of falls and several medical conditions including Alzheimer's disease, dementia, and a hip replacement, experienced multiple falls over a period of time. The medical record review revealed that the resident had severely impaired cognitive skills and was dependent on staff for daily activities. Despite this, the interventions documented after each fall were inadequate to prevent further incidents. The resident's falls were documented on three separate occasions, with the first incident occurring when the resident's feet got tangled in her walker, causing her to fall and hit her head. Subsequent falls included slipping in her own urine while attempting to go to the bathroom. The care plan interventions, such as reminding the resident to get her balance before moving and wearing well-fitted shoes, were confirmed by the Director of Nursing to be inappropriate for preventing falls in this resident. The facility's failure to implement effective fall prevention strategies contributed to the ongoing risk of falls for the resident.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation. This deficiency was identified for three residents who were reviewed for accident hazards. The facility's policy requires an assessment of risks, including entrapment, and obtaining informed consent before installing bed rails. However, for residents with severe cognitive impairments and various medical conditions, such as chronic heart failure, dementia, and diabetes, there was no documentation of such assessments being conducted. Resident #15, who had severe cognitive skills for daily decision-making and required total assistance with activities of daily living, was observed with bed rails in place without prior risk assessment. Similarly, Resident #11, with a history of falls and severe cognitive impairment, and Resident #20, who was totally dependent on staff for mobility, also had bed rails installed without documented risk assessments. Interviews with the facility administrator confirmed the lack of assessments for these residents, indicating a failure to adhere to the facility's policy and procedures regarding bed rail installation.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
