Mary Goss Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 3300 White Street, Monroe, Louisiana 71203
- CMS Provider Number
- 195596
- Inspections on file
- 21
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Mary Goss Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of elopement managed to exit a facility despite wearing a wanderguard bracelet and being monitored every 30 minutes. The resident was found outside in the parking lot, and although the door alarm activated, it remains unclear how the resident was able to open the door. No injuries were reported.
The facility did not conduct monthly resident council meetings, with no documented minutes since mid-April. A resident, the Activity Director, and the DON confirmed the absence of meetings, indicating a failure to uphold residents' rights to organize and participate in facility groups.
Two residents were found with improperly applied pelvic restraints, lacking pre-restraint assessments and proper documentation in their care plans. One resident, severely cognitively impaired, had a restraint he could not remove, while another had a restraint tied in a tight knot. The facility's policies lacked guidelines for restraint assessments and monitoring.
The facility failed to conduct required assessments for two residents, leading to deficiencies in care. One resident, with severe cognitive impairment, did not receive quarterly smoking assessments despite being an unsafe smoker. Another resident, requiring extensive assistance, was observed with a pelvic restraint without a pre-restraint assessment. These deficiencies were confirmed by staff and acknowledged by the facility's administration.
The facility failed to develop and implement comprehensive care plans for residents, particularly regarding restraint use and monitoring for bleeding. Two residents had pelvic restraints without pre-restraint assessments or care plan documentation. Another resident's care plan for bleeding risk due to aspirin use was not implemented, as confirmed by an LPN.
The facility failed to revise care plans for two residents after falls, despite one resident having severe cognitive impairment and another with dementia. The care plans were not updated with new interventions, and the administrator and DON were informed of these deficiencies.
The facility failed to ensure residents were free from accident hazards, as evidenced by inadequate investigations and care plan updates for two residents. One resident, severely cognitively impaired, had falls without proper investigation or timely care plan updates, and inappropriate interventions were noted. Another resident experienced an injury of unknown origin, with no investigation conducted. Staff interviews confirmed these deficiencies.
The facility failed to ensure nursing staff competency in medication administration and adherence to physician orders for three residents. One resident had undocumented insulin administration sites and missed medications, another lacked prescribed fall prevention measures, and a third had an undocumented accucheck result. These deficiencies were confirmed by facility staff.
The facility failed to conduct monthly State Adverse Action checks for CNAs, affecting six personnel files. An interview with the administrator confirmed the checks were not performed as required, indicating a systemic issue in compliance with state regulations.
A medication cart was found unlocked and unattended in a hallway, with medications in direct view and accessible to residents. The responsible LPN was assisting another resident, leaving the cart unsupervised. The DON confirmed the policy requiring carts to be locked when not in use.
The facility failed to maintain food service safety standards, with dirty serving trays, grime on kitchen surfaces, and expired nutritional supplements found during a survey. Additionally, employee food items were improperly stored in a resident-accessible area. The dietary staff confirmed these issues, and the administrator was notified.
The facility did not ensure that the designated Infection Preventionist, an LPN/MDS, completed the necessary specialized training in infection prevention and control. This was confirmed through interviews with the LPN/MDS and the DON, as well as a review of the facility's Infection Control Records, which lacked documentation of the training.
The facility failed to maintain safe operating conditions for kitchen equipment, as metal shavings were observed on a large manual can opener blade. A dietary staff member was using the can opener to open a can of sweet green peas when informed of the issue, and she confirmed the need for cleaning. The administrator was notified of the findings.
The facility failed to provide dementia management training to six CNAs, as revealed by a review of personnel records. The CNAs, hired between 1994 and 2024, lacked documentation of this essential training. The DON confirmed the absence of dementia care training for these staff members.
A facility failed to ensure consistent documentation of a resident's code status, leading to a discrepancy between a 'No Code' sticker and a 'Full Code' status in the resident's medical records. The resident's LaPOST form, signed by her family and physician, indicated her wish for CPR, but the DON was unaware of the inconsistency until it was highlighted during an interview.
A resident with Type II diabetes had an accucheck result of 455 mg/dL, exceeding the threshold for physician notification. The facility failed to inform the physician or nurse practitioner, as confirmed by interviews and record reviews. The ADON acknowledged the oversight, indicating a lapse in communication and protocol adherence.
A cognitively impaired resident at high risk for elopement exited the facility through an unsecured door and was found a half block away with injuries. The facility's Wandering and Elopement policy lacked guidance on supervision, and there was no documentation of monitoring the resident's needs before or after the incident. Staff confirmed the lack of documentation, and the facility did not have wander guard bracelets on hand at the time.
A cognitively impaired resident at high risk for elopement was found a half block away from the facility after exiting through an unsecured door. The resident sustained injuries and was sent to the hospital. The facility lacked a system to monitor locked doors and did not have wander guard bracelets on hand. Monitoring of the resident was not documented.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident identified as at risk for wandering. The resident, who had a history of elopement and was diagnosed with several medical conditions including myocardial infarction and severe cognitive impairment, was found outside the facility in the parking lot. Despite having a wanderguard bracelet and being monitored every 30 minutes, the resident managed to exit through a door that was supposed to be secured with an alarm system. The alarm did activate, but the resident was still able to leave the building. The incident report indicated that the resident was discovered approximately 100 feet from the exit door, and no injuries were noted upon assessment. The facility's policy required that residents at risk of elopement have specific interventions in their care plans, including the use of a wanderguard and regular checks to ensure the device was functioning. However, the report does not clarify how the resident was able to open the door despite the alarm system being in place and functioning correctly prior to the incident.
Failure to Conduct Monthly Resident Council Meetings
Penalty
Summary
The facility failed to organize monthly resident council meetings, as evidenced by the absence of documented meeting minutes since April 17, 2024. An interview with a resident revealed that the resident council had not convened in the last couple of months. This was corroborated by the Activity Director and the Director of Nursing, both of whom confirmed that no meetings had taken place since the specified date. The lack of regular meetings indicates a failure to honor the residents' right to organize and participate in resident/family groups within the facility.
Improper Use and Documentation of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by the cases of two residents. Resident #31, who was admitted with multiple diagnoses including severe cognitive impairment, was observed with a pelvic restraint tied in a manner that he could not remove. There was no documentation of a pre-restraint assessment to determine the least restrictive option, and the restraint was not identified in his care plan. Interviews with staff confirmed these deficiencies. Resident #136, who had no cognitive impairment but required assistance for daily activities, was also observed with a pelvic restraint improperly tied in a tight knot, which was not in accordance with proper procedures. There was no physician's order to monitor and release the restraint every two hours, and no documentation of such monitoring. The resident's care plan did not identify the restraint or include interventions for its safe use. Staff interviews confirmed the lack of a pre-restraint assessment and the absence of the restraint in the care plan. The facility's restraint policies and procedures were found to be lacking, as they did not include guidelines for pre-restraint assessments, obtaining consents, or monitoring restraint use. This oversight contributed to the improper use and documentation of restraints for the residents involved, highlighting a systemic issue in the facility's approach to restraint management.
Deficiencies in Resident Assessments for Smoking and Restraints
Penalty
Summary
The facility failed to conduct comprehensive assessments for two residents, leading to deficiencies in their care. For one resident with severe cognitive impairment and multiple diagnoses, including quadriplegia and dementia, the facility did not perform quarterly smoking assessments as required by their policy. Despite being identified as an unsafe smoker who required supervision, the last documented smoking assessment was conducted nearly two years prior. This oversight was confirmed by the LPN/MDS and acknowledged by the facility's Administrator and DON. Another resident, who had no cognitive impairment but required extensive assistance due to conditions such as hemiplegia and congestive heart failure, was observed using a pelvic restraint without a documented pre-restraint assessment. The facility's restraint policies lacked guidelines for comprehensive assessments, including pre-restraint evaluations. Despite having a physician's order for the restraint, there was no evidence of an assessment to determine the least restrictive option. This deficiency was confirmed by both the LPN/MDS and a Nurse Consultant, and acknowledged by the facility's Administrator and DON.
Deficiencies in Care Plan Implementation and Restraint Assessment
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for residents, specifically regarding the use of restraints and monitoring for bleeding. For one resident, the care plan did not include any approaches for a pelvic restraint, despite the resident being observed with a pelvic restraint in place. Additionally, there was no pre-restraint assessment completed for this resident. Another resident also had a pelvic restraint in place without a documented pre-restraint assessment or inclusion in the care plan. Interviews with staff confirmed these omissions. Furthermore, the facility did not implement the care plan for a resident who was at risk for bleeding due to daily aspirin use. The care plan included monitoring for signs of bleeding, but there was no documentation in the Medication Administration Record that this monitoring was being conducted. An interview with an LPN confirmed that the monitoring approach had not been implemented as per the resident's care plan.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised in a timely manner to address new fall interventions. Resident #2, who was admitted with multiple diagnoses including Parkinson's disease and severe cognitive impairment, experienced two falls within a short period. The first fall occurred in the chapel, and the second in her room, both without injury. However, the care plan was not updated promptly to include new interventions, such as reminding the resident to wait for assistance, and the intervention was deemed inappropriate. Additionally, the resident's bilateral fall mats were not documented in her care plan. Resident #24, who was readmitted with conditions such as dementia and heart disease, was found on his knees after a fall while attempting to enter the bathroom. Despite this incident, the resident's care plan was not revised to address the fall. The LPN/MDS staff confirmed that the care plan had not been updated following the incident. Both the administrator and the DON were informed of these deficiencies, highlighting the facility's failure to revise care plans to meet the residents' needs after falls.
Failure to Investigate Falls and Injuries in LTC Facility
Penalty
Summary
The facility failed to ensure that residents remained as free from accident hazards as possible, specifically for two residents. For one resident, the facility did not conduct a thorough investigation following falls that occurred in June 2024. The resident, who was severely cognitively impaired and at high risk for falls, had a fall mat improperly placed under her bed, which was confirmed by a CNA. Additionally, the resident's care plan was not updated in a timely manner with appropriate interventions following the falls, and the interventions that were added were not suitable given the resident's cognitive impairment. Another resident, who was also severely cognitively impaired and at high risk for falls, experienced an injury of unknown origin. The facility did not conduct an investigation into the incident that resulted in a laceration above the resident's right eye, nor was there documentation of the incident in the facility's records. A similar incident occurred in April 2024, where the resident had a laceration of unknown origin, and again, no investigation was conducted to determine the cause of the injury. Interviews with facility staff, including the Director of Nursing, confirmed the lack of investigations and documentation for both residents' incidents. The facility's failure to conduct thorough investigations and update care plans with appropriate interventions contributed to the deficiencies identified by the surveyors.
Deficiencies in Medication Administration and Fall Prevention
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in administering medications and following physician orders for three residents. For one resident, there was no documentation of the administration site for Lantus insulin and sliding scale Humulin R insulin over several days. Additionally, there were omissions in the administration of Azithromycin, Sulfamethoxazole-Trimethoprim, and Zidovudine on specific dates. The Director of Nursing confirmed these documentation lapses during an interview. Another resident, who was at high risk for falls due to severe cognitive impairment, did not have the prescribed fall prevention measures in place. The physician had ordered a bed alarm and fall mats, but these were not observed in the resident's room during the survey. Despite documentation indicating that these measures were in place, the LPN confirmed their absence, and the Director of Nursing and Administrator were informed of these findings. For a third resident with diabetes, the facility failed to document an accucheck result as ordered by the physician. The resident was supposed to have accuchecks twice daily, but there was no record of the result for one of the scheduled times. The Assistant Director of Nursing confirmed the lack of documentation and that the physician was not informed of the missed accucheck. These deficiencies highlight a lack of adherence to medication administration protocols and physician orders, impacting resident care.
Failure to Conduct Monthly State Adverse Action Checks for CNAs
Penalty
Summary
The facility failed to ensure that monthly State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNAs). This deficiency was identified through a review of personnel records for six CNAs, all of whom had documentation of a State Adverse Actions check on 04/23/2024, but no subsequent checks were documented through the present date of 07/17/2024. The CNAs involved had varying hire dates, ranging from as early as 12/06/1994 to as recent as 03/25/2024, indicating a systemic issue in maintaining compliance with the monthly check requirement. During an interview conducted on 07/17/2024, the facility's administrator confirmed that the monthly State Adverse Action checks were not being performed as required. This lapse in procedure affected all six personnel files reviewed, highlighting a failure in the facility's process to ensure ongoing compliance with state regulations regarding the monitoring of adverse actions for CNAs.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by their policy. During an observation, a medication cart located in the hallway of hall A was found unlocked with drawers open, exposing medications to unauthorized access. At the time of the observation, no nurse or staff member was present to monitor the cart, and a resident was seen passing by the open cart in a wheelchair. The Director of Nursing (DON) confirmed the policy that medication carts should be locked when not in use and when the nurse is not in view of the cart. Despite this policy, the cart was left unattended and unlocked while the responsible LPN was assisting another resident behind a closed door. A subsequent observation revealed the cart was again left unlocked with no staff in sight, indicating a repeated failure to secure medications properly.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. Dirty serving trays with old dried food particles were found on a rolling cart near the steam table. Additionally, there was a significant build-up of thick, black grime on the kitchen cabinets, shelves, and window ledge, where various cooking pots, pans, and eating utensils were stored. These conditions indicate a lack of proper cleaning and maintenance in the kitchen area. Further inspection revealed an expired nutritional supplement, Boost, stored in the refrigerator, and food items belonging to an employee were improperly stored in the storage room, making them available for resident use. The dietary staff member present during the survey confirmed these findings, acknowledging the cleanliness issues and the inappropriate storage of the expired supplement and employee food items. The facility administrator was informed of these deficiencies.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist, responsible for the infection prevention and control program, had completed the necessary specialized training. A review of the facility's Infection Control Records showed no documented evidence that the Infection Preventionist, who is also an LPN/MDS, had completed the required training in infection prevention and control. During an interview, the LPN/MDS confirmed that she had not completed the Infection Preventionist Training. This was further corroborated by an interview with the Director of Nursing, who also confirmed the lack of completion of the required training by the LPN/MDS.
Failure to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to maintain all mechanical equipment in safe operating condition, as evidenced by the presence of metal shavings on the blade of a large manual can opener. During an initial tour of the kitchen, an observation was made of the can opener with a buildup of metal shavings. A dietary staff member began using the can opener to open a large can of sweet green peas for lunch service, at which point she was informed of the metal shavings and acknowledged that the can opener blade required cleaning. The facility administrator was notified of these findings shortly thereafter.
Lack of Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that all required in-service training for Certified Nurse Aides (CNAs) included dementia management training. This deficiency was identified through a review of personnel records and interviews, which revealed that six CNAs (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) did not have documentation of dementia care management training in their files. The hire dates for these CNAs ranged from 1994 to 2024, indicating a systemic issue across different hiring periods. An interview with the Director of Nursing confirmed that the dementia care training had not been provided to these CNAs.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. The resident, who was admitted with diagnoses of Parkinson's disease and age-related cognitive decline, was found to have a discrepancy in her medical records. Her medical record had a red sticker indicating 'No Code,' while a physician's order and her care plan indicated 'Full Code.' Additionally, her Louisiana Physician Orders for Scope of Treatment (LaPOST) form, signed by her family member and physician, indicated her wish to receive CPR if unresponsive, pulseless, and not breathing. The Director of Nursing (DON) was unaware of this discrepancy until it was pointed out during an interview. The inconsistency was confirmed upon review of the resident's medical record, which showed conflicting information between the red 'No Code' sticker and the LaPOST, physician order, and care plan, all of which indicated a 'Full Code' status. This failure to maintain consistent documentation of the resident's code status represents a deficiency in honoring the resident's right to have her treatment preferences accurately reflected in her medical records.
Failure to Notify Physician of Critical Blood Sugar Level
Penalty
Summary
The facility failed to immediately notify the physician when a resident experienced a significant change in condition. Specifically, a resident with Type II diabetes mellitus and diabetic polyneuropathy had an accucheck result of 455 milligrams/deciliter, which was above the threshold of 400 milligrams/deciliter that required physician notification according to the care plan. Despite this, there was no documentation indicating that the physician or nurse practitioner was informed of this critical result. Interviews with the nurse practitioner and physician confirmed that they were not notified of the resident's high blood sugar level. The Assistant Director of Nursing also acknowledged the lack of documentation and confirmed that the physician should have been notified. The deficiency was identified during a review of the resident's medical records and interviews with facility staff, highlighting a failure in communication and adherence to established protocols for managing the resident's diabetes.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide an environment free of accident hazards for a resident identified at high risk for elopement. The resident, who had severe cognitive impairment and was at high risk for falls, managed to exit the facility through an unsecured door. The resident was found a half block away, sitting in a ditch with a laceration to his left eye and a bruise on his left shoulder. The door the resident exited was supposed to be locked and require a code to open, but it did not close completely, allowing the resident to push it open and trigger the alarm. The facility's Wandering and Elopement policy lacked guidance on supervision or monitoring for residents who had eloped, and there was no documentation of monitoring the resident's needs prior to the elopement or the census checks every 30 minutes after the incident. The resident's medical record revealed multiple diagnoses, including myocardial infarction, alcoholic cardiomyopathy, acute respiratory failure with hypoxia, syphilis, heart failure, alcohol abuse, trichomonas, acute kidney failure, and metabolic encephalopathy. The resident required assistance with bed mobility and transfers and was identified as high risk for falls. Despite these risks, the only intervention noted before the elopement was a bed alarm. After the elopement, the care plan was updated to include census checks every 30 minutes, but there was no documentation to confirm these checks were being performed. Interviews with staff confirmed the lack of documentation for monitoring the resident before and after the elopement. The Administrator acknowledged the door malfunction and stated that the facility did not have wander guard bracelets on hand, which were ordered after the incident. The Director of Nurses also confirmed that the resident was being monitored every 30 minutes, but this monitoring was not documented. The facility's failure to secure exit doors and provide adequate supervision resulted in an Immediate Jeopardy situation when the resident eloped and sustained injuries.
Failure to Supervise High-Risk Resident Leads to Elopement and Injury
Penalty
Summary
The facility failed to administer its resources effectively and efficiently by not having an adequate system in place to supervise a resident at high risk for elopement. This resulted in an Immediate Jeopardy situation when a cognitively impaired resident, identified as an elopement risk, was found a half block away from the facility. The resident eloped through an unsecured door, was found in a ditch with a laceration to his left eye and a bruise on his left shoulder, and was subsequently sent to the local hospital for evaluation. The door the resident exited was supposed to be locked and require a code to open, but it did not close completely, allowing the resident to push it open and trigger the alarm. The facility did not have wander guard bracelets on hand and had to order them after the incident. Additionally, there was no system in place to monitor the locked doors to ensure they were functioning properly, and there was no documented evidence of monitoring the resident for elopement before or after the incident. The facility's Wandering and Elopement policy, dated December 2009, lacked guidance on placing a resident who had eloped under any type of supervision or monitoring. The Incident and Accident report confirmed the resident's injuries and the timeline of events. Interviews with the Administrator and the Director of Nurses revealed that the facility did not have a system to monitor the locked doors and that the resident was being monitored every 30 minutes without documentation. The Immediate Jeopardy was removed after the facility implemented an acceptable Plan of Removal, but the deficiency highlighted significant lapses in the facility's supervision and monitoring systems for high-risk residents.
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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