New Iberia Manor South
Inspection history, citations, penalties and survey trends for this long-term care facility in New Iberia, Louisiana.
- Location
- 600 Bayard St, New Iberia, Louisiana 70560
- CMS Provider Number
- 195326
- Inspections on file
- 28
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at New Iberia Manor South during CMS and state inspections, most recent first.
A resident with bipolar disorder, anxiety, dementia, and depression was receiving buspirone, olanzapine, and venlafaxine with Q-shift behavior monitoring ordered and care-planned, including documentation of specific behavior codes and medication effectiveness. Despite ongoing, frequent yelling and hollering episodes reported by night-shift and day-shift staff as longstanding and occurring both day and night, these behaviors were rarely recorded on the MAR and were instead noted mainly on informal nurse report sheets that were not part of the clinical record. The DON, administrator, and corporate nurse confirmed that required behavior monitoring was not documented in the official record, and psychiatric providers, who relied on MAR-based 24-hour reports, documented the resident’s sleep as fair without full awareness of the resident’s recurrent outbursts.
Nursing staff failed to follow professional standards by leaving medications at the bedside for three residents, including one with severe cognitive impairment and two with intact cognition, without documented assessments authorizing self-administration. LPNs confirmed the medications were not supposed to be left in resident rooms, and facility staff acknowledged the absence of required documentation.
Two residents identified as fall risks, both with histories of falls and recent joint replacement surgeries, were observed with their beds not properly positioned or locked as required by their care plans. An LPN confirmed that one bed was not locked and another was left in the highest position after staff left the room, contrary to fall prevention protocols.
A resident with end stage renal disease who required regular dialysis did not have consistent and complete communication between the facility and the dialysis provider. Multiple dialysis communication forms were missing required pre-dialysis information, such as meal provision, medication administration, and condition alerts, and several forms were unsigned or missing altogether. Facility staff confirmed these documentation lapses, which were not in line with established protocols.
Three residents reported or were observed receiving food that was unpalatable, served cold, poorly prepared, or in portions deemed too small. One resident with severe malnutrition and end stage renal disease received a burnt, hard hamburger patty that was difficult to cut, despite her dietary needs and swallowing difficulties. Staff, including a CNA, LPN, and RD, confirmed the poor quality of the meal.
Surveyors found that opened food items in the kitchen's walk-in cooler were not labeled with opening or use-by dates, the deep fryer had not been cleaned after use and contained significant debris, and a cook was observed preparing food with exposed facial hair, all in violation of facility policies for food storage, sanitation, and staff hygiene.
Residents repeatedly reported issues with food quality, including cold, uncooked meals and small portions, during council meetings over several months. Despite ongoing complaints, the concerns were not addressed, and residents stated the situation had worsened. The Activity Director confirmed the persistent nature of these unresolved grievances.
A resident reported the theft of a wallet containing cash and personal identification shortly after admission and stated that the incident was reported to administrative staff. However, there was no evidence that the grievance was investigated or that follow-up occurred, and staff could not provide documentation of any actions taken.
A resident with a midline catheter and multiple infections did not have their catheter dressing changed according to physician orders. The dressing remained unchanged past the scheduled date, as confirmed by the ADON/IP, resulting in a failure to follow prescribed infection control protocols.
A resident with heart failure and other chronic conditions experienced shortness of breath and a low O2 saturation. An LPN applied oxygen but did not document the resident's condition or notify the provider before the resident was transported to a medical appointment. Staff interviews confirmed the lack of documentation and provider notification prior to the resident's hospital transfer.
A resident was found with a suction canister containing drainage left on their dresser for several days. The resident reported the canister had not been changed, and an LPN confirmed it should have been discarded but was unsure of its duration in the room. The DON stated there was no policy for suction equipment, though the canister should have been replaced.
A resident with severe cognitive and physical impairments was found secured in a wheelchair seat belt she could not remove, used to prevent falls. Staff confirmed the resident's inability to remove the belt, and records showed no physician order, care plan intervention, or interdisciplinary assessment for its use, contrary to facility policy.
A resident with End Stage Renal Disease and Dependence on Renal Dialysis was transferred to the hospital and later returned, but the transfer was not documented in the Emergency Transfer Log or reported to the State LTC Ombudsman as required. Both the Social Service Director and Administrator confirmed the omission during interviews and record reviews.
A resident with end stage renal disease and dependence on dialysis did not have required dialysis communication forms completed and documented for two dialysis sessions. Staff confirmed that these forms, which are used to assess the resident before each dialysis transfer and communicate with the dialysis agency, were missing from the medical record as required by facility policy.
A CNA working on a PRN basis did not receive a required annual performance evaluation, as confirmed by both the CNA and a review of her personnel file. The DON stated that PRN staff were not evaluated due to not receiving raises, and the administrator was unaware that such evaluations were required for PRN staff.
A resident with multiple complex medical conditions did not receive prescribed Hydrocodone-Acetaminophen for pain due to delays in prescription processing and pharmacy delivery. Despite repeated complaints of pain and inquiries from the resident and family, staff did not administer the ordered medication or implement effective alternative pain management, and communication breakdowns prevented timely resolution.
A resident with multiple complex medical conditions did not receive ordered Hydrocodone-Acetaminophen for pain because the prescription was not sent to the pharmacy in a timely manner. Nursing staff documented the absence of the medication, offered Tylenol instead, and explained the situation to the resident and family, but the pain medication was not available when needed.
The facility failed to implement comprehensive care plans for two residents, resulting in uncompleted monitoring and wound care. A resident with multiple diagnoses did not receive daily monitoring and treatment for a hematoma and laceration as ordered. Another resident with a fracture and dementia did not receive scheduled wound care for surgical incisions. The Treatment Nurse confirmed these deficiencies, indicating a lapse in following care plans.
The facility failed to provide and document adequate care for pressure ulcers in five residents, as evidenced by missing treatment records and unverified administration of physician-ordered wound care. This included neglecting to check the functionality of a low air loss mattress for a resident, potentially compromising their health. Interviews with staff confirmed the lack of documentation and inability to verify treatment administration.
The facility did not post daily nursing staffing information in a visible area for residents and visitors. An observation found no evidence of the required posting, and a blank board was discovered in Hall B. The Corporate Nurse confirmed the board should display the census, staff numbers, and hours worked, and acknowledged it was not visible as required.
The facility did not adhere to the scheduled menus, affecting 80 residents. During lunch, the served menu differed from the planned one, lacking pureed options for residents needing them. S5Cook admitted to not checking the menu, and S8RD confirmed the kitchen staff did not use the substitution list, nor did they contact her for guidance.
The facility failed to maintain sanitary conditions in the kitchen, affecting 80 residents. Observations showed unclean kitchen equipment, improperly labeled and expired foods, and lack of temperature monitoring. An activity coordinator was also seen without a hair covering, violating facility policy.
The facility did not post the most recent survey results in an accessible location for residents, family members, and legal representatives. A binder near the main entrance contained survey results from 2018 to 2021, but lacked those from 2022 to 2024. The DON and Administrator confirmed the oversight.
The facility failed to implement comprehensive care plans for two residents. A resident with Type 2 Diabetes Mellitus did not receive prescribed insulin or a blood sugar recheck after an elevated reading. Another resident with Functional Quadriplegia lacked enabler bars on their bed, essential for mobility and care, despite being part of their care plan. These deficiencies were confirmed by the DON and an LPN.
The facility failed to follow recipes for pureed diets, affecting residents with conditions like dysphagia and hemiplegia. A cook prepared pureed potatoes without measuring ingredients or using a recipe, despite available resources. Interviews confirmed that recipes were accessible and should have been used, highlighting a lack of training or oversight in the kitchen.
The facility failed to maintain effective infection control practices, as a CNA did not remove PPE before exiting a COVID-19 positive room and did not perform hand hygiene. Additionally, a housekeeper handled a dirty mop pad without gloves and did not sanitize her hands afterward, both actions against the facility's infection control procedures.
A resident with Chronic Kidney Disease and Heart Failure was observed with an uncovered urinary catheter drainage bag, compromising their dignity. The RN Supervisor confirmed the absence of a privacy cover and was unsure of the facility's policy on covering catheter bags. Another staff member confirmed that a privacy cover should have been used.
A resident in an LTC facility was found to have a stained pillowcase, which was not changed despite the bed being made. The resident had medical conditions requiring assistance with personal care. An LPN confirmed that linens should be clean and changed, highlighting a failure to maintain a homelike environment.
The facility failed to accurately complete PASARR Level 1 screenings for two residents. One resident's screening omitted a diagnosis of Bipolar Disorder, while another's did not include Schizophrenia. The inaccuracies were confirmed by facility staff, indicating a lapse in reviewing and ensuring accurate preadmission screenings for residents with serious mental health diagnoses.
A resident with intact cognition was left with medication at their bedside by an LPN, contrary to the facility's policy requiring a physician's order and evaluation for self-administration. The RN Supervisor was unaware of this policy, and the DON confirmed the resident should not have self-administered the medication without proper authorization.
The facility failed to ensure proper reconciliation of controlled drugs during shift changes, as required by their policy. Missing signatures for narcotic reconciliations were found for several shifts, indicating that the process was not followed. This deficiency had the potential to affect the 80 residents in the facility.
The facility failed to properly store drugs and biologicals, with a multi-use vial of flu vaccine found open and unlabeled, and loose pills discovered in a medication cart. These deficiencies were confirmed by staff and had the potential to affect 80 residents.
A resident sustained injuries after unlocking their wheelchair on a van's ramp, causing it to roll backward and flip over. The van driver failed to follow proper procedure by not standing behind the resident to assist them off the ramp. The facility lacked a policy for unloading residents from the van's wheelchair ramp, and the transportation supervisor confirmed the driver should have ensured the resident's safe removal.
A resident with intact cognition experienced a breach of dignity when an LPN threatened to leave the room if the resident continued to scream during a painful wound care session. The facility's DON and Administrator acknowledged the comment was unprofessional and contrary to the facility's policy on respectful communication.
A resident with multiple diagnoses, including muscle weakness and repeated falls, was dropped by staff during a transfer, resulting in a skin tear. The facility failed to notify the physician and family immediately, with notifications occurring two days later, contrary to the facility's policy.
The facility failed to provide ordered nutritional supplements to two residents, one of whom did not receive Ensure Plus due to a lack of stock, and another who was given milk-based Ensure instead of Ensure Clear, which he could not consume.
The facility failed to document and offer a resident's nutritional supplement as ordered. An LPN signed the MAR without verifying the availability of the supplement, and the Administrator and Corporate Nurse confirmed this should not have occurred. This deficiency could potentially affect all 82 residents.
Failure to Document Behavioral Symptoms for Resident on Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to document and monitor the behaviors of a resident with multiple mental health diagnoses, as required by the care plan and physician orders. The resident was admitted with bipolar disorder, anxiety disorder, and dementia, and had physician orders for buspirone for anxiety, olanzapine for dementia, and venlafaxine for depression. The care plan and orders required behavior monitoring every shift for anti-psychotic, anti-anxiety, and anti-depression medications, using specific behavior codes and documentation of side effects and effectiveness. Review of the MARs from October 2025 to January 2026 showed only sporadic entries of behavior code “6. Noisy” on a few dates, despite standing orders for Q-shift behavior monitoring. Interviews with nursing staff revealed that the resident had frequent nighttime and daytime yelling and hollering episodes that were known and ongoing since admission. Night shift LPNs and CNAs reported that the resident regularly yelled out at night because he did not like to be alone, sometimes after bad dreams, and that this behavior occurred often. Staff described going into the room, asking the resident to stop yelling because others were sleeping, and attempting to meet his requests, but the yelling would resume. One LPN stated she had written a note in July 2025 about the behavior but otherwise the behaviors were typically recorded only on nurses’ report sheets used for shift-to-shift communication, which were not part of the clinical record. The DON, administrator, and corporate nurse confirmed that the nurses were not documenting the resident’s behaviors on the MARs as required and that the nurses’ report sheets were not official documentation. The DON stated she was unaware of the resident’s nighttime outbursts prior to a July 2025 note and that their process for new behaviors was to contact psychiatric services. Review of monthly psychiatric service notes showed the psychiatric provider documented the resident’s sleep as “fair” and relied on 24-hour nursing reports generated from MARs and progress notes. Because the resident’s frequent yelling and outbursts were not documented in the official record, these behaviors were not reflected in the reports used by the psychiatric provider, and the resident did not receive services based on accurate behavior monitoring as required by his care plan and orders.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
Nursing staff failed to ensure that medications were administered according to professional standards, resulting in medications being left at the bedside for three residents. One resident with a history of falling and intact cognition was found with a Zyrtec tablet on her bed, which she stated was given by the nurse, and she had not signed any form to self-administer her medications. Another resident with severe cognitive impairment was observed with a Vitamin D tablet left on her over bed table, and there was no documentation that she was permitted to self-administer medications. The LPN confirmed the pill matched the resident's prescribed medication and acknowledged it should not have been left in the room. A third resident, who had intact cognition and diagnoses including bipolar disorder and dysphagia, was observed keeping his Albuterol inhaler on his person and on his window seal. Nursing notes indicated that staff assisted the resident in accessing the inhaler, but there was no documented assessment authorizing the resident to self-administer this medication. Facility staff confirmed the lack of documentation for self-administration for all three residents involved.
Failure to Maintain Safe Bed Positioning for Residents at Fall Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for residents at risk for falls, as evidenced by observations and interviews involving two residents. One resident, with a history of falling, a left pubis fracture, and recent joint replacement surgery, was observed in bed with the bed not locked, despite clear indicators and care plan interventions requiring the bed to be locked and in a low position. A therapy screen had previously identified this resident as a fall risk with safety concerns, and a yellow falling star was posted outside the room to indicate this risk. The LPN confirmed during the observation that the bed was not locked as required. Another resident, also with a history of falls and recent joint replacement, was found in bed with the bed left in the highest position, contrary to the care plan intervention to keep the bed in the lowest position. The resident, identified as a fall risk by a yellow falling star, reported that staff had been present to assist with therapy but left the bed elevated and unattended. The LPN confirmed that the bed should not have been left in the highest position. These failures demonstrate that the facility did not consistently implement fall prevention interventions as outlined in their policy and residents' care plans.
Failure to Ensure Proper Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice. The resident, admitted with end stage renal disease and dependent on renal dialysis, had physician orders to receive dialysis three times a week at an external provider. Review of the facility's dialysis communication sheets revealed multiple instances where required pre-dialysis information was missing, including documentation of meal provision, medication administration, and condition alerts. Several forms were also not signed by facility staff, and on some dates, the forms were missing entirely. Interviews with the Director of Nursing and an LPN confirmed the missing information and incomplete forms. The LPN explained that the forms should include vital signs, meal status, and the resident's condition, and that the forms serve as the primary means of communication with the dialysis provider. The Director of Nursing acknowledged that the facility's protocol required these forms to be completed and signed by nursing staff, which was not consistently done for the resident in question.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature, as evidenced by observations, interviews, and record reviews involving three residents. One resident reported dissatisfaction with the preparation of food, stating that meals were served cold and portion sizes were inadequate. Another resident expressed that the food was unappetizing, lacked seasoning, the meat was tough, and portions were too small. A Certified Nursing Assistant confirmed that this resident often did not eat meals due to dislike of the food provided. A third resident, who had diagnoses including severe protein-calorie malnutrition and end stage renal disease, was observed receiving a meal that included a burnt and hard hamburger patty, which she struggled to cut. Both a Licensed Practical Nurse and a Certified Nursing Assistant attempted to cut the hamburger and stated they would not serve it to anyone due to its poor quality. The Registered Dietician also confirmed the meat was hard and dry. The resident's medical records indicated she had difficulty or pain when swallowing, and her diet required regular texture and thin consistency, further highlighting the inappropriateness of the meal served.
Failure to Maintain Food Storage, Sanitation, and Staff Hygiene Standards
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage and kitchen sanitation practices. During a kitchen tour, several opened food items in the walk-in cooler, including containers of garlic, mayonnaise, cherries, mustard, margarine, and various bags of produce and prepared foods, were found without labels indicating the date and time they were opened or their use-by dates. These findings were confirmed by the dietary aide present, who acknowledged that the items should have been labeled according to facility policy. Additionally, the deep fryer’s cooking oil collection area was observed to have a thick layer of debris and large pieces of fried food material, with staff confirming that the fryer had not been cleaned after its last use the previous week. Further observation revealed a cook in the kitchen with exposed facial hair while preparing to puree a lunch meal, in violation of the facility’s dress code policy requiring facial hair to be properly covered. The staff member confirmed that his facial hair should have been covered. These deficiencies were found despite the facility’s written policies mandating proper food labeling, storage, and employee hygiene practices.
Failure to Address Resident Group Food Complaints
Penalty
Summary
The facility failed to address and resolve grievances voiced by the resident group regarding the quality of food served. Review of monthly resident council meeting minutes from January to July 2025 documented repeated complaints that meals were cold, improperly cooked, and served in small portions. During a resident council meeting in July, multiple residents reported that the food issues had not been addressed and had worsened, with meals being served uncooked, cold, and with tough meat. The Activity Director, present at the meeting per residents' request, confirmed that these complaints had been ongoing since January and remained unresolved at the time of the survey.
Failure to Investigate and Address Resident Grievance Regarding Theft
Penalty
Summary
The facility failed to provide evidence that a resident's grievance regarding the theft of his wallet was reported and investigated. The resident stated that upon admission to the facility, his wallet containing $350, a driver's license, and a social security card was stolen, and he reported this to administrative staff. Despite this report, the resident indicated that no one followed up with him about the incident or conducted an investigation. Review of the resident's nurse notes confirmed the report of the theft, and a registered nurse recalled being informed of the incident but could not remember if it was reported further. The administrator was aware of the grievance but was unable to provide documentation showing that the grievance was addressed or investigated by the time of the survey exit conference.
Failure to Change Midline Catheter Dressing as Ordered
Penalty
Summary
The facility failed to implement a physician's order for a resident who had a midline catheter, resulting in the dressing not being changed as prescribed. The resident, who was admitted with diagnoses including urinary tract infection, ESBL resistance, and enterococcus, had a physician's order dated 07/11/2025 to change the midline dressing and apply an antimicrobial patch every Friday during the day shift. Observation on 07/21/2025 revealed that the dressing on the resident's midline catheter was still dated 07/11/2025, indicating it had not been changed as ordered. This was confirmed by the Assistant Director of Nursing/Infection Preventionist, who acknowledged that the dressing should have been changed on 07/18/2025 but was not.
Failure to Notify Provider and Document Resident's Respiratory Decline
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including heart failure, COPD, chronic kidney disease, and cirrhosis, received care and treatment in accordance with professional standards of practice. On the day in question, the resident exhibited a low oxygen saturation of 88% and was experiencing shortness of breath. The LPN on duty applied 2 liters of oxygen but did not document the resident's O2 saturation or conduct a full assessment of the resident's condition prior to the resident being transported to a scheduled doctor's appointment. Furthermore, the LPN did not notify the resident's physician or nurse practitioner about the low oxygen saturation and respiratory distress. Interviews with facility staff, including the transportation driver, MDS coordinator, and DON, confirmed that there was no documentation of the resident's clinical condition prior to transport and that the physician or nurse practitioner was not informed. The lack of documentation and failure to communicate the resident's deteriorating condition to the appropriate medical provider resulted in the resident being sent to the hospital, where he was found to be in fluid overload and continued to experience respiratory distress.
Failure to Maintain Sanitary and Homelike Environment Due to Unchanged Suction Canister
Penalty
Summary
The facility failed to provide a sanitary and homelike environment for one resident when a suction canister containing drainage was observed on the resident's dresser. The resident reported that the canister had been present for several days. When an LPN entered the room, she acknowledged the canister should have been discarded but was unsure how long it had been there. The Director of Nursing confirmed that the facility did not have a policy or procedure regarding suction equipment, but agreed the canister should have been changed out. These observations and interviews indicate that the facility did not maintain a clean and comfortable environment for the resident, as required.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, severe intellectual disabilities, and aphasia was found using a wheelchair seat belt that she was unable to remove. Observations confirmed that the seat belt was secured across her lap, and both a CNA and an LPN verified that the resident could not remove it herself. The seat belt had been in use since the resident's admission, and staff stated it was used to prevent falls. The resident's cognitive assessment indicated severely impaired decision-making abilities, and she was unable to complete a mental status interview. Record review revealed there was no physician order for the seat belt, and the resident's care plan did not address its use. The MDS assessment did not code the resident as using restraints. The facility's policy requires an interdisciplinary team assessment, consideration of less restrictive alternatives, and proper documentation before using restraints, none of which were completed in this case. The DON confirmed that the seat belt was used without assessment, care planning, or a physician order.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis, was initially admitted on 08/29/2024 and re-admitted on 04/15/2025. Nurse's notes documented that the resident was transferred to the hospital on 03/30/2025 and returned to the facility on 04/15/2025. However, a review of the Emergency Transfer Log for March and April 2025 showed that this transfer was not recorded. During interviews and record reviews with the Social Service Director and the Administrator, both confirmed that the resident's transfer to the hospital was not included in the notification list sent to the State Long Term Care Ombudsman, as required. The Social Service Director acknowledged responsibility for completing and sending the Emergency Transfer Log and confirmed the omission. The Administrator also confirmed that the Ombudsman was not notified of the facility-initiated transfer, which should have occurred.
Failure to Document and Communicate Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper assessment and ongoing communication with the contracted dialysis agency for a resident requiring dialysis services. According to the facility's agreement with the dialysis agency, healthcare staff are required to assess each patient's physical condition and determine stability prior to every transfer for outpatient hemodialysis, with this assessment and communication documented on a dialysis communication form. For one resident with end stage renal disease and dependence on renal dialysis, there was no documented evidence of completed dialysis communication forms for two specific dates following the resident's re-admission. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that the dialysis communication forms were not present in the facility's records for the identified dates. Staff acknowledged that these forms are the established method for communication between the facility and the dialysis agency, and that they should have been completed and included in the resident's electronic health record for each dialysis session.
Failure to Complete Annual Performance Review for PRN CNA
Penalty
Summary
The facility failed to complete a yearly performance review for one Certified Nurse Assistant (CNA) out of four personnel records reviewed. The CNA, who was hired on 06/06/2023, reported during an interview that she had not received a performance evaluation since starting employment. Review of her personnel file confirmed the absence of a performance evaluation. The Director of Nursing stated that the CNA, who works on a PRN (as needed) basis, had not received an evaluation because she did not receive raises. The Administrator indicated unawareness that performance evaluations were required for PRN staff.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the lack of timely administration of prescribed pain medication. The resident, who had multiple complex medical diagnoses including spastic cerebral palsy, paraplegia, recent coronary artery bypass graft, and chronic heart failure, was admitted with an order for Hydrocodone-Acetaminophen to be given every six hours as needed for pain. Despite this order, the medication was not available or administered for at least two days following admission, during which time the resident repeatedly complained of pain, including a documented pain score of 5 out of 10. Nursing staff documented that the resident and his mother inquired multiple times about the pain medication, but it was not available due to issues with the prescription and pharmacy delivery. Staff offered Tylenol as an alternative, which the resident refused, stating a need for stronger pain relief. There was confusion among staff regarding the status of the prescription, and communication with the nurse practitioner and pharmacy was delayed or ineffective. Documentation shows that staff did not escalate the issue to administrative personnel in a timely manner, and there was no evidence that alternative pain management strategies were implemented while awaiting the ordered medication. Interviews with staff confirmed that the prescription for Hydrocodone-Acetaminophen was not properly processed or delivered, and that there was a lack of clear communication and follow-up to ensure the resident's pain was managed according to the care plan and physician's orders. The facility's own pain management policy required assessment and intervention for pain, but these steps were not effectively carried out for this resident, resulting in unrelieved pain over a documented period.
Failure to Provide Ordered Pain Medication Due to Prescription Processing Delay
Penalty
Summary
The facility failed to ensure that pain medication was available for a resident who had a physician's order for Hydrocodone-Acetaminophen 5-325 mg to be given every 6 hours as needed for pain. The resident, who had multiple complex medical diagnoses including atrial septal defect, post-myocardial infarction complications, CABG, spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure, and dysarthria, was admitted with this order in place. Nursing progress notes documented that the resident and his mother inquired about the pain medication, but it was not available in the medication bins delivered by the pharmacy. Staff explained that a hard script from the nurse practitioner was needed for the pharmacy to fill the medication, and Tylenol was offered instead when the resident complained of chest pain. Further review revealed that the pharmacy did not receive the prescription for the ordered pain medication until two days after the initial order, and the medication was not available for administration when the resident reported pain. The Assistant Director of Nursing confirmed that there was no documentation showing the prescription was sent to the pharmacy on the day of admission. As a result, the resident did not receive the ordered pain medication when needed, and the facility did not meet the pharmaceutical needs of the resident as required.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, leading to deficiencies in monitoring and wound care. Resident #1, who was admitted with multiple diagnoses including cerebral infarction and end-stage renal disease, had specific physician orders to monitor a hematoma and perform wound care for a laceration daily. However, the Treatment Administration Record (TAR) showed no documentation of these actions being completed on several dates in October and November 2024. Similarly, Resident #3, admitted with conditions such as a displaced intertrochanteric fracture and dementia, had orders for wound care on surgical incisions to be performed every other day and as needed. The TAR indicated that these treatments were not documented as completed on specific dates in December 2024. The Treatment Nurse confirmed that the required monitoring and treatments for both residents were not carried out as ordered, highlighting a failure in the facility's adherence to the care plans.
Failure to Document and Administer Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent and treat pressure ulcers for five residents. The deficiencies were identified through a review of treatment administration records (TARs) and physician orders, which revealed multiple instances where wound care was not documented as administered according to the physician's orders. This lack of documentation suggests that the treatments may not have been provided as required, potentially compromising the residents' health and safety. Resident #1 had several pressure injuries, including those on the left ankle, left foot, right heel, and left ischium. The facility failed to document the administration of prescribed treatments on multiple occasions across October, November, and December 2024. Additionally, the facility did not consistently check the proper functioning of a low air loss mattress, which was part of the resident's care plan to manage pressure ulcers. Similar issues were found with Resident #2, who had pressure injuries on the left buttocks, right lower lateral leg, and right heel, with missing documentation of treatment administration in December 2024. Resident #3 also experienced a lack of documented wound care for pressure injuries on the right buttocks, sacrum, and left ankle. The facility's failure to administer and document wound care treatments extended to Residents #4 and #5, with missing documentation spanning several months. Interviews with the treatment nurse and director of nursing confirmed the absence of documentation and the inability to provide evidence that the treatments were administered as ordered.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post daily nursing staffing information in a prominent place accessible to residents and visitors. On July 22, 2024, at 3:30 p.m., an observation was conducted throughout the facility, revealing no evidence of the required posting. An interview with the Corporate Nurse confirmed that the daily census should be posted and that staff had been posting it on Hall B. However, upon inspection, a white dry-eraser board located under the TV on Hall B was found to be blank, lacking the necessary information such as the census, the number of staff, and the total number and actual hours worked. The Corporate Nurse acknowledged that the board was not visible to all residents and visitors, as it should have been.
Failure to Follow Scheduled Menus
Penalty
Summary
The facility failed to ensure that the menus were followed for residents, which had the potential to affect a census of 80 residents. During an observation of the meal service at lunch, it was noted that the residents were served a different menu than what was scheduled. The served menu included Rice Pilaf, Glazed Ham, Baked beans, Pureed Ham, Chopped Ham, Mashed Potatoes, Pork Chops with Gravy, Pureed Beans, Dinner Rolls, and Lemon Cake, while the scheduled menu was supposed to include Glazed Ham, Baked sweet potato, Braised cabbage, Cornbread, and Frosted cake. Additionally, there was no pureed dinner rolls or cornbread available for residents requiring pureed meals. An interview with S5Cook confirmed the discrepancy between the served and scheduled menu, and she admitted to not preparing and serving pureed bread for residents on pureed diets. S5Cook acknowledged that she should have checked the menu. Furthermore, S8RD, the Registered Dietician, stated that the kitchen staff should not change the menu on their own and confirmed that the substitution list was not used. S8RD also mentioned that she was available by phone for any menu concerns but did not receive any calls from the facility.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect the 80 residents consuming food from it. Observations revealed that the kitchen fryer, fryer baskets, and the floor beside the fryer were not cleaned, with oil and food residue present. The baking oven doors were also dirty with caked-on grease stains. The cook confirmed that these areas had not been cleaned as required. Additionally, refrigerated foods were not labeled or dated properly, and expired foods were not discarded, contrary to the facility's policy. Items such as pitchers of juice, mixed beans, and tomato paste lacked labels indicating content and preparation dates, while other items like mousse, fruit, butterscotch, cheese slices, and parmesan cheese were found to be expired. The facility also failed to monitor and document refrigerator, freezer, and dishwasher temperatures and chemicals, as required by their policies. No temperatures were recorded for a specific date, and the cook confirmed this oversight. Furthermore, an activity coordinator was observed in the kitchen without a hair covering, which is against the facility's policy for maintaining sanitary conditions. The cook acknowledged that all staff were aware of the requirement to wear hair restraints in the kitchen.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were posted in a location easily accessible to residents, family members, and legal representatives. During an observation on July 21, 2024, a clear plastic file holder was found mounted to the wall outside the human resources office near the main entrance. Inside the holder was a binder containing licensing surveys from 2018 to 2021, but it lacked the survey results and plans of correction for the years 2022 through 2024. In an interview conducted on July 23, 2024, the Director of Nursing and the Administrator confirmed that the survey results for the last three years were not included in the binder and acknowledged that they should have been posted in an accessible location.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered plan of care for two residents, leading to deficiencies in their care. For Resident #33, who was diagnosed with Type 2 Diabetes Mellitus, the facility did not follow the physician's orders for managing elevated blood sugar levels. On June 27, 2024, the resident's blood glucose level was recorded at 404 mg/dL, but the prescribed 12 units of Humulin R were not administered, nor was a recheck of the blood sugar conducted as required. The Director of Nursing confirmed the oversight, noting the absence of documentation for the administration of insulin or a recheck, and no record of the resident refusing treatment. For Resident #1, who had a diagnosis of Functional Quadriplegia, the facility failed to ensure the presence of enabler bars on the resident's bed, which were necessary to assist with bed mobility and turning during care. Observations on July 21 and July 22, 2024, confirmed the absence of enabler bars, despite their inclusion in the resident's care plan. An LPN verified the lack of enabler bars and acknowledged their importance for the resident's care, highlighting a failure to adhere to the care plan designed to meet the resident's needs.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that recipes were followed for residents on pureed diets, specifically in the preparation of mashed potatoes. This deficiency was identified through observations, record reviews, and interviews. Four residents, all of whom had physician orders for pureed diets due to conditions such as dysphagia and hemiplegia following cerebral infarctions, were affected. During an observation, a cook was seen preparing pureed potatoes without measuring the ingredients or following a recipe, despite recipes being available on the packaging and in a recipe book provided by the facility. The cook admitted to never having measured ingredients or used a recipe, indicating a lack of training or oversight in the kitchen. Interviews with the corporate nurse and registered dietician confirmed that recipes were available and should have been used. The dietician noted that a recipe book had been printed to accompany the menus, and she was available for consultation, yet no contact was made to address any concerns with the recipes. This oversight in food preparation compromised the dietary needs of residents requiring pureed diets.
Infection Control Deficiencies in PPE and Housekeeping Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving staff. In the first incident, a Certified Nursing Assistant (CNA) was observed exiting a COVID-19 positive resident's room without removing her personal protective equipment (PPE) inside the room. The CNA removed her isolation gown while walking down the hallway and discarded it in a room without performing hand hygiene afterward. This action was confirmed by a Registered Nurse Supervisor, who acknowledged that the CNA should have removed the PPE before leaving the isolation room and sanitized her hands after discarding the gown. In the second incident, a housekeeper was observed handling a dirty mop pad with her bare hands and failing to perform hand hygiene afterward. The housekeeper admitted to not using gloves and not sanitizing her hands after handling the soiled mop pad. This was confirmed by the Housekeeping Supervisor and the Infection Preventionist, who both stated that the housekeeper's actions were against the facility's infection control procedures.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not providing a covering for a urinary catheter bag. Resident #428, who was admitted with diagnoses including Chronic Kidney Disease and Heart Failure, was observed on July 21, 2024, with an uncovered urinary catheter drainage bag. During an interview and observation with the Registered Nurse Supervisor, it was confirmed that the catheter bag lacked a privacy cover, and the supervisor was unsure of the facility's policy regarding this matter. Further confirmation was obtained from another staff member, who acknowledged that a privacy cover should have been placed on the resident's urinary drainage bag.
Failure to Provide Clean Bed Linens
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, as evidenced by the presence of stained bed linens. The deficiency was identified during observations and interviews conducted by surveyors. A resident, who was admitted with diagnoses including cerebral infarction, muscle weakness, unspecified lack of coordination, and a need for assistance with personal care, was found to have a pillowcase with a large red and brown stain. This observation was made on two consecutive days, and the stain remained on the pillowcase despite the bed being made. An LPN confirmed the presence of the stain and acknowledged that bed linens should be clean and changed when the bed is made.
Inaccurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the PASARR Level 1 screening was completed accurately for two residents. Resident #43 was admitted with diagnoses including Bipolar Disorder, End Stage Renal Disease, and Essential Hypertension. However, her Level 1 PASARR did not indicate any serious mental health diagnoses, specifically omitting her Bipolar Disorder. The Acting Administrator confirmed the omission upon review, and the Director of Nursing acknowledged that the nursing home staff failed to review the Level 1 PASARR for accuracy, which was initially submitted by the hospital. Resident #1 was admitted with a diagnosis of Schizophrenia, but his Level 1 PASARR screening, completed at another facility, only indicated Major Depression Disorder. The Corporate Nurse confirmed that Schizophrenia was not checked on the PASARR and was unable to verify if a corrected submission was sent. These inaccuracies in the PASARR screenings for both residents highlight a failure in the facility's process to ensure accurate and complete preadmission screenings for residents with serious mental health diagnoses.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to safely meet the needs of residents, as evidenced by an incident involving a Licensed Practical Nurse (LPN) leaving medication at the bedside of a resident. The resident, who had been admitted with diagnoses including Chronic Kidney Disease and Heart Failure, had a Brief Interview for Mental Status (BIMS) score indicating intact cognition. However, the facility's policy required a physician's order and an evaluation to determine if a resident could safely self-administer medication, which the resident did not have. On the day of the incident, the LPN left a medicine cup with seven pills on the resident's over-bed table, allowing the resident to take the medication after breakfast without supervision. The RN Supervisor was unaware of the facility's policy on self-administration, and the Director of Nursing confirmed that the resident should not have been left to self-administer medication without the proper order and evaluation. The Administrator identified the LPN responsible for the medication administration, highlighting a lapse in adherence to the facility's medication administration policy.
Failure in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring proper drug record reconciliation of controlled substances during shift changes. This deficiency was identified during an annual survey, where it was found that the reconciliation process for Medicine Cart 1 (MC1) was not properly documented. The facility's policy requires that both the nurse coming on duty and the nurse going off duty perform the count together and document any discrepancies. However, during the review of the July 2024 Controlled Drugs-Count Record, it was discovered that there were missing signatures for the off-going nurse for the 7:00 a.m. - 3:00 p.m. shift on July 22, 2024, indicating that the narcotics were not reconciled as required. Further investigation revealed additional instances of missing signatures for narcotic reconciliations on other dates, including July 20 and July 21, 2024. The Director of Nursing (DON) confirmed that the nurses for these shifts should have signed the records to indicate that the narcotics were reconciled, but they had not. This failure to adhere to the facility's policy for controlled substances had the potential to affect the 80 residents residing in the facility, as it compromised the accountability and security of controlled drugs.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to properly store drugs and biologicals, as evidenced by two specific incidents. During an observation of the medication storage room, a multi-use vial of flu vaccine was found open without a labeled opening date. This was confirmed by both the LPN and the Corporate Nurse, who acknowledged that the vial should have been labeled with the date it was opened. This oversight indicates a failure to adhere to the facility's policy on medication storage, which requires all drugs and biologicals to be stored in a safe, secure, and orderly manner. Additionally, during an inspection of a medication cart, loose pills were discovered in the bottom drawers. An LPN confirmed the presence of two round white pills in the second drawer and one white round pill in the bottom drawer, acknowledging that these pills should not have been loose. This incident further highlights the facility's failure to maintain medication storage areas in a clean, safe, and sanitary manner, as required by their policy. These deficiencies had the potential to affect the 80 residents residing in the facility.
Inadequate Supervision During Van Unloading Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident while exiting the transportation van's wheelchair ramp, resulting in the resident sustaining injuries. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 15, and had diagnoses including Bipolar, Depression, and Chronic Obstructive Pulmonary Disease. On the day of the incident, the resident was positioned on the van's wheelchair ramp, and the van driver, who was responsible for assisting the resident, stood on the side of the ramp instead of behind the resident. As the ramp hit the ground, the resident unlocked his wheelchair, causing it to roll backward and flip over, leading to a head injury, shoulder contusion, neck strain, and scalp abrasion. The facility did not have a policy or procedure for unloading residents from the van's wheelchair ramp, and the van driver did not follow the proper procedure of standing behind the resident to assist them off the ramp. The van driver admitted to being caught off guard and acknowledged that she did not follow the facility's procedure. The administrator stated that the van driver was not responsible for the fall, attributing it to the resident unlocking his wheelchair. However, the transportation supervisor confirmed that the van driver should have stood behind the resident to ensure safe removal from the ramp.
Resident Dignity Compromised During Wound Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident with intact cognition who was subjected to inappropriate comments by a staff member. The resident, who had been admitted with diagnoses including post-procedural complications and anxiety, reported that during a wound care session, she was in significant pain and expressed this by hollering. In response, an LPN assisting with the care threatened to leave the room if the resident continued to scream, which was deemed unprofessional and inappropriate by the facility's Director of Nursing and Administrator. The incident was documented in a facility investigation, and the LPN involved confirmed during an interview that she had made the statement due to the resident's loud screams causing discomfort. The facility's policy on dignity, which mandates respectful communication with residents at all times, was not adhered to in this instance. The Director of Nursing acknowledged that the LPN's response was not suitable and that alternative approaches to managing the resident's pain should have been considered.
Failure to Notify Physician and Family Immediately After Resident Accident
Penalty
Summary
The facility failed to notify the physician and responsible party immediately after an accident involving a resident. On 02/17/2024, a resident with diagnoses including Acute Embolism and Thrombosis of the Left Femoral Vein, Generalized Muscle Weakness, and Repeated Falls, was dropped by staff members while being transferred from a wheelchair to a bed. The incident resulted in a skin tear to the resident's left shin. Despite the incident occurring on 02/17/2024, the resident's physician was not notified until 02/19/2024 at 10:00 a.m., and the family member was notified on 02/19/2024 at 3:00 p.m. The deficiency was identified through interviews and record reviews. The facility's policy requires immediate notification of the physician and family in the event of an incident or accident involving a resident. However, this policy was not followed in this case. The administrator confirmed that the notifications were not made immediately as required. This failure to promptly inform the physician and family member was highlighted in a complaint filed by the resident's family member and corroborated by the incident report prepared by the LPN involved.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to implement a person-centered care plan for two residents by not ensuring they received the nutritional supplements ordered by their physicians. Resident #1, who was admitted with severe protein-calorie malnutrition and other health issues, had an order for Ensure Plus before meals. However, during an observation, it was found that Ensure Plus was not stocked in the facility's refrigerators. The LPN responsible for ordering supplements confirmed that she had not ordered Ensure Plus in 2024 and was not aware of the need to do so. Resident #2, who had multiple health conditions including dysphagia and protein-calorie malnutrition, had an order for Ensure Clear in the afternoon. Despite this, the resident reported not receiving Ensure Clear since admission and was instead given milk-based Ensure, which he could not consume. The LPN responsible for ordering supplements confirmed that she had ordered Ensure Clear but switched to regular Ensure after residents reported disliking the flavors of Ensure Clear. This switch was made without ensuring the specific needs of Resident #2 were met.
Failure to Document and Offer Nutritional Supplements
Penalty
Summary
The facility failed to provide accurate documentation that a resident's nutritional supplement was offered. Specifically, for one resident, the order to encourage intake of supplements brought by family was not followed. The resident's MAR indicated that the supplements were to be offered every shift, but an LPN confirmed that she had signed off on the order without actually offering the supplement. During an observation and interview, the LPN was unaware of the supplements and could not find them in the resident's room. The LPN admitted to signing the MAR without verifying the availability or offering the supplement. Further interviews with the facility's Administrator and Corporate Nurse confirmed that the LPN should not have signed the MAR if the supplement was not available. They agreed that the LPN should have indicated the supplement was not available or offered an equal substitute from the facility. This deficiency has the potential to affect all 82 residents in the nursing home.
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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