Oak Lane Wellness & Rehabilitative Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eunice, Louisiana.
- Location
- 1400 W Magnolia, Eunice, Louisiana 70535
- CMS Provider Number
- 195588
- Inspections on file
- 20
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Oak Lane Wellness & Rehabilitative Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and dementia had multiple physician orders for daily wound care to various skin tears and a forehead laceration, as well as q-shift monitoring of knee swelling, over several consecutive months. Review of the TARs and MAR showed that ordered treatments and monitoring were repeatedly not documented as completed on multiple dates, including entire periods where no evidence of treatment existed for a right forearm skin tear and several missed entries for wounds to the elbow, forehead, fingers, eye, and hand, as well as for knee swelling checks. The DON confirmed during interview that there was no documented evidence that the ordered treatments and monitoring were carried out on the identified dates.
A resident with a history of constipation and multiple chronic conditions did not receive prescribed laxatives as outlined in standing physician's orders, despite not having a bowel movement for several days. The care plan called for medication administration and monitoring, but the MAR showed no laxatives were given, and staff confirmed the omission.
Surveyors identified multiple deficiencies in food service safety, including the storage of expired food, failure to label and date opened food items in various kitchen areas, the presence of a dented can in dry storage, and a dietary cook working with exposed facial hair. These actions were confirmed by the Dining Service Coordinator as not meeting facility policy requirements.
A resident with severe cognitive impairment was served mixed vegetables and beans despite documented dislikes for these foods on his meal ticket. Staff confirmed that the resident's preferences were known and should have been honored, but appropriate substitutions were not provided.
A resident with heart failure was discharged home with home health services following active discharge planning, but the MDS assessment was incorrectly coded as an unplanned discharge instead of a planned discharge. This error was confirmed by the staff member responsible for the assessment.
A resident with upper extremity impairment and dementia was not provided timely assistance with personal hygiene, resulting in her right hand and fingernails being coated with a dried, stool-colored substance. CNAs responsible for her care did not check on her at the start of their shift or before breakfast, despite care plan interventions and supervisory expectations to do so.
Two residents requiring respiratory care did not have their equipment properly stored according to facility policy. One resident's CPAP mask was kept in an outdated plastic bag, while another's nebulizer mask was left on a chair and not stored in a bag. Both issues were confirmed by nursing staff and were not in compliance with established infection control procedures.
Staff failed to follow infection control protocols by not wearing required PPE during care for two residents. An LPN administered an insulin injection without gloves, and a CNA provided a bed bath to a resident on Enhanced Barrier Precautions for ESBL without wearing a gown, despite clear facility policies and signage.
A resident with moderate cognitive impairment and a history of dementia eloped from the facility after staff failed to recognize repeated exit-seeking behaviors and did not respond appropriately to a Wanderguard alarm. Staff were unfamiliar with alarm procedures and did not identify the source of the alarm, allowing the resident to leave undetected and travel to his home before being returned by facility staff.
A resident with diabetes and a history of pressure ulcers did not receive documented weekly skin assessments as required by facility policy. During a period when no body audits were recorded, a new unstageable sacral wound developed. The treatment nurse could not provide evidence that head-to-toe assessments, including the buttocks, were completed for this resident during that time.
The facility failed to implement its antibiotic stewardship policy, resulting in delayed evaluation of culture and sensitivity results for several residents. This led to inappropriate antibiotic usage and delayed treatment for infections, including a resident who was sent to the emergency room and another who was discharged without appropriate antibiotic therapy.
The facility failed to ensure complete dialysis communication forms for a resident with End Stage Renal Disease, resulting in 39 incomplete forms missing critical information such as vital signs, medications, and nurse signatures. Both an LPN and the Assistant Director of Nurses confirmed the deficiency.
The facility failed to ensure that recipes for pureed, chopped, and bite-sized meals were used during meal preparation. Kitchen staff, under the direction of the Dietary Manager, did not follow established recipes and used unmeasured amounts of ingredients, potentially affecting residents' dining experience and nutritional needs.
A resident with intact cognition and mobility issues was found to have multiple areas of paint scraped off the walls in his bathroom and a sharp piece of metal trim sticking out from the doorway. These deficiencies were confirmed by the Maintenance Supervisor and the DON, who acknowledged the potential risk of harm.
The facility failed to complete a comprehensive assessment, including a resident's dental status, within 14 days of admission. The resident had missing and broken teeth causing continuous pain, and the MDS had blank sections under Oral/Dental Status. The MDS coordinator confirmed the assessment was not completed on time.
The facility failed to ensure that a resident's discharge assessment was opened, completed, and transmitted in a timely manner. A review of the resident's EMR showed no evidence of a discharge assessment being completed within the last 120 days, which was confirmed by an LPN during an interview.
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASRR evaluation. The resident was admitted with Bipolar Disorder and prescribed Seroquel, but no Level II PASRR was submitted. The Social Service Director confirmed this oversight.
A facility failed to follow physician's orders for a resident by not checking gastric residual volume before administering PEG tube water flush and bolus feeding. The LPN and DON confirmed the oversight, highlighting a deficiency in proper procedure adherence.
A resident with multiple medical conditions and significant oral health issues experienced continuous pain that was not effectively managed by the facility. Despite repeated complaints and minimal relief from Tylenol, the staff failed to reassess the resident's pain in a timely manner and did not contact the physician for alternative pain management options.
The facility failed to store food in accordance with professional standards by not labeling and dating opened containers in dry storage and the freezer. The Dietary Manager confirmed the oversight during an inspection.
A resident with severe cognitive impairment was involved in a suspected sexual abuse incident when another resident attempted to remove her pants. The nurse intervened but failed to notify the resident's responsible party on the day of the incident, leading to a deficiency in communication. The responsible party was informed two days later by the DON.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with a history of inappropriate behavior. Despite awareness of the risk, the facility failed to implement specific interventions to monitor or prevent such incidents, leading to an event where the resident's pants were partially removed. Staff were not adequately informed or prepared to handle the situation, resulting in a deficiency in safeguarding vulnerable residents.
A facility failed to report an alleged sexual abuse incident involving a resident within the required 24-hour timeframe. The incident occurred but was not reported until two days later due to the DON not notifying the Administrator promptly. The resident had multiple diagnoses, including dementia and schizoaffective disorder. This delay had the potential to affect the safety of 78 residents.
Failure to Implement and Document Ordered Wound Care and Monitoring Over Multiple Months
Penalty
Summary
The deficiency involves the facility’s failure to implement and document physician-ordered wound care treatments and monitoring over a five-month period for a resident with Alzheimer’s disease and dementia. The resident was admitted with these diagnoses and subsequently developed multiple skin tears and a forehead laceration requiring daily cleansing with normal saline, application of triple antibiotic or Bacitracin ointment, and covered dressings until healed. Review of the November 2025 physician’s orders and Treatment Administration Record (TAR) showed an order for daily treatment of a right forearm skin tear, but there was no evidence on the TAR or MAR that this treatment was administered at all during that month. Further review of the resident’s TARs and physician’s orders for December 2025, January 2026, February 2026, and March 2026 revealed multiple missed or undocumented treatments and monitoring. In December, daily treatments for a right elbow skin tear and a forehead laceration, including Bacitracin applications twice daily, lacked nurses’ initials or evidence of administration on several specified dates. In January, a daily treatment order for a skin tear between the fingers of the left hand was not documented as given on one date. In February, a daily treatment for a right pinky finger skin tear was not documented on one date. In March, daily treatments for skin tears to the right outer eye and right outer hand, as well as ordered q-shift monitoring of right knee swelling, were missing documentation on multiple shifts and dates. During interviews, the DON reviewed the records and confirmed there was no documented evidence that these ordered treatments and monitoring were completed on the identified dates.
Failure to Implement Standing Orders for Constipation Management
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan and physician's orders for a resident with a history of constipation. The resident, who had diagnoses including Alzheimer's disease, diabetes mellitus, and cerebral infarction, was assessed as moderately cognitively impaired and always incontinent of bowel. The care plan identified a risk for inadequate bowel pattern and included interventions such as administering medication as ordered and monitoring for signs of constipation. However, despite standing physician's orders for laxatives to be administered if no bowel movement occurred in three days, the resident did not receive the prescribed medications. Review of the resident's records showed no bowel movements for six consecutive days, and the Medication Administration Record confirmed that neither milk of magnesia nor bisacodyl was given during this period. Interviews with the resident, an LPN, and the DON confirmed the lack of medication administration despite the standing orders and the resident's ongoing constipation. The failure to follow the care plan and physician's orders resulted in the deficiency.
Failure to Maintain Food Service Safety and Hygiene Standards
Penalty
Summary
Surveyors observed multiple failures to maintain professional standards for food service safety within the facility. During an initial kitchen tour, expired food items, including nineteen 8-ounce containers of chocolate milk past their use-by date, were found in the reach-in cooler. Additionally, several opened food items, such as a 48-ounce cream cheese, a container of browning seasoning sauce, a container of minced garlic, a container of chicken base, and a container of ground cinnamon, were stored without proper labeling or dating to indicate when they were opened. A dented 50-ounce can of chicken noodle soup was also found in the pantry, contrary to safe food storage practices. Further observations revealed that kitchen staff did not adhere to hygiene standards, as one dietary cook was seen with exposed facial hair while working in the kitchen and cleaning the stove. Interviews with the Dining Service Coordinator confirmed that these practices were not in compliance with the facility's policies, which require discarding expired food, labeling and dating all opened food items, removing dented cans, and ensuring staff wear appropriate hair restraints.
Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to honor and facilitate a resident's right to self-determination by not providing meals in accordance with the resident's stated food preferences. The resident, who had a history of cerebral infarction, dementia, and vitamin deficiency, was assessed as having severely impaired cognition. Despite the resident's meal ticket clearly indicating dislikes for mixed vegetables and beans, these items were still included on his lunch tray. During observation, the resident did not consume these items and stated he had previously informed the facility of his dislikes. Staff interviews confirmed that the resident's meal ticket listed his food dislikes and that these preferences should have been honored. Both the CNA and the dietary cook acknowledged that substitutes should have been provided in place of the disliked foods, and the dietary cook admitted she had not clarified the resident's preferences regarding beans. The dining service coordinator also confirmed that resident meal preferences documented on meal tickets are to be followed, and substitutions should be made when necessary.
Inaccurate Coding of Discharge Status on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status, as evidenced by the case of one resident who was admitted with diagnoses including unspecified combined systolic and diastolic heart failure. The resident's care plan included active discharge planning with the intention to return to the community, and a physician's order was documented for discharge home with home health services. However, the Discharge Minimum Data Set (MDS) assessment was incorrectly coded as an unplanned discharge instead of a planned discharge. This error was confirmed during an interview and record review with the staff member responsible for completing the MDS assessment.
Failure to Provide Timely Personal Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, unspecified dementia, and palliative care needs was not provided adequate assistance with activities of daily living (ADLs), specifically personal hygiene. The resident's Minimum Data Set (MDS) assessment indicated upper extremity impairment and a need for assistance with personal hygiene, with care plan interventions to check and clean fingernails daily. Despite these documented needs, the resident was observed lying in bed with a dried, brown, stool-colored substance coating her right hand, fingers, and underneath her fingernails. Certified Nursing Assistants (CNAs) responsible for the resident's care admitted to not checking on her at the start of their shift, prioritizing other tasks such as assisting residents in the dining room. One CNA stated she had not checked the resident since starting her shift, and another reported feeding the resident without checking her hands or incontinent brief. Supervisory staff confirmed that CNAs were expected to check all residents at the beginning of their shift and before breakfast, but this was not done in this case, resulting in the resident remaining uncleaned for an extended period.
Failure to Properly Store Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to properly store respiratory equipment for two residents who required respiratory care. For one resident with obstructive sleep apnea, the CPAP mask was observed stored in a plastic bag that had not been changed in accordance with the facility's policy, which requires the storage bag to be replaced monthly when the mask is changed. The Director of Nursing confirmed that the bag was dated from the previous month and should have been replaced at the time of the mask change, as per physician orders and facility policy. For another resident with hypertensive heart disease and heart failure, the oxygen nebulizer mask was found connected to the breathing treatment machine and placed on a chair, not stored in a bag as required. Both a CNA and an LPN confirmed that the nebulizer mask was not stored in a bag and acknowledged that it should have been. Facility policy specifies that nebulizer circuits should be stored in a dated plastic bag marked with the resident's name between uses, which was not followed in this instance.
Failure to Ensure Proper PPE Use During Resident Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two separate incidents involving staff not following established protocols for personal protective equipment (PPE) use. In the first incident, a Licensed Practical Nurse (LPN) administered an insulin injection to a resident with diagnoses including Type 2 Diabetes mellitus, cerebral infarction, and chronic obstructive pulmonary disease, without donning gloves prior to the procedure. The LPN acknowledged during an interview that gloves should have been worn during the injection. In the second incident, a Certified Nursing Assistant (CNA) provided a bed bath to a resident who was on Enhanced Barrier Precautions (EBP) due to colonization with an extended-spectrum beta-lactamase (ESBL) producing organism, as indicated by a posted sign and the resident's care plan. The CNA did not wear a gown during this high-contact activity, despite being aware of the EBP requirements. The Assistant Director of Nursing/Infection Preventionist confirmed that both gown and gloves are required for such care activities under EBP protocols.
Failure to Recognize and Respond to Exit-Seeking Behaviors Resulting in Resident Elopement
Penalty
Summary
Facility staff failed to recognize and appropriately respond to a resident exhibiting exit-seeking behaviors, resulting in the resident eloping from the facility. The resident, who had a diagnosis of Alzheimer's disease and dementia with moderate cognitive impairment, repeatedly asked staff for the code to the facility's door alarm and expressed a desire to go home. Despite these clear indications of exit-seeking, staff did not interpret these behaviors as a risk for elopement and did not take preventive action. On the day of the incident, the resident approached multiple staff members requesting to be let out and for the door code. Staff directed the resident to speak with the nurse but did not monitor his movements or alert other staff to his intentions. When the door alarm sounded as the resident exited, staff were unable to identify the source of the alarm or its significance. One staff member checked the door, did not see anyone outside, and disarmed the alarm without confirming the resident's whereabouts. The resident was able to leave the facility undetected and walked approximately 0.2 miles to his home, where he was later retrieved by facility staff. Interviews and record reviews revealed that the staff involved were unfamiliar with the facility's alarm system and did not know how to respond to or locate the source of an alarm. The facility's elopement policy did not provide clear guidance on alarm response or recognizing exit-seeking behaviors. Additionally, the staff members involved had only recently started working at the facility and had not received adequate training on these procedures prior to the incident.
Removal Plan
- The facility initiated in-service with staff regarding door alarms within the facility and the Elopement Policy.
- Staff were educated on how to respond to an activated door alarm.
- An additional in-service on the Door Guardian, Wander Guard Policy to all staff on duty was conducted.
- Pictures of the alarming modules located at the nurse's stations were presented to staff for visual recognition.
- Education continued to all staff as they came for their assigned shifts.
- The facility continued to educate to all on coming staff members on the policies and procedures for dealing with elopements, residents with elopement risk, alarming doors and how to react and respond accordingly to an alarm.
- The administrator and/or designee will evaluate new hires and agency staff prior to beginning their shifts on policies and procedures for dealing with elopements, resident with elopement risk, alarming doors and how to react and respond accordingly to an alarm.
- The charge nurse will evaluate any agency staff to ensure full understanding prior to beginning their shifts.
- The administrator and/or designee will provide additional monthly education on elopements, elopement risk residents, exit seeking behavior, alarms within the facility and how to properly respond to alarms within the facility to staff for the next 6 months.
- The DON (Director of Nursing) and/or designee will conduct random weekly audits of staff's knowledge on the policies and procedures on elopements, residents with elopement risk, alarming doors and how to react and respond accordingly for 8 weeks.
- The Policy on Elopement was revised to include attempted elopements and exit seeking behaviors and how to deal with exit seeking behaviors.
Failure to Document and Complete Weekly Skin Assessments for Pressure Ulcer Prevention
Penalty
Summary
A resident with diagnoses including type 2 diabetes and a pre-existing pressure ulcer was admitted to the facility. The facility's policy required weekly skin assessments and documentation of any changes. The resident's care plan included scheduled body audits to monitor for skin issues. However, a review of the medical record showed that weekly body audits were not documented for the period between admission and the identification of a new, unstageable sacral wound. Specifically, there was no evidence of body audits from 12/11/2024 through 12/24/2024. Further review revealed that the weekly skin impairment assessment conducted during this period did not include an assessment of the resident's buttocks, focusing instead on a yeast infection rash. The treatment nurse confirmed that she was responsible for weekly head-to-toe assessments, including the backside, but could not provide documentation to support that these assessments were completed for the resident in question during the specified timeframe. As a result, a facility-acquired, unstageable wound was identified on the resident's sacrum on 12/24/2024.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy effectively, resulting in delayed evaluation of culture and sensitivity results for several residents. Specifically, the facility did not obtain culture reports and sensitivity data in a timely manner for two residents, and failed to notify the physician of these results for another resident. This led to inappropriate antibiotic usage and delayed treatment for infections. For instance, Resident #43's urine culture collected on 04/23/2024 showed the presence of Klebsiella pneumoniae, but the facility did not have the final report in the resident's record by 05/20/2024. Consequently, the physician was not notified, and no treatment was initiated. The resident later complained of weakness and dizziness, was sent to the emergency room, and was diagnosed with a urinary tract infection (UTI) that required antibiotic therapy. Similarly, Resident #77's urine culture collected on 04/30/2024 revealed Enterococcus faecalis, but the physician was not notified until 05/05/2024, two days after the results were available. This delay in communication and treatment is a clear violation of the facility's antibiotic stewardship policy, which mandates timely communication of lab results to the prescriber for appropriate antibiotic management. Additionally, Resident #380 was prescribed Macrobid for a UTI, but the culture and sensitivity report showed that the bacteria was resistant to this antibiotic. The facility failed to notify the physician of these results, and no change in treatment was initiated. The resident was discharged to her home without appropriate antibiotic therapy. The facility's failure to follow its own policy resulted in delayed and inappropriate treatment for infections, posing significant risks to the residents' health and well-being.
Incomplete Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility by not completing dialysis communication forms for a resident requiring dialysis services. Specifically, the facility did not fill out the required information on 39 dialysis communication forms for a resident with End Stage Renal Disease, Essential Hypertension, and Type 2 Diabetes Mellitus. The missing information included critical details such as blood pressure, pulse, respirations, temperature, date, time, medications administered, time of last meal, diet, fluid restriction, fluid restriction amount, significant alerts, and the facility nurse's name and signature. During the survey, both an LPN and the Assistant Director of Nurses confirmed that the dialysis communication forms were incomplete. The LPN acknowledged that the nurses are responsible for filling out the forms completely before the resident leaves for dialysis treatment. The Assistant Director of Nurses also confirmed the same and verified that 39 forms were indeed incomplete. No facility policy for dialysis communication was provided upon request during the survey.
Failure to Follow Recipes for Modified Diets
Penalty
Summary
The facility failed to ensure that recipes for pureed, chopped, and bite-sized meals were used during meal preparation. This deficiency was observed during the preparation of meals for residents requiring specific dietary consistencies. The kitchen staff, under the direction of the Dietary Manager, did not follow the established recipes and instead used unmeasured amounts of ingredients, relying on visual estimation. This practice was observed during the preparation of pureed hamburger steak with onion gravy, where the staff added unmeasured amounts of beef broth and thickener, and during the preparation of chopped and bite-sized hamburger steak, where the staff similarly used unmeasured amounts of beef broth and did not adhere to the recipe guidelines. The Dietary Manager confirmed that the kitchen staff did not use the recipes and had instructed them to put their own spin on the preparation process. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for residents receiving these modified diets. Specifically, one resident received pureed meals, six residents received mechanical chopped meals, and thirteen residents received bite-sized meals. The facility's policy on therapeutic diets, which requires that residents on such diets receive portions and modifications as approved by the attending physician and clinical dietitian, was not followed. The Dietary Manager's approval of the texture without using the recipes further highlights the lack of adherence to the established dietary guidelines.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident who was admitted with diagnoses including Hypertension, Heart Failure, and Hyperlipidemia. The resident, who had intact cognition and used a wheelchair for mobility, was found to have multiple areas of paint scraped off the walls in his bathroom, specifically on the left side of the toilet and near the shower. Additionally, a sharp piece of metal trim was observed sticking out from the doorway trim, posing a potential hazard. These deficiencies were confirmed during observations and interviews with the Maintenance Supervisor and the Director of Nursing. Both staff members acknowledged the unacceptable condition of the bathroom and the potential risk of harm to the resident. Despite the initial observation, the issues remained unaddressed during a follow-up observation two days later, indicating a failure to maintain a safe and homelike environment for the resident.
Failure to Complete Comprehensive Assessment Including Dental Status
Penalty
Summary
The facility failed to complete a comprehensive assessment, including the resident's dental status, within 14 days of admission for a resident reviewed for pain management. The resident was admitted with multiple diagnoses including Vitamin Deficiency, Depression, Acute Embolism and thrombosis of deep veins, Long Term Use of Anticoagulants, Gastro Esophageal Reflux Disease, and Hypertension. An observation revealed the resident had missing and broken teeth, causing continuous pain, especially when eating. The Minimum Data Set (MDS) for the resident, with an Assessment Reference Date (ARD) of 5/7/2024, had blank sections under Oral/Dental Status, indicating that the oral assessment was not completed. The MDS coordinator confirmed that the oral assessment should have been completed by 05/14/2024 but was not done.
Failure to Complete and Transmit Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that resident assessments were opened, completed, and electronically transmitted in a timely manner for one resident out of three investigated for Resident Assessment. Specifically, a review of a resident's Electronic Medical Record (EMR) revealed that the resident was admitted with diagnoses including Edema and Hypothyroidism and was later discharged. However, there was no documented evidence that a discharge assessment was opened, completed, or transmitted within the last 120 days. This was confirmed during a concurrent record review and interview with an LPN, who acknowledged that the discharge assessment should have been completed after the resident's discharge.
Failure to Submit Level II PASRR for New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASRR evaluation and determination. The deficiency was identified during a review of the facility's policy and the resident's electronic medical record. The policy indicated that a Resident Review may be required if a resident has a new mental health diagnosis. Resident #20 was admitted with a diagnosis of Bipolar Disorder, Unspecified, and was prescribed the antipsychotic medication Seroquel. However, there was no evidence that a Level II PASRR had been submitted for this new diagnosis. The Social Service Director confirmed that the Level II PASRR had not been submitted as required.
Failure to Follow Physician's Orders for PEG Tube Feeding
Penalty
Summary
The facility failed to follow the physician's orders for a resident by not checking for gastric residual volume (GRV) before administering PEG tube water flush and bolus feeding. The resident, who had severe cognitive impairment and required nutrients via a feeding tube, had specific physician's orders to monitor for placement and perform residual checks before administering the feeding and water flush. However, during an observation, an LPN was seen administering the water flush and bolus feeding without performing the required residual check. The LPN confirmed in an interview that she did not check the resident's stomach residual before administering the PEG tube water flush and bolus feeding, acknowledging that she should have done so according to the physician's orders. The Director of Nursing also confirmed that the residual check should have been performed before administering the feeding and water flush. This failure to follow the physician's orders was identified during a survey, highlighting a deficiency in the facility's adherence to proper procedures for enteral feeding administration.
Failure to Effectively Manage Resident's Pain
Penalty
Summary
The facility failed to effectively manage pain for a resident with multiple medical conditions, including Vitamin Deficiency, Depression, and Hypertension. The resident, who had moderate cognitive impairment, was observed to have significant oral health issues, including missing and broken teeth, which caused continuous pain, especially while eating. Despite the resident's repeated complaints of pain and the presence of a bad taste and odor in her mouth, the facility's staff did not adequately address her pain management needs. The facility's policy required consistent pain assessment and re-assessment at least each shift for acute pain. However, the resident's Treatment Administration Record indicated that pain assessments were only documented at 6:00 a.m. and 6:00 p.m. daily. The resident reported that the Tylenol provided only minimal relief and did not bring her pain to a tolerable level. Observations and interviews confirmed that the resident's pain was not adequately managed, and the staff failed to reassess her pain in a timely manner after administering medication. The Assistant Director of Nursing (ADON) acknowledged that the nurses should have been more proactive in managing the resident's oral pain and should have contacted the physician when Tylenol was ineffective. The ADON's review of the resident's records confirmed that the nurses did not reassess the resident's pain within the required timeframe on multiple occasions. This lack of timely reassessment and appropriate pain management led to the resident experiencing ongoing, intolerable pain.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions in the kitchen. During an initial tour of the facility's kitchen, it was observed that a one-gallon bottle of vanilla extract and a 16-ounce plastic container of grated parmesan in the dry storage area were opened and used without being labeled and dated. Additionally, in the facility's walk-in freezer, a one-gallon storage bag of frozen chicken breast and a large opened bag of breaded chicken tenders were found without labels and dates. The Dietary Manager confirmed that these items should have been labeled and dated as per the facility's policy and procedure for food receiving and storage, which was last reviewed on 08/02/2023.
Failure to Notify Responsible Party of Suspected Sexual Abuse Incident
Penalty
Summary
The facility failed to notify the responsible party of a resident involved in an incident of suspected sexual abuse. The incident occurred when a resident with severe cognitive impairment, diagnosed with Dementia with psychotic disturbance, Schizoaffective disorder, Major depressive disorder, Anxiety disorder, and Neurocognitive disorder with Lewy bodies, wandered into another resident's room. The second resident was observed attempting to remove the first resident's pants. The nurse on duty intervened immediately but did not notify the responsible party of the first resident, who was her daughter, on the day of the incident. The facility's policy on abuse reporting did not explicitly require notifying the responsible party, which contributed to the oversight. The incident was documented in the facility's records, but the responsible party was only informed two days later by the Director of Nursing. Interviews confirmed that the nurse involved did not notify the responsible party, despite claiming to have done so. This delay in communication was identified as a deficiency in the facility's handling of the incident.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to implement immediate safeguards to protect a resident with severe cognitive impairment from sexual abuse. Resident #1, who had a BIMS score of 02 indicating severe cognitive impairment, was involved in an incident where Resident #2, with a history of inappropriate sexual behavior, attempted to remove Resident #1's pants. The facility's policy on abuse clearly defines nonconsensual sexual contact as abuse, yet the facility did not have measures in place to prevent such incidents, especially given Resident #2's documented history of sexually inappropriate behavior. Resident #2 had a BIMS score of 09, indicating moderate cognitive impairment, and was known to exhibit inappropriate sexual behavior towards staff, including grabbing and making inappropriate comments. Despite these behaviors being documented in Resident #2's care plan, the facility did not extend protective measures to other residents, particularly those who were vulnerable, like Resident #1. The facility's staff, including the DON and LPNs, were aware of Resident #2's behaviors but did not implement specific interventions to monitor or prevent interactions with other residents. The incident occurred when Resident #1 wandered into Resident #2's room while an LPN was gathering supplies at a medication cart. Video footage showed Resident #2 standing in the doorway and later attempting to remove Resident #1's pants. The LPN, who was not informed of Resident #2's history, did not monitor the residents closely, leading to the incident. Interviews with staff revealed a lack of communication and specific interventions to address Resident #2's behaviors, resulting in a failure to protect vulnerable residents on the dementia care unit.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving a resident within the required 24-hour timeframe to the State Survey Agency. The incident occurred on April 27, 2024, at 3:32 p.m., but was not reported until April 29, 2024, at 10:41 a.m. This delay in reporting was due to the Director of Nursing (DON) not notifying the Administrator about the incident in a timely manner. The facility's policy mandates that such incidents be reported immediately, but this protocol was not followed. The resident involved in the incident was admitted to the facility with multiple diagnoses, including dementia with psychotic disturbance, schizoaffective disorder, major depressive disorder, anxiety disorder, and neurocognitive disorder with Lewy bodies. The failure to report the incident promptly had the potential to affect the welfare and safety of the facility's 78 residents. The DON confirmed during an interview that the Administrator should have been notified immediately about the incident, acknowledging the lapse in protocol.
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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