Matthews Memorial Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 5100 Jackson Street Ext., Alexandria, Louisiana 71303
- CMS Provider Number
- 195600
- Inspections on file
- 32
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Matthews Memorial Health Care Center during CMS and state inspections, most recent first.
Two residents with existing pressure ulcers and high risk for skin breakdown did not receive ordered pressure-relief interventions and scheduled repositioning. One resident with multiple comorbidities and a Stage 2 heel ulcer had a care plan and posted signage requiring heel protectors, yet surveyors repeatedly observed the resident in bed or in a specialized wheelchair with heels on the mattress and the heel protectors stored on top of a closet; a family member reported never seeing them applied, and nursing staff acknowledged they should have been in use. Another resident with paraplegia, bilateral above-knee amputations, and Stage 4 buttock ulcers was care planned for a q2h turn schedule with wedges, but was repeatedly observed lying on his back with no supportive equipment while the wedges remained unused in a box; the resident stated staff did not turn or offer to turn him, and the assigned CNA and DON later acknowledged that q2h turning should have been provided but was not.
The facility did not ensure timely physician notification for an antibiotic order following a consultant's recommendation for a resident with a tooth abscess, resulting in a delay of several days before treatment was initiated. Additionally, another resident with multiple stage 4 pressure ulcers did not receive wound care as ordered on several occasions, with gaps in documentation and responsibility among nursing staff.
A resident with severe malnutrition and quadriplegia fell while attempting to get up from bed, resulting in acute right pubic fractures. The facility failed to immediately inform the resident's representative and consult the physician, with the representative only learning of the fall during a visit. The responsible LPN was suspended for not notifying the representative promptly.
The facility failed to notify physicians of elevated blood sugar levels for two residents with diabetes, despite physician orders requiring such notifications. One resident had CBG levels exceeding 300 on multiple occasions, while another had levels over 400, with no documentation of physician notification. The Corporate RN confirmed the oversight.
Two residents in a LTC facility experienced inadequate pain management. One resident with Multiple Sclerosis did not receive prescribed Oxycodone despite reporting severe pain, while another resident with Type 2 Diabetes reported high pain levels without receiving any medication. Staff failed to administer pain relief or contact a physician, violating care standards.
The facility failed to ensure accurate reconciliation of controlled medications at each shift change. Despite the policy requiring a controlled drug count by both outgoing and incoming nurses, an LPN confirmed she did not reconcile narcotics with the off-going nurse. Another LPN also failed to reconcile medications with the incoming nurse. The DON confirmed the requirement for controlled substances to be counted at the beginning and end of each shift.
The facility failed to provide snacks and timely meals according to residents' needs and preferences. Observations and interviews revealed that snacks were not readily available, and residents had to request them from the nurse's station. Some residents did not receive meals in a timely manner, with one resident not receiving breakfast until late morning after being admitted the previous day. The facility's meal service times exceeded 14 hours from dinner to breakfast, and only residents with a doctor's order received snacks at specific times.
Two residents with cognitive impairments were not provided with necessary shaving services, as required by the facility's policy. One resident, dependent on staff for personal hygiene, was observed with facial hair, and the CNA Task Schedule showed inadequate documentation of care. Another resident, requiring substantial assistance, was also observed with facial hair and expressed that the usual caregiver was unavailable. The ADON confirmed both residents needed assistance with shaving, which they did not receive.
A facility failed to provide necessary treatment and services for a resident with stage 4 pressure ulcers, leading to inadequate wound assessments and care. The resident, who required assistance with mobility, did not receive consistent turning and repositioning as per their care plan. The facility lacked a wound care nurse, resulting in missing wound assessments and unawareness of the current status of the resident's wounds.
A facility failed to provide proper respiratory care for a resident with chronic respiratory failure. The resident's nebulizer mask and oxygen tubing were found uncovered and undated, contrary to professional standards. The DON confirmed that the equipment should be covered and changed every seven days.
A resident fell and sustained a femur fracture after being placed in a shower chair without a safety belt by a CNA. The facility's policy required safety belts on shower chairs, but this was not followed. Multiple CNAs were aware of the missing safety belts but did not report the issue, and the maintenance logs had no records of the problem. The resident required emergency surgery following the fall.
A resident experienced a fall and was not immediately assessed with no injury noted. The facility failed to promptly notify the physician and the resident's representative. Later, the resident was found to have swelling and bruising, and an X-ray revealed an acute fracture. This indicates a failure to follow the facility's policy on immediate notification.
A facility failed to promptly resolve a grievance filed by a resident's RP regarding delayed notification of a fall. The RP was informed of the fall a day later, and the grievance was not resolved within the required timeframe, contrary to the facility's policy.
Failure to Implement Pressure-Relief Devices and Turning Program for Two Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure-relieving interventions and turning/repositioning necessary to promote healing of existing pressure ulcers and prevent further skin breakdown for two of three sampled residents. One resident, admitted with multiple comorbidities including squamous cell carcinoma of the skin, type 2 diabetes with neuropathy, peripheral arterial disease, and identified as at risk for pressure ulcers, had a documented Stage 2 pressure ulcer on the right heel. The resident’s care plan, initiated in late August 2024, included heel protectors as an intervention under a focus on safety devices and special equipment to maintain optimal functioning. Despite posted signage in the room stating the resident was to wear heel protectors, surveyor observations on multiple days and times showed the resident lying on her back in bed or sitting in a specialized wheelchair with her heels resting on the mattress and the heel protectors stored on top of the clothes closet rather than on her heels. Across several observations, the heel protectors remained unused on top of the closet while the resident’s heels were in direct contact with the mattress, and no positioning supports were in place. A family member reported never having seen the heel protectors applied to the resident. The treatment nurse confirmed the resident had a Stage 2 pressure ulcer on the right heel that had previously been a deep tissue injury and stated that pressure reduction was one of the interventions in place to promote wound healing. An LPN later confirmed that the resident’s heel protectors were on top of the closet instead of on the resident’s heels, and acknowledged that they should have been applied as part of the wound-healing interventions. The second resident involved had paraplegia, neuromuscular bladder dysfunction, bilateral above-the-knee amputations, and existing Stage 4 pressure ulcers on both buttocks, with documented wound measurements from a recent skin evaluation. This resident was dependent for bed mobility and transfers and was care planned for the facility’s turn and repositioning program, with a posted turn schedule indicating side-to-side repositioning every two hours. However, repeated observations over two days showed the resident in bed on his back with the head of the bed elevated, without any supportive positioning equipment in use, while two positioning wedges remained unused in a box in the corner of the room. The resident reported that staff did not turn or reposition him every two hours, that he did not refuse turning, and that no one had offered to reposition him that day. A CNA assigned to the resident stated she was familiar with his care needs but believed he was not on a turn schedule, admitted she had not turned or offered to turn him during her shift, and then acknowledged, upon review of the posted schedule, that she should have offered repositioning every two hours but did not. The DON also acknowledged the resident should have been turned or offered turning every two hours and was not.
Failure to Ensure Timely Physician Notification and Wound Care as Ordered
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for two residents. For one resident with a history of gastro-esophageal reflux disease, hypertension, delusional disorder, and cellulitis, there was a delay in obtaining an antibiotic for a tooth abscess. After returning from a medical appointment with a recommendation for an antibiotic, the nurse contacted the resident's physician and left a message but did not follow up the next day. The oncoming nurse was not made aware of the situation, and the issue was not documented in the 24-hour report as required. The physician was not contacted again until several days later when the resident complained of pain and swelling, at which point an antibiotic was finally ordered. Another resident with quadriplegia, pain, hypertension, urinary tract infection, and multiple stage 4 pressure ulcers did not receive wound care as ordered on several documented dates. The treatment nurse, who worked weekdays, stated that floor nurses were responsible for treatments in her absence, and the RN supervisor was responsible on weekends. However, there was no documentation that wound care was provided on specific dates, and this was confirmed by the DON. The lack of timely follow-up and communication among staff led to missed treatments and a delay in physician notification for necessary care.
Failure to Notify Resident's Representative After Fall
Penalty
Summary
The facility failed to immediately inform a resident's representative and consult the resident's physician following an accident involving the resident that resulted in injury and had the potential for requiring physician intervention. The incident involved a resident who was found on the floor after attempting to get up from bed, reporting no pain or head injury at the time. Despite the resident's fall, the facility did not notify the resident's representative immediately, and the representative only learned of the incident during a visit later that day. The resident, who had a history of severe protein-calorie malnutrition and functional quadriplegia, was admitted to the facility with previous pelvis fractures. After the fall, the resident's family requested an x-ray, which revealed acute right pubic fractures. The facility's failure to notify the resident's representative promptly was acknowledged by the Director of Nursing and Corporate Nurse, and the responsible LPN was suspended following the event.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two residents. Resident #27, who was admitted with Type 2 Diabetes Mellitus with Neuropathy and long-term use of insulin, had physician orders for insulin administration and capillary blood glucose (CBG) monitoring. The orders specified that the physician should be notified if CBG levels were less than 60 or greater than 300. However, the resident's CBG levels exceeded 300 on multiple occasions in September 2024, and there was no documentation that the physician was notified of these elevated levels. Similarly, Resident #64, who was admitted with Type 2 Diabetes Mellitus and other conditions, had physician orders for insulin administration and CBG monitoring. The orders required notification of the physician if CBG levels were greater than 400. Despite this, the resident's CBG levels exceeded 400 on several occasions in August and September 2024, and there was no documentation that the physician was informed. Interviews with the Corporate RN confirmed the lack of documentation and acknowledged that the physician should have been notified in both cases.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident #4, who has a history of Multiple Sclerosis and Chronic Pain Syndrome, reported severe pain and did not receive her prescribed pain medication, Oxycodone, as needed. Despite calling for the nurse multiple times during the night, Resident #4 did not receive any pain relief, as confirmed by the CNA and the LPN on duty, who admitted to not attending to the resident throughout her shift. Resident #64, diagnosed with Type 2 Diabetes Mellitus and other conditions, consistently reported high pain levels without receiving any pain medication. The resident's MAR documented pain levels ranging from 6 to 7, yet no pain relief was administered. The LPN responsible for Resident #64 acknowledged the resident's pain but failed to contact the physician to address the lack of pain medication orders. The facility's policy on pain management emphasizes the importance of treating pain and revising care plans as necessary. However, both residents experienced unrelieved pain due to the staff's failure to administer medication or seek medical advice, resulting in a breach of professional standards and the residents' care plans.
Failure to Reconcile Controlled Medications at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate reconciliation of controlled medications for each resident. This deficiency occurred because the facility did not conduct a physical inventory of controlled medications at each shift change, as required by their policy. The policy, revised in November 2017, mandates that a controlled drug count be performed at the beginning of each shift by both the outgoing and incoming medication nurses. However, on September 8, 2024, an LPN who reported to work at 7:00 a.m. confirmed that she did not reconcile narcotics with the off-going nurse or any other nurse, despite acknowledging that she should have. Similarly, another LPN who worked the previous shift from 11:00 p.m. to 7:00 a.m. also confirmed that she did not reconcile medications with the incoming nurse. The Director of Nursing (DON) confirmed that all controlled substances should be counted at the beginning and end of each shift by both the on-coming and off-going nurses.
Failure to Provide Snacks and Timely Meals
Penalty
Summary
The facility failed to ensure that snacks were served at times in accordance with residents' needs, preferences, and requests. Observations and interviews revealed that snacks were not available at all times, and residents had to request them from the nurse's station. Residents reported that snacks were labeled with specific names, and those without a label did not receive any. Additionally, the facility did not provide snacks for residents outside of scheduled meal service times, and some residents reported not receiving meals in a timely manner. For instance, one resident did not receive breakfast until 11:30 a.m. after being admitted the previous day and had not eaten since the previous evening. Interviews with the Director of Nursing (DON) and the Dietary Manager revealed that only residents with a doctor's order received snacks at specific times, and bedtime snacks were left at the nurse's station. This practice excluded residents who could not go to the nurse's station to request a snack. The facility's meal service times were also noted to be longer than 14 hours from dinner to breakfast, which contributed to residents not receiving adequate nourishment. The Administrator and Dietary Manager acknowledged these issues, indicating awareness of the deficiencies in meal and snack distribution.
Failure to Provide Necessary Shaving Services for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to perform Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents were not provided with shaving services as required. Resident #2, who has severe cognitive impairment and is dependent on staff for personal hygiene, was observed with facial hair on multiple occasions, indicating a lack of shaving. The CNA Task Schedule for September 2024 showed no documentation of a bath for Resident #2, and personal hygiene was only recorded on two specific dates. Resident #82, who has moderate cognitive impairment and requires substantial assistance for bathing, was also observed with facial hair. The resident expressed that someone usually shaved him, but the person was not available. Both residents were confirmed by the Assistant Director of Nursing (ADON) to need assistance with shaving, which they did not receive. These observations and interviews highlight the facility's failure to adhere to its policy of providing necessary personal hygiene care, including shaving, for residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice, to promote healing and prevent infection. The resident, who was cognitively intact and required assistance with mobility, had multiple stage 4 pressure ulcers on the sacral region and buttocks. Despite having physician's orders for specific wound care treatments, the facility did not ensure that the resident's wounds were accurately assessed and documented on a weekly basis as required by their policy. The Director of Nursing (DON) confirmed that there were missing wound assessments for the resident's pressure ulcers over a specified period, and acknowledged that the assessments should have been conducted weekly by a nurse. Additionally, the facility failed to implement a consistent turning and repositioning program for the resident, which was part of the care plan to prevent further skin breakdown. During an observation, the resident reported that staff did not turn or reposition him every two hours as required, and that his positioning wedge was not in use. The DON was unaware of the current status of the resident's sacral wound and why treatment orders for a stage 4 pressure ulcer were still in place. The facility had not had a wound care nurse since June 2024, which contributed to the lack of proper wound assessments and care.
Failure to Properly Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of hypertensive heart failure, gastrostomy status, and chronic respiratory failure with hypoxia. The resident's care plan indicated a risk for shortness of breath and required oxygen as ordered. During observations, the resident's nebulizer mask and oxygen tubing were found uncovered and undated, lying on the over-bed table and oxygen concentrator, respectively. Interviews confirmed that the oxygen equipment was not properly labeled or stored, and the Director of Nursing acknowledged that the equipment should be covered and changed out every seven days.
Failure to Secure Resident in Shower Chair Leads to Injury
Penalty
Summary
The facility failed to ensure that Resident #3 was safely secured in a shower chair prior to showering, resulting in a fall and subsequent injury. On 04/19/2024, Resident #3, who required substantial assistance with bathing and transfers, was placed in a shower chair without a safety belt by S5 CNA. During the shower, Resident #3 fell from the chair to the floor, sustaining a displaced left intertrochanteric femur fracture, which required surgical intervention. The facility's policy mandated the use of safety belts on shower chairs, but this was not adhered to in this instance. Interviews with multiple CNAs revealed that the shower chairs had been without safety belts for an unspecified period, and the issue had not been reported to maintenance. S5 CNA admitted to using the shower chair without a safety belt on multiple occasions, assuming the issue had already been reported. Other CNAs confirmed the absence of safety belts on the shower chairs and acknowledged that they were aware of the requirement for safety belts but did not log the issue in the maintenance log. The maintenance supervisor confirmed that there were no records in the maintenance logs regarding the missing safety belts on the shower chairs. The administrator acknowledged that the shower chair used for Resident #3 did not have a safety belt and confirmed that all shower chairs should have safety belts attached for resident safety. This deficiency resulted in actual harm to Resident #3, who required emergency medical treatment and surgery following the fall.
Failure to Immediately Notify Physician and Resident's Representative After Fall
Penalty
Summary
The facility failed to immediately consult with the physician and notify the resident's representative when a resident experienced a fall. On 04/05/2024, Resident #1 slid out of bed at approximately 9:12 p.m. and was assessed with no injury noted. The nurse's progress notes documented that the resident was assisted back to bed and instructed to use the call light, but there was no documentation that the resident's physician or representative had been notified of the fall. The incident report indicated that the physician was contacted at 9:15 p.m., but the time of contact for the resident's representative was not documented. Later, on the same day at 9:19 p.m., while assisting Resident #1 to undress, a CNA noted swelling and bruising on the resident's right upper arm, and the resident complained of pain in the right ribcage and back. The physician was notified, and an order for a stat X-ray was given. The resident's representative was also notified at this time. The X-ray results revealed an acute fracture of the right 6th rib. This sequence of events indicates a failure to promptly notify the physician and the resident's representative immediately after the initial fall, as required by the facility's policy.
Failure to Promptly Resolve Grievance Regarding Resident Fall Notification
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance filed by a resident's Responsible Party (RP). The grievance was related to the RP not being notified of a fall that the resident sustained. The facility's policy requires that grievances be resolved promptly and that findings and recommendations be discussed with the complainant within five workdays. However, the RP was not informed of the fall until the day after it occurred, and the grievance was not resolved within the required timeframe. The incident involved a resident who fell on the night of April 5, 2024. The RP was not notified of the fall until the following night, despite the facility's policy requiring immediate notification. The Director of Nursing (DON) registered the grievance electronically on April 8, 2024, but the complaint had not been completed by the time of the survey. Interviews with the involved staff confirmed the delay in notification and the failure to resolve the grievance promptly.
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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