Old Jefferson Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 8340 Baringer Foreman Road., Baton Rouge, Louisiana 70817
- CMS Provider Number
- 195571
- Inspections on file
- 24
- Latest survey
- February 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Old Jefferson Community Care Center during CMS and state inspections, most recent first.
The facility failed to provide scheduled baths for two residents and necessary perineal care for three residents after incontinent episodes. Despite being cognitively intact and requiring assistance, the residents did not receive the care as scheduled, as confirmed by staff and resident interviews. Observations showed that residents were not cleansed after soiled briefs were removed, and the CNA admitted to not providing the required care.
The facility failed to store medications properly, as evidenced by loose pills found in Med Cart B. An observation revealed 18 whole tablets and 2 halves of tablets loose in the cart, which was confirmed by an LPN. The Director of Nursing acknowledged that the pills should not have been loose, indicating a failure to adhere to the facility's medication storage policy.
The facility failed to store foods under sanitary conditions by not dating opened food items and not documenting temperatures on logs daily. During a kitchen inspection, undated opened food items were found, and temperature logs for storage areas were blank. The Dietary Manager and Administrator confirmed these oversights, which could affect 110 residents receiving meals from the kitchen.
A resident was incorrectly coded for active infections of Pneumonia and Septicemia on their MDS, despite no evidence of these conditions being present. Interviews with family and staff, along with a review of medical records, confirmed the error, highlighting a failure in accurate assessment and documentation.
A resident with Dementia and Protein-Calorie Malnutrition did not receive meals according to her preference for double portions, as indicated on her meal ticket. Despite the dietary instructions, she was served single portions, which was confirmed by staff interviews.
A facility failed to adhere to its infection prevention and control program by not ensuring staff wore proper PPE during care of a resident with a PEG tube. An LPN was observed providing care without a gown, despite the resident being on Enhanced Barrier Precautions (EBP) due to the feeding tube. The LPN admitted uncertainty about the EBP protocol, and the DON confirmed the expectation for staff to follow the EBP PPE protocol.
The facility did not post daily nurse staffing data in a prominent location accessible to residents and visitors, as required by policy. During an observation, no staffing data sheets were found, and interviews with staff confirmed the oversight. The staff member responsible for posting the data acknowledged the failure to post the information for that day.
A resident with dysphagia and severe cognitive impairment was left unsupervised during a meal, despite requiring supervision. The resident was found on the floor, gasping for air with food particles in his mouth. Attempts to clear the airway were unsuccessful, and the resident expired. Staff interviews revealed inconsistent understanding of the resident's supervision needs, and surveillance footage confirmed the lack of supervision.
Two residents in the facility had inaccurate MDS assessments regarding their dietary needs. Despite physician orders for mechanical soft diets, the MDS for both residents incorrectly indicated no need for mechanically altered diets. This discrepancy was confirmed by the staff responsible for MDS assessments and the DON, highlighting a failure in accurately reflecting residents' dietary orders.
Failure to Provide Scheduled Baths and Perineal Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, two residents did not receive their scheduled baths. One resident, who was cognitively intact and required substantial assistance with bathing, did not receive a bed bath on her scheduled days. Interviews with the resident and staff confirmed the inconsistency in providing the scheduled baths. Another resident, also cognitively intact and requiring moderate assistance, did not receive a shower on her scheduled day, as confirmed by staff interviews. Additionally, the facility failed to provide necessary perineal care after incontinent episodes for three residents. One resident, who was occasionally incontinent and required moderate assistance with toileting hygiene, was observed not receiving peri-care after a soiled brief was removed. Another resident, who was also occasionally incontinent, reported that a CNA regularly changed her brief without cleansing her peri-area. Observations confirmed that the resident's brief and bed were wet, and no peri-care was provided. A third resident, who was always incontinent and required maximum assistance, was observed not receiving peri-care after a urine-saturated brief was removed. Interviews with the residents confirmed their desire to be cleansed after incontinent episodes, and they had not refused such care. The CNA involved admitted to not providing peri-care and acknowledged that rounds should be made every two hours. The Director of Nursing confirmed that staff should perform peri-care after each incontinent episode and conduct rounds every two hours.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that drugs were stored in accordance with current accepted professional principles, as evidenced by the condition of Med Cart B. During an observation on February 4, 2025, at 10:08 a.m., it was found that Med Cart B contained a total of 18 whole tablets and 2 halves of tablets that were loose and not properly stored. The loose tablets included various shapes and colors, such as oval, round, and oblong white and yellow tablets. This observation was made in the presence of S6LPN, who confirmed the presence of the loose pills in the medication cart. Further interviews revealed that the facility's Director of Nursing (S2DON) was informed of the findings and confirmed that there should not have been any loose pills on the medication cart. The facility's policy, revised in November 2020, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner. However, the presence of loose pills in Med Cart B indicates a failure to adhere to this policy, as confirmed by both S6LPN and S2DON during their respective interviews.
Failure to Store Foods Sanitarily and Document Temperatures
Penalty
Summary
The facility failed to store foods under sanitary conditions, as observed during a survey. Specifically, the facility did not date food items after opening, which is a requirement according to their policy. During an inspection of the kitchen, several opened food items, including a gallon of mayonnaise, containers of chopped lettuce, tomatoes, and sliced cheese, were found undated. This oversight was confirmed by the Dietary Manager (S3DM) and the Administrator (S1ADM), who acknowledged that all opened items should have been labeled with an open date. Additionally, the facility did not document temperatures on temperature logs daily, as required by their policy. The review of temperature logs for the walk-in freezer, walk-in refrigerator, and snack/nourishment refrigerator showed no documentation of temperatures from January 2025 to the current date. Both S3DM and S1ADM confirmed that temperatures should have been documented daily, and the logs should have been completed. This deficiency had the potential to affect 110 residents who were provided meals from the facility's kitchen.
Inaccurate MDS Coding for Resident Infections
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically regarding the coding of infections. Resident #49 was admitted with diagnoses of Sepsis and Pneumonia, but during the review of her Annual MDS with an Assessment Reference Date (ARD) of 11/14/2024, it was found that these conditions were incorrectly coded as active diagnoses. Interviews and record reviews revealed that there were no physician orders, medication administration records, nurse's notes, or entries in the facility's infection log indicating that the resident had active infections of Pneumonia and Septicemia during November 2024. Interviews with the resident's family member, an LPN, and the facility's Care Coordinator confirmed that Resident #49 did not have any active infections, including Pneumonia and Septicemia, at the time. The Care Coordinator, who was responsible for completing the MDS assessments, acknowledged that the conditions were admit diagnoses and should not have been coded as active. The Director of Nursing also confirmed the incorrect coding on the MDS, indicating a failure in accurately assessing and documenting the resident's current health status.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the preferences of a resident diagnosed with Dementia and Protein-Calorie Malnutrition. The resident, who was admitted to the facility on an unspecified date, had a documented preference for double portions with all meals, as indicated on her meal ticket. However, during an observation of her breakfast tray, it was noted that she received only single portions of grits, scrambled eggs, sausage, and French toast, contrary to the double portions specified. Interviews with the CNA, LPN, and Dietary Manager confirmed that the resident's meal ticket indicated a preference for double portions, which was not fulfilled. The Director of Nursing also acknowledged that the resident's preference for double portions should have been provided.
Failure to Adhere to Enhanced Barrier Precautions for Resident with PEG Tube
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically in the use of Enhanced Barrier Precautions (EBP) for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The facility's policy required staff to wear gloves and gowns during high-contact resident care activities, such as device care or use, to prevent the spread of multidrug-resistant organisms. However, during an observation, a Licensed Practical Nurse (LPN) was seen providing care for the resident's PEG tube site without wearing a gown, despite the resident being on EBP due to the feeding tube. The LPN acknowledged not wearing a gown during the PEG site assessment and residual check, stating uncertainty about the proper EBP protocol. The Director of Nursing (DON) confirmed that the resident was on EBP related to the PEG tube and expected staff to follow the EBP PPE protocol by applying a gown and gloves during direct care. This deficiency highlights a lapse in adherence to the facility's infection control policy, potentially compromising the safety and sanitary conditions required to prevent the transmission of infections.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location accessible to residents and visitors, as required by their policy. During a tour and observation conducted on February 3, 2025, at 11:10 a.m., no staffing data sheets were observed in the facility. Interviews with staff members confirmed the deficiency. S5CS, who was responsible for posting the staffing data sheets, acknowledged that the information was not posted for that day. S1ADM also confirmed that the staffing data information was not posted and should have been, according to the facility's policy.
Resident Left Unsupervised During Meal Results in Fatal Incident
Penalty
Summary
The facility failed to provide adequate supervision to a resident who required assistance during meals, leading to a critical incident. The resident, who had a history of dysphagia and was severely cognitively impaired, was left unsupervised while eating in his room. Despite being coded for supervision or touching assistance with eating, the resident was left alone by a CNA and later by an LPN, who both exited the room without ensuring the resident was adequately monitored. The resident was on a mechanically altered diet due to swallowing difficulties, and his care plan required supervision during meals. However, on the day of the incident, the resident was left unsupervised with his meal tray. Shortly after, the LPN found the resident on the floor, gasping for air with food particles in his mouth. Despite attempts to clear the airway using the Heimlich maneuver and suction, the resident became pulseless and expired. Interviews with staff revealed a lack of consistent understanding and communication regarding the resident's need for supervision during meals. Some staff members believed the resident did not require supervision, while others confirmed the need for oversight. The facility's surveillance footage corroborated the timeline of events, showing the resident was left unsupervised for several minutes, which ultimately led to the fatal incident.
Inaccurate MDS Dietary Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their dietary needs as reflected in the Minimum Data Set (MDS). Resident #2, who was admitted with a diagnosis of dysphagia, had physician orders for a mechanical soft diet with regular-thin liquids. However, the MDS assessment for Resident #2 incorrectly indicated that no mechanically altered diet was required, despite the physician's orders. This discrepancy was confirmed during an interview with the staff member responsible for completing the MDS assessments, who acknowledged that the MDS should have been coded to reflect the mechanical soft diet. Similarly, Resident #3, who also had physician orders for a mechanical soft diet with chopped meats and regular-thin liquids, was inaccurately assessed in the MDS. The MDS for Resident #3 also failed to indicate the need for a mechanically altered diet, contrary to the physician's orders. This error was confirmed by the same staff member responsible for the MDS assessments, who admitted that the coding should have reflected the dietary orders. The Director of Nursing corroborated that the MDS should accurately reflect the resident's diet orders, indicating a systemic issue in the assessment process.
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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