New Iberia Manor North
Inspection history, citations, penalties and survey trends for this long-term care facility in New Iberia, Louisiana.
- Location
- 1803 Jane Street, New Iberia, Louisiana 70563
- CMS Provider Number
- 195328
- Inspections on file
- 24
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at New Iberia Manor North during CMS and state inspections, most recent first.
A resident requiring substantial assistance for bathing did not receive scheduled showers on multiple occasions due to insufficient CNA and shower aide staffing. Staff interviews and records confirmed that aides were frequently reassigned from the shower room to floor duties, leaving residents without needed hygiene care as outlined in their care plans. Facility leadership acknowledged missed and undocumented showers, and observations showed the shower room was unused during scheduled times.
A resident with Cerebral Infarction, Aphasia, and Dementia was subjected to verbal abuse by a CNA, as reported by the resident's roommate. The roommate, who had intact cognition, overheard the CNA telling the nonverbal resident to "shut up" multiple times and reported hearing slapping noises. The CNA admitted to possibly saying "shut up" out of reflex, which violated the facility's policy against verbal abuse.
A resident with chronic pain conditions reported that his pain medication was not effective, consistently rating his pain at 8-10. Despite informing the nursing staff and the NP, no changes were made to his pain regimen, and there was no documentation of the ineffectiveness of the pain management plan.
The facility failed to ensure that the NP re-evaluated a resident's UTI symptoms after lab results and did not respond to staff reporting changes in medical status for two residents. One resident self-treated UTI symptoms and reported untreated depression, while another experienced severe pain despite multiple medications and reported ineffectiveness to the NP.
The facility failed to maintain a medication error rate below five percent due to an LPN administering medications late for four residents. The LPN was late for work, and despite informing the DON and ADON, the medications were still administered significantly later than scheduled, affecting residents with serious health conditions.
The facility failed to maintain a resident's dignity by not keeping the urine collection bag covered and private, despite physician orders and care plan interventions requiring a privacy bag or covering. Observations confirmed the bag was visible from the hallway on two separate occasions, and an LPN acknowledged the oversight.
The facility failed to ensure a resident's MDS was completed accurately. The resident's MDS indicated the use of an anticoagulant, but a review of active physician orders revealed no such medication was prescribed. This discrepancy was confirmed by the Regional MDS coordinator.
The facility failed to refer two residents with newly diagnosed mental disorders for Level II PASARR evaluation. One resident was diagnosed with Unspecified Psychosis, and another with multiple mental disorders, but neither had a Level II PASARR conducted after their diagnoses. The Administrator and Social Service Director confirmed the oversight.
A resident with Major Depressive Disorder and Psychotic Disorder was admitted without a PASARR Level I screening. The facility did not request the necessary screening from the previous facility until prompted by surveyors, leading to a deficiency.
The facility failed to perform daily wound care and weekly wound assessments for a resident with multiple pressure ulcers, as ordered by the physician. The Director of Nursing/Infection Preventionist confirmed that treatments were not completed on a specific date and that weekly assessments were missing for certain wounds.
A resident with limited range of motion did not receive the recommended restorative nursing program after therapy was discontinued due to a change in payer source. The necessary form to initiate the program was not submitted, resulting in no order for restorative care.
The facility failed to update a physician's order to reflect the correct dialysis treatment days for a resident with End Stage Renal Disease (ESRD), resulting in a discrepancy between the care plan and the physician's order. This was confirmed during an interview and record review with the Director of Nursing/Infection Preventionist.
The facility failed to ensure an RN was on duty for 8 consecutive hours per day for 7 days per week. A review of PBJ Staffing Data and Time Card Reports for October and November 2023 revealed that an RN did not work the required hours on specific dates. This was confirmed by the facility's PBJ representative.
The facility failed to follow the menu for two residents on pureed diets. Despite physician orders and the menu listing a pureed biscuit for breakfast, the residents did not receive it. An observation revealed that the pureed biscuit was not served, and the container remained unopened.
A resident with a history of cerebral infarction and malnutrition was observed eating a breakfast that did not comply with his prescribed mechanically soft chopped meats diet. An LPN confirmed the discrepancy, noting that the resident should have received bacon crumbles instead of a whole slice of bacon.
The facility failed to store food according to professional standards and maintain sanitary conditions in the kitchen. Cooked food items were stored on the same shelf as raw food items, and expired food items were found in the walk-in cooler. The Dietary Manager confirmed these issues during an observation.
The facility failed to maintain an infection prevention and control program by not ensuring that clean laundry and linen were stored separately from contaminated items in the laundry department. Clean mop heads, mop pads, towels, blankets, and comforters were found stored on the contaminated side, contrary to the facility's policy.
The facility failed to develop and implement person-centered care plans for two residents. One resident did not receive timely wound care following a fall, and another resident did not have a urine culture performed as ordered due to an incomplete lab request.
A resident with a history of falls and moderate cognitive impairment fell and sustained a laceration after a CNA failed to follow an LPN's instruction to place the resident in bed, leaving the resident unsupervised in a wheelchair.
The facility failed to ensure a resident received necessary respiratory care and services by not assessing the resident for respiratory therapy and not obtaining a physician's order for oxygen administration via tracheostomy. The resident was observed receiving oxygen at 5 Liters without proper documentation or orders, as confirmed by staff interviews and record reviews.
Failure to Provide Adequate CNA Staffing for Resident Hygiene Needs
Penalty
Summary
The facility failed to provide a sufficient number of Certified Nurse Aides (CNAs) and Shower Aides to meet the needs of residents as outlined in their care plans. Specifically, a resident with metabolic encephalopathy and morbid obesity, who required substantial to maximal assistance for bathing, did not receive scheduled showers on multiple occasions. The resident reported missed showers due to short staffing, and this was corroborated by interviews with staff and review of the electronic shower log and whirlpool schedule. On several days, the shower room was not used during the day shift, and CNAs assigned to the shower room were pulled to work on the floor, leaving no one available to provide showers to residents who required two-person assistance. Staff interviews confirmed that when only one shower aide was present, residents needing two-person assistance did not receive showers because other aides were unavailable to help. Multiple CNAs stated they were unable to provide showers due to being reassigned to floor duties or lacking sufficient help. The DON and Administrator acknowledged that there were missed and undocumented scheduled showers, and observations confirmed the shower room was unused on certain days. These actions and inactions resulted in the facility's failure to ensure residents received necessary hygiene care in accordance with their care plans.
Verbal Abuse Incident Involving CNA and Nonverbal Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a nonverbal resident with diagnoses including Cerebral Infarction, Aphasia, and Dementia. The incident was reported by the resident's roommate, who had intact cognition and overheard the CNA telling the nonverbal resident to "shut up" multiple times. The roommate also reported hearing slapping noises, although he could not see the incident due to a privacy curtain. The CNA involved admitted to possibly telling the resident to "shut up" out of reflex, which is against the facility's professionalism and company policy. The Social Service Director (SSD) and the Director of Nursing (DON) were informed of the incident by the roommate, and the Administrator confirmed the identity of the CNA involved. The incident was reported to have occurred on a night when the roommate was awake and able to hear the interaction between the CNA and the resident. Interviews with the staff and the roommate confirmed the inappropriate behavior of the CNA, who expressed frustration towards the resident. The facility's Abuse Prohibition Policy clearly states that residents have the right to be free from all forms of abuse, including verbal abuse, which was violated in this case. The incident highlights a failure in ensuring the resident's right to a safe and respectful environment, free from verbal mistreatment.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to thoroughly investigate and adequately intervene when a resident reported that his pain medication was not effectively managing his pain. The resident, who had diagnoses including Pain Unspecified, Other Chronic Pain, and Chronic Venous Hypertension with Ulcer of Bilateral Lower Extremity, was receiving Acetaminophen, Gabapentin, and Oxycodone-Acetaminophen. Despite receiving Oxycodone-Acetaminophen 4-5 times a day, the resident consistently reported a pain level of 8-10. On the morning of 05/14/2024, the resident reported a pain level of 10, even after receiving a dose of pain medication approximately two hours earlier. He stated that he had informed the nurses about the ineffectiveness of his pain medications. An LPN confirmed that the resident frequently requested pain medication and that his current regimen was not effective. The LPN had informed the Nurse Practitioner (NP) at least three times about the issue. The NP acknowledged that the pain regimen was ineffective but chose to wait before making any changes. There was no documentation from the NP or nursing staff regarding the ineffectiveness of the pain regimen since the resident's admission. This lack of documentation and timely intervention led to the deficiency in providing appropriate pain management for the resident.
Failure to Follow Up on UTI Symptoms and Address Pain Management
Penalty
Summary
The facility failed to ensure that the Nurse Practitioner (NP) re-evaluated a resident's urinary tract infection (UTI) symptoms after lab results were received and did not respond to staff reporting a change in medical status for two residents. Resident #66, who had a history of Major Depressive Disorder, reported symptoms of a UTI, and a urinalysis was ordered. The results indicated the presence of bacteria, but no follow-up was conducted by the NP, and the resident self-treated with over-the-counter medication. Additionally, the resident reported feelings of depression and trouble sleeping, which were documented but not addressed by the NP despite being placed on a list for evaluation. Resident #326, who had diagnoses including chronic pain and venous hypertension, was receiving multiple pain medications but continued to report severe pain. The resident's pain regimen was reported as ineffective by the nursing staff to the NP multiple times, but no changes were made to the pain management plan. The NP acknowledged the ineffectiveness of the pain regimen but chose to wait before making any adjustments, and there was no documentation of the resident's pain management issues in the progress notes. These deficiencies had the potential to affect 73 residents in the facility. The lack of follow-up on lab results, failure to address reported symptoms, and inadequate pain management highlight significant lapses in the care provided by the NP, impacting the residents' well-being and quality of life.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure that their medication error rate was less than five percent by not administering medications at the right time for four residents during the morning medication pass. The facility's policy required medications to be administered within one hour of their prescribed time, but this was not adhered to. On the day of the observation, the LPN responsible for the medication pass was late for work, which resulted in medications being administered significantly later than scheduled. For instance, one resident's Carvedilol tablet, scheduled for 7:00 a.m., was administered at 12:18 p.m., and another resident's Xanax and Buspirone tablets, scheduled for 7:00 a.m., were administered at 11:34 a.m. The LPN confirmed that she was late for work and reported this to the Director of Nursing and the Assistant Director of Nursing. Despite this, the medications were still administered late, affecting residents with serious conditions such as Cardiomyopathy, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus. The Director of Nursing and the Assistant Director of Nursing were aware of the LPN's tardiness but did not take immediate action to ensure timely medication administration. This oversight led to a medication error rate that exceeded the acceptable threshold, potentially impacting the health and well-being of the residents involved.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that Resident #35 was treated with respect and dignity by not keeping the resident's urine collection bag covered and private. Resident #35, who was admitted with diagnoses including Urinary Tract Infection, Other Retention of Urine, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, had a physician's order and care plan intervention requiring a privacy bag or covering over the urine collection bag for dignity. However, observations on two separate occasions revealed that the urine collection bag was visible from the hallway without a privacy bag or covering. On the first observation, the resident's urine collection bag was seen hanging at the foot of the bed without a privacy cover while the room door was open. A similar observation was made the following day, with the urine collection bag again visible from the hallway. During an interview and observation with an LPN, it was confirmed that the urine collection bag did not have a privacy cover, and the LPN acknowledged that there should have been a privacy bag or covering to ensure the resident's dignity.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for one resident. The resident, who was admitted with diagnoses including Hypertension, Angina Pectoris, Cerebral Infarction, and Chronic Venous Insufficiency, had a quarterly MDS dated 02/14/2024 that incorrectly indicated the use of an anticoagulant. A review of the resident's active physician orders as of 05/15/2024 revealed no order for an anticoagulant medication. This discrepancy was confirmed by the Regional MDS coordinator during a review of the resident's MDS and current physician orders on 05/15/2024.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer two residents with newly diagnosed mental disorders to the appropriate state-designated authority for Level II PASARR evaluation and determination. Resident #37 was diagnosed with Unspecified Psychosis on 03/13/2024, but a review of their medical record revealed no Level II PASARR was conducted after this diagnosis. Despite interviews with the Social Service Director and the Administrator, no further information was provided by the facility by the time of the survey exit on 05/15/2024. Resident #57 was diagnosed with multiple mental disorders, including Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Unspecified Mood (Affective Disorder), and Anxiety Disorder. Although a Level II PASARR evaluation summary dated 07/10/2023 stated that a Level II decision was not required, there were no additional PASARR forms on or after the resident's subsequent diagnoses. Both the Administrator and the Social Service Director confirmed that the facility had not resubmitted for a Level II PASARR, despite the qualifying diagnoses.
Failure to Complete PASARR Screening Before Admission
Penalty
Summary
The facility failed to ensure that a resident with a qualifying mental disorder was not admitted before a preadmission screening by the State Office of Behavioral Health (OBH) was completed. Resident #33, who had diagnoses including Major Depressive Disorder and Psychotic Disorder with Delusions, was admitted without a PASARR Level I screening. The resident's medical records revealed a PASARR Level II dated 04/28/2020, which indicated that the resident did not meet federal criteria for serious mental illness. However, there was no documentation of a PASARR Level I in the record. Interviews with facility staff revealed that the resident had been transferred from another facility and had not had a new diagnosis since the transfer. The Social Services Director confirmed that the facility did not request a Level I PASARR screening from the previous facility until it was requested by the survey team. The Level I PASARR from the previous facility, dated 01/28/2020, indicated that the resident was suspected of having no mental illness. This oversight led to the deficiency noted in the report.
Failure to Perform Daily Wound Care and Weekly Assessments
Penalty
Summary
The facility failed to perform daily wound care as ordered by the physician and did not provide weekly wound assessments for a resident with multiple pressure ulcers. The resident, who was admitted with several serious medical conditions including Cerebral Ischemia, End Stage Renal Disease, and Atherosclerotic Heart Disease, had specific physician orders for wound care on her right big toe, right foot inner heel, left great toe, right great toe, and right heel. These orders included cleaning with normal saline, applying betadine, and covering with appropriate dressings daily and as needed. However, there was no documentation that these treatments were performed on 05/07/2024, and weekly wound assessments were missing for the week of 04/30/2024 for the right great toe and right heel wounds. This was confirmed by the Director of Nursing/Infection Preventionist during an interview and record review on 05/14/2024. The resident's Treatment Administration Record (TAR) and Weekly Wound Observation Tool revealed lapses in the prescribed wound care regimen. The Director of Nursing/Infection Preventionist acknowledged that the treatments were not completed as ordered on 05/07/2024 and that there were no documented assessments or measurements for the right great toe and right heel wounds for the week of 04/30/2024. This failure to adhere to the physician's orders and to conduct regular wound assessments represents a significant deficiency in the care provided to the resident, potentially impacting her overall health and recovery.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the appropriate treatment and services. Resident #62, who was admitted with diagnoses including Cerebral Vascular Accident and muscle wasting, initially received therapy for 3 to 4 days. However, therapy was discontinued due to a change in payer source, and the resident was not placed on a restorative nursing program as recommended by the physical and occupational therapy departments. The resident confirmed that she was not receiving any restorative care. The Director of Nursing confirmed that the necessary form to initiate the restorative nursing program was not submitted to the Medical Records department, resulting in no order being generated for the resident to receive restorative care. This oversight led to the resident not receiving the recommended restorative program, which was intended to maintain or improve her range of motion and mobility.
Failure to Update Physician's Order for Dialysis Treatment
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility, resulting in an inaccurate physician's order for a resident requiring dialysis. The resident, who was admitted with diagnoses including End Stage Renal Disease (ESRD) and dependence on renal dialysis, had a care plan indicating dialysis treatment on Monday, Wednesday, and Friday. However, the physician's order in the resident's electronic health record incorrectly stated dialysis treatment on Tuesday, Thursday, and Saturday. This discrepancy was confirmed during an interview and record review with the Director of Nursing/Infection Preventionist, who acknowledged that the physician's order should have been revised to reflect the correct dialysis treatment days.
Failure to Ensure RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours per day for 7 days per week. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1, 2024, which revealed a One Star Staffing Rating. Further examination of Time Card Reports and RN clock-in hours for October and November 2023 showed that an RN did not work a total of 8 hours on specific dates in both months. This was confirmed during a phone interview with the facility's PBJ representative, who acknowledged the absence of an RN for the required hours on the mentioned dates.
Failure to Follow Menu for Pureed Diets
Penalty
Summary
The facility failed to ensure the menu was followed for two residents who received pureed diets. Resident #27, diagnosed with Unspecified Dementia and Gastro-Esophageal Reflux Disease, had a physician's order for a regular diet with pureed texture and thin consistency. Resident #37, diagnosed with Other Sequelae of Cerebral Infarction, Type 2 Diabetes Mellitus, and Gastro-Esophageal Reflux Disease, had a physician's order for a reduced concentrated sweets diet with pureed texture and nectar thickened consistency. On the morning of 05/13/2024, the facility's menu included a pureed biscuit for breakfast, but both residents did not receive the pureed biscuit as ordered by their physicians and listed on the menu. An observation in the facility's kitchen revealed that the pureed biscuit was not served to the residents. Nursing staff returned to the kitchen, stating that Resident #37 did not have enough food on his plate and complained about the small portions. The kitchen staff made a second plate but did not include the pureed biscuit. When asked about the pureed biscuit, S14Dietary confirmed that the container of pureed biscuit was covered with saran wrap and had not been opened or removed, resulting in the residents not receiving the pureed biscuit on their breakfast tray as required by their diet orders.
Failure to Provide Mechanically Soft Chopped Meats Diet as Ordered
Penalty
Summary
The facility failed to ensure that a resident received a mechanically soft chopped meats diet as ordered. The resident, who had diagnoses including sequelae cerebral infarction, potential for malnutrition, and other speech and language deficits following cerebral infarction, was observed feeding himself breakfast that included a whole slice of bacon and a biscuit, contrary to his prescribed diet of mechanical soft texture with chopped meats. The meal ticket on the resident's tray indicated a regular diet with mechanical soft and chopped meat, specifying bacon crumbles. An LPN confirmed that the resident's breakfast did not comply with the ordered diet, acknowledging that the resident should have received bacon crumbles instead of a whole slice of bacon.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions in the kitchen. Specifically, cooked food items were stored on the same shelf as raw food items in the walk-in cooler, which is against the facility's policy. During an observation, two rolls of uncooked ground beef, uncooked sausage, and raw chicken were found defrosting on the bottom shelf next to a large pan of cooked pinto beans. Additionally, two containers of cottage cheese with expired dates were found in the cooler. The Dietary Manager confirmed that the cooked beans should not have been stored with raw meat and that the expired cottage cheese should have been removed.
Failure to Maintain Proper Laundry Separation
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that clean laundry and linen were stored separately from contaminated items in the laundry department. During an observation, it was noted that clean mop heads, mop pads, and towels were stored on the contaminated side of the laundry department. The Housekeeping Supervisor confirmed that these items were clean but were kept on the contaminated side until distributed to the housekeeping staff. Additionally, clean blankets and comforters were found stored on the contaminated side in a covered cart and a gray bin next to soiled laundry barrels. The Director of Nursing/Infection Preventionist confirmed that clean laundry should not be stored on the contaminated side of the laundry department. The facility's environmental services policy, last revised in October 2023, states that clean linen must always be kept separate from contaminated linen using separate rooms, closets, or other designated spaces with closing doors. However, the observations and interviews conducted revealed that this policy was not being followed, leading to the potential risk of accidental contamination of clean laundry and linen. The failure to adhere to the policy was confirmed by both the laundry staff and the Housekeeping Supervisor, indicating a systemic issue in the handling and storage of clean and contaminated laundry within the facility.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents. For Resident #37, who was admitted with multiple diagnoses including Cerebral Infarction and Hemiplegia, the facility did not follow the physician's orders for wound care. The resident had a fall resulting in a skin tear above his right eyebrow on 04/21/2024, but the treatment ordered by the physician on 04/25/2024 was not initiated until that date, despite the order specifying that treatment should have started immediately after the fall. For Resident #66, who was admitted with Major Depressive Disorder, the facility failed to request a urine culture and sensitivity (C/S) test as ordered by the nurse practitioner on 03/26/2024. The lab request form sent to the outpatient lab only indicated a urinalysis with reflex to culture, but did not specifically request a urine culture. Consequently, the urine culture was not performed, as confirmed by the phlebotomist and medical technician from the lab.
Failure to Prevent Resident Fall
Penalty
Summary
The facility failed to ensure that Resident #37 was free from accidents, leading to a fall and injury. Resident #37, who had a history of falls and moderate cognitive impairment, was instructed to be placed in bed after lunch by an LPN. However, the CNA did not follow this instruction and left the resident unsupervised in his wheelchair in his room. As a result, Resident #37 attempted to slide out of his wheelchair and fell, sustaining a small laceration to his forehead above the brow line. The incident was investigated by the facility, and it was determined that the fall could have been prevented if the CNA had followed the LPN's instructions to place the resident in bed. The resident's care plan indicated a risk for falls, and previous falls had been documented. Despite these precautions, the failure to provide adequate supervision and follow the care plan led to the resident's fall and injury.
Failure to Ensure Necessary Respiratory Care and Services
Penalty
Summary
The facility failed to ensure a resident received necessary respiratory care and services. Specifically, the facility did not assess the resident for respiratory therapy and did not obtain a physician's order for the therapy. The resident, who was readmitted with diagnoses including Dysphagia Following Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Seizures, and Tracheostomy Status, was observed receiving oxygen at 5 Liters via a tracheostomy without a corresponding physician's order or respiratory assessment documented in the medical record. This was confirmed through multiple observations and interviews with staff, including the Director of Nursing/Infection Preventionist. The facility's policy on oxygen administration requires a physician's order and thorough documentation, including assessment data before, during, and after the procedure. However, the resident's electronic medical record lacked an assessment for respiratory therapy and an order for oxygen administration via tracheostomy tube. Despite the resident being observed with oxygen in place at 5 Liters via tracheostomy on multiple occasions, there was no documentation to support this treatment. The Director of Nursing confirmed the absence of the necessary respiratory assessment and physician's order, indicating a failure to adhere to the facility's policy and procedure for oxygen administration.
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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