Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pierremont Healthcare Center during CMS and state inspections, most recent first.
Failed Room and Bathroom Call Light Functionality: Two residents had nonworking light/call equipment. One resident with intact cognition reported the wall light by the bed did not work, and surveyors observed the light was missing the pull cord and switch. Another resident with moderately impaired cognition had a bathroom emergency call light that did not activate the call system when pulled, and staff confirmed it was not working.
Failure to provide ordered splinting and ROM services for two residents with CVA-related hemiplegia and impaired ROM. One resident had a contracted right hand with the splint left on the bedside table during observations, while the other resident had no documented splint application for 30 days and was repeatedly observed in bed without the ordered hand splint in place; staff confirmed the order existed and the resident did not have the splint.
A resident identified as an unsafe smoker was observed with a lighter and cigarettes kept in his room and was seen smoking outside without staff present. Although his care plan required supervision while smoking, a smoking apron, and staff control of smoking supplies, staff reported he was often allowed to keep his own cigarettes and lighter because he became angry when they tried to take them. Interviews also confirmed quarterly smoking safety evaluations were not completed, and an LPN said she did not know the resident’s smoking status.
Improper Storage of Resident Food in Snack Refrigerators: Resident snack/nourishment refrigerators contained multiple food items that were unsealed, unlabeled, and undated, including eggs, applesauce, chicken salad, cranberry cocktail, a covered plate of food, and thickened apple juice. The DON, ADON, and an LPN observed the items and confirmed they should have been sealed, labeled with the resident name, and dated when placed in the refrigerator, but were not.
Missed Suprapubic Catheter Care: A resident with quadriplegia, urinary retention, UTI, and neurogenic bladder had an order for suprapubic catheter care every shift and PRN, but the TAR showed multiple missed documented care episodes across day and night shifts. During interview, the DON acknowledged the missed catheter care entries.
A resident with dysphagia, DM2, malnutrition, and a gastrostomy had continuous enteral feeding in progress with Jevity 1.5 at 60 cc/hr while lying in bed with HOB elevated 30 degrees. The feeding container and the H2O flush bag were not labeled with the date and time they were prepared, and an LPN confirmed they should have been.
A resident with moderately impaired cognition suffered a hand fracture after a CNA allegedly bent her fingers back in frustration during care. The incident was reported by the resident the following morning, and an x-ray confirmed the injury. The resident consistently identified the CNA responsible, and the case was reported to the DON, Administrator, and police.
A resident with moderately impaired cognition and resistive to care reported pain in her hand, alleging a staff member bent her fingers back. A CNA and an LPN failed to report the allegation to the abuse coordinator as required by facility policy. The LPN assessed the resident and found no physical signs of abuse, leading to the incident not being reported immediately. The facility's administration later acknowledged the failure to report the potential abuse.
The facility failed to implement fall prevention interventions in baseline care plans for three residents assessed as at risk for falls. Despite being identified as high or moderate risk, interventions were not included in their baseline care plans upon admission, only being added to comprehensive care plans days later. This oversight was confirmed by facility staff, indicating a lapse in adhering to the facility's fall prevention policy.
A facility failed to implement a comprehensive care plan for a resident at moderate risk for falls. The resident's care plan included only two interventions, lacking essential measures like bed positioning and call light accessibility. MDS Coordinators acknowledged the omission, which did not align with the facility's Fall Prevention Program policy.
A resident at risk for pressure ulcers was admitted to the hospital with severe infections due to inadequate care at the facility. The resident's heel dressing, dated months prior, was not removed, and weekly skin assessments were missed. Staff failed to remove heel protector boots during care, preventing proper skin evaluation. The resident developed sepsis and required intensive care and surgical intervention.
A resident under transmission-based precautions did not receive timely skin assessments and proper ADL care, leading to hospitalization with severe conditions including sepsis and infected pressure ulcers. The facility lacked a process to ensure accurate weekly skin assessments, contributing to the oversight.
An LPN in an LTC facility left medications for two residents to self-administer without ensuring they were assessed for this capability, contrary to the facility's policy. The residents confirmed this was a regular practice, and their medical records lacked the necessary assessments.
The facility failed to assess residents for entrapment risk and obtain informed consent before installing bed rails. Nine residents were observed using assist rails without documented assessments or consents, despite facility policy requirements. Staff confirmed the lack of necessary evaluations and consents.
A facility failed to provide necessary contracture management devices for a resident with cerebral infarction and hemiplegia. Despite physician orders for a right resting hand splint and left palmar guard, observations revealed the resident did not have these devices in place. An LPN was unaware of the orders, and the medication administration record lacked documentation of their use and required skin checks.
The facility's kitchen dishwasher had a drainage issue, causing water to flow improperly and requiring staff to use a squeegee and a blanket for makeshift drainage solutions. The problem was reported to administration but remained unresolved, with water spilling onto the floor and the motor covered due to dripping water.
The facility failed to develop an individualized care plan for a resident with severe cognitive impairment and multiple behavioral issues, including cursing, hitting, wandering, and refusing care. Despite these behaviors being documented in nurse's notes, they were not reflected in the resident's MDS or care plan, and no interventions were implemented.
A resident with severe cognitive impairment and multiple diagnoses fell out of bed while receiving incontinence care, resulting in a right patella fracture. The incident occurred due to improper use of assistive devices and lack of adequate supervision by the CNA.
A resident with severe cognitive impairment and multiple diagnoses fell and fractured their right patella due to the facility's failure to place fall mats as ordered by the physician. Video footage and interviews confirmed the absence of the fall mat and the CNA's lack of awareness of the order.
Failed Room and Bathroom Call Light Functionality
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not maintaining required room and bathroom call/light equipment. Resident #5, who had a BIMS score of 14 indicating intact cognition, reported that the wall light next to the bed did not work. Survey observations on 02/10/2026 and again on 02/12/2026 showed the over-bed wall light did not have a pull cord to turn it on. A CNA confirmed the light lacked a pull cord, and the CNA reported that the Administrator had been told the prior day that the light did not have a cord. The Maintenance Supervisor later observed the light and confirmed it was missing the entire light switch and the pull cord attached to the switch and needed repair. Resident #100, whose 5-day MDS assessment showed a BIMS score of 11 indicating moderately impaired cognition, had a bathroom emergency call light that did not activate the call system when pulled. The resident stated she used the bathroom for toileting, washing her hands, and brushing her teeth. A Social Worker observed the bathroom call light and confirmed it did not work, and the Maintenance Supervisor later observed the same issue and confirmed it needed to be fixed again or replaced. Survey observations on a later date again showed the bathroom emergency call light did not activate the call system when pulled.
Failure to Provide Ordered Splinting and ROM Services
Penalty
Summary
The facility failed to provide services to maintain range of motion and prevent further contractures for two residents reviewed for positioning and mobility. Resident #24 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and contracture of the right hand. The resident was dependent for dressing, toileting, bed mobility, transfers, shower/bathe, eating, and personal hygiene. Physician orders directed use of a right elbow extension hand splint before breakfast and off after lunch or as tolerated, along with restorative nursing services at least 6 times per week for PROM and splinting due to CVA. The care plan identified the resident as at risk for loss of ROM and directed splints as ordered, but observations on multiple days showed the right hand contracted and the splint lying on the bedside table rather than in use. Resident #81 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the dominant side and right shoulder muscle wasting and atrophy, with quarterly MDS assessments showing impairment to ROM in one side of the upper and lower extremities and dependence for dressing, toileting, bed mobility, transfers, shower/bath, eating, and personal hygiene. Physician orders included restorative nursing program passive ROM to the right upper elbow and shoulder and a right resting hand splint to be applied after breakfast and removed after lunch. The task record for the prior 30 days did not show documentation that the splint had been applied, and the amount of minutes for splint or brace assistance was marked not applicable every day. Observations on multiple days showed the resident lying in bed without the splint in place, and staff interviews confirmed the resident did not have the splint and that the order for the splint existed.
Unsafe smoker not supervised and smoking supplies left accessible
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents and failed to keep a resident’s smoking environment free of hazards. Resident #83 was identified on the facility smoker’s list as an unsafe smoker. His record showed diagnoses including cerebral infarction due to occlusion or stenosis of a small artery, COPD, lack of coordination, visual disturbance, weakness, and tobacco use. His care plan directed staff to observe him for cigarette burns, require a smoking apron, provide supervision while smoking, and store his smoking supplies on the med cart. His most recent smoking/vaping safety evaluation stated he was not a safe smoker/vaper and noted he had a smoking apron that he wore every day. Observations showed Resident #83 in possession of smoking materials in his room and while seated in his wheelchair. A cigarette lighter was seen in his lap, and a pack of cigarettes was seen on his bedside table on multiple occasions. He told the surveyor he went outside to smoke about three times a day and said he had burned himself about a year earlier, after which he was required to wear the smoking apron, but he was still allowed to keep his own smoking supplies. On another observation, he was outside on the patio smoking with his smoking apron in place, while another resident was present holding cigarettes and lighting his cigarette. No staff member was present outside with him. Staff interviews confirmed the resident was an unsafe smoker who should have been supervised when smoking and should not have been in possession of his own smoking supplies. An LPN stated she did not know the resident’s smoking status. The ADON confirmed the policy required unsafe smokers to be supervised and smoking supplies to be kept by staff, but reported the resident did not always have staff supervision because he wore a smoking apron and staff did not keep his cigarettes and lighter because he became angry when they tried to take them. The ADON, Corporate Nurse, and MDS Nurse also confirmed quarterly smoking safety assessments had not been completed for the resident, even though they should have been.
Improper Storage of Resident Food in Snack Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not ensuring resident snack/nourishment refrigerators contained sealed, dated, and labeled food items from residents. Review of the facility policy for food brought in by visitors stated that food intended for later consumption was to be stored separate or easily distinguishable from facility food, kept in a sealed container, and labeled with the resident name and current date, with refrigerated items monitored daily and discarded if stored for more than 7 days. During observation, the Hall A resident snack/nourishment refrigerator contained an unsealed, unlabeled, and undated carton of a dozen eggs in a plastic grocery bag and a partially used, unsealed, unlabeled, and undated 4-ounce container of applesauce. The Hall B refrigerator contained a partially used, unlabeled, and undated container of chicken salad, three partially used, unsealed, unlabeled, and undated containers of applesauce, a partially used unlabeled and undated carton of cranberry cocktail, an undated and unlabeled paper plate with food covered in plastic wrap, and a partially used carton of thickened apple juice. The DON, ADON, and an LPN each observed the items and stated that the food should have been sealed, labeled with the resident name, and dated when placed in the refrigerator, but was not.
Missed Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate suprapubic catheter care for Resident #122, who had diagnoses including quadriplegia C1-C4 complete, urinary retention, UTI, and neuromuscular dysfunction of the bladder. The resident’s care plan directed indwelling catheter care with suprapubic catheter care as ordered and as needed, and a physician order dated 05/15/2024 required suprapubic catheter care every shift and as needed for patency. Review of the April 2025 TAR showed that suprapubic catheter care was not documented as provided on day shift 04/04/2025 and 04/23/2025, and on night shift from 04/01/2025 to 04/04/2025, 04/07/2025 to 04/10/2025, 04/12/2025, 04/14/2025, 04/23/2025, and 04/24/2025. During interview, the DON reviewed the TAR and acknowledged the missed catheter care entries.
Unlabeled Tube Feeding and Flush Water
Penalty
Summary
The facility failed to provide appropriate treatment and services for Resident #90, who had diagnoses including dysphagia following cerebral infarction, type 2 diabetes mellitus with other specified complication, moderate protein-calorie malnutrition, and encounter for attention to gastrostomy. The resident had physician orders for continuous enteral feeding with Osmolite 1.5 at 60 cc/hr for 22 hours with 150 cc H2O flushes every 4 hours, and Jevity 1.5 could be used if Osmolite was not available. During observation, the resident was lying in bed with the head of bed elevated 30 degrees and had tube feeding in progress with Jevity 1.5 at 60 cc/hr. The container of Jevity and the bag of water for flushes were not labeled with the date and time they were prepared. An LPN observed the container and bag and confirmed they were not labeled and should have been.
Resident Suffers Injury Due to Alleged Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in actual harm. On the evening of January 10, 2025, a Certified Nursing Assistant (CNA) allegedly bent the resident's fingers back to her wrist, causing significant injury. The resident, who had moderately impaired cognition and was dependent on staff for daily activities, reported the incident the following morning, complaining of pain and showing visible signs of swelling and bruising on her right hand. Upon assessment by a Licensed Practical Nurse (LPN), the resident's hand was found to be purplish and swollen, and an x-ray confirmed fractures in the hand. The resident consistently reported that the injury occurred when the CNA became frustrated during care and bent her fingers back. Multiple staff members, including another CNA and an LPN, were informed of the resident's account, and the resident maintained the same story when questioned by police and medical personnel. The incident was reported to the facility's Director of Nursing (DON) and Administrator, who were responsible for abuse coordination. The resident's physician was notified, and the police were involved. The resident's consistent identification of the CNA responsible for the injury was corroborated by staff interviews and the resident's statements to law enforcement.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that staff reported alleged violations regarding abuse immediately to the proper facility authority as per facility policy. This deficiency involved a resident with moderately impaired cognition who was dependent on staff for activities of daily living and was known to be resistive to care. On a particular shift, a CNA assisted the resident, who complained of pain in her hand and alleged that a staff member bent her fingers back. The CNA did not observe any physical signs of abuse and only reported the incident to the nurse, not to the abuse coordinator as required by the facility's policy. The LPN on duty also failed to report the allegation to the abuse coordinator, despite being aware of the facility's policy. The LPN assessed the resident and found no swelling, bruising, or increased pain, and therefore did not suspect abuse. It was only the following day that the LPN was informed of the resident's hand being swollen and bruised. The facility's administration acknowledged that the allegation should have been reported immediately to the abuse coordinator as potential abuse, but it was not. This failure to report in a timely manner was a violation of the facility's abuse prohibition policy.
Failure to Implement Fall Prevention Interventions in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans to address fall prevention for three residents who were assessed as being at risk for falls. Resident #3, who was admitted with conditions including Type 2 Diabetes Mellitus and muscle weakness, was identified as being at high risk for falls with a score of 50 on the Fall Scale. However, the baseline care plan created on 12/12/2024 did not include any interventions to minimize falls, and interventions were only added to the comprehensive care plan on 12/16/2024. Similarly, Resident #5, with a high fall risk score of 45, and Resident #6, with a moderate fall risk score of 35, also had baseline care plans that failed to identify fall prevention interventions. Interventions for these residents were only included in their comprehensive care plans several days after their initial assessments. The facility's policy requires that all residents be assessed for fall risk at admission and that specific interventions be implemented based on the assessment results. Despite this policy, the facility did not adhere to these procedures for the three residents in question. Interviews with the S2 Corporate Nurse and S1 DON confirmed that the baseline care plans for these residents did not include necessary interventions to minimize falls, despite their assessed risk levels. This oversight indicates a failure to promptly address the immediate needs of residents at risk for falls upon admission.
Inadequate Fall Risk Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as being at moderate risk for falls. The resident, who was cognitively intact and had a history of medical conditions including fractures and osteomyelitis, was admitted with a fall risk score indicating moderate risk. The care plan initiated for the resident included only two interventions: educating the resident, family, and caregivers about safety reminders and involving physical therapy for evaluation and treatment as needed. During interviews, the MDS Coordinators acknowledged that the care plan lacked appropriate interventions to address the resident's fall risk adequately. The care plan did not include essential interventions such as maintaining the bed in a low position and ensuring the call light was within reach, which were part of the facility's Fall Prevention Program policy. The omission of these interventions was recognized as a deficiency in the care plan's comprehensiveness and implementation.
Failure in Pressure Ulcer Care Leads to Severe Infection
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to severe health complications. The resident, who was at risk for pressure ulcers due to conditions such as quadriplegia and fragile skin, was admitted to the hospital with infected bilateral lower extremity pressure ulcers. Upon examination, a dressing dated from several months prior was found on the resident's left heel, indicating a lack of proper wound care and monitoring. The resident's condition deteriorated to sepsis with shock, requiring intensive care and surgical intervention. The facility's records revealed multiple lapses in weekly skin assessments for the resident, with several weeks showing no documented assessments. Interviews with staff indicated that heel protector boots were not consistently removed during skin assessments or bathing, preventing proper evaluation of the resident's skin condition. The resident reported that staff did not remove the boots during care, and the nursing staff confirmed they were unaware of the dressing on the resident's heel. The facility's policies required weekly skin checks and proper documentation, but these were not adhered to, resulting in the resident's severe condition. The Director of Nursing and other staff acknowledged the failure to conduct thorough skin assessments and provide adequate care, which should have identified the resident's wounds before hospitalization. The lack of oversight and adherence to care protocols contributed to the resident's health decline.
Deficiency in Skin Assessment and Care Leads to Hospitalization
Penalty
Summary
The facility failed to administer care in a manner that ensured effective and efficient use of resources, resulting in a deficiency in the care of a resident who was under transmission-based precautions. The resident did not receive complete and timely skin assessments and proper care during activities of daily living (ADLs). This oversight led to the resident being admitted to the hospital with severe conditions, including sepsis with shock, a urinary tract infection, and infected bilateral lower extremity pressure ulcers. Upon hospital admission, it was discovered that the resident had a large area of superficial ulceration on the dorsal right foot and multiple areas of superficial ulcerations on the dorsal aspect of the right foot, lateral right forefoot, lateral left forefoot, and posterior heel. The wounds were found to have green purulent drainage, indicating infection. An x-ray revealed possible osteomyelitis of the second digit, and the resident's wounds required surgical debridement by podiatry. Interviews with facility staff revealed that there was no process in place to ensure accurate and timely weekly skin assessments and proper skin care during ADLs. The Director of Nursing (DON) acknowledged responsibility for overseeing nursing staff to ensure proper skin assessments and care, but confirmed that the resident's wounds had not been identified prior to hospital admission. The lack of a systematic approach to skin assessments and care contributed to the resident's severe condition.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards for two residents. Observations revealed that an LPN left medication cups containing pills on the bedside tables of two residents, allowing them to take the medications on their own without supervision. Interviews with the residents confirmed that this was a regular practice by the LPN, who admitted to leaving the medications for the residents to self-administer. The medical records for both residents did not contain any assessments indicating that they had been evaluated and approved to self-administer their medications. The facility's Medication Administration Policy requires that residents may only self-administer medications if they have been assessed and deemed capable by the attending physician and the interdisciplinary care planning team. The LPN involved was unaware of whether such assessments had been conducted for the residents in question.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails and did not obtain informed consent from the residents or their representatives prior to the installation of bed rails. This deficiency was identified for nine residents who were reviewed for bed rail use. The facility's policy on physical restraints and involuntary seclusion requires a side rail evaluation, an assessment of the resident's ability to move about in bed, and an entrapment risk assessment, among other steps, before bed rails are used. However, these steps were not documented in the medical records of the residents involved. Resident #8, who has moderately impaired cognition, was observed using assist rails without a documented assessment or informed consent. Similarly, Resident #9, with intact cognition, reported using the assist rails for positioning, yet there was no record of an entrapment risk assessment or informed consent. Other residents, such as Resident #16, who is cognitively intact, and Resident #39, with moderately impaired cognition, were also found to have assist rails in use without the necessary assessments and consents documented. The deficiency was further confirmed during interviews with facility staff, including a corporate nurse who reviewed the medical records and acknowledged the lack of assessments and informed consents for the residents in question. Observations of the residents consistently showed the use of assist rails, yet the facility did not adhere to its own policy requirements for evaluating and documenting the safety and appropriateness of bed rail use.
Failure to Provide Contracture Management Devices
Penalty
Summary
The facility failed to provide necessary services to prevent further contractures and potential decline in range of motion for a resident with significant medical conditions. The resident, who was admitted with diagnoses including cerebral infarction, aphasia, hemiplegia, hemiparesis, and contractures in both knees, had specific physician orders for the use of a right resting hand splint and left palmar guard. These were to be applied before breakfast and removed after lunch, with skin checks performed before and after application. However, observations on multiple occasions revealed that the resident did not have the splint or palmar guard in place as ordered. The medical record review for the resident's November 2024 medication administration record did not show documentation of the use of the splint and palmar guard or the required skin checks. During an interview, an LPN stated she was unaware of the orders for the resident to have a right resting hand splint or left palmar guard. This lack of awareness and failure to follow the physician's orders contributed to the deficiency in care, as the resident was observed multiple times without the necessary devices for contracture management.
Dishwasher Drainage Issue in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen's dishwasher in a safe operating condition. During a kitchen tour, it was observed that the mechanical dishwasher had a drainage issue, causing water to flow to the left side and requiring staff to squeegee the water into the sink. A blanket was placed behind the sink to assist with drainage. Additionally, there was a gap between the dishwasher and the table on the right side, leading to water spilling onto the floor. The motor of the dishwasher was covered with a plate lid due to water dripping from the gap. The Dietary Manager reported the drainage problem to the administration a long time ago, but it remained unresolved. The Corporate Nurse and the Administrator both observed the issue and confirmed the improper water flow and makeshift solutions in place.
Failure to Develop Individualized Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop an individualized person-centered plan of care to meet the needs of a resident with severe cognitive impairment and multiple behavioral issues. The resident, diagnosed with dementia with behavior disturbance, schizoaffective/bipolar disorder, and other conditions, exhibited behaviors such as cursing, hitting, wandering, and refusing care. Despite these behaviors being documented in the nurse's progress notes, the resident's Minimum Data Set (MDS) and Comprehensive Plan of Care did not reflect these issues, and no interventions were put in place to address them. The resident's responsible party was not informed of the refusal of care, which could have allowed for additional support from family members. Interviews with staff revealed that the resident continued to wear the same clothes since admission, refused bathing and changing, and exhibited combative and wandering behaviors. The staff acknowledged the resident's behaviors but did not document them accurately in the MDS or develop appropriate care plan interventions. The social service staff member responsible for completing the MDS admitted that the behaviors should have been recorded, indicating a lapse in the facility's assessment and care planning processes.
Failure to Prevent Resident Fall
Penalty
Summary
The facility failed to ensure that Resident #4 received the necessary supervision and assistive devices to prevent avoidable accidents, resulting in actual harm. Resident #4, who had severe cognitive impairment and required total dependence for bed mobility, fell out of bed while S2 CNA was providing incontinence care. The incident occurred when S2 CNA turned to get an item from a bedside table drawer, leaving Resident #4 unsupported. The resident rolled off the bed and suffered a closed non-displaced fracture of the right patella, requiring hospitalization and subsequent return to the facility with a new diagnosis of a right patella fracture. Resident #4 had multiple diagnoses, including hemiplegia and hemiparesis following a cerebral vascular accident, cerebral infarction, seizures, and muscle weakness. The resident had physician orders for assist bars and fall mats, which were not properly utilized at the time of the incident. Video footage confirmed that the assist rail was not in the correct position, and a fall mat was not present on the floor. Interviews with staff revealed that S2 CNA was unaware of the fall mat order and that the assist rails were not positioned correctly, contributing to the resident's fall. The incident report and progress notes detailed the sequence of events, including the resident's fall, the immediate response by staff, and the resident's transfer to the emergency room. Interviews with the corporate nurse and S2 CNA confirmed that the resident was too close to the edge of the bed, and supplies were not safely within reach. The corporate nurse acknowledged that Resident #4 should have been a two-person assist due to his behaviors and mobility issues, and the assist bars were not in the correct position when the incident occurred.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to provide services according to the written plan of care for a resident with multiple diagnoses, including hemiplegia, hemiparesis following a CVA, cerebral infarction, seizures, and muscle weakness. The resident had a physician's order for fall mats to be in place on both sides of the bed during every shift. However, on the night of the incident, video footage revealed that a fall mat was not in place on the right side of the resident's bed when the resident fell to the floor, resulting in a right patella fracture. The resident's BIMS score indicated severe cognitive impairment, further emphasizing the need for strict adherence to the care plan to prevent falls. Interviews conducted with the resident's Responsible Party (RP), the Certified Nurse Assistant (CNA) involved, and the Corporate Nurse confirmed the absence of the fall mat at the time of the fall. The CNA admitted to not being aware of the physician's order for fall mats, and the Corporate Nurse verified the findings after reviewing the video footage. This failure to follow the care plan directly led to the resident's fall and subsequent injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shreveport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Booker T. Washington Skilled Nursing And Rehabilit | 1.2 mi | ★★★★★ | 0 | 0 |
| Magnolia Manor Nursing And Rehab Ctr, Llc | 1.9 mi | ★★★★★ | 6 | 0 |
| Claiborne Healthcare Center | 2 mi | ★★★★★ | 7 | 1 |
| Spring Lake Skilled Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 5 | 0 |
| Roseview Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 12 | 1 |
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