Pierremont Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 725 Mitchell Lane, Shreveport, Louisiana 71106
- CMS Provider Number
- 195312
- Inspections on file
- 38
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pierremont Healthcare Center during CMS and state inspections, most recent first.
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.
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.
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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