Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mary Goss Nursing Home during CMS and state inspections, most recent first.
Failure to maintain required RN coverage. Review of PBJ staffing data and RN time cards showed the facility did not have 8 consecutive hours of RN coverage on multiple days, and on one day no RN worked in the facility. The Administrator, who completed the PBJ staffing report, confirmed the lack of RN coverage.
Failure to provide a NOMNC for a resident discharged from Medicare Part A services. Record review showed the discharge from therapy was facility initiated even though skilled benefit days remained, and the resident’s chart did not contain the required NOMNC. The DON confirmed she was responsible for beneficiary notifications and stated she did not know the resident required the form.
Physical restraint used without consent, order, or assessment: A resident with CVA, schizophrenia, dementia, and other diagnoses was observed sitting in a geri-chair with a lap tray in place and later being fed breakfast in the chair. The record showed severe cognitive impairment, no restraint use on the MDS, and no documented pre-restraint assessment, consent from the resident or RP, or physician order. An LPN stated the facility was trying the geri-chair and lap tray before completing the assessment, care plan, or obtaining the order, and the DON confirmed the resident had been placed in the chair since admission without those requirements.
Failure to Provide Ordered Low Air Loss Mattress: A resident with a stage 4 sacral PU, severe cognitive impairment, hemiplegia, and high Braden risk did not receive an ordered low air loss mattress. Staff observed a deflated low air loss device on top of the pressure-reducing mattress, and a CNA reported the pump was missing. The DON and Maintenance later confirmed the device remained deflated and the ordered intervention was not implemented.
Failure to Provide Ordered Thickened Liquids: A resident with COPD, impaired cognition, and an order for honey/moderately thick liquids was observed drinking unthickened water despite care plan and ST recommendations for thickened liquids. Staff, including the CNA, DON, LPN, and ST, confirmed the resident was supposed to receive only thickened liquids, and thickener was present in the room but not being used.
Improper Storage of Suction Equipment: A resident with an order for oral suctioning was observed with suction equipment left out in the room, including a canister with liquid and an uncovered Yankauer tip with visible residue available for reuse. An LPN stated the equipment should not have been left out and should have been cleaned and stored properly, and the DON acknowledged it should have been cleaned, stored, and covered after use.
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.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure an RN was on duty for 8 consecutive hours a day, 7 days a week during Fiscal Year Quarter 2 2025. Review of the facility’s PBJ Staffing Data Report for January 1 through March 31, 2025 showed there were no consecutive 8 hours of RN coverage for 3 days within the quarter. Review of RN time cards showed that on 02/01/2025 and 02/02/2025, the RN did not work 8 consecutive hours within the 24-hour period, and no RN worked in the facility on 03/05/2025. During interview, the Administrator stated he was responsible for completing the PBJ staffing report and confirmed there was not 8 hours of consecutive RN coverage on 02/01/2025 and 02/02/2025 and that no RN worked in the facility on 03/05/2025.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide CMS form 10123, Notice of Medicare Non-Coverage (NOMNC), for one resident reviewed for SNF beneficiary notification. Record review showed the facility initiated the resident’s discharge from Medicare Part A services even though benefit days were not exhausted, and the resident was discharged from Medicare Part A services while skilled benefit days remained. Further review of the resident’s record did not reveal a NOMNC form. During interview, the DON confirmed she was responsible for providing beneficiary notifications and stated the discharge from therapy was facility initiated, with skilled benefit days still remaining at the time of discharge, and she did not know the resident required a NOMNC form.
Physical restraint used without consent, order, or assessment
Penalty
Summary
The facility failed to ensure Resident #44 was free from a physical restraint used without the required consent, physician order, or pre-restraint assessment. Resident #44 was admitted with diagnoses including CVA, schizophrenia, major depressive disorder, anxiety disorder, insomnia, vascular dementia, and hypertension. The admission MDS indicated the resident was severely cognitively impaired, unable to make daily decisions, and had no upper or lower extremity range-of-motion impairments. The MDS also indicated no restraints were used, and the medical record contained no documented assessment before use of a geri-chair and lap tray, no consent from the resident or responsible party, and no physician's order for the geri-chair. Observations showed Resident #44 sitting in a geri-chair with a lap tray in place in the room and later being fed breakfast while seated in the geri-chair with the lap tray. A CNA stated the resident was placed in the geri-chair with lap tray daily when out of bed. An LPN stated there was no order for the geri-chair and lap tray or care plan because the facility was trying it out before doing the assessment, care plan, or obtaining the physician's order. The DON confirmed the resident had been placed in the geri-chair with lap tray since admission without a pre-restraint assessment, written physician order, or consent from the resident or responsible party.
Failure to Provide Ordered Low Air Loss Mattress
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for Resident #39, who was admitted with diagnoses including hemiplegia and hemiparesis following a non-traumatic intracranial hemorrhage affecting the right dominant side, a stage 4 sacral pressure ulcer, and hypertension. The resident's MDS indicated severe cognitive impairment, substantial to maximal assistance with bed mobility, dependence with toileting, and use of an indwelling catheter. The Braden Scale score was 12, indicating high risk for pressure ulcer development, and the care plan included maintaining a pressure reduction mattress to the bed. Review of the electronic order summary showed an order for a low air loss mattress, but this intervention was not noted in the active plan of care for the pressure ulcer. During observation, staff identified a deflated low air loss device on top of the resident's pressure reducing mattress, and a CNA reported that the pump needed to inflate the device was missing. The DON later observed the deflated device and confirmed that the intervention was not implemented as ordered, and Maintenance also observed that the device remained deflated.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide thickened liquids as ordered for one resident who had an order for honey/moderately thick consistency liquids. The resident had a history of chronic obstructive pulmonary disease, a BIMS score of 7 indicating moderately impaired cognitive skills for daily decision making, and a care plan that identified an alteration in nutrition with gluten free, pureed foods and honey thick liquids. A speech therapy dysphagia evaluation also recommended honey thickened liquids for pleasure. During observations, the resident was seen with an opened 8-ounce water bottle with a straw, and the water was not thickened. An open container with unopened packages of thickener was on the resident’s nightstand, and a note on the wall stated, "All liquids to be nectar thickened liquids only." Staff interviews confirmed the resident was supposed to receive thickened liquids and should not have been drinking unthickened liquids. The CNA, DON, LPN, and speech therapist all acknowledged the resident was supposed to only have thickened liquids.
Improper Storage of Suction Equipment
Penalty
Summary
Infection control measures were not followed for Resident #22, who had an order for oral suctioning as needed and a history of transient cerebral ischemic attack. On 08/25/2025 at 9:28 a.m., the resident was observed sitting in a geri chair in her room with suction equipment on the side table. The clear canister contained liquid, and the connected Yankauer suction tip had a white substance spread unevenly inside it. The Yankauer tip was left uncovered, lodged upright between the wall and the side table, and was available for reuse. New suctioning tips were not available in the resident’s room at the time of the observation. The facility’s undated policy for suctioning the upper airway stated that oropharyngeal suctioning is performed using aseptic technique and that after suctioning, water or saline should be discarded in the commode, the cup disposed of in the designated receptacle, and the collection container emptied and rinsed as indicated by facility protocol. During interview, an LPN stated the suctioning machine and Yankauer tip should not have been left out after use and should have been cleaned and stored properly, and reported not knowing who had last used the equipment. The DON acknowledged the equipment should be cleaned and stored after each use and that the Yankauer tip should be covered in a clear plastic covering, and stated she was aware the equipment was out in the resident’s room but did not know who used it last.
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.
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Illustrative
What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Skilled Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 11 | 0 |
| The Oaks | 2.4 mi | ★★★★★ | 2 | 0 |
| Delta Grande Skilled Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 5 | 0 |
| Ouachita Healthcare And Rehabilitation Center | 3.3 mi | ★★★★★ | 5 | 0 |
| Avalon Place | 4.1 mi | ★★★★★ | 9 | 0 |
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