Natchitoches Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Natchitoches, Louisiana.
- Location
- 781 Highway 494, Natchitoches, Louisiana 71457
- CMS Provider Number
- 195405
- Inspections on file
- 25
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Natchitoches Community Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes and a foot ulcer, had an abrasion on the right rear thigh that required wound care. Although a nurse practitioner gave a verbal order for specific wound care, the order was not transcribed into the physician's orders, and the care was not formally implemented as required by facility policy. Nursing staff confirmed the omission, resulting in wound care being provided without the necessary physician order.
A resident with multiple health conditions, including a foot ulcer and fungal skin infection, received wound care from an LPN who did not remove personal items or sanitize the work area before treatment and failed to perform hand hygiene between glove changes, contrary to facility policy. Both the LPN and DON confirmed these infection control lapses during interviews.
A resident did not receive mail in a timely manner, with some pieces being over five months old, due to a lack of clear procedures for mail handling at the facility. The resident's mail included important documents such as bills and retirement check notifications.
A resident with moderate cognitive impairment was served a salad with ham, contrary to their religious dietary preference for no pork. Despite facility policy requiring dietary preferences to be assessed and communicated, staff confirmed the resident was inappropriately served and the same salad was returned after removing the ham. The Dietary Manager acknowledged the error, confirming a new salad should have been provided.
A resident with moderate cognitive impairment and religious dietary restrictions was served a salad containing ham, which was against her beliefs. Despite her request for a turkey salad, staff removed the ham and returned the same salad, which she refused. The incident was reported but not formally recorded as a grievance until weeks later, after the resident's discharge. Staff interviews confirmed the grievance process was not followed timely.
A facility failed to document a clinical rationale for denying a dosage reduction of Trazodone for a resident with Major Depressive Disorder. The resident, who was cognitively intact, was receiving the medication as part of their treatment plan. Despite a request for a Gradual Dose Reduction, the NP did not provide the required documentation, which was confirmed during an interview with the DON.
A facility failed to ensure the accuracy of an MDS assessment for a resident, omitting critical information about her skin conditions and nutritional status. The resident, with multiple health issues including diabetes and vascular disease, had documented sores and treatment orders for wounds, which were not reflected in the MDS. The MDS nurse incorrectly assumed the wounds had resolved, leading to an inaccurate assessment.
A facility failed to promptly notify the RD of a tube feeding change for a resident with cerebral infarction and gastrostomy status. The resident's Peptamen 1.5 was substituted with Pivot 1.5 due to stock issues, but the RD was informed two days later, highlighting a communication lapse and lack of policy.
A resident with moderately impaired cognition reported not receiving her medication and confronted an LPN at the nurses' station. The LPN slammed the door in the resident's face, leading to a physical altercation where the resident was pushed and fell, injuring herself. Staff interviews and video footage confirmed the incident, highlighting a failure to treat the resident with respect and dignity.
A resident receiving PEG tube feedings in a facility experienced significant weight loss due to an incorrect feeding rate being administered. The RN Clinical Coordinator misread the RD's recommendation, resulting in the resident receiving 25 ml/hr instead of the recommended 45 ml/hr. Despite the resident's complaints of hunger and nausea, the facility failed to notify the physician or adjust the feeding rate, highlighting a lack of standardized processes for dietary recommendations.
A resident receiving PEG tube feeding experienced significant weight loss and hunger due to incorrect transcription of RD recommendations, while another resident developed a stage 2 pressure ulcer due to delayed skin assessment. The facility lacked standardized processes for implementing dietary recommendations and failed to adhere to policies for medication orders and skin assessments.
A resident with a PEG tube experienced significant weight loss due to an incorrect feeding rate entered by a clinical coordinator, who misread the dietician's recommendation. Despite the resident's communication of hunger and weight loss, the error persisted until surveyor intervention. Interviews revealed a lack of standardized processes for implementing dietary recommendations, contributing to the deficiency.
A facility failed to complete necessary Dialysis Communication Forms for a resident with chronic kidney disease before sending them to a dialysis facility. Despite the resident having an intact cognition and receiving dialysis three times a week, the forms were not completed on multiple occasions, missing vital information such as problems since the last visit, diet, fluid restrictions, and vital signs. Interviews with facility staff confirmed the oversight, and a contracted dialysis facility RN noted the frequent lack of completed forms.
A facility failed to monitor a resident's medication regimen, specifically for edema while on Furosemide and for side effects and effectiveness of Lexapro. The resident, with severe cognitive impairment and multiple diagnoses, required careful monitoring as per their care plan. However, the July 2024 MAR showed no documentation of such monitoring, which was confirmed by the Clinical Coordinator, leading to a deficiency in care.
Two residents in a facility did not receive necessary ADL support and incontinence care. One resident with severe cognitive impairment was not assisted with oral hygiene or nail care, while another resident, dependent on staff for incontinence care, was left in wet briefs for extended periods. Staff interviews confirmed these lapses, highlighting deficiencies in adhering to care plans.
The facility failed to maintain proper infection control practices during meal service and wound care. A CNA did not perform hand hygiene between assisting two residents during meal service. Additionally, a Treatment Nurse exited a resident's room without doffing gown and gloves after performing wound care, breaching Enhanced Barrier Precautions.
The facility failed to maintain the dignity and privacy of two residents. One resident was exposed during wound care due to open window blinds, while another was assisted with meals by an LPN standing over their bed, contrary to facility policy. The incidents highlight lapses in adhering to dignity and privacy standards.
Failure to Transcribe and Implement Verbal Wound Care Order
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that a nurse practitioner's verbal wound care order was transcribed and implemented for a resident. The facility's policy requires that each wound site have a separate wound care order specifying the wound location, cleaning method, primary dressing, and frequency of dressing change. For a resident admitted with multiple diagnoses including Type 2 Diabetes Mellitus with a foot ulcer and muscle weakness, the care plan documented an actual impairment to skin integrity on the right rear thigh due to an abrasion. However, review of the physician's orders showed no wound care order for the abrasion, despite documentation in the skin and wound evaluation that described the wound and the treatment being provided. Observations confirmed that wound care was being performed on the abrasion, but the specific orders for cleaning, applying Nystatin powder and collagen, and covering with a dry dressing were not present in the physician's orders. Interviews with nursing staff and the wound care nurse practitioner confirmed that a verbal order for wound care had been given but was not transcribed into the resident's physician orders and therefore not formally implemented. This lapse resulted in the resident's wound care being conducted without the required physician order, contrary to facility policy and professional standards.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to adhere to established infection control practices during wound care for a resident with multiple medical conditions, including Type 2 Diabetes Mellitus with a foot ulcer, cerebral infarction, muscle wasting, and a fungal skin infection. During an observed wound care procedure, the LPN responsible did not remove the resident's personal items or sanitize the side table before placing a barrier pad and beginning treatment. This action was not in accordance with the facility's wound care policy, which requires preparation of a clean, dry work area at the bedside. Additionally, the LPN did not perform hand hygiene between glove changes throughout the wound care process, despite the resident's care plan specifically noting the risk for multi-drug resistant organism (MDRO) infections and the need for proper hand hygiene. Both the LPN and the Director of Nursing confirmed during interviews that these infection control steps were omitted, acknowledging that the required procedures were not followed during the resident's wound care treatment.
Failure to Deliver Resident Mail Timely
Penalty
Summary
The facility failed to ensure timely delivery of mail to a resident, violating the resident's right to receive mail promptly. The facility's policy mandates that mail and packages be delivered to residents within 24 hours of arrival at the facility. However, a resident reported receiving a stack of mail in January 2025, which included 12 or 13 pieces of mail, some of which were date-stamped as received by the facility several months prior. This mail included important documents such as bills and letters regarding uncashed retirement checks. Interviews with facility staff revealed that the Accounts Manager, who had been working at the facility for about five months, found a large pile of undelivered mail in the office upon starting her role. She was not informed of the procedure for handling the mail and had to seek guidance from multiple staff members. The Accounts Manager confirmed that some of the resident's mail was over five months old. The facility administrator acknowledged the delay in mail delivery and recognized that the resident should receive all mail addressed to them, even if it pertains to bills or insurance information.
Failure to Honor Religious Dietary Preferences
Penalty
Summary
The facility failed to respect and honor a resident's religious dietary preferences, which is a violation of the resident's rights to dignity and self-determination. The resident, who had moderate cognitive impairment and required assistance with eating, was served a salad with ham despite having a documented preference and physician order for no pork due to religious beliefs. This incident occurred despite the facility's policy that requires dietary preferences to be assessed and communicated to the interdisciplinary team upon admission. Interviews with facility staff, including the Dietary Manager, Assistant Director of Nursing, and a Certified Nursing Assistant, confirmed that the resident was served a salad with ham and that the ham was removed and the same salad was returned to the resident, which was inappropriate given the resident's religious dietary restrictions. The Dietary Manager acknowledged that the homemaker was responsible for ensuring that food served to residents adhered to their dietary preferences and orders, and confirmed that a new salad without ham should have been provided to the resident.
Failure to Timely Record Grievance Regarding Dietary Preferences
Penalty
Summary
The facility failed to adhere to its grievance policy by not recording a grievance within the appropriate timeframe for a resident who had dietary preferences due to religious beliefs. The resident, who had moderate cognitive impairment, was served a chef salad containing ham, which was against her religious dietary restrictions. Despite the resident's request for a salad with turkey, the staff removed the ham from the original salad and served it back to her, which she refused. The incident was reported to a dietary aide and a nurse, but the grievance was not formally recorded until several weeks later, after the resident had been discharged. Interviews with facility staff confirmed the incident and acknowledged that the resident should have been served a new salad without ham. The Dietary Manager was aware of the incident on the day it occurred but did not file a grievance until prompted by the State Ombudsman weeks later. The Assistant Director of Nursing also confirmed the resident's dietary preferences were not respected, and the grievance process was not followed as per the facility's policy, leading to a delay in addressing the resident's concerns.
Failure to Document Clinical Rationale for Medication Dosage Decision
Penalty
Summary
The facility failed to ensure that a clinical rationale was documented for the denial of a psychoactive medication dosage reduction for one of the sampled residents. The facility's policy requires that when a Gradual Dose Reduction (GDR) is contraindicated, the prescribing clinician must document a clinical rationale. However, in the case of a resident with diagnoses including Parkinson's Disease, Major Depressive Disorder, Type 2 Diabetes Mellitus, and Hypertension, the necessary documentation was not provided. The resident, who was cognitively intact with a BIMS score of 15, was receiving Trazodone for Major Depressive Disorder. The Pharmaceutical Consultant Report indicated that a GDR was requested for the resident's Trazodone dosage, but the Nurse Practitioner (NP) did not document a valid clinical rationale for denying the dosage reduction. During an interview, the Director of Nursing (DON) acknowledged the lack of documentation and confirmed with the NP that the clinical rationale should have been documented. This oversight indicates a failure to adhere to the facility's policy on documenting clinical rationales for medication management decisions.
Inaccurate MDS Assessment for Resident's Skin Conditions
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, specifically regarding her skin conditions and nutritional status at the time of the Assessment Reference Date (ARD). The resident, who was admitted from a skilled nursing facility, had multiple diagnoses including congestive heart failure, Alzheimer's disease, vascular dementia, diabetes mellitus with diabetic neuropathy, and peripheral vascular disease. The Quarterly MDS did not accurately reflect the resident's skin conditions, as it omitted information about existing ulcers, wounds, and skin problems. The MDS nurse, responsible for completing the assessment, incorrectly assumed that the resident's wound had resolved before the ARD. Further investigation revealed that the resident had sores on her pinky toes, as documented by an LPN in the Nurse's Notes, and had ongoing treatment orders for a laceration on the right lateral foot and a diabetic ulcer on the right medial calf. The resident's medical history, including type 2 diabetes and a previous toe amputation, placed her at high risk for foot complications. Despite this, the MDS did not reflect these conditions, leading to an inaccurate assessment of the resident's health status.
Failure to Notify RD of Tube Feeding Change
Penalty
Summary
The facility failed to ensure timely communication with the Registered Dietician (RD) regarding a change in tube feeding orders for a resident. The resident, who was cognitively intact and had medical diagnoses including cerebral infarction and gastrostomy status, was initially receiving Peptamen 1.5 as an enteral feed. On a specific date, the facility ran out of Peptamen 1.5, and a Nurse Practitioner (NP) authorized the use of Pivot 1.5 as an equivalent substitute. However, the nurse who received this order did not inform the RD as instructed, leading to a delay in the RD being notified about the change in the resident's nutritional plan. The Director of Nursing (DON) later acknowledged that there was no existing policy for notifying the RD about changes in tube feeding orders. The RD was eventually informed two days later, both by phone and email, about the substitution of Pivot 1.5 for Peptamen 1.5. This delay in communication was attributed to the Clinical Coordinator not informing the RD upon returning to work. The lack of a formal policy and the failure of staff to communicate promptly with the RD resulted in a deficiency in maintaining the resident's nutritional care plan.
Resident's Dignity Compromised in Medication Dispute
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by an incident involving a resident with moderately impaired cognition. The resident, who had a history of cerebral infarction, gout, hypertension, and major depressive disorder, reported not receiving her thyroid medication and approached the nurses' station to address the issue. The resident claimed that a nurse, identified as S3 LPN/ADON, slammed the door in her face, leading to a confrontation where the resident was pushed and subsequently fell, injuring her hip and hand. Interviews with staff members corroborated the resident's account of the incident. S5 LPN, who was present during the altercation, confirmed that the resident accused S3 LPN/ADON of lying about administering the medication, which escalated into a physical altercation. S6 CNA and S9 CNA also witnessed the incident, noting that the nurse slammed the door in the resident's face and later engaged in a physical struggle with the resident, resulting in the resident's fall. Video surveillance footage reviewed by the facility's administration confirmed the sequence of events, showing the resident approaching the nurses' station, the door being slammed, and the subsequent physical interaction between the resident and the nurse. The footage supported the accounts provided by the staff and the resident, highlighting the inappropriate handling of the situation by S3 LPN/ADON, which compromised the resident's dignity and safety.
Deficiency in Nutritional Management for Resident with PEG Tube Feeding
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the nutritional management of a resident receiving PEG tube feedings. The administration did not ensure that the Registered Dietician's (RD) recommendations for PEG tube feedings were accurately transcribed into the medical record. This led to a situation where a resident, who was cognitively intact and able to communicate, received an incorrect feeding rate of 25 ml/hr instead of the recommended 45 ml/hr. This error persisted from July 5, 2024, to July 15, 2024, resulting in significant weight loss for the resident. The resident expressed feelings of hunger, nausea, and concern about weight loss, which were communicated to the nursing staff. Despite these complaints, the facility failed to notify the physician or adjust the feeding rate accordingly. The RN Clinical Coordinator admitted to misreading the RD's recommendation and entering the incorrect feeding rate into the system. The resident experienced a weight loss of 9.6 pounds, which was 7.79% of her body weight, during this period. Interviews with facility staff revealed a lack of a standardized process for obtaining, communicating, and implementing dietary recommendations. The Director of Nursing (DON) and Quality Improvement (QI) Nurse acknowledged the absence of a system to ensure accurate communication and entry of RD recommendations. The Assistant Director of Nursing (ADON) also failed to verify the accuracy of the feeding rate against the RD's recommendations, contributing to the resident's inadequate nutritional intake.
Deficiencies in Nutritional and Skin Care Management
Penalty
Summary
The facility failed to ensure services met professional standards of quality by not accurately transcribing and implementing recommendations from the Registered Dietician (RD) for a resident receiving nutrition via PEG tube feeding. The RD recommended a feeding rate of 45 ml/hr, but the RN Clinical Coordinator incorrectly entered the order as 25 ml/hr. This error led to the resident experiencing significant weight loss, hunger, and nausea over a period of several days. Despite the resident's complaints and a request to increase the feeding rate, the physician was not notified in a timely manner, and the feeding rate remained incorrect for an extended period. Additionally, the facility did not perform and document a comprehensive skin assessment for another resident who was readmitted after hospitalization. The resident developed a stage 2 pressure ulcer, which was not assessed or treated until several days after their return to the facility. The facility's policy required a comprehensive skin assessment within 24 hours of readmission, but this was not completed until four days later, delaying necessary wound care. Interviews with staff revealed a lack of a standardized process for obtaining, communicating, and implementing dietary recommendations, contributing to the errors in the resident's care. The facility's failure to adhere to its policies and procedures for medication orders and skin assessments resulted in immediate jeopardy for the resident receiving PEG tube feeding and potential harm for other residents receiving similar care.
Incorrect PEG Tube Feeding Rate Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with a PEG tube maintained acceptable nutritional and hydration status, consistent with the resident's comprehensive assessment. This deficiency was identified when a clinical coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended 45 ml/hr. The resident, who was cognitively intact and able to communicate via typing, expressed feelings of hunger, nausea, and significant weight loss over a period of time due to the incorrect feeding rate. The resident's medical record revealed a significant weight loss of 9.6 pounds, or 7.79% of body weight, between the dates of the incorrect feeding rate. Despite the resident's communication of hunger and weight loss to the nursing staff, the feeding rate was not corrected until after the surveyor's intervention. The clinical coordinator admitted to misreading the dietician's recommendation, which led to the incorrect order being placed and maintained for several days. Interviews with facility staff revealed a lack of a standardized process for obtaining, communicating, and implementing dietary recommendations. The Director of Nursing and Quality Improvement Nurse acknowledged the absence of a system to ensure accurate communication and entry of dietician recommendations. The Assistant Director of Nursing, who was responsible for supervising the clinical coordinator, also failed to verify the accuracy of the feeding rate against the dietician's recommendations, contributing to the resident's inadequate nutritional intake.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident who required such services. Specifically, the facility did not complete the necessary Dialysis Communication Forms for a resident with chronic kidney disease, among other diagnoses, before sending them to the dialysis facility. The resident, who had an intact cognition as per their BIMS score, was observed to have a catheter site on the right chest wall and received dialysis services three times a week. Despite the resident being sent to dialysis with a communication binder, the forms within the binder were not completed on multiple occasions, failing to include vital information such as problems or concerns since the last visit, current diet, fluid restrictions, and vital signs. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that it was the nursing staff's responsibility to complete these forms with pertinent information before the resident's dialysis sessions. The DON acknowledged that the forms were not completed on several specified dates, which was a requirement. Additionally, a telephone interview with an RN at the contracted dialysis facility revealed that the facility frequently did not complete the dialysis communication forms, which were essential for reviewing the resident's vitals and other necessary information upon their arrival for dialysis treatment.
Failure to Monitor Resident's Medication Regimen
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, leading to a deficiency in care. Specifically, the facility did not monitor a resident for edema while they were on a diuretic medication, Furosemide, and also failed to monitor for side effects and effectiveness of an antidepressant, Lexapro. The resident, who had severe cognitive impairment with a BIMS score of 4, was admitted with diagnoses including Alzheimer's Disease, Heart Failure, Hypertension, and Other Depressive Disorders. The resident required varying levels of assistance with daily activities, indicating a need for careful monitoring of their medication regimen. The resident's care plan included interventions for depression and hypertension, which required monitoring for side effects and effectiveness of medications, as well as monitoring for edema. However, a review of the July 2024 Medication Administration Record (MAR) revealed no documentation of such monitoring. This lack of documentation was confirmed by the Clinical Coordinator during an interview, indicating a failure to adhere to the care plan and physician's orders, thus resulting in a deficiency in the resident's care.
Deficiencies in ADL Support and Incontinence Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform Activities of Daily Living (ADLs) independently, specifically in maintaining good grooming and personal hygiene. Resident #33, who had severe cognitive impairment and required substantial assistance for personal hygiene, was observed with poor oral hygiene and long, dirty fingernails. Despite being scheduled for regular personal and oral care, staff did not assist Resident #33 with brushing her teeth or trimming her nails, as confirmed by both the resident and the LPN. Resident #77, who was dependent on staff for incontinence care due to muscle weakness and impaired cognition, did not receive timely incontinent care. The resident reported not being changed while in her wheelchair and expressed discomfort in asking for assistance, as staff were aware of the need for regular changes. Observations confirmed that Resident #77 was left in wet briefs for extended periods, and staff interviews revealed a lack of adherence to the facility's policy of providing care every two hours. Interviews with staff, including the CNA and RN Clinical Coordinator, confirmed the lapses in care for Resident #77, acknowledging that the resident should have been changed more frequently. The facility's failure to provide adequate care for these residents highlights deficiencies in adhering to care plans and ensuring the well-being of residents who are unable to perform ADLs independently.
Infection Control Lapses During Meal Service and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents. During a meal service, a CNA assisted two residents without performing hand hygiene between assisting each resident. This was confirmed through observation and interview, where the CNA acknowledged the lapse in hand hygiene, and an LPN confirmed that hand hygiene should have been performed between assisting residents. In a separate incident, a Treatment Nurse and an assisting Treatment Nurse were observed performing wound care on a resident requiring Enhanced Barrier Precautions. The assisting Treatment Nurse exited the resident's room to retrieve supplies without removing the gown and gloves used during the procedure, which was confirmed through an interview. This failure to follow proper infection control practices during wound care was noted as a deficiency in the facility's infection prevention and control program.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during care activities. For one resident, the treatment nurses did not close the window blinds while providing wound care, leaving the resident exposed to a person outside cutting the lawn. The resident, who had a BIMS score indicating intact cognition, was unaware of the exposure during the procedure but expressed concern about being seen undressed. This incident occurred despite the facility's policy emphasizing the importance of maintaining residents' dignity and privacy. In another instance, an LPN assisted a resident with meal service while standing over the resident's bed, despite the presence of chairs in the room. The facility's policy on meal assistance clearly states that residents should be fed with attention to dignity, which includes not standing over them. The LPN admitted to not knowing that standing while assisting residents with meals was against policy, indicating a lack of awareness or training regarding the facility's standards for maintaining resident dignity during meal times.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
