Our Lady Of Wisdom Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 5600 General Degaulle Dr, New Orleans, Louisiana 70131
- CMS Provider Number
- 195509
- Inspections on file
- 21
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Our Lady Of Wisdom Community Care Center during CMS and state inspections, most recent first.
A resident with insomnia did not consistently receive prescribed Doxepin HCl at the scheduled time, with multiple documented instances of late administration well beyond the facility's one-hour policy window. The DON confirmed these delays, which were not in accordance with physician orders.
A resident with bilateral heel deep tissue injuries did not have heel protectors applied while in bed as ordered by the physician and outlined in the care plan. Multiple observations and interviews confirmed the devices were not used, and documentation was lacking to show compliance with the prescribed treatment.
Surveyors observed that a portable electric fan in the Hall B Mini Pantry had an accumulation of a light gray unknown substance on its grill. Both the Food Safety Manager and the Administrator confirmed that the fan should have been kept clean and sanitary, but it was not maintained appropriately, resulting in a deficiency related to food service area sanitation.
Two residents who were dependent on staff for toileting and had intact cognition were not provided incontinence care as requested before meal service. Despite staff being notified of their requests, care was withheld due to a practice of not providing incontinence care during meal times. Both residents were brought to the dining area and ate lunch without having their incontinence needs addressed, contrary to facility policy and their expressed preferences.
A CNA applied a medicated steroid ointment to a resident after receiving it from an LPN, despite facility policy requiring only licensed personnel to administer medications. Interviews with facility leadership confirmed that CNAs are not permitted to apply medicated ointments, and the practice was not in line with professional standards.
Two residents who were dependent on staff for toileting and incontinent care experienced significant delays in receiving assistance after requesting to be changed. Despite activating call lights and directly asking staff for help, both residents remained in soiled briefs for over two hours, as staff did not provide incontinence care during meal service. Staff interviews confirmed this practice, and both residents expressed discomfort with the delay.
Surveyors found medicated ointments and lotions, including Ammonium Lactate Lotion and Mometasone Furoate Ointment, stored in unlocked supply cabinets accessible to unauthorized individuals. Staff interviews revealed that these medications were not properly secured or labeled, and a CNA admitted to placing a resident's ointment in an unlocked cabinet due to an inability to administer it at the time. The facility administrator confirmed that these items should have been kept in locked storage.
A facility failed to ensure proper infection control practices during incontinent care for a resident. A CNA was observed not removing gloves or performing hand hygiene before using a clean wipe on a resident. Both the CNA and the DON acknowledged the lapse in protocol.
The facility failed to ensure food was not expired and stored in a sanitary manner, with expired items and improperly labeled food found in the pantry. Additionally, a nutritional supplement was not stored per manufacturer's guidelines, being left unrefrigerated and without a time of opening. The Food Service Manager and DON confirmed these deficiencies.
A facility failed to ensure a resident's advance directive was accurately reflected in their medical record, resulting in a discrepancy between the electronic medical record (EMR) and the physical chart. The EMR indicated a Do Not Resuscitate (DNR) order, while the physical chart showed a Full Code order. This inconsistency was confirmed by the S3MDS Nurse and the Director of Nursing (DON).
A resident's PEG tube feeding pole was observed to be unstable and leaning, posing a risk of falling over. Despite multiple observations of the issue, the equipment was not removed from service. Interviews with staff confirmed the equipment's instability and the oversight in addressing the problem.
A facility failed to accurately document the disposal of a controlled medication for a resident. The facility's policy requires that when a medication is not administered, it should be destroyed and documented by two nurses. However, a discrepancy was found in the records for a resident prescribed Norco, where a tablet was wasted but not documented, leading to an inaccurate count of the medication.
Failure to Administer Medication Timely
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for one resident. According to the facility's Medication Administration policy, medications are to be given within one hour of the prescribed time unless otherwise specified. Review of the clinical record for a resident with a diagnosis of insomnia showed a physician's order for Doxepin HCl 30mg to be administered at bedtime, specifically scheduled for 8:00PM. The resident's care plan also included an intervention to administer medications as ordered by the physician. Interviews and record reviews revealed that the resident frequently did not receive the sleeping medication on time, with administration times often significantly delayed. The medication administration audit report documented multiple instances where the medication was given more than one hour after the scheduled time, including some occasions where it was administered several hours late, such as after midnight or even in the early morning. The Director of Nursing confirmed these late administration times and acknowledged that the medication should not have been given so late.
Failure to Apply Ordered Heel Protectors for Pressure Ulcer Prevention
Penalty
Summary
A resident with a history of deep tissue injury to both heels was admitted to the facility and had a physician's order, as well as a care plan directive, for bilateral heel protectors to be applied while in bed. The resident was cognitively intact and dependent on staff for lower body footwear. Review of the electronic Medication Administration Record for the relevant month showed no documented evidence that heel protectors were applied as ordered. Multiple observations over several days revealed the resident lying in bed without heel protectors, with the devices found on a shelf in the room instead. The resident confirmed in interviews that staff had not been applying the heel protectors. The DON also acknowledged that the resident should have had the heel protectors on as ordered. There was no documentation or evidence provided by the facility to show that the physician's order and care plan were followed.
Unsanitary Portable Fan in Mini Pantry
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Hall B Mini Pantry, as observed by surveyors. During an inspection, a portable electric fan in the Hall B Mini Pantry was found to have an accumulation of a light gray unknown substance on its grill. This observation was confirmed by the Food Safety Manager, who acknowledged that the fan should have been kept clean and sanitary. The Administrator also confirmed that the fan should have been maintained in a clean condition. The deficiency was identified based on direct observation and staff interviews, with reference to the 2022 FDA Food Code regarding the importance of clean ventilation equipment in food service areas. No residents or specific patient conditions were mentioned in relation to this deficiency.
Failure to Provide Timely Incontinence Care Prior to Meals
Penalty
Summary
Staff failed to provide incontinence care to two residents as requested prior to meal service, resulting in a lack of dignity and respect for their needs. Both residents had intact cognition and were dependent on staff for toileting due to mobility impairments and incontinence. The facility's policy required staff to check and provide incontinence care after each episode, but this was not followed in these instances. For one resident, the call light was activated to request a change before lunch. A staff member entered, turned off the call light, and stated help would be provided, but no care was given. The resident's request was relayed to the nurse and CNA, but the CNA did not provide care, stating that incontinence care was not performed during meal service. The resident remained unchanged through lunch, despite multiple staff being aware of the request. The second resident also requested to be changed before being brought to the dining area. The CNA acknowledged hearing the request but did not address it, instead bringing the resident to the dining table without providing care. Staff interviews confirmed that it was common practice not to provide incontinence care during meal times, citing infection control concerns. Both residents expressed a preference not to attend meals without being changed, and staff acknowledged that they would not want to be in a similar situation themselves.
Unlicensed Staff Administered Medicated Ointment
Penalty
Summary
The facility failed to ensure that only licensed personnel administered medications, as required by their policy and professional standards. During an observation, a cup containing a clear ointment was found in a cabinet, and a Certified Nursing Assistant (CNA) reported that she had applied the ointment to a resident's chest, abdomen, and groin. The CNA stated she had received the ointment from an LPN, who confirmed that the ointment was Mometasone Furoate 0.1%, a medicated steroid cream prescribed for the resident's psoriasis. The LPN indicated that it was common practice in the facility for CNAs to apply medicated ointments, despite the facility's policy stating only licensed or permitted individuals may administer medications. Interviews with the Interim Director of Nursing and the Minimum Data Set Clinical Coordinator confirmed that CNAs were not permitted to apply medicated ointments to residents. The administrator also acknowledged that the LPN should not have given the medicated ointment to the CNA for application. The resident involved had a physician's order for the medicated ointment to be applied once daily for psoriasis, but the administration of this medication by unlicensed staff was not in accordance with facility policy or professional standards.
Failure to Provide Timely Incontinence Care During Meal Service
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for toileting and personal hygiene. Both residents had care plans indicating total assistance was required for toileting due to mobility impairments and incontinence of bowel and bladder. Despite activating their call lights and directly requesting assistance from staff, both residents experienced significant delays in receiving incontinence care. For one resident, the call light was activated prior to lunch to request a change after a bowel movement. Although a staff member acknowledged the request and notified the appropriate personnel, the resident was not changed until over two hours later, after lunch had been served and meal trays were removed. During this period, the resident remained in soiled briefs, and staff interviews confirmed that incontinence care was not provided during meal service. The second resident also requested to be changed before being brought to the dining area for lunch. The request was acknowledged by staff, but the resident was taken to the dining room and left to eat lunch without being changed. The resident remained in soiled briefs for an extended period, with incontinence care not provided until more than two hours after the initial request. Staff interviews revealed a practice of not providing incontinence care during meal times, and both residents expressed discomfort and dissatisfaction with the delays.
Failure to Secure Medicated Ointments and Lotions in Locked Storage
Penalty
Summary
Surveyors observed that medicated ointments and lotions were not stored in locked compartments as required by facility policy and professional standards. Specifically, a bottle of Ammonium Lactate Lotion 12% was found on a shelf inside an unlocked supply cabinet accessible to residents, visitors, and unauthorized personnel. The prescription label on the bottle was partially removed, leaving no identifiable resident information or prescription number. Staff interviewed were unable to explain why the lotion was stored in this manner. Additionally, a medication cup containing a clear ointment was found in another unlocked cabinet. The cup had no identifying information, and a CNA admitted to placing it there because she was unable to apply the ointment to a resident at the time, believing the cabinet was a safe place for storage. An LPN confirmed that the ointment was Mometasone Furoate 0.1%, prescribed for a resident with psoriasis. The facility administrator acknowledged that these medicated products should have been stored in locked compartments and not in accessible supply cabinets.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident. During an observation, a Certified Nurse Assistant (CNA) was seen unfastening a resident's adult brief while wearing gloves but did not remove the gloves or perform hand hygiene before obtaining a clean wipe to clean the resident's buttock. The CNA acknowledged the failure to remove dirty gloves and perform hand hygiene before continuing care. The Director of Nursing also acknowledged that the CNA should have removed the dirty gloves, performed hand hygiene, and applied clean gloves.
Deficiencies in Food Storage and Nutritional Supplement Handling
Penalty
Summary
The facility failed to ensure that food was not expired and was stored in a sanitary manner. During an observation of the storage pantry, several expired food items were found, including packages of refried beans, a container of taco sauce, bread crumbs, and enchilada sauce. Additionally, an opened and undated container of blue cheese dressing was observed with an unidentified creamy and green fuzzy substance on its rim and outside. An undated open box of small pastries was also found without proper labeling. The Food Service Manager confirmed the presence of expired food and the unsanitary condition of the blue cheese dressing container, acknowledging that the pastries should have been dated and labeled. The facility also failed to store a nutritional supplement according to the manufacturer's guidelines. An LPN reported finding an opened carton of Med Pass 2.0 nutritional supplement on a medication cart without knowing when it was opened. The supplement was observed unrefrigerated and without a time of opening, despite the manufacturer's instructions to use it within 4 hours if not refrigerated. The DON confirmed that the supplement should have been labeled with the date and time of opening and discarded if not used within the specified time frame. The unrefrigerated supplement should not have been available for use on the medication cart.
Discrepancy in Resident's Code Status Orders
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was accurately reflected in their medical record. Specifically, there was a discrepancy in the code status orders for Resident #355. The electronic medical record (EMR) contained an order for Do Not Resuscitate (DNR), while the physical chart had an order for Full Code. This inconsistency was confirmed during interviews with the S3MDS Nurse and the Director of Nursing (DON), both of whom acknowledged that there should not have been a discrepancy in the resident's code status orders.
Unsafe PEG Tube Feeding Pole for Resident
Penalty
Summary
The facility failed to ensure that a resident's percutaneous endoscopic gastrostomy (PEG) tube feeding pole was in safe operating condition. Resident #46, who was dependent on staff for all activities of daily living and received all nutrition via a PEG tube, was observed multiple times with a feeding pole that leaned to the side and swayed back and forth when touched. This was noted during observations on four separate occasions, indicating a consistent issue with the stability of the equipment. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that the equipment was unstable and should have been removed from service. The DON acknowledged that the PEG tube feeding pole was significantly leaning and had the potential to fall over, which was not addressed by the nursing staff. This oversight in maintaining essential equipment in safe working condition led to the deficiency identified in the report.
Inaccurate Documentation of Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain an accurate count of controlled medications for one of the residents reviewed for pharmaceutical services. According to the facility's Controlled Substance policy, when a resident's medication is not administered, it should be destroyed and documented by two nurses on the resident's individual narcotic record. However, a discrepancy was found in the medication records for a resident who had an order for Norco (Hydrocodone-Acetaminophen) 5-325 mg to be administered every 8 hours for pain. On a specific date, the records indicated an incorrect count of the remaining tablets after administration. The Director of Nursing (DON) confirmed that there was a discrepancy in the controlled substance record for the resident's Hydrocodone-Acetaminophen tablets. It was noted that a tablet was wasted by the nurse but was not documented on the resident's individual controlled substance record as required by the facility's policy. This failure to document the wastage of medication led to an inaccurate count of the controlled substances, which was not in compliance with the facility's procedures for handling controlled medications.
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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