Mid City Community Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 4005 North Blvd, Baton Rouge, Louisiana 70806
- CMS Provider Number
- 195505
- Inspections on file
- 27
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mid City Community Nursing And Rehab during CMS and state inspections, most recent first.
A resident with a PEG tube, who was under Enhanced Barrier Precautions, received incontinent care from a CNA who failed to wear a gown as required by facility policy. The CNA acknowledged not using the appropriate PPE, and the DON confirmed that staff are expected to follow EBP protocols during high-contact care activities.
A resident with morbid obesity and cognitive intactness was repeatedly found with her call light out of reach, requiring her to yell for assistance. Staff confirmed the call light was often inaccessible, and the DON acknowledged the expectation for call lights to be within reach.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect coding of functional abilities and medications. One resident was incorrectly coded as independent in certain ADLs, while another was inaccurately coded for anticoagulant use instead of antiplatelets. Staff interviews confirmed these discrepancies.
A facility failed to conduct ordered HGBA1C tests for a diabetic resident. Despite a physician's order for quarterly tests starting in November 2024, the last recorded test was in October 2024. The resident's care plan required lab work to be obtained as ordered, but this was not followed. Interviews confirmed the absence of the required tests.
The facility failed to make the results of the most recent complaint survey available for resident review. During an observation, it was found that the Survey Results folder near the entrance contained outdated information, missing the survey results from a complaint survey conducted earlier in the year. The facility's administrator confirmed the absence of these results, potentially affecting the 104 residents in the facility.
The facility failed to report multiple incidents of physical abuse between residents to the administrator and state agency within the required timeframe. In one case, a resident punched another, resulting in a fracture, but the incident was not reported immediately. Another incident involved a resident slapping another, which was reported internally but not to the state. A third incident involved scratching, which was also not reported to the state. The administrator at the time did not consider these incidents as abuse, leading to a delay in reporting.
The facility failed to manage resources effectively, leading to deficiencies in PASRR Level II evaluations for residents with new mental illness diagnoses and delayed reporting of physical abuse incidents. Staff interviews revealed confusion over responsibilities, resulting in unreported abuse incidents and delayed communication to the administrator.
A facility failed to prevent multiple incidents of resident-to-resident physical abuse, involving cognitively intact residents with behavioral issues. Despite immediate staff intervention and separation of residents, the facility's measures were insufficient to prevent recurring aggressive interactions, highlighting a deficiency in managing resident behavior and ensuring safety.
The facility failed to conduct PASARR Level II evaluations for two residents who were diagnosed with new psychiatric conditions after admission. Despite having new diagnoses of Schizophreniform Disorder, Unspecified Psychosis, and Bipolar Disorder, the required evaluations were not completed. Interviews revealed confusion among staff regarding responsibility for initiating the PASARR process, contributing to the oversight.
Two residents with cognitive disorders were involved in a physical altercation, and the facility failed to notify the on-call NP immediately as required by policy. The incident was reported to an LPN, but the NP was not informed until two days later when one resident showed signs of injury.
A facility failed to protect a resident from verbal and mental abuse by a CNA, who exhibited rude and aggressive behavior during care. The resident, with moderate cognitive impairment and significant physical needs, felt worthless and tearful due to the CNA's harsh tone and negative attitude. The Director of Nursing and Administrator confirmed the resident was not treated with respect and dignity.
The facility failed to incorporate PASRR Level II recommendations into the care plans for three residents with psychiatric diagnoses, including training in daily living skills, crisis intervention plans, and outpatient therapy. Staff interviews confirmed the lack of documentation and implementation of these services.
The facility failed to maintain a clean kitchen environment, with slugs and food debris observed on the floor and under appliances. Kitchen staff confirmed the floor had not been cleaned nightly as required, affecting 109 residents who received food from this kitchen.
The facility failed to implement PASRR Level II recommendations and ensure MDS coding accuracy for three residents, leading to a lack of necessary services such as training in daily living skills and outpatient therapy. Staff interviews revealed disorganization and unclear responsibilities regarding PASRR document handling.
The facility failed to accurately code a resident's MDS for PASRR Level II, despite the resident having a serious mental illness. This error was confirmed by both the MDS Coordinator and the Director of Nursing.
The facility failed to follow a physician's order to provide a house supplement with meals three times daily for a resident who was cognitively intact. Observations and interviews confirmed that the supplement was not provided on multiple occasions, despite being ordered.
A resident reported that his food was often served cold and his requests to have meals reheated or substituted were not honored. Interviews with staff confirmed that the resident's requests were sometimes missed by the kitchen staff, leading to a failure in providing appealing meal options of similar nutritive value.
The facility failed to ensure that a resident's code status was consistently documented across all medical records. The resident's electronic health record indicated a full code status, while the hard chart and an advanced directive form indicated a DNR status. Interviews confirmed that the records should match to reflect the resident's wishes accurately.
The facility failed to ensure staff wore proper PPE while providing catheter care for a resident on Enhanced Barrier Precautions (EBPs). A CNA was observed cleaning a resident's catheter without wearing a gown, despite the resident having a physician's order for EBPs. The Director of Nursing confirmed that staff should wear gloves and a gown during such care.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program as required, specifically in relation to Enhanced Barrier Precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. According to the facility's policy, staff are required to wear gloves and a gown during high-contact resident care activities, such as changing briefs, for residents on EBP. The resident in question had a physician order and care plan in place mandating EBP, including the use of appropriate personal protective equipment (PPE) during contact care. On the date of observation, a certified nursing assistant (CNA) was seen changing the resident's brief without wearing a gown, despite signage above the resident's bed and facility policy clearly indicating the requirement for both gloves and a gown during such care. The CNA confirmed during an interview that she did not wear the appropriate PPE and acknowledged the resident's PEG tube status. The Director of Nursing (DON) also confirmed that staff are expected to wear the required PPE when providing incontinent care to residents with indwelling medical devices.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, who was admitted with a diagnosis of morbid obesity and was cognitively intact with a BIMS score of 14, was observed multiple times with her call light on the floor behind her bed, making it inaccessible. Despite being independent with eating, the resident was dependent on staff for all other activities of daily living (ADL) care and reported having to yell for assistance when the call light was out of reach. Interviews with staff confirmed the issue, with an LPN acknowledging that call lights should always be within reach and verifying that the resident's call light was frequently not accessible. The Director of Nursing (DON) was informed of these observations and confirmed the expectation that staff should keep call lights within reach of residents. This repeated failure to ensure the call light was accessible indicates a lapse in meeting the resident's needs and preferences as required.
Inaccurate MDS Assessments for Functional Abilities and Medications
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in coding their functional abilities and medication use. Resident #4 was admitted to the facility and had a Significant Change MDS assessment with an ARD of 02/25/2025, which inaccurately coded her as independent in toileting hygiene, showering/bathing, and putting on/taking off footwear. Interviews with the resident and staff, including an LPN and the MDS coordinator, confirmed that Resident #4 was actually dependent on assistance for these activities. The Director of Nursing also verified the inaccuracies in the coding. Resident #50's Quarterly MDS assessment inaccurately coded him as receiving anticoagulants, while his physician orders indicated he was prescribed antiplatelet medications, specifically Aspirin and Clopidogrel. The MDS coordinator and the Director of Nursing confirmed that the resident's MDS assessment should not have included anticoagulants, as the medications listed were antiplatelets. These inaccuracies in the MDS assessments reflect a failure in ensuring the residents' statuses were correctly documented.
Failure to Conduct Ordered Laboratory Tests for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident's laboratory tests were completed as ordered by the physician. A resident, who was admitted with a diagnosis of Diabetes, had a physician's order for an HGBA1C blood draw every three months starting in November 2024. However, the last recorded HGBA1C test was conducted on October 26, 2024, and there was no documented evidence of subsequent tests being performed as required. The resident's care plan included an intervention to obtain lab work as ordered, but this was not followed. Interviews with a local laboratory spokesperson and the Director of Nursing confirmed the absence of the required HGBA1C tests from admission to the present date.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that the results from the most recent complaint survey were readily available for resident review. This deficiency was identified during an observation on March 17, 2025, at 9:30 a.m., when the Survey Results folder located near the entrance of the facility was reviewed. The folder contained the last survey dated April 18, 2024, but lacked the documented evidence of the survey results from the complaint survey conducted on February 11, 2025. An interview with the facility's administrator confirmed the absence of the most recent survey results in the folder. This oversight had the potential to affect the 104 residents currently residing in the facility.
Failure to Timely Report Physical Abuse Incidents
Penalty
Summary
The facility failed to report allegations of physical abuse to the administrator and the state agency within the required timeframe for four residents involved in separate incidents. The first incident involved a physical altercation between two residents, where one resident punched the other in the face multiple times after being poked with a reacher tool. This incident was not reported to the administration or the state agency immediately, as required by the facility's policy. The staff member who witnessed the altercation reported it to a Licensed Practical Nurse (LPN), but the LPN did not escalate the report until two days later when the resident who punched the other was diagnosed with a fracture. In another incident, a resident slapped another resident in the face, which was immediately reported to an LPN by a Certified Nursing Assistant (CNA). The LPN then reported the incident to the nurse practitioner and the administrator on the same day. However, the administrator at the time did not report the incident to the state agency, as they did not consider it to be physical abuse. A third incident involved a resident who scratched another resident, resulting in a deep laceration. This incident was reported to the nurse practitioner, Director of Nursing (DON), and responsible party the following morning, but not to the state agency. The administrator at the time was aware of all these incidents but failed to report them to the state agency, believing they did not constitute physical abuse.
Deficiencies in Resource Management and Abuse Reporting
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in several deficiencies. Two residents with newly diagnosed mental illnesses were not reevaluated for PASRR Level II determinations. Specifically, one resident was diagnosed with Unspecified Psychosis, and another with Bipolar Disorder, yet no documentation indicated that a Level II evaluation and determination had been submitted for either resident. Interviews with staff revealed a lack of clarity regarding who was responsible for completing these assessments and submitting the necessary paperwork. Additionally, the facility did not report allegations of physical abuse to the state agency within the required timeframe. Four residents were involved in incidents that were not reported immediately, as required. One incident involved a cognitively intact resident who punched another resident, resulting in a fracture. Despite being aware of these incidents, the responsible staff did not report them to the state agency, citing a misunderstanding of what constituted physical abuse. Furthermore, the facility failed to report incidents of physical abuse to the administrator immediately. In one case, a CNA witnessed an altercation between two residents and reported it to an LPN, who did not escalate the report until two days later when a resident's injury was noted. The administrator confirmed that the incident should have been reported immediately but was not. Interviews with staff indicated a lack of understanding and communication regarding the reporting process for abuse incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple incidents of aggression among residents. Resident #1, who was cognitively intact and diagnosed with schizophrenia, was involved in several altercations. On one occasion, Resident #1 punched Resident #2 in the face multiple times, leading to a fracture in Resident #1's hand. Prior to this, Resident #1 had also been involved in an incident with Resident #4, where he scratched Resident #4's arm. These incidents indicate a pattern of aggressive behavior that was not adequately managed by the facility. Resident #2, also cognitively intact, was involved in an altercation with Resident #3, where he slapped Resident #3 on the forehead. This incident was witnessed by a CNA, who reported it immediately. Despite the immediate separation of the residents and assessment for injuries, the facility's failure to prevent these incidents highlights a deficiency in managing resident interactions and ensuring a safe environment. The facility's incident logs and interviews with staff and residents reveal that these aggressive interactions were not isolated events. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents of physical aggression. The staff's response to these incidents, while prompt, did not prevent the recurrence of similar events, indicating a need for more effective measures to manage resident behavior and prevent abuse.
Failure to Conduct PASARR Level II Evaluations for Residents with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that residents with newly identified mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. Specifically, two residents were identified with new psychiatric diagnoses after their initial admission and Level I screening. Resident #1 was diagnosed with Schizophreniform Disorder and later with Unspecified Psychosis, while Resident #2 was diagnosed with Bipolar Disorder. Despite these new diagnoses, no Level II evaluations were conducted for either resident, which is a requirement when a new serious mental disorder is identified. Interviews with facility staff revealed a lack of clarity regarding the responsibility for initiating the PASARR process following new psychiatric diagnoses. The social worker, S11SW, and the administrator, S1ADM, both expressed uncertainty about who should complete the necessary assessments and submit the required documentation for Level II evaluations. The psychiatric nurse practitioner, S10PNP, confirmed that while she was responsible for assessing and treating psychiatric conditions, she was not tasked with submitting PASARR documentation. This lack of role clarity contributed to the oversight in not conducting the required Level II evaluations for the residents in question.
Failure to Timely Notify Nurse Practitioner of Resident Altercation
Penalty
Summary
The facility failed to ensure timely communication of a significant change in status to the nurse practitioner for two residents involved in an altercation. Resident #1, diagnosed with Schizophreniform Disorder, and Resident #2, diagnosed with Bipolar Disorder, were involved in a physical altercation where Resident #2 hit Resident #1 with a reacher tool, and Resident #1 retaliated by punching Resident #2. The incident was immediately reported by the CNA to the LPN on duty, but the on-call nurse practitioner was not notified until two days later when Resident #1 began to show signs of swelling in his right hand. The facility's policy requires that the attending or on-call physician be notified immediately in the event of an accident or incident involving a patient. However, the LPN admitted to delaying the notification to the nurse practitioner, which was confirmed by the nurse practitioner who reviewed her call logs and found no record of being informed about the incident on the day it occurred. This delay in communication represents a failure to adhere to the facility's policy on notifying changes in a resident's condition or status.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member. The incident involved a moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome, who was observed to become visibly tense and tearful when a CNA entered her room. The CNA rushed through care and became argumentative with a rude, aggressive tone when the resident requested to have her teeth brushed. This interaction left the resident feeling worthless and tearful, as she reported that the CNA and other staff members often spoke to her with harsh tones and exhibited negative attitudes and body language towards her. The resident's clinical record revealed she required significant assistance for transfers and activities of daily living due to her condition. During an interview, the resident stated that the CNA was rough when assisting her with care and would respond rudely when asked to be gentler. The resident expressed that the CNA's tone, body language, and facial expressions made her feel judged and like a burden. She also reported that the CNA would rush through her care and not meet all her needs, leaving her feeling ignored and with a negative attitude. The resident's roommate corroborated these observations, stating that the CNA spoke to the resident in a rude manner and made it clear she did not want to provide the requested assistance. The Director of Nursing and the Administrator both confirmed that staff should handle residents with respect and dignity, and agreed that the resident was not treated appropriately. The report concluded that the facility failed to protect the resident's right to be free from verbal and mental abuse, resulting in psychosocial harm.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into the residents' assessment, care planning, and transitions of care for three residents. Resident #12 was admitted with diagnoses including Schizoaffective Disorder and Bipolar Type. The PASRR Level II Summary recommended services such as training in activities of daily living, independent living skills, and outpatient therapy, none of which were documented or implemented in the resident's care plan. Interviews with staff confirmed the lack of documentation and implementation of these services for Resident #12. Resident #24, admitted with Schizoaffective Disorder and cognitive function issues, also had recommendations for training in independent living skills, a crisis intervention plan, and outpatient therapy. Similar to Resident #12, there was no documented evidence that these services were created or implemented in the resident's care plan. Interviews with staff confirmed the absence of these services for Resident #24. Resident #63, with diagnoses including Major Depressive Disorder and Paranoid Schizophrenia, had recommendations for training in independent living skills, a crisis intervention plan, and outpatient therapy. The clinical record and care plan for Resident #63 showed no evidence of these services being provided. Interviews with the resident and staff confirmed the lack of implementation of the recommended services. The facility administrator acknowledged that the facility did not provide the services indicated in the PASRR Level II Determination Letters for any of the Level II residents currently in the facility.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store, prepare, and distribute foods under sanitary conditions by not maintaining a clean kitchen environment. During an initial tour of the kitchen, a slug was observed moving on the floor under the mixer, and three slugs were seen behind the plate warmer. Food debris was found on the floor throughout the kitchen, including under the oven, stove, plate warmer, steam table, and dishwasher. Four french fries were observed on the floor between the steam table and plate warmer, which were confirmed to be from the previous night's supper. Interviews with kitchen staff confirmed that the kitchen floor had not been cleaned nightly as required, and the kitchen staff were responsible for this task. The facility had 109 residents who received food from this kitchen.
Failure to Implement PASRR Recommendations and Ensure MDS Coding Accuracy
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable physical, mental, and psychosocial well-being of its residents. Specifically, the facility did not incorporate recommendations from PASRR Level II Determinations and PASRR Evaluation Reports into the residents' assessments, care plans, and transitions of care for three residents. For instance, Resident #12, who was diagnosed with Schizoaffective Disorder and Bipolar Type, did not have documented evidence of receiving recommended services such as training in activities of daily living, independent living skills, or outpatient therapy. Similarly, Resident #24 and Resident #63 also lacked documented evidence of receiving their recommended services, including crisis intervention plans and outpatient therapy, as indicated in their PASRR Level II Determinations. Interviews with facility staff revealed a lack of clarity and responsibility regarding the handling and processing of PASRR documents. The administrator (S1ADM) and social workers (S5SSD) were unsure of their roles in ensuring that PASRR recommendations were implemented. The administrator admitted to not understanding the necessary services indicated in the PASRR determinations, while the social worker stated that PASRR documents were scattered in various locations, making them difficult to locate and process. This disorganization contributed to the failure to implement the required services for the residents. Additionally, the facility failed to ensure the coding accuracy for Minimum Data Set (MDS) assessments regarding PASRR Level II. For example, Resident #12's MDS assessment incorrectly indicated that the resident had not been evaluated by Level II PASRR, despite having a documented PASRR Level II Summary and Determination Notice. Interviews with the MDS coordinator (S13MDSC) and the Director of Nursing (S2DON) confirmed that they were not provided with the necessary documentation to code the MDS accurately. The administrator acknowledged that there was no system in place to ensure correct MDS coding and the provision of required services for residents with PASRR Level II determinations.
Inaccurate Coding of PASRR Level II in MDS Assessment
Penalty
Summary
The facility failed to ensure a resident's assessment accurately reflected the resident's status by not correctly coding the Minimum Data Set (MDS) for PASRR Level II. Specifically, Resident #12, who was admitted with a diagnosis of Schizoaffective Disorder, Bipolar Type, had an Annual MDS assessment that incorrectly indicated 'No' for PASRR Level II evaluation despite having a serious mental illness. This discrepancy was confirmed through interviews with the MDS Coordinator and the Director of Nursing, who both acknowledged that the MDS should have been coded as 'Yes' for PASRR Level II evaluation.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to implement a comprehensive person-centered plan of care by not following the physician's orders for a resident's nutritional needs. Resident #45, who was cognitively intact with a BIMS score of 15, was admitted to the facility and had a physician's order to receive a house supplement with meals three times daily. However, observations and interviews revealed that the resident did not receive the house supplement with his meals on multiple occasions. Specifically, the supplement was missing from his lunch tray on 04/17/2024 and from his breakfast tray on 04/18/2024. Both the Dietary Manager and the Director of Nursing confirmed that the supplement was ordered but not provided as required.
Failure to Provide Appealing Meal Options and Reheat Food
Penalty
Summary
The facility failed to ensure that appealing options of similar nutritive value were offered to residents who chose not to eat the food initially served or who requested a different meal choice. Specifically, Resident #45, who was cognitively intact with a BIMS of 13, reported that his food was often served cold. Despite his requests to the kitchen staff to have his meals reheated or substituted, these requests were not honored. This issue was confirmed through multiple interviews with the resident, the LPN, the DON, and the Dietary Manager, all of whom acknowledged that the resident's requests were sometimes missed by the kitchen staff. Resident #45 was admitted to the facility and had a care plan that included offering food alternatives when appropriate. However, the resident consistently experienced issues with the temperature and substitution of his meals. The LPN and Dietary Manager both confirmed that the resident frequently complained about his food being cold and needing substitutes, and that these requests were sometimes overlooked by the kitchen staff. The DON also confirmed that the resident should have received alternative options and had his meals reheated upon request, but this did not occur as it should have.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. Specifically, for one resident, the electronic health record indicated a full code status, while the hard chart and an advanced directive form signed by the resident indicated a Do Not Resuscitate (DNR) status. The resident, who was cognitively intact, confirmed during an interview that he wished to remain a DNR in the event of an emergency. Interviews with the nursing staff and the Director of Nursing (DON) revealed that in the event of an emergency, they would refer to the hard chart to determine a resident's code status. Both the nursing staff and the DON confirmed that the resident's hard chart and electronic health record should match to accurately reflect the resident's end-of-life wishes, which was not the case for this resident. This inconsistency in the medical records could lead to actions that do not align with the resident's documented wishes.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. Specifically, the facility did not ensure that staff wore proper Personal Protective Equipment (PPE) while providing catheter care for a resident. The facility's policy on Enhanced Barrier Precautions (EBPs) requires staff to wear gowns and gloves during high-contact care activities, including catheter care for residents with indwelling medical devices. However, during an observation, a CNA was seen providing catheter care to a resident without wearing a gown, despite the resident being on EBPs. The resident in question was admitted with diagnoses including Neuromuscular Dysfunction of the Bladder and Paraplegia and had a physician's order for EBPs. During an interview, the CNA confirmed that she did not wear a gown while providing catheter care, even though she was aware that the resident was on EBPs. The Director of Nursing also confirmed that nursing staff should wear gloves and a gown when providing catheter care for this resident. This failure to adhere to the facility's infection control policy represents a deficiency in maintaining a safe and sanitary environment.
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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