Meadowview Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minden, Louisiana.
- Location
- 400 Meadowview Drive, Minden, Louisiana 71055
- CMS Provider Number
- 195281
- Inspections on file
- 30
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Meadowview Health & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, tracheostomy, and dependence on staff for ADLs did not receive the ordered oral hygiene care every shift as outlined in the care plan. The care plan required morning and nighttime oral care, but observation revealed white debris on the resident’s lips, and staff interviews showed that CNAs and an RT had differing understandings of who was responsible for providing oral care. An LPN confirmed the resident had not received oral care the previous day, and leadership confirmed that CNAs were responsible for providing oral care each shift and that this had not occurred.
A resident with severe cognitive impairment, multiple sclerosis, hemiplegia, and a Stage 4 sacral pressure ulcer had physician orders and a care plan for sacral wound care three times weekly and as needed when soiled. During an observed treatment, a treatment nurse removed a saturated sacral dressing and completed the ordered wound care while leaving a soiled brief in place, then secured the same soiled brief on the resident afterward and replaced the bed linens. The nurse acknowledged the brief was soiled during treatment, and the DON stated the brief should have been changed before and not left on after the wound care, contrary to the facility’s pressure injury prevention policy requiring residents to be kept clean and dry.
A resident with chronic respiratory failure, lumbar osteomyelitis, complete paraplegia, a sacral pressure ulcer, and a tracheostomy had only one documented face-to-face physician visit during an extended stay, despite requirements for physician evaluation at least every 60 days. Record review showed a single visit shortly after admission with no further face-to-face physician encounters documented, and the DON confirmed that additional 60-day visits should have occurred but did not.
A resident with significant physical and mental health needs, who required substantial assistance for bathing, did not receive this care for a two-week period. Staff incorrectly documented bathing as 'not applicable' instead of providing and recording the required ADL care, as confirmed by interviews with the resident and facility staff.
A resident with multiple serious diagnoses, including heart failure and kidney failure, was prescribed Furosemide for edema. Despite care plan and physician orders requiring monitoring, staff did not document or monitor the resident's edema while the diuretic was administered. This lapse was confirmed by both an LPN and a corporate nurse during interviews.
A resident with diabetes, an open wound, and dementia was transferred to the hospital without a required head to toe skin assessment by an LPN, and a CNA failed to report a newly observed skin injury. The facility did not follow its policy for skin integrity monitoring and notification of changes in skin status.
A facility failed to prevent pressure ulcers for a resident with severe cognitive impairment and multiple medical conditions. Despite a care plan requiring repositioning every two hours, there was no documentation of these actions on specific shifts, leading to the development of a stage 2 pressure ulcer. Interviews confirmed the lack of adherence to the care plan.
A resident with severe cognitive impairment suffered a fall resulting in a right femur fracture. The facility failed to report the injury of unknown source with serious bodily injury to the state agency within the required 2-hour timeframe, as per their Abuse Prohibition Policy. The incident was reported approximately 12 hours after the injury was confirmed by x-ray.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and multiple fractures. The care plan lacked measurable objectives and timeframes, and necessary interventions, such as monitoring a cast and using a stabilizer, were not implemented. This deficiency was confirmed by the Corporate Nurse during an interview.
A facility failed to ensure residents were free from accident hazards by not completing quarterly fall risk assessments and not implementing specific interventions for a resident with severe cognitive impairment. The resident experienced a fall resulting in a femur fracture, and interviews confirmed the absence of documented interventions and adherence to the facility's Fall Prevention Program policy.
A CNA in an LTC facility failed to follow the Incident/Accident policy by moving a resident found on the floor before a nurse's assessment. The resident, with severe cognitive impairment and multiple health issues, was at risk for falls. The CNA's actions did not align with the facility's procedures, as confirmed by the DON.
The facility failed to complete a discharge assessment for a resident who was sent to the hospital due to worsened wounds and abnormal vital signs. Both the MDS RN and the Corporate Nurse confirmed that the discharge MDS was not completed as required.
The facility failed to apply splints as ordered for two residents with limited range of motion. One resident with anoxic brain damage and muscle atrophy did not have bilateral hand splints applied on multiple dates, and another resident with Parkinson's disease and muscle wasting did not have a right-hand splint applied on several dates. Observations and staff interviews confirmed these deficiencies.
The facility failed to change the enteral feeding container every 24 hours for a resident with multiple medical conditions, as required by physician's orders. Observations and staff interviews confirmed the deficiency.
The facility failed to ensure annual performance reviews for three CNAs, as their personnel records lacked evidence of such reviews. The Administrator confirmed the absence of these reviews during an interview.
The facility failed to ensure that a resident with moderate cognitive impairment and multiple medical conditions had access to a call light, as it was repeatedly found on the floor behind the bed. The resident confirmed the inability to reach the call light, and a CNA verified this observation.
The facility failed to ensure proper garbage disposal, as multiple trash bags and loose trash were found scattered around the dumpster, and the dumpster lids were not closed. The Maintenance Director confirmed the trash should be inside the dumpster and the lids should be closed.
Failure to Provide Ordered Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary oral hygiene care as outlined in the care plan. The resident was admitted with diagnoses including sequelae of cerebral infarction, acute respiratory failure with hypoxia, aphasia, tracheostomy, and gastrostomy, and had an ADL self-care performance deficit related to cardiovascular accident and respiratory failure. The care plan specified an oral care routine in the morning and at night, including brushing teeth, cleaning gums with a toothette, and rinsing the mouth. An MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for oral hygiene. On observation, the resident was noted to have a tracheostomy and lips covered with white debris, and the respiratory therapist acknowledged that oral care was needed and stated that CNAs were responsible for providing oral care and that it should have been done. An LPN reported that she cared for the resident and that the resident did not receive oral care the previous day and was unsure how often CNAs provided oral care. A CNA stated she did not provide oral care because she believed the respiratory therapist did so. The ADON confirmed that oral care was in the resident’s plan of care, that CNAs were responsible for providing oral care every shift, and that the resident should have received oral care, demonstrating that the ordered oral hygiene interventions were not carried out as required.
Failure to Maintain Clean, Dry Conditions During Sacral Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with its own pressure injury prevention policy and professional standards of practice for a resident with a Stage 4 sacral pressure ulcer. The facility’s policy required residents to be kept clean and dry and to receive appropriate incontinent care as part of pressure injury prevention and treatment. The resident had multiple significant diagnoses, including multiple sclerosis, a Stage 4 sacral pressure ulcer, altered mental status, and hemiplegia/hemiparesis, and was documented as severely cognitively impaired and dependent on staff for toileting and personal hygiene. Physician orders and the resident’s care plan directed that the sacral area be cleaned with wound cleanser, Ioplex applied, and the area covered with a super absorbent dressing three times weekly and as needed if soiled. During an observed wound care treatment, the treatment nurse removed a saturated dressing from the resident’s sacral area and performed the ordered wound care while leaving a soiled brief in place. After completing the wound care and securing the new dressing, the nurse repositioned and secured the same soiled brief on the resident and replaced the bed linens without changing the brief. The treatment nurse acknowledged during interview that the brief was soiled during the wound care treatment. The DON later stated in interview that the soiled brief should have been changed prior to starting wound care and should not have been left on the resident after the wound care was completed.
Failure to Ensure Required Face-to-Face Physician Visits Every 60 Days
Penalty
Summary
The facility failed to ensure that a resident was seen face to face by a physician at least once every 60 days as required. Record review showed that the resident was admitted on 04/11/2025 with multiple serious diagnoses, including chronic respiratory failure, osteomyelitis of the lumbar vertebra, complete paraplegia, a sacral pressure ulcer, and a tracheostomy requiring ongoing attention. From admission on 04/11/2025 through discharge on 11/22/2025, the medical record contained documentation of only one face-to-face physician visit, dated 05/06/2025, with no additional face-to-face physician visits recorded for the remainder of the stay. During an interview on 01/06/2026 at 3:18 p.m., the DON confirmed that the resident had only one face-to-face physician visit during the entire period from admission to discharge and acknowledged that a face-to-face physician visit should have occurred every 60 days after the initial visit.
Failure to Provide and Document Required Bathing Assistance
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Multiple Sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness, agitation, polyosteoarthritis, and schizoaffective disorder, did not receive required assistance with bathing. The resident was assessed as needing substantial to maximal assistance for bathing, meaning staff were expected to provide more than half the effort. Despite this, documentation for a two-week period showed no evidence that bathing was completed, with staff entering a code indicating 'not applicable' for bathing on multiple consecutive days. Interviews with the resident, CNAs, the DON, and a corporate nurse confirmed that the resident did not receive a bath during this period and that the 'not applicable' code was incorrectly used in place of proper documentation. The resident reported not receiving a bath for two weeks, and staff verified that the resident required assistance for bathing. The facility used a kiosk system for documenting care, which included an option for 'not applicable,' but this was not appropriate for the resident's needs. The failure to provide and document required ADL care for bathing led to the identified deficiency.
Failure to Monitor Edema in Resident Receiving Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for edema while the resident was receiving a diuretic. The resident, who had diagnoses including acute respiratory failure with hypoxia, pneumonia, acute kidney failure, and heart failure, was admitted with a care plan that required monitoring and documentation of any edema. Physician orders indicated the resident was to receive Furosemide 40mg twice daily for edema. However, a review of the February Medication Administration Record (MAR) showed no evidence that edema was monitored during this period. Both an LPN and a corporate nurse confirmed during interviews that the required monitoring for edema was not performed while the resident was on the diuretic.
Failure to Complete Skin Assessment and Report New Pressure Injury
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and manage pressure ulcers for one resident. Specifically, a Certified Nursing Assistant (CNA) observed a red spot and a blister on the resident's bottom while preparing the resident for transfer to the hospital but did not report this new skin issue to the licensed nurse. As a result, the required notification of a change in skin status was not made, and the incident was not documented or addressed at the time it was discovered. Additionally, a head to toe assessment was not completed by the Licensed Practical Nurse (LPN) prior to the resident's discharge to the hospital, as required by the facility's Skin Integrity Prevention and Treatment Program Policy. The resident involved had a medical history including type 2 diabetes mellitus, an unspecified open wound on the right ankle, and dementia with behavioral disturbances. The care plan for this resident included monitoring for potential skin integrity impairment and reporting abnormalities, which was not followed in this instance.
Failure to Prevent Pressure Ulcers Due to Inadequate Repositioning
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for one of the residents reviewed. The facility's policy on pressure injury prevention included interventions such as turning and repositioning residents every two hours. However, there was no documented evidence that the nursing staff adhered to this policy for a resident with severe cognitive impairment and multiple medical conditions, including a history of fractures and dementia. The resident was re-admitted to the facility without any pressure ulcers, but a stage 2 pressure ulcer was later identified on the sacrum, indicating a failure in preventive care. The resident's care plan required turning and repositioning every two hours, but records showed no documentation of these actions on specific shifts over two days. Interviews with the Wound Care Nurse and the Director of Nursing confirmed the lack of documentation for the required care. This deficiency highlights a lapse in following the care plan and maintaining proper records, which are crucial for preventing pressure ulcers in residents with significant health challenges.
Failure to Timely Report Resident Injury
Penalty
Summary
The facility failed to report an incident involving a resident's injury of unknown source with serious bodily injury within the required timeframe. The facility's Abuse Prohibition Policy mandates that such incidents be reported immediately or within 2 hours to the state agency. However, in this case, the incident was reported approximately 12 hours after the injury was identified. The resident, who had severe cognitive impairment and required assistance with daily activities, suffered a fall resulting in a right femur fracture. The incident occurred at 12:17 a.m., and the injury was confirmed by x-ray at 9:55 a.m., but the state agency was not notified until 10:16 p.m. The resident involved had a complex medical history, including severe cognitive impairment, chronic heart failure, and a history of fractures. After the fall, the resident exhibited signs of pain, prompting an x-ray that revealed the fracture. Despite the facility's policy, the administrator did not report the incident to the state agency within the required 2-hour window after being notified of the injury. This delay in reporting constitutes a deficiency in adhering to the facility's own policies and state regulations regarding the timely reporting of serious injuries.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The resident in question had a complex medical history, including severe cognitive impairment, multiple fractures, and other significant health conditions. Despite these needs, the care plan did not adequately address the necessary interventions, such as monitoring the cast on the right lower arm and using a stabilizer with an ace bandage on the right leg, ankle, and toes. The deficiency was confirmed during an interview with the Corporate Nurse, who acknowledged that the facility did not implement the specified interventions on the care plan. This oversight was identified through a review of the resident's records, which showed no documented evidence of the interventions being carried out as required. The lack of implementation of these critical interventions highlights a failure in the facility's responsibility to provide appropriate care for the resident's complex medical needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents remained as free of accident hazards as possible, specifically for one resident who was reviewed for accidents. The facility did not complete fall risk assessments quarterly as required by their Fall Prevention Program Policy. The resident, who had a severe cognitive impairment and required assistance with activities of daily living, experienced a fall resulting in a right femur fracture. The facility's records showed that a fall risk assessment was not completed quarterly, with the last assessment done in April, prior to the fall in August. Interviews with facility staff revealed that specific interventions were not implemented for residents assessed to be at risk for falls, despite the facility's policy requiring such measures. The Corporate Nurse and Administrator confirmed that the facility did not have documented evidence of interventions being implemented when the resident returned from the hospital. Additionally, the facility did not follow its own policy and procedure for the Fall Prevention Program, as evidenced by the lack of a fall risk assessment on the specified date and the absence of specific interventions for the resident at risk.
Failure to Follow Incident Policy Leads to Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide care that maximizes the well-being of residents. This deficiency was evidenced by an incident involving a Certified Nurse Aide (CNA) who did not follow the facility's Incident/Accident policy when a resident was found on the floor. The policy required that the resident should not be moved until assessed by a licensed nurse, but the CNA assisted the resident back into bed before notifying the Licensed Practical Nurse (LPN). The resident involved had a complex medical history, including severe cognitive impairment, multiple fractures, heart failure, and other serious conditions. The resident was at risk for falls, and interventions were in place to mitigate this risk. However, the CNA's actions did not align with the established procedures, as she moved the resident without a nurse's assessment, potentially compromising the resident's safety. The Director of Nursing confirmed that the CNA's actions were not in accordance with the facility's policy.
Failure to Complete Discharge Assessment
Penalty
Summary
The facility failed to ensure a discharge assessment was completed for Resident #98 after being sent to an acute hospital. Record review revealed that Resident #98 was transported to the emergency room due to worsened wounds and abnormal vital signs. However, the Minimum Data Set (MDS) for Resident #98 did not include a discharge assessment following this hospitalization. During interviews, both the MDS RN and the Corporate Nurse confirmed that a discharge MDS should have been completed but was not.
Failure to Apply Splints as Ordered
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to increase or maintain their range of motion. Specifically, the facility did not apply splints as ordered for two residents. Resident #102, who has diagnoses including anoxic brain damage and muscle atrophy, had physician orders for bilateral hand splints to be applied daily. However, the documentation revealed that the splints were not applied on multiple dates in May 2024. Observations confirmed that the resident did not have the splints on during several checks, and a corporate nurse acknowledged the failure to follow the orders. Similarly, Resident #118, who has diagnoses including Parkinson's disease and muscle wasting, had orders for a right-hand splint to be applied daily. The documentation also showed that the splint was not applied on several dates in May 2024. Observations confirmed the absence of the splint during multiple checks, and an LPN confirmed that the splint should have been on but was not. The corporate nurse reviewed the clinical record and confirmed the lack of documentation for the splint application on the specified dates.
Failure to Change Enteral Feeding Container at Appropriate Interval
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding by not changing the enteral feeding container at the appropriate interval for one resident. The resident had multiple medical diagnoses, including cerebral infarction, facial weakness from a cerebrovascular accident, dysphagia, lack of coordination, and unspecified dementia. The physician's orders specified that the enteral feeding should be administered every night shift and the container should be changed every 24 hours. However, an observation revealed that the feeding tubing and container were dated four days prior, indicating they had not been changed as required. Interviews with the LPN, Corporate Nurse, and ADON confirmed that the enteral feeding should have been changed every 24 hours but was not.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews were completed at least every 12 months for three Certified Nursing Assistants (CNAs). Specifically, the personnel records for S5CNA, S6CNA, and S7CNA did not contain evidence of annual performance reviews. S5CNA was hired on 08/09/2022, S6CNA on 02/23/2023, and S7CNA on 02/28/2023. During an interview, the Administrator confirmed the absence of these performance reviews in the personnel records for the mentioned CNAs.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs of Resident #38 by not ensuring that the call light was within reach. Resident #38, who has a history of Alzheimer's disease, hypertension, chronic atrial fibrillation, seizures, intracerebral hemorrhage, cognitive communication deficit, major depressive disorder, and unspecified psychosis, was observed on multiple occasions with the call light on the floor behind the bed, out of reach. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 09, confirmed during an interview that he could not reach the call light. A CNA also observed and confirmed that the call light was not within the resident's reach, contrary to the care plan's directive to ensure the call light is accessible and to respond promptly to the resident's needs.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure garbage was disposed of properly. During an observation on 05/13/2024 at 8:40 a.m., multiple trash bags and loose trash were found scattered around the perimeter of the dumpster outside the facility. Additionally, the lids to the dumpster were not closed. In an interview conducted at 8:41 a.m. on the same day, the Maintenance Director confirmed that the trash should not be outside of the dumpster and that the dumpster lids should be closed.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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