Pelican Pointe Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Maurice, Louisiana.
- Location
- 405 Milton Road, Maurice, Louisiana 70555
- CMS Provider Number
- 195342
- Inspections on file
- 21
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pelican Pointe Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident, who was cognitively intact, reported that CNAs were not responding promptly to her call bell, affecting her ability to use the restroom. Despite the grievance being acknowledged by the DON and an LPN, there was no evidence of a thorough investigation, violating the facility's grievance policy.
A facility failed to accurately code a resident's MDS for anticoagulant use. The MDS indicated anticoagulant use, but a review of physician orders showed no such medication was prescribed. A staff member confirmed the resident had not received anticoagulants and acknowledged the coding error.
A facility failed to include a physician's order for an AFO brace in a resident's care plan. The resident, with a history of cerebral infarction and hemiplegia, was observed with the brace, but staff interviews revealed no order was issued by the therapy department, and nursing staff were unaware of any order. This oversight resulted in a deficiency in the resident's care plan.
A resident with impaired cognition and mobility issues fell while transferring from bed to wheelchair due to wearing regular socks instead of nonskid socks. The facility failed to update the care plan to include nonskid socks as a fall prevention measure, despite acknowledging the improper footwear as a factor in the fall. Interviews revealed the resident lacked access to clean nonskid socks, underscoring the oversight.
A facility failed to document daily assessments of a resident's dialysis site, as required by their care plan and facility policy. The resident, with Chronic Kidney Disease and End Stage Renal Disease, had a hemodialysis catheter and received dialysis three times a week. However, the nursing staff only assessed the site upon the resident's return from dialysis, not daily, which was confirmed by both an LPN and the DON.
A resident with a cognitive score indicating intact mental status reported a bruise caused by CNAs during a shower. The LPN observed the bruise but did not document or report it, assuming it was due to repositioning. The DON was unaware of the incident until informed by a surveyor and confirmed the bruise's presence, acknowledging the need for documentation and reporting.
A resident with severe cognitive impairment and multiple diagnoses was not provided with the required divided plate or bowl during meal times, as observed in a survey. The facility's policy mandates adaptive eating devices for those who need them, but the resident was seen eating from a regular plate, confirmed by an LPN and the Dietary Manager.
The facility failed to follow professional standards for food service safety by not labeling and cleaning opened refrigerated food items in the kitchen. Items such as sweet and sour sauce, Italian dressing, sour cream, nectar thick liquid, and ham base were found opened and unlabeled. The Dietary Manager confirmed these findings, acknowledging the oversight, which could potentially impact the 115 residents consuming food from the kitchen.
A resident with ESBL and a UTI was not provided with appropriate PPE while on contact precautions. The resident was observed moving through the facility and participating in therapy without PPE, contrary to the facility's policy. The infection preventionist confirmed the oversight, and the occupational therapist was unaware of the precautions.
A resident with moderate cognitive impairment and mobility issues was found to have a bed with a 6-inch gap between the mattress and assist bars, posing a safety risk. The facility failed to adjust the bed frame after replacing a bariatric mattress with a regular-sized one, and lacked a process to assess mattress compatibility, leading to the deficiency.
The facility failed to coordinate hospice care for four residents, not providing them with a choice of hospice provider and lacking necessary documentation such as hospice plans of care and certifications. Additionally, the facility did not notify the hospice agency of an alleged abuse incident involving a resident. These deficiencies were confirmed through interviews and record reviews, highlighting lapses in communication and documentation.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure that all grievances were thoroughly investigated, as evidenced by the case of a resident who voiced concerns about the response time of CNAs to her call bell. The resident, who was cognitively intact with a BIMS score of 15, expressed her grievance on September 25, 2024, stating that CNAs were not responding quickly enough to assist her to the restroom, and she did not want to use a brief when she could go to the restroom. Despite the resident's clear communication of her needs, the facility did not conduct a thorough investigation into her grievance. Interviews with the Director of Nursing (DON) and an LPN revealed that while the resident's grievance was acknowledged, there was no evidence of a comprehensive investigation. The DON admitted to speaking with the resident but could not recall specific details about the CNA involved or the shift in question. Similarly, the LPN confirmed speaking with the resident but was unable to provide documentation of any investigative efforts. This lack of documentation and follow-through indicates a failure to adhere to the facility's grievance policy, which mandates thorough investigation and resolution of resident grievances.
MDS Coding Error for Anticoagulant Use
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) regarding anticoagulant use. Specifically, the MDS for a resident indicated that they were taking anticoagulants, but a review of the resident's August 2024 physician orders did not show any order for such medication. During an interview, the staff member responsible for the MDS confirmed that the resident had not received any anticoagulant medication and acknowledged making an error in coding the resident for anticoagulant use.
Lack of Physician's Order for AFO Brace
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, specifically regarding the use of an Ankle Foot Orthosis (AFO) brace. The resident, who was admitted with diagnoses including Cerebral Infarction and Hemiplegia and Hemiparesis of the right dominant side, was observed with an AFO brace on the right lower leg. However, there was no physician's order for the brace in the resident's clinical record. Interviews with staff, including a CNA, a PT, and two LPNs, revealed that the therapy department did not issue an order for the AFO brace, and the nursing staff were unaware of any such order. This lack of documentation and communication led to the deficiency in the resident's care plan.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident, which was a deficiency identified during the survey. The resident, who had moderately impaired cognition and used a wheelchair or walker for mobility, was at risk for falls due to unsteadiness and medication use. The care plan initially included interventions such as anti-rollbacks for the wheelchair, a clutter-free pathway, and reminders to ask for assistance during transfers. However, after the resident fell while attempting to transfer from bed to wheelchair due to wearing regular socks instead of nonskid socks, the care plan was not updated to address this specific risk factor. The incident report and progress notes indicated that the resident slipped because of improper footwear, specifically the lack of nonskid socks, which was acknowledged by the staff. Despite this, the care plan was not revised to include the use of nonskid socks as a fall prevention measure. Subsequent interviews with the resident revealed that he did not have access to clean nonskid socks, as they were in the laundry, further highlighting the oversight in updating the care plan to ensure the resident's safety.
Failure to Document Daily Dialysis Site Assessment
Penalty
Summary
The facility failed to ensure that a resident received dialysis care consistent with accepted professional standards and the resident's comprehensive person-centered care plan. Specifically, the nursing staff did not document the daily assessment and monitoring of the resident's dialysis site. The facility's policy required the dialysis site to be assessed and monitored for bleeding or abnormalities as ordered by the physician. However, a review of the resident's electronic health record revealed no evidence of such assessments being documented. The resident in question was admitted with diagnoses including Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis. The care plan indicated that the resident received dialysis three times a week and had a double lumen tunneled hemodialysis catheter placed. Despite this, the nursing staff only assessed the dialysis access site upon the resident's return from the dialysis center and documented it on the dialysis communication form, rather than daily as required. This was confirmed by both an LPN and the Director of Nursing, who acknowledged the lack of documented evidence for daily assessments.
Failure to Assess and Report Resident Bruise
Penalty
Summary
The facility's nursing staff failed to demonstrate appropriate competency and skills by not assessing and reporting a bruise on a resident's forearm. The resident, who was cognitively intact with a BIMS score of 15, reported that the bruise was caused by CNAs pulling on her arm during a shower. Despite observing the bruise, the LPN did not document an assessment or report the incident, believing the CNAs were merely trying to reposition the resident. The Director of Nursing (DON) was unaware of the bruise until it was pointed out by the surveyor. Upon inspection, the DON confirmed the presence of a large purple bruise on the resident's right forearm. The resident reiterated that the bruise occurred 3 to 4 days prior during a shower when a CNA pulled on her arm. The DON acknowledged that the nurse should have documented the bruise and reported the incident.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide an assistive device at meal times for a resident who required it, as observed during a survey. The facility's policy on adaptive eating devices mandates that such devices be available for those who need them, and that the food service department is responsible for ensuring each resident receives the appropriate feeding devices. However, during an observation, a resident with severe cognitive impairment and multiple diagnoses, including aphasia, dysphagia, and Parkinson's disease, was seen eating from a regular plate instead of the required divided plate or bowl. This resident's care plan specifically noted the need for a divided high-sided plate or bowl due to their risk for weight fluctuations and malnutrition. The deficiency was confirmed through interviews with facility staff, including an LPN and the Dietary Manager, who acknowledged that the resident should have been served with a divided plate or bowl. The resident's dietary card also indicated the need for a divided plate or bowl, which was not provided during the observed meal. This oversight highlights a failure in the facility's procedure to ensure that adaptive devices are provided as required by the resident's care plan and dietary card.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not properly storing, preparing, distributing, and serving food. During an observation of the kitchen's walk-in cooler, several refrigerated food items were found opened, used, and not labeled with the date they were opened. These items included a container of sweet and sour sauce with sticky residue on the outside, a container of Italian dressing, a container of sour cream, two plastic bottles of nectar thick liquid, and a container of ham base. The Dietary Manager confirmed these findings and acknowledged that all opened food items should have been cleaned and labeled with an open date, which was not done. This deficiency had the potential to affect the 115 residents who consumed food prepared in the kitchen.
Failure to Enforce Contact Precautions for Resident with ESBL
Penalty
Summary
The facility failed to ensure that appropriate personal protective equipment (PPE) was worn by staff and a resident who was on contact transmission-based precautions. This deficiency was observed in the case of a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) Resistance and a urinary tract infection (UTI). The resident's care plan required contact precautions, including the use of gowns and gloves for interactions that might involve contact with the resident or potentially contaminated areas. Despite these requirements, the resident was observed propelling herself in a wheelchair down the hall and into the dining hall without PPE, and later participating in therapy in the gym without PPE, in the presence of other residents and staff. The facility's infection preventionist confirmed that the resident was on contact precautions and should have had therapy conducted in her room. However, the occupational therapist working with the resident was unaware of the contact precautions and allowed the resident to participate in therapy in the gym. The infection preventionist and corporate registered nurse verified that the resident's room had a sign indicating contact precautions, but the precautions were not followed, leading to the deficiency.
Improper Mattress Fit Leads to Safety Deficiency
Penalty
Summary
The facility failed to conduct regular inspections of beds for proper mattress fit, leading to a deficiency involving a resident. The resident, who was admitted with conditions including insomnia, atrial fibrillation, a history of falling, and a healing femur fracture, was found to have a bed with a significant safety issue. Observations revealed a 6-inch gap between the mattress and the assist bars on both sides of the bed, indicating that the mattress was too small for the bed frame. This gap was confirmed by facility staff, who acknowledged that the bed frame had been extended to accommodate a bariatric mattress, but the mattress had been replaced with a regular-sized one without adjusting the frame. The resident's medical records indicated moderate cognitive impairment and a need for substantial assistance with mobility, making the proper fit of the mattress crucial for safety. The facility's lack of a process to assess beds for mattress incompatibility contributed to this oversight. The owner's manual for the bed model used by the facility warned of potential hazards from incompatible mattresses, emphasizing the need for accurate assessment and monitoring to prevent entrapment. Despite these warnings, the facility did not have measures in place to ensure the correct mattress size was used, resulting in the identified deficiency.
Failure to Coordinate Hospice Care and Notify of Abuse
Penalty
Summary
The facility failed to coordinate hospice care services for four residents, as evidenced by the lack of choice in hospice provider, missing documentation, and failure to notify the hospice agency of an alleged abuse incident. Residents and their responsible parties were not given the option to choose from different hospice providers, as the facility directed them to use their contracted hospice service. This lack of choice was confirmed through interviews with the responsible parties of the residents. Additionally, the facility did not maintain up-to-date hospice documentation for the residents. The electronic health records (EHR) of the residents lacked recent hospice care conference summary reports, initial certifications, and recertifications of terminal illness, as well as hospice plans of care (POC). The Assistant Director of Nursing confirmed that these documents were not current and were not scanned into the EHR, indicating a failure in maintaining proper records. Furthermore, the facility did not notify the hospice agency of an alleged abuse incident involving one of the residents. The Director of Nursing and the Administrator confirmed that the hospice company should have been informed about the incident, but there was no documentation to indicate that this notification occurred. This oversight highlights a significant lapse in communication and coordination with the hospice agency, which is crucial for the residents' care and safety.
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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