Ouachita Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 7950 Millhaven Road, Monroe, Louisiana 71203
- CMS Provider Number
- 195531
- Inspections on file
- 27
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ouachita Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure call lights were within reach for three high-risk residents, leading to potential safety concerns. One resident in a wheelchair had their call light on the bed, while another in bed had it draped over a recliner. A third resident in a wheelchair also had their call light on the bed. All residents were at high risk for falls and dependent on staff for daily activities.
A resident's privacy was compromised when she was left exposed to the hallway during care. The incident occurred when a CNA left the room, and the door swung open, leaving the resident uncovered. The resident, who was cognitively intact and dependent on staff for daily living activities, expressed discomfort with being exposed. The DON was informed of the situation.
Two residents with cognitive and physical impairments did not receive necessary assistance with personal hygiene, as evidenced by untrimmed eyebrows and chin hair. Despite care plans indicating the need for staff assistance, observations confirmed the lack of grooming support, as acknowledged by the ADON and DON.
The facility failed to administer oxygen therapy as ordered for two residents. One resident, with a history of subdural hemorrhage and other conditions, had their oxygen set at 2 liters instead of the prescribed 3 liters. Another resident, with chronic obstructive pulmonary disease, had their oxygen set at 3.5 liters instead of the prescribed 2 liters. These discrepancies were confirmed by staff, indicating a failure to follow physician orders.
The facility did not follow the prescribed menu for residents on pureed diets, affecting seven individuals. The menu required pureed cornbread, but the facility served regular cornbread instead. This issue was observed on two consecutive days, and the Dietary Manager confirmed the oversight.
The facility failed to maintain food safety standards, with issues such as improper storage of personal items in the freezer, undated and uncovered food in the refrigerator, and improper handling of food with gloves. Staff were observed handling food after touching other items without changing gloves, and thawing meat improperly. These deficiencies were noted by the dietary manager.
The facility failed to maintain a manual can opener in safe operating condition, as it had a buildup of metal shavings. This was confirmed by a cook during an observation, affecting the preparation of 168 diets served from the kitchen.
The facility failed to maintain an effective pest control program, leading to an ant infestation in the kitchen's dry pantry area. Small black ants were observed on containers of grits and sugar, and a cook confirmed ongoing issues with ants. This deficiency had the potential to impact 168 residents receiving meals from the kitchen.
A facility failed to document a discharge summary for a resident with multiple health conditions, including cerebral infarction and diabetes, who required assistance with daily activities. The resident was discharged home without the necessary documentation, as confirmed by the DON.
The facility failed to provide dignified care and assistance to two residents. A resident with cognitive impairment was observed with a disposable brief used as a cushion in his wheelchair, while another resident with Parkinson's disease ate breakfast directly from the table without staff assistance, despite staff presence. The DON and ADON were informed of these incidents.
The facility failed to maintain a sanitary environment in the laundry department, as personal cell phones were placed on tables designated for folding clean clothing and linens, risking cross-contamination. This was confirmed by laundry workers and the supervisor, who acknowledged the breach in infection control protocols.
A resident received an incorrect dosage of Nifedipine ER due to an LPN's failure to verify the medication card label against the e-MAR before administration. The error was traced back to a nurse sending in a label from a previously discontinued dosage, leading to the pharmacy filling the wrong dosage.
A resident with multiple medical conditions was administered Nifedipine ER 30 mg instead of the prescribed 90 mg due to a labeling error by a nurse, which was confirmed by the DON.
The facility failed to follow dietary orders for two residents who were prescribed mighty shakes and did not adhere to a resident's preference for wheat bread. Despite the availability of the required items, the dietary staff did not place them on meal carts, and CNAs did not provide them to the residents.
The facility failed to maintain sanitary conditions in the kitchen, with grease build-up in fryers, old food particles on a toaster and microwaves, and unlabeled opened bags of pasta. The Culinary Supervisor confirmed these issues.
The facility failed to ensure consistent documentation of a resident's code status, resulting in a discrepancy between the paper and electronic medical records. The resident's paper record indicated Full Code, while the electronic record and a physician's order indicated DNR. The DON was unaware of this inconsistency.
The facility failed to ensure a resident received appropriate treatment and care according to professional standards and the care plan. The resident, with diagnoses of Parkinson's disease, cerebrovascular disease, and unspecified dementia, was frequently observed in a high back wheelchair with a tilted lap tray and unsupported feet. Staff confirmed ongoing issues with the wheelchair and lap tray positioning, and the DON acknowledged the facility's failure to address these concerns in a timely manner.
A resident with moderate cognitive impairment and multiple serious health conditions was found with a cup of pills left at the bedside. An LPN confirmed the medications were administered before her arrival and should not have been left there. The DON also confirmed this practice was incorrect.
A resident with Parkinson's disease and dementia had an ongoing issue with a tilted wheelchair lap tray that was not repaired in a timely manner. The tray had a tear causing a rough edge and a blue substance that the resident was picking at. The LPN was unsure if maintenance was aware of the issue, and the DON confirmed that the concerns should have been addressed.
Call Lights Out of Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, all of whom were at high risk for falls. During observations, it was noted that Resident #102, who was in a wheelchair, had their call light placed on the bed, making it inaccessible. This resident was cognitively intact with a BIMS score of 15 and had multiple diagnoses, including cerebral infarction and vascular dementia. Resident #141 was observed lying in bed with the call light draped over a recliner, out of reach, and was unable to call for assistance when needed. This resident had significant cognitive impairment with a BIMS score of 2 and was diagnosed with conditions such as metabolic encephalopathy and chronic atrial fibrillation. Similarly, Resident #143, who was sitting in a high-back wheelchair, had their call light placed on the bed, out of reach. This resident had moderate cognitive impairment with a BIMS score of 11 and was diagnosed with Parkinson's disease and coronary artery disease. All three residents were dependent on staff for activities of daily living and were always incontinent of bladder and bowel. The Director of Nursing was informed of the situation, highlighting the facility's failure to accommodate the residents' needs and preferences by ensuring call lights were accessible.
Resident Privacy Not Maintained During Care
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during care. On March 9, 2025, at 1:45 p.m., a resident was observed lying on the bed with no sheets covering her, and her brief was exposed to the hallway. This occurred when a CNA left the room to get a gown for the resident, and the door swung open, leaving the resident exposed. The resident, who was cognitively intact with a BIMS score of 15, expressed discomfort with being exposed during care. The resident had diagnoses including cerebral infarction, psychotic disorders with delusions, chronic respiratory failure with hypercapnia, major depressive disorder with psychotic symptoms, and vascular dementia with behavioral disturbances. She was always incontinent of bladder and bowel and dependent on staff for all activities of daily living. The Director of Nursing was notified of the incident on March 11, 2025.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for two residents who were unable to perform activities of daily living independently. Resident #14, who was admitted with Parkinson's disease and had moderate cognitive impairment, required partial to moderate assistance with personal hygiene, including shaving. Observations revealed that the resident had long, untrimmed eyebrows, indicating a lack of assistance in maintaining personal hygiene. Despite being care planned to receive one staff assistance for personal hygiene, the resident's needs were not adequately met, as confirmed by the Assistant Director of Nursing and the Director of Nursing. Similarly, Resident #63, who was admitted with hemiplegia, hemiparesis, and severe cognitive impairment, was dependent on staff for personal hygiene due to a self-care deficit. Observations showed that the resident had a large amount of long, untrimmed chin hair, suggesting a failure to provide necessary grooming assistance. The resident's care plan included staff assistance with hygiene and grooming tasks, but this was not effectively implemented, as confirmed by the Assistant Director of Nursing. Both cases highlight the facility's failure to ensure residents received the required assistance with personal hygiene, as documented in their care plans.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for two residents receiving oxygen therapy. Resident #138, who has a history of subdural hemorrhage, insomnia, and other health conditions, was observed with an oxygen concentrator set at 2 liters per minute, despite a physician's order for 3 liters per minute. This discrepancy was confirmed by both the LPN and the Director of Nurses during interviews, indicating a failure to adhere to the prescribed oxygen administration. Similarly, resident #48, with a history of cerebrovascular disease and chronic obstructive pulmonary disease, was found with an oxygen concentrator set at 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. The resident, who is cognitively intact, confirmed that she does not adjust her oxygen settings. This was corroborated by an LPN and the Director of Nurses, highlighting a failure to maintain the correct oxygen flow as ordered by the physician.
Failure to Serve Pureed Cornbread as Per Menu
Penalty
Summary
The facility failed to adhere to the prescribed menus for residents on pureed diets, affecting seven residents. The lunch menu for pureed diets indicated that residents were to receive pureed cornbread, but instead, the facility substituted cornbread without pureeing it. This discrepancy was observed on two consecutive days, where residents did not receive the pureed cornbread as specified in their dietary plan. The Dietary Manager confirmed in an interview that the pureed diets were not served the appropriate cornbread, indicating a failure to follow the planned menu and meet the nutritional needs of the residents as required.
Food Safety and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations and interviews. A personal drink was found in the reach-in freezer, which was confirmed by the dietary staff as inappropriate. In the walk-in refrigerator, a pan of pureed rib meat was not fully covered or dated, and a pan of taco soup was available for consumption despite being dated 02/27/2025. Additionally, large containers of powdered mashed potatoes were found with scoops and handles improperly stored inside. Dishes were stored in an upright position rather than inverted, which was noted by the dietary manager. Further deficiencies were observed during meal service. Dietary staff were seen handling food with gloved hands after touching various items without changing gloves. A bag of chips that fell on the floor was picked up and handled without changing gloves, and the same gloves were used to continue food preparation. During lunch service, cornbread was served with gloved hands that had touched other items, and a dietary staff member continued to serve food after cleaning a spill without changing gloves. Additionally, hamburger meat was observed thawing improperly in standing water without cold water running over it. These findings were communicated to the dietary manager.
Unsafe Mechanical Equipment in Kitchen
Penalty
Summary
The facility failed to ensure that mechanical equipment was in safe operating condition, specifically a manual can opener in the kitchen. During an observation on March 9, 2025, at 8:00 a.m., it was noted that there was a buildup of metal shavings on the large mechanical can opener. An interview with a cook confirmed the presence of these metal shavings. This deficiency affected the preparation of 168 diets served from the kitchen.
Ant Infestation in Kitchen's Dry Pantry Area
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in the dry pantry area. During an observation on March 9, 2025, at 7:45 a.m., small black ants were found on large containers of grits and sugar in the kitchen's dry food storage area. S5Cook confirmed the presence of the ants and acknowledged that the facility had been experiencing issues with them. This deficiency had the potential to affect the 168 residents receiving meals from the kitchen.
Failure to Document Discharge Summary
Penalty
Summary
The facility failed to document a discharge summary for a resident who was discharged from the facility. The resident, who had a history of cerebral infarction, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, morbid obesity, epilepsy, and type 2 diabetes mellitus, required partial to moderate assistance with activities of daily living according to their Admission Minimum Data Set (MDS) assessment. The resident was discharged home, but the facility did not complete the necessary discharge summary documentation. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Provide Dignified Care and Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity, impacting their quality of life. Resident #143, who has moderate cognitive impairment and is dependent on staff for activities of daily living, was observed sitting in a high back wheelchair with a disposable brief used as a cushion behind his head. This observation was made on 03/09/2025, and the Director of Nursing was informed of this inappropriate use of a disposable brief on 03/11/2025. Resident #14, also with moderate cognitive impairment and a self-care deficit due to Parkinson's disease, was observed eating breakfast in the main dining room. Pieces of his meal were found on the table, and he was seen picking them up with his hands and eating directly from the table. Despite the presence of an LPN and two CNAs in the dining area, no assistance was offered to the resident. The Assistant Director of Nursing and the Director of Nursing were notified of this incident, confirming that staff should have assisted the resident with his meal.
Infection Control Breach in Laundry Department
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry department, which led to a deficiency in infection prevention and control. During an observation, two laundry workers were found in the clean laundry room, where one worker placed a personal cell phone directly on a table used for folding clean clothing and linen items. This action was confirmed by the worker, who acknowledged that the table was designated for clean items. A second table in the same room also had a cell phone lying on it, which was confirmed by another laundry worker to be used for folding resident items. The laundry supervisor was informed of these observations and confirmed that personal belongings should not be placed on these tables due to the risk of cross-contamination. The facility administrator was also notified of these findings.
Medication Administration Error
Penalty
Summary
The facility failed to provide services that met professional standards during medication administration for a resident. Specifically, a Licensed Practical Nurse (LPN) administered the incorrect dosage of Nifedipine Extended Release (ER) to a resident. The resident's physician's orders specified a dosage of 90 mg daily, but the LPN administered a 30 mg tablet. The LPN did not verify the medication card label against the Electronic-Medication Administration Record (e-MAR) before administration, leading to the error. The discrepancy was confirmed during a review of the resident's medication card and physician's orders, and the LPN acknowledged the mistake. Further investigation revealed that the incorrect dosage was filled by the pharmacy due to a nurse sending in a label from a previously discontinued dosage. The Director of Nursing (DON) confirmed that the LPN did not follow the facility's Medication Administration Policy and Procedure, which requires verifying that the medication selected matches the order and label, and ensuring the medication is administered at the prescribed dose. The resident involved had multiple diagnoses, including cerebral infarction, pressure ulcer, hemiplegia, type 2 diabetes mellitus, and hypertension.
Incorrect Medication Dosage Administered
Penalty
Summary
The facility failed to accurately obtain pharmaceutical services for a resident, resulting in the administration of an incorrect medication dosage. Resident #90, who has a medical history including cerebral infarction, dysphagia, pressure ulcer, hemiplegia, type 2 diabetes mellitus, and hypertension, was observed receiving Nifedipine ER 30 mg instead of the prescribed Nifedipine ER 90 mg. This error occurred because a nurse sent in a label from a previously discontinued dosage, leading the pharmacy to fill the incorrect medication. The Director of Nursing confirmed the error and acknowledged that the resident should have been receiving the correct dosage of 90 mg daily.
Failure to Follow Dietary Orders and Preferences
Penalty
Summary
The facility failed to ensure dietary orders were followed for two residents who had orders for mighty shakes and dietary preferences were followed for one resident. Resident #38, who had multiple diagnoses including end-stage renal disease and type 2 diabetes, did not receive the prescribed mighty shakes during observed meals. Despite the availability of mighty shakes in the refrigerator, the dietary staff did not place them on the meal carts, and the CNAs did not provide them to the resident, stating that the residents do not drink them anyway. Similarly, Resident #62, who had diagnoses including bilateral above-the-knee amputation and vascular dementia, also did not receive the prescribed mighty shakes during observed meals. The dietary card indicated that mighty shakes were to be served, but they were not included on the meal trays. The Culinary Supervisor confirmed that the dietary department should have placed the mighty shakes on the meal carts, but this was not done. Resident #73, who was cognitively intact and had a preference for wheat bread, was consistently served white bread instead. Despite the resident's repeated requests and the availability of wheat bread, the dietary staff continued to serve white bread. The Culinary Supervisor confirmed that the resident should have been served wheat bread according to her preference, but this was not followed during the observed meals.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions, as observed during an initial tour and subsequent inspection of the kitchen. Observations included a large build-up of grease and grime in the lower compartments of small and large deep fryers, old food particles and sticky build-up on a large toaster, and unlabeled opened bags of pasta in the Dry Storage Area. Additionally, two small microwaves on top of covered dietary carts were found with old food particles on the bottom, top, and sides. The Culinary Supervisor confirmed the lack of labeling on the food items and the need for cleaning the kitchen appliances.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. The resident, who was admitted with diagnoses of unspecified dementia and cerebral infarction, had a severely impaired cognitive status and required supervision to moderate assistance for most activities of daily living. The paper medical record indicated that the resident's code status was Full Code, as signed by a family member, while the electronic medical record and a physician's order indicated a Do Not Resuscitate (DNR) status. This discrepancy was not known to the Director of Nursing (DON) until it was pointed out during the survey. The facility's Advance Directive Policy and Procedure required that any changes to an advance directive be communicated to the DON to ensure that physician orders are carried out and the resident's medical record is updated accordingly. However, in this case, the DON was unaware of the inconsistency between the paper and electronic records. This failure to maintain consistent and accurate records regarding the resident's code status led to a deficiency in honoring the resident's right to request, refuse, and/or discontinue treatment as per their advance directive.
Failure to Address Resident's Positioning Needs
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #69, who was admitted with diagnoses of Parkinson's disease, cerebrovascular disease, and unspecified dementia, required staff assistance for all activities of daily living (ADLs). Despite the care plan being revised to include assistance with repositioning while in her wheelchair, multiple observations revealed that the resident's positioning needs were not addressed in a timely manner. The resident was frequently found in a high back wheelchair with a soft lap tray that was tilted to the right, and her feet were not supported by the wheelchair footrest. Additionally, the lap tray had a rough edge due to a tear, and the footrest was improperly positioned, causing discomfort and improper support for the resident's feet. Interviews with staff members, including a CNA and an LPN, confirmed ongoing issues with the resident's wheelchair and lap tray positioning. The CNA reported difficulty in adjusting the footrest, while the LPN acknowledged the persistent problem with the lap tray slanting and the footrest not providing adequate support. The Director of Nursing (DON) was informed of these concerns and confirmed that the facility had failed to address the resident's positioning needs in a timely manner. These findings indicate a deficiency in the facility's ability to provide appropriate treatment and care according to the resident's care plan and professional standards of practice.
Medications Left at Bedside for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident and adhered to state and federal requirements. Specifically, medications were left at the bedside for a resident with moderate cognitive impairment. The resident, who had a Brief Interview Mental Status (BIMS) score of 10, was observed with a cup of pills on the bedside table while waiting for breakfast. The resident had multiple diagnoses, including cerebral infarct, type 2 diabetes, hypertension, chronic atrial fibrillation, end-stage renal disease requiring dialysis, systolic congestive heart failure, history of cardiac arrest, hypotension, chronic metabolic acidosis, and dysphagia. An LPN confirmed that the medications were administered at 6:00 a.m. before her arrival and should not have been left at the bedside. The Director of Nursing also confirmed that medications should not be left at the bedside.
Failure to Maintain Safe Operating Condition of Wheelchair Lap Tray
Penalty
Summary
The facility failed to ensure all patient care equipment was maintained in safe operating condition by not repairing a wheelchair lap tray in a timely manner for a resident with Parkinson's disease, cerebrovascular disease, and unspecified dementia. The resident required moderate to maximal assistance for most activities of daily living (ADLs) and had a care plan intervention for a wheelchair with a lap tray. Observations over two days revealed the lap tray was tilted to the right and had a tear in the right corner of the plastic overlay, causing a rough edge. Additionally, a blue substance was found under the torn area, which the resident was picking at with her right hand, resulting in the substance being on her fingers. An interview with an LPN revealed that the issue with the lap tray slanting had been ongoing, and the tear was noted on the Nurses' Report Form. However, the LPN was unsure if maintenance was aware of the need for repair or replacement. The Director of Nursing confirmed that the concerns with the lap tray, including the tear, the blue substance, and the tilting, should have been addressed and repaired. The failure to repair the lap tray in a timely manner compromised the safety and comfort of the resident.
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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