Natchitoches Nursing And Rehabilitation Center, Ll
Inspection history, citations, penalties and survey trends for this long-term care facility in Natchitoches, Louisiana.
- Location
- 750 Keyser Avenue, Natchitoches, Louisiana 71457
- CMS Provider Number
- 195293
- Inspections on file
- 39
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Natchitoches Nursing And Rehabilitation Center, Ll during CMS and state inspections, most recent first.
The facility failed to provide ordered meals, supplements, and adequate feeding assistance to several cognitively intact but fully dependent residents. One resident with quadriplegia, malnutrition, and pressure ulcers reported often receiving only one meal per day, not being awakened or assisted for meals, and not consistently receiving prescribed supplements. Another resident with quadriplegia and severe protein-calorie malnutrition stated that staff did not always wake him for meals, that multiple meals were missed when he was sleeping, and that he felt rushed when being fed. A third resident with quadriplegia and diabetes reported relying on staff for feeding, sometimes not receiving her meal tray because it was left on the cart and returned to the kitchen, and on one occasion being told the kitchen was closed so she received nothing to eat. Staff interviews described problems with feeding during shift change, residents reporting missed meals, and communication failures that led to meal tickets not being printed for residents who had returned from the hospital.
A resident with quadriplegia, intact cognition, depression, low BMI, and a stage 4 sacral pressure ulcer required assistance with all ADLs but repeatedly did not have an accessible call light. Surveyors observed the call bell placed between the bed and side rail and later on a dresser, both out of the resident’s reach. The resident reported being unable to use the call system and sometimes relying on a roommate to call for help, and stated they would not have been able to summon assistance over a weekend if needed. A hospice RN noted that although the call bell was placed within reach during her visit, she did not believe the resident could effectively use it, and the administrator later confirmed the call bell was not within reach.
A resident with quadriplegia, intact cognition, and multiple comorbidities, fully dependent on staff for ADLs, reported repeated delays in receiving incontinent care despite a care plan requiring prompt call light response and q2h peri care. The resident stated that requests for assistance beginning in the early morning hours were not addressed for several hours and that staff sometimes turned off the call light without providing care. The resident filed multiple grievances about call bell response times, and an SSD, an LPN, a CNA, and the ombudsman all confirmed that the resident had complained of not being bathed and changed in a timely manner, demonstrating a failure to provide necessary ADL services and timely incontinent care.
Surveyors found that the facility failed to meet professional standards by not completing ordered monthly suprapubic catheter changes for a resident, and by not entering or following wound clinic orders for a Stage 3 gluteal pressure ulcer, resulting in the wound being observed open without a dressing. In addition, another resident with diabetic and chronic foot ulcers had physician wound care orders that were not followed, demonstrating multiple lapses in adherence to ordered catheter and wound treatments by nursing staff, including an LPN and the treatment RN.
Staff failed to maintain resident dignity during meals when several CNAs stood while feeding total-care residents who required full assistance with eating. One resident with quadriplegia and chronic pain, another with quadriplegia, multiple contractures, chronic pain, and visual impairment, and a third with dementia, generalized weakness, dysphagia, and coordination deficits were all observed being fed by standing CNAs. In interviews, the CNAs confirmed these residents were total care and dependent for meals, and the DON acknowledged that staff had been instructed not to stand while feeding residents.
A cognitively intact resident was unable to access money from a personal trust fund despite repeatedly requesting it from the Administrative Assistant/Office Manager. The resident sought reimbursement for wheelchair parts and other purchases made by family, and submitted receipts, which were forwarded to a regional financial consultant for approval. The Administrative Assistant/Office Manager acknowledged that reimbursement checks were not issued within the required 3-day timeframe after receipt submission, resulting in a delay in the resident’s access to his own funds.
A resident with intact cognition and multiple conditions, including neuromuscular bladder dysfunction and a suprapubic catheter, did not have the catheter addressed in the comprehensive person-centered care plan, despite physician orders for catheter placement, routine care each shift, and scheduled changes. The facility's policy required care plans to identify resident problems and needs and to be reviewed at least quarterly, yet the care plan contained no documentation related to the suprapubic catheter. The resident was observed in a wheelchair with the suprapubic catheter hanging from the wheelchair arm, and the care plan coordinator confirmed that the catheter had not been included in the care plan as required.
A resident with diabetes, cellulitis, venous insufficiency, and multiple lower extremity ulcers had physician orders and a care plan for daily wound care and monitoring of infected wounds. Surveyors observed an RN performing wound care with a clean field prepared, but using soiled gloves to handle scissors from the clean field, failing to perform hand hygiene between glove changes, and using the same pair of gloves to cleanse and dress three separate purulent wounds while repeatedly accessing clean supplies. The resident was also observed with a soiled dressing with yellow drainage on one leg and exposed wounds with copious slough on the other leg and foot. The RN later acknowledged not following hand hygiene and glove-change practices, and the DON confirmed these findings.
A resident with a history of dementia and hip issues experienced a fall and was in significant pain, prompting a STAT x-ray order. Although the x-ray revealed a nondisplaced intertrochanteric fracture and results were available the same evening, nursing staff did not follow up or review the results until the next morning, resulting in a delay in care. Both LPNs involved acknowledged the lapse in timely follow-up, and the DON confirmed that standard protocol was not followed.
The facility failed to monitor and address the nutritional needs of two residents, leading to significant deficiencies. One resident experienced severe weight loss due to inadequate meal intake documentation and lack of assistance, while another was not provided a meal tray during lunchtime. Staff interviews revealed lapses in communication and adherence to care protocols, contributing to these deficiencies.
The facility failed to include the Infection Preventionist (IP) in its Quality Assessment and Assurance (QAA) committee meetings, as required by policy. Despite having various staff members present, the IP's absence was confirmed by the Administrator, highlighting a significant oversight in infection control and prevention efforts for the facility's 58 residents.
A facility failed to notify a physician about a resident's 3+ edema, as required by physician orders. Despite multiple instances of 3+ edema documented over several months, the physician was not informed. An LPN confirmed the oversight, and the DON acknowledged the failure to meet professional standards of care.
A resident with cognitive intactness and multiple health conditions required assistance with ADLs, including nail care. Despite a care plan intervention to trim nails, observations revealed long, dirty nails, and the resident expressed a desire for them to be cut. The DON confirmed the need for nail trimming, indicating a lapse in care.
A facility failed to develop a comprehensive person-centered care plan for a resident with schizophrenia, diabetes mellitus, and chronic pain syndrome, who was involved in active discharge planning. Despite the resident's expressed desire to move to another facility, the care plan lacked discharge planning. Interviews confirmed the oversight, with the MDS coordinator attributing it to the care plan being completed before her employment, and the Administrator acknowledging the deficiency.
The facility failed to provide an ongoing activities program that supports residents' choices, particularly on weekends. Three residents reported a lack of organized activities, with one resident noting that bingo was the only activity offered during the week. Staff interviews confirmed the absence of weekend activities, and the Activity Director's time card showed no logged hours on the days in question. This deficiency affected the residents' ability to engage in meaningful activities as outlined in their care plans.
A hospice resident with Alzheimer's and other conditions experienced an accident resulting in injury and unrelieved pain. Despite the facility's policy requiring notification of the physician for abnormal pain, the Medical Director was not informed. The resident was found on the floor with a potential injury, but the facility delayed sending her to the ER, waiting for hospice assessment. Pain relief was ineffective, and the resident remained in severe pain until she was eventually sent to the ER the next day.
A resident with Alzheimer's and under hospice care experienced a fall and reported pain. Despite orders for Hydromorphone and Lorazepam every four hours, the resident did not receive these medications as prescribed, resulting in a nearly 12-hour gap in pain management. The resident was eventually sent to the ER for further evaluation and pain control.
The facility failed to maintain resident privacy during showering by leaving the shower room door open, contrary to policy. This affected two residents, one of whom expressed a preference for the door to be closed. Staff confirmed the door should have been closed, highlighting a breach of residents' rights to privacy and dignity.
A resident with severe cognitive impairment and a urinary tract infection did not receive the prescribed antibiotic, Augmentin, as ordered by the physician. The medication was not administered over several days, and there were no documented refusals. This failure was confirmed by the DON and a Corporate RN, highlighting a lapse in following the facility's medication administration policy.
The facility failed to properly dispose of garbage and refuse, as a dumpster outside the kitchen was found with its sliding door open, allowing a cat to jump out. Trash was on the ground, and a torn mattress and two walkers were outside the dumpster area. Despite signage to keep the door closed, it remained open. The Housekeeping Supervisor confirmed the area should be clean and the door closed, which was not adhered to.
The facility failed to ensure a safe and comfortable environment by not repairing a toilet base in a resident's room and a shower room door on X Hall. A resident reported the toilet had been in disrepair since moving in last year, and maintenance confirmed the issues. Observations revealed broken material under the toilet and a hole in the shower door.
A facility failed to ensure residents received care according to professional standards and care plans, affecting six residents. Critical lab results were not communicated to physicians, and ordered lab tests were not obtained. One resident with a history of Coumadin toxicity was hospitalized due to continued administration of Coumadin despite critical lab results. Other residents experienced missed medication doses and incomplete lab monitoring, highlighting deficiencies in adherence to physician orders and monitoring protocols.
The facility failed to effectively manage lab monitoring and communication, impacting several residents. A resident with a history of Coumadin toxicity was not properly monitored, leading to an Immediate Jeopardy situation. Other residents experienced missed lab draws and medication administration errors, highlighting systemic issues in the facility's resource management.
The facility failed to provide a private space for Resident Council Meetings, holding them in an open area near the entrance and nurses' station, compromising privacy. Additionally, the facility did not promptly address ongoing grievances from residents about staff not rounding, call lights not being answered, beds not being made, and loud CNAs at night. These issues persisted over several months, with the facility's response limited to monthly staff in-service training.
A resident with diabetes was not provided with an artificial sugar sweetener, Sweet'n Low, as part of their dietary needs. The resident reported not having access to the sweetener for several days, affecting their meal consumption. The deficiency was due to the dietary management's oversight in ordering and maintaining an adequate supply of artificial sweeteners, and the administrator acknowledged the failure to ensure availability for residents on diabetic precaution diets.
A resident with moderate cognitive impairment and a history of wandering eloped from a facility due to inadequate supervision. The resident asked an agency nurse to unlock the front door, expressing a desire to see his wife, and left unnoticed. The nurse, unaware of the resident's elopement risk, did not notify other staff or increase supervision. The resident was later found 0.4 miles away by staff from his Intensive Outpatient Program.
A resident at risk for elopement exited the facility unattended after an agency nurse unlocked the front door without notifying other staff. The resident, who was moderately cognitively impaired, was found 0.4 miles away on a busy roadway. The facility lacked effective supervision and communication systems, and there was no policy to train all staff on managing elopement risks.
Failure to Provide Ordered Meals, Supplements, and Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide nourishing, palatable, well-balanced diets and supplements as ordered and to ensure necessary feeding assistance for three dependent residents. Facility policy stated that clients are to be served their diets as ordered, and care plans and MDS assessments documented that these residents were cognitively intact but dependent on staff for all activities of daily living, including feeding. For one resident with quadriplegia, chronic kidney disease, neuromuscular dysfunction, pressure ulcers, anorexia, malnutrition, and an inability to feed himself, the care plan directed staff to feed all meals and give supplements as prescribed. This resident reported usually only getting to eat one meal a day, that staff sometimes did not come to feed him, and that if he was asleep staff would not wake him to feed him. He also stated he did not receive his ordered supplements very often or every day and denied refusing them. Another resident with quadriplegia, severe protein-calorie malnutrition (on hospice), low BMI, depression, and a stage 4 sacral pressure ulcer was also documented as cognitively intact and dependent on staff for all ADLs. His care plan included providing and serving diet as ordered. He reported that he sleeps a lot and that staff did not always wake him to feed him if he was asleep. He further stated that two of six meals over a weekend were missed because he was sleeping and no one returned to feed him, and that when he was fed he felt rushed, which caused him to feel full too quickly. A third resident with type 2 diabetes mellitus, quadriplegia, hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, also cognitively intact and fully dependent on staff, reported relying on staff for feeding and usually being fed only after all trays were passed on the hall. She stated there were two occasions in recent weeks when she did not receive her meal tray because it remained on the cart and was returned to the kitchen. On one of those occasions, after she asked a CNA and an agency nurse to retrieve the tray, they told her the kitchen was already shut down and being cleaned, so she did not receive anything to eat. Staff interviews corroborated systemic issues: a CNA reported problems with residents being fed at dinner due to meal carts arriving during shift change, an LPN reported residents (including the first two residents) complaining they had not been fed or had not eaten, and the dietary manager described communication failures about residents leaving and returning to the facility, resulting in meal tickets not being printed and residents not receiving trays, without these issues being reported to the Administrator.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring an appropriate and accessible call light system. The resident was admitted with major depressive disorder, quadriplegia, low BMI, depression, and a stage 4 sacral pressure ulcer, and had a BIMS score of 13 indicating intact cognition. The resident had impairments on both sides and required assistance with all ADLs. During an observation, the resident was seen lying in bed with the call bell positioned between the bed and side rail, out of reach. The resident reported being unable to use the call bell system and stated that at times he had to ask his roommate to call for help. Further observations showed that on another day the resident was again lying in bed with the call bell placed on a two-drawer dresser, out of reach. The resident stated that he would not have been able to call for help over the weekend if needed. The hospice RN reported that during her visit the call bell had been within reach but she did not think the resident could use it. In a subsequent interview, the administrator confirmed that the call bell was not within reach and the resident reported difficulty using the current call bell system due to mobility issues when it was not appropriately placed at all times.
Failure to Provide Timely Incontinent and ADL Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living, specifically incontinent care, to a resident who was fully dependent on staff. The resident had multiple diagnoses including Type 2 Diabetes Mellitus, quadriplegia, essential hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, and had an admission MDS BIMS score of 15 indicating intact cognition. Her care plan, reviewed on 03/04/2026, identified an ADL self-care performance deficit related to impaired mobility and included interventions such as responding to call lights promptly and providing perineal care every two hours and as needed. Despite these documented interventions, the resident reported that staff did not respond to her call bell in a timely manner for incontinent care. The resident stated that she began requesting incontinent care assistance at 2:30 a.m. and was not changed until between 7:00 a.m. and 7:30 a.m., and that staff sometimes entered her room, turned off the call light, and left without providing care. She reported using an Alexa device to track the time and stated she had notified several staff members, including the administrator, about these delays. The Social Services Director confirmed that the resident had filed three grievances in the last three months, two of which involved call bell response times related to incontinent care. An LPN and a CNA both reported that the resident had informed them she was not being cared for in a timely manner, and the ombudsman also reported that the resident had complained of not being bathed and changed in a timely manner. These observations and interviews demonstrated that the facility did not follow its own policy and care plan interventions to ensure timely ADL and incontinent care for this resident.
Failure to Follow Physician Orders for Catheter and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of quality for residents with suprapubic catheter and wound care needs. One resident with multiple diagnoses including Type 2 diabetes, UTIs, cellulitis of both lower limbs, venous insufficiency, neuromuscular bladder dysfunction, and bowel and bladder incontinence had a physician order dated 09/15/2025 for a suprapubic catheter change every month and PRN for leakage/occlusion, with the GU bag to be changed on the 15th of each month. Review of the November and December Treatment Administration Records (TARs) showed that the scheduled suprapubic catheter changes on 11/15/2025 and 12/15/2025 were not documented as completed, and there was no documentation or progress note explaining why the catheter was not changed. The LPN responsible for treatments and the Unit Manager both confirmed, after reviewing the TARs, that the catheter had not been changed in those months despite the standing order and the facility expectation that missed treatments be documented with a reason. The same resident was also followed by an external wound care clinic for a left posterior gluteal pressure ulcer. A wound care clinic physician note dated 01/02/2026 documented an open Stage 3 pressure ulcer on the left posterior gluteus, with orders to cleanse with normal saline once daily, apply a topical antibiotic compound once daily when available, and cover with a 6x6 border gauze dressing once daily. Review of the resident’s January 2026 physician orders and TAR revealed no orders entered for treatment of this left posterior gluteal pressure ulcer and no documentation that the ordered wound care was performed. During interview, the treatment RN stated that she receives and inputs wound care clinic orders into the computer and adds them to the facility’s orders and TAR, and that the resident never refuses wound care. However, observation on 01/14/2026 showed the resident had an open wound on the left posterior gluteus with no dressing or bandage in place, and the treatment RN confirmed there were no other treatment orders for this wound beyond application of Calazinc cream to the buttocks and groin. Another resident with diagnoses including Type 2 diabetes with skin ulcer, non-pressure chronic ulcer of the right heel and midfoot, CKD stage 3A, Charcot joint of the left ankle and foot, depression, and an unspecified open wound of the left foot had physician orders for wound care that included cleansing with normal saline, applying ointment to the wound bed, covering with sterile gauze, and wrapping with Kerlix secured with tape. The report identifies this as an additional instance where physician wound care orders were not followed, contributing to the overall finding that the facility failed to provide care and services in accordance with professional standards of quality for wound and catheter management for sampled residents.
Staff Standing While Feeding Total-Care Residents During Meals
Penalty
Summary
Staff failed to honor residents' rights to a dignified existence and self-determination during meal service by standing while feeding multiple dependent residents. Resident #8, admitted on 10/12/2022 with diagnoses including other muscle spasm, complete C5-C7 quadriplegia, and other chronic pain, was observed on 01/12/2026 at 12:39 p.m. being fed by S7 CNA, who was standing during the meal. In a subsequent interview, S7 CNA stated that Resident #8 was total care and required assistance with meals. Resident #9, admitted on 11/19/2025 with multiple contractures, quadriplegia, other muscle spasm, chronic pain syndrome, age-related nuclear cataract, myopia, and primary generalized osteoarthritis, was observed on 01/12/2026 at 12:44 p.m. being fed by S8 CNA, who was standing, and again on 01/13/2026 at 12:26 p.m. being fed by S10 CNA, who was also standing. Both CNAs reported that this resident was total care and required assistance with meals. Resident #10, admitted on 12/26/2025 with unspecified dementia, generalized muscle weakness, lack of coordination, other symbolic dysfunctions, dysphagia, and idiopathic normal pressure hydrocephalus, was observed on 01/13/2026 at 12:25 p.m. being fed by S9 CNA, who was standing. S9 CNA stated that this resident was total care and required meal assistance. The DON (S2) confirmed that all staff were aware they were not to stand while feeding residents and that these CNAs should not have been standing to feed residents.
Failure to Provide Timely Access to Resident Trust Fund Reimbursement
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to manage his own financial affairs by not providing timely access to his personal funds. A quarterly MDS with an ARD of 11/24/2025 documented that Resident #4 had a BIMS score of 15, indicating he was cognitively intact. During an interview on 01/13/2026 at 9:25 a.m., the resident reported he had been unable to obtain money from his trust fund despite requesting it from the Administrative Assistant/Office Manager since 10/28/2025 and being repeatedly told he would receive it “tomorrow.” The Administrative Assistant/Office Manager stated the resident wanted money from his trust fund to reimburse his family for wheelchair parts and other purchases made in October 2025, and that he submitted receipts for these items on 12/02/2025, which she then emailed to the regional financial consultant for approval. In a subsequent interview, she confirmed she did not provide the reimbursement checks to the resident within 3 days after he submitted his receipts, and acknowledged that she should have done so. This sequence of events shows that despite the resident’s intact cognition and repeated requests, the facility did not ensure timely disbursement of the resident’s trust fund money following submission of receipts, resulting in a delay in his access to his own funds.
Failure to Develop Care Plan for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing a resident's suprapubic indwelling catheter. The facility's policy required each resident to have a person-centered care plan identifying problems, needs, strengths, preferences, goals, and how the interdisciplinary team would provide care, with review and revision at least quarterly and with MDS assessments. Resident #7 was admitted with multiple diagnoses including Type 2 diabetes mellitus with diabetic mononeuropathy, UTI, anxiety, cellulitis of both lower limbs, edema, venous insufficiency, and neuromuscular dysfunction of the bladder. The resident had intact cognition, as evidenced by a BIMS score of 14 on the quarterly MDS. Physician orders included a urology consult for suprapubic catheter placement, suprapubic catheter care with soap and water every shift, and monthly suprapubic catheter changes with PRN changes for leakage or occlusion. Despite these orders and the presence of the suprapubic catheter, review of the resident's care plan showed no documentation or evidence that the catheter was addressed in the care plan. During observation, the resident was seen sitting in a wheelchair in the hallway with the suprapubic indwelling catheter hanging on the right wheelchair arm with a privacy cover. In an interview, the care plan coordinator, who was responsible for developing and updating all resident care plans and stated she reviewed and revised care plans quarterly and with changes in condition, confirmed that the care plan for this resident did not address the suprapubic catheter but acknowledged that it should have been included.
Failure to Follow Standard Precautions During Multi-Site Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and standard precautions during wound care for a resident with multiple lower extremity wounds. The facility’s policy on Standard Precautions required hand hygiene and appropriate use of personal protective equipment (PPE), including gloves and gowns, as the primary strategy to prevent healthcare-associated infections. The resident’s medical record showed multiple diagnoses including Type 2 diabetes with diabetic mononeuropathy, cellulitis of both lower limbs, edema, chronic venous insufficiency, and neuromuscular bladder dysfunction. The resident’s MDS indicated intact cognition, partial/moderate assistance with hygiene, and an infection of the foot with purulent drainage. The care plan documented actual skin integrity impairment with arterial and venous ulcers and directed staff to treat ulcers as indicated, keep skin clean and dry, and monitor and document wound status and signs of infection. Prior to the observed wound care, the resident was seen sitting in a wheelchair in the hallway with a suprapubic indwelling catheter bag hanging on the wheelchair arm and covered for privacy. A soiled dressing with yellow drainage was observed on the right leg, and the left lower leg and left foot had no dressings in place, leaving wounds exposed with copious slough in the wound bed. Physician orders for the resident included daily and PRN wound care to multiple sites on both lower extremities and toes, specifying cleansing with normal saline, application of an antibiotic compound, and coverage with ABD pads and Kerlix wraps secured with tape. During the observed wound care, the treatment RN prepared a clean field on the bedside table with normal saline, ABD pads, gauze, scissors, and a bottle of antibiotic compound, and donned a gown and clean gloves. She removed the old dressing from the right lower anterior leg wound and then removed dressings from the left lower leg and left foot, using the same soiled gloves to pick up scissors from the clean field to cut remaining bandages and then placing the scissors on the resident’s bed. After exposing wounds with copious yellow purulent drainage, she removed her gloves and donned a new pair without performing hand hygiene. She cleansed and dressed the right anterior wound, then, without changing gloves, handled clean supplies on the bedside table and cleansed and treated three separate wounds on the left lower leg and left toe, using the same gloves throughout. The RN did not change soiled gloves between wounds and continued to reach into the clean supply area. After completing wound care, she removed her gown and gloves and walked away to discard supplies. In interviews, the treatment RN acknowledged she failed to sanitize or wash her hands between glove changes and that she used the same soiled gloves to clean three separate wounds without changing them, and the DON confirmed these findings.
Failure to Timely Follow Up on STAT X-ray Results
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring timely follow-up on STAT x-ray results for a resident with a history of Alzheimer's Disease, dementia, left hip pain, and previous fractures. After an unwitnessed fall, the resident complained of left hip pain, prompting a nurse practitioner to order a STAT x-ray. The x-ray was performed, and the results, which showed a nondisplaced intertrochanteric fracture, were electronically signed and available the same evening. However, the results were not reviewed or acted upon until the following morning. Nursing staff on the evening and overnight shifts were aware that the x-ray results were pending but did not follow up with the imaging center or check for the results within the expected timeframe. The LPN on the night shift acknowledged that she did not call to check on the results, despite knowing that STAT results are typically received within a few hours. The Director of Nursing Services confirmed that the nurse assigned to the resident should have followed up on the x-ray results that night. As a result, there was a delay in identifying and responding to the resident's fracture.
Nutritional Care Deficiencies for Two Residents
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of two residents, leading to significant deficiencies in their care. Resident #3, who has dementia and Alzheimer's disease, experienced a severe weight loss of 7.7% over a three-month period. The facility did not consistently record meal intake for Resident #3, failed to assist with all meals as care planned, and did not notify the MD/NP when the resident refused to eat or exhibited severe weight loss. Interviews revealed that the CNAs did not document meal intake in the medical record or report it to the nurse, and the dietary staff discarded meal tickets without recording intake information. Resident #36, who has multiple diagnoses including Type 2 Diabetes Mellitus and morbid obesity, was not provided a meal tray during lunchtime. The resident was observed sitting alone without a lunch tray while other residents were served. The CNA responsible for Resident #36's meal service mistakenly believed the resident had refused the meal and discarded the lunch tray without offering an alternative. Interviews with staff confirmed that Resident #36 typically eats in the day area and does not refuse meals, indicating a failure in communication and adherence to care protocols. The facility's policies on meal time observation and food acceptance were not followed, resulting in harm to Resident #3 and a failure to provide adequate nutrition to Resident #36. The Director of Nursing acknowledged the lapses in documentation and communication, which contributed to the deficiencies in care. The Registered Dietician's recommendations and weight records were not effectively communicated to the medical staff, delaying necessary interventions for Resident #3's weight loss.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee meetings included the required staff members, specifically the Infection Preventionist (IP), for the facility's quarterly meetings. The facility's policy, revised in October 2022, mandates that the QAA committee should include the Director of Nursing Services (DNS), Medical Director or designee, and three other staff members, one of whom must be in a leadership role, and the IP. However, a review of the facility's QAA Committee list and sign-in sheets for meetings held in 2024 and 2025 revealed that the IP was not present at any of the quarterly meetings. The absence of the IP from these meetings was confirmed during an interview with the facility's Administrator. The QAA Committee meetings were attended by various staff members, including the Executive Director, Director of Rehab, Activities Director, Dietary Manager, Housekeeping, Unit Manager-LPN, LPN-MDS, Medical Records, and Medical Director, among others. Despite the presence of these members, the lack of the IP's attendance was a significant oversight, as the IP plays a crucial role in infection control and prevention, which is vital for the health and safety of all 58 residents in the facility.
Failure to Notify Physician of Resident's 3+ Edema
Penalty
Summary
The facility failed to meet professional standards of quality by not notifying the physician of a resident's 3+ edema, as required by the physician's orders. The resident, who was admitted with a diagnosis of edema, had physician orders to monitor edema every shift and notify the physician if the edema reached 3+ or 4+. Despite this, the resident's medical records showed multiple instances of 3+ edema documented over several months, from January to March, without any notification to the physician. Interviews and observations confirmed the oversight. An LPN admitted to documenting 3+ edema on two consecutive days in March but did not notify the physician, as required. The Director of Nursing also confirmed that the physician was not notified of the resident's 3+ edema on these dates, acknowledging that the notification should have occurred. This failure to notify the physician of significant changes in the resident's condition represents a deficiency in the facility's adherence to professional standards of care.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living independently. Resident #59, who was admitted with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, and hypertension, was cognitively intact with a BIMS score of 15. The resident required partial to moderate assistance with various movements and had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and stroke. The care plan included interventions such as checking and trimming nails on bath day and as necessary. Despite these interventions, observations on two consecutive days revealed that Resident #59 had long, dirty fingernails, and the resident expressed a desire to have them cut. The resident stated that no one had offered to cut the nails, and he had never refused such care. The Director of Nursing confirmed the need for nail trimming and indicated that the Treatment Nurse should have performed this task, highlighting a lapse in the facility's adherence to the care plan for maintaining the resident's personal hygiene.
Failure to Develop Comprehensive Care Plan for Discharge Planning
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident #23, who was admitted with diagnoses including schizophrenia, diabetes mellitus, and chronic pain syndrome. Despite having a BIMS score indicating intact cognition and being involved in active discharge planning, the resident's care plan lacked any evidence of discharge planning. The facility's policy requires each resident to have a person-centered care plan that includes discharge planning, but this was not adhered to in the case of Resident #23. Interviews revealed that the resident had expressed a desire to move to another facility and had communicated this to the Director of Nursing and the Administrator, but had not received any feedback. The MDS coordinator confirmed that the resident was not care planned for either remaining in the facility long-term or for discharge planning, attributing the oversight to the care plan being completed by someone else before her employment. The Administrator acknowledged that the resident should have been care planned for discharge planning, which was not done.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activities program that supports residents' choices based on comprehensive assessments, care plans, and preferences. This deficiency was identified for three residents out of a sample of 24, with the potential to affect all 58 residents in the facility. The facility's policy requires daily activities, including weekends and holidays, but the activities calendar and interviews revealed a lack of activities on weekends. Specifically, on the weekend of March 8th and 9th, 2025, scheduled activities did not occur, and residents reported a lack of organized activities. Resident #41, with diagnoses including cerebral infarction and diabetes, expressed dissatisfaction with the facility's activities, noting that bingo was the only organized activity and that no activities occurred on the weekend in question. The resident's care plan emphasized the importance of group activities and personal preferences, which were not met. Interviews with staff confirmed the absence of activities on weekends, and the Activity Director's time card showed no logged hours on the days in question, indicating she was not present to conduct activities. Resident #25, with conditions such as paraplegia and major depressive disorder, also reported that no activities were offered on weekends since admission. Similarly, Resident #23, diagnosed with schizophrenia and chronic pain syndrome, stated that the facility lacked weekend activities and had insufficient activities during the week. The resident's care plan highlighted the need for activities that empower and engage the resident, which were not provided. The facility's failure to adhere to its policy and provide adequate activities led to this deficiency.
Failure to Notify Medical Director and Delay in Emergency Care for Hospice Resident
Penalty
Summary
The facility failed to notify the Medical Director when a hospice resident experienced an accident resulting in injury and unrelieved pain. The incident involved a resident with Alzheimer's Disease, Major Depressive Disorder, and other conditions, who was under hospice care. The resident was found on the floor with a raised area on her left knee, indicating potential injury. Despite the presence of aides and the resident's daughter, the facility did not immediately send the resident to the emergency room but instead waited for hospice to assess the situation. The facility's policy required notification of the physician or responsible party in cases of abnormal pain complaints or ineffective pain relief. However, the hospice nurse advised against sending the resident to the ER, suggesting that the absence of immediate bruising indicated no fracture. The resident was given Lorazepam and Hydromorphone for pain, but these medications did not alleviate her discomfort. The hospice nurse was unable to visit promptly, and the facility delayed further action until the following day, resulting in prolonged pain for the resident. Interviews with staff and the resident's responsible party revealed that the resident was in severe pain throughout the night and into the next day. The facility's Director of Nursing acknowledged that further action should have been taken when hospice did not arrive as expected. The resident was eventually sent to the ER, where her hip was repositioned, and an immobilizer was applied to her broken leg. The failure to notify the Medical Director and the delay in sending the resident to the ER contributed to the deficiency identified in the report.
Inadequate Pain Management for Resident Post-Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, as per professional standards and the resident's comprehensive care plan. The resident, who had a history of Alzheimer's Disease, Major Depressive Disorder, and was under hospice care, experienced a fall and reported pain. Despite having orders for Hydromorphone and Lorazepam to be administered every four hours for pain management, the resident did not receive these medications as prescribed. On the night of the incident, a nurse found the resident on the floor, displaying signs of pain with a swollen knee. The nurse contacted the hospice nurse, who advised administering the existing pain medications and scheduling an x-ray for the following morning. The resident received the medications approximately 20-30 minutes after the fall, which were effective in allowing the resident to sleep. However, the resident did not receive any further pain medication for nearly 12 hours, despite the order for administration every four hours. The following morning, another nurse assessed the resident's pain as significant, based on facial expressions, but delayed administering additional pain medication due to the previous nurse's report. The resident's daughter was consulted but declined further medication at that time. The resident was eventually sent to the ER for further evaluation and pain management. The facility's Director of Nursing acknowledged the lapse in administering pain medication as ordered.
Failure to Maintain Resident Privacy During Showering
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not maintaining privacy during showering. Observations on two separate occasions revealed that the shower room door was propped open while residents were receiving care, allowing staff, residents, and visitors to pass by and potentially see inside. This was contrary to the facility's policy, which required the door to be closed for warmth and privacy during resident care. Interviews with staff confirmed that the door should have been closed, but it was not. Two residents were directly affected by this deficiency. One resident, who had intact cognition, expressed a preference for the door to be closed while showering, indicating a lack of respect for his personal preferences and dignity. The other resident had moderately impaired cognition, which may have affected his ability to advocate for his privacy needs. The facility's failure to adhere to its own policies and procedures resulted in a breach of the residents' rights to privacy and dignity.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not implementing a physician's order for a resident. Specifically, the facility did not administer the prescribed antibiotic, Augmentin, to a resident who was diagnosed with a urinary tract infection, among other conditions. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was supposed to receive the medication starting on October 18, 2024, as per the physician's order. Upon review of the resident's Medication Administration Record (MAR), it was found that the antibiotic was not administered from October 18 to October 23, 2024, and there were no documented refusals of the medication. This oversight was confirmed during an interview with the Director of Nursing and a Corporate Registered Nurse, who acknowledged that the medication should have been administered as ordered. The facility's policy on medication administration emphasizes the responsibility of licensed nursing personnel to administer medications according to physician's orders, which was not adhered to in this case.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The facility's policy on garbage and rubbish disposal requires that all outside dumpsters be maintained in a clean and sanitary condition, with storage areas kept clean to discourage pests and outdoor trash receptacles kept covered. However, during an observation of the area outside the facility's kitchen, a blue dumpster was found with its sliding door left open, allowing a cat to jump out. Trash was observed on the ground in front of the dumpster, and a torn mattress and two walkers were found outside the dumpster area. Despite signage instructing that the dumpster door be closed at all times, the door remained open during a subsequent observation. An interview with the Housekeeping Supervisor confirmed that housekeeping was responsible for maintaining the cleanliness of the area and acknowledged that the sliding door should be closed and the area free of litter, which was not the case.
Facility Fails to Repair Toilet and Shower Door
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for its residents, as evidenced by two specific deficiencies. Firstly, the toilet base in Room A was found to be in disrepair, with broken pieces of solid material observed underneath the toilet on two separate occasions. A resident occupying Room A reported that the toilet had been in disrepair since moving into the room the previous year. The resident's Quarterly MDS indicated a BIMS score of 15, suggesting intact cognitive function. Secondly, the shower room door on X Hall was observed to have a hole approximately 6 inches in width near the bottom. The maintenance staff confirmed the presence of the hole and acknowledged that the toilet base in Room A had rebroke, necessitating repair. These observations and interviews highlight the facility's failure to address and repair these issues in a timely manner.
Deficiencies in Lab Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and residents' person-centered care plans. This deficiency was identified for six out of thirteen sampled residents. The facility did not have a system in place to notify physicians of critical lab results, obtain ordered lab tests, and ensure medications were administered as prescribed. Specifically, the facility failed to notify the physician of a critically low hemoglobin level for a resident and did not document bleeding monitoring for two residents receiving anticoagulant therapy. Additionally, the facility did not obtain ordered weekly PT/INR levels for these residents. One resident, who had a history of Coumadin toxicity and gastrointestinal bleeding, was not monitored appropriately. The facility failed to obtain a PT/INR level and did not notify the primary care physician of a critically low hemoglobin level. Despite these critical lab results, the resident continued to receive Coumadin, leading to hospitalization for Coumadin toxicity. The resident required a blood transfusion and Vitamin K injection. This situation resulted in an Immediate Jeopardy finding due to the potential for more than minimal harm to residents requiring lab monitoring and physician notification. Other residents were also affected by the facility's deficiencies. One resident did not have their PT/INR levels drawn due to refusals and a lack of follow-up by staff. Another resident did not receive their prescribed medications and had missing documentation for blood glucose levels and vital signs. Additionally, routine laboratory draws were not completed for two residents, and a suprapubic catheter was not changed as ordered for another resident. These failures highlight the facility's lack of adherence to physician orders and monitoring protocols, leading to potential harm to residents.
Deficiencies in Lab Monitoring and Communication
Penalty
Summary
The facility failed to effectively administer its resources to ensure the highest practicable well-being of its residents, as evidenced by multiple deficiencies in monitoring and communication of laboratory results. Specifically, the facility did not have a system in place to ensure the completion of laboratory draws and timely communication of abnormal lab results to the provider. This failure affected several residents, including one who experienced an Immediate Jeopardy situation due to the facility's negligence in obtaining and communicating critical lab results. Resident #5, who had a history of Coumadin toxicity and gastrointestinal bleeding, was particularly affected. The facility failed to obtain a PT/INR level as ordered and did not notify the primary care physician of a critically low hemoglobin level. Despite these critical lab results, the resident continued to receive Coumadin, leading to a hospital transfer for a blood transfusion and Vitamin K injection. This oversight was discovered during a routine visit by the resident's PCP, highlighting the facility's failure to monitor and communicate critical lab results. Other residents were also impacted by similar deficiencies. Resident #12 did not have a PT/INR level drawn for over a month, yet continued to receive Coumadin without proper monitoring. Resident #9 had missed documentation of vital signs and medication administration, while Resident #10 and Resident #3 had lab tests that were not conducted as ordered. Additionally, Resident #4's suprapubic catheter was not changed according to the physician's schedule. These failures were acknowledged by the facility's Director of Nursing, who cited high turnover in leadership positions as a contributing factor to these care issues.
Failure to Provide Privacy and Address Resident Grievances
Penalty
Summary
The facility failed to provide a private space for the Resident Council Meeting held on 10/07/2024, which was conducted in the day room near the front entrance, nurses' station, and dining room. This area was open to anyone entering the facility, compromising the privacy of the meeting. During the meeting, a staff member conversed with the social services staff, and a visitor stood in the day room area, listening to part of the meeting. This lack of privacy was acknowledged by the facility's administrator and director of nursing. Additionally, the facility did not act promptly upon grievances voiced by residents during monthly Resident Council meetings. Residents consistently complained about staff not rounding every two hours, call lights not being answered timely, beds not being made, and CNAs being too loud at night. These issues were reported as ongoing problems that had not been addressed effectively, despite being raised in meetings from July to October 2024. The facility's response was limited to monthly in-service training for staff, with no other documented interventions.
Failure to Provide Diabetic Dietary Needs
Penalty
Summary
The facility failed to provide a resident with a diet specific to their special dietary needs and preferences, particularly for a diabetic precautions diet. Resident #1, who has a medical history including diabetes, diabetic neuropathy, hyperlipidemia, hypertension, schizophrenia, mood disorder, and intellectual disabilities, was not provided with an artificial sugar sweetener, Sweet'n Low, which is part of their dietary requirements. The resident reported not having access to Sweet'n Low for several days, which affected their ability to consume certain foods like grits and water with ice cubes. The deficiency was due to the dietary management's oversight in ordering and maintaining an adequate supply of artificial sweeteners. The dietary aide confirmed the absence of alternative sweeteners until the supply truck's arrival. The dietary manager admitted to overlooking the need to replenish the Sweet'n Low supply and failing to notify the office to purchase it locally. The administrator acknowledged that the dietary manager should have taken steps to ensure the availability of sugar substitutes for residents on diabetic precaution diets.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, who was assessed to be at risk for elopement, from exiting the facility without staff knowledge. The resident, who had moderate cognitive impairment and a history of wandering, was able to leave the facility unnoticed. This incident occurred when the resident asked an agency nurse to unlock the front door, expressing a desire to see his wife, while holding a trash bag with clothing items. The nurse did not notify other staff of the resident's exit-seeking behavior, and the resident was later found 0.4 miles away from the facility by staff from his Intensive Outpatient Program (IOP). The resident's medical records indicated a history of wandering and a risk for elopement, with interventions such as door alarms and hourly location monitoring in place. However, the agency nurse, who was not properly oriented to the facility's procedures or informed of the resident's elopement risk, failed to increase supervision or alert other staff members. The nurse signed off on the resident's location monitoring without accurately verifying his whereabouts, contributing to the resident's unsupervised departure. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's elopement risk. The facility's administrator acknowledged that the resident was not included in the elopement binder until after the incident, and there was no policy for training all staff, including agency staff, on elopement risks. The situation was further complicated by another resident's family moving belongings out of the facility, which may have distracted staff and allowed the resident to leave unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to effectively administer its resources to ensure the safety and well-being of its residents, specifically for a resident identified as being at risk for elopement. This resident, who was moderately cognitively impaired, managed to exit the facility unattended after asking an agency nurse to unlock the front door. The nurse did not inform other staff members of the resident's intention to leave. The resident was last seen at the nurses' station and was later found 0.4 miles away on a busy roadway by staff from the resident's Intensive Outpatient Program (IOP). The IOP staff notified the facility's Director of Nursing (DON), who then arranged for the resident's return to the facility. The incident highlighted a lack of effective supervision and communication among staff regarding residents at risk for elopement. The facility's administrator acknowledged that the resident was not placed in the elopement binder until after the incident, indicating a failure in the system to identify and monitor at-risk residents adequately. Additionally, there was no policy in place to ensure that all staff, including agency staff, were trained on identifying and managing residents at risk for elopement. This deficiency resulted in an Immediate Jeopardy situation, as the resident was able to leave the facility without proper supervision.
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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