Pilgrim Manor Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bossier City, Louisiana.
- Location
- 1524 Doctors Drive, Bossier City, Louisiana 71111
- CMS Provider Number
- 195594
- Inspections on file
- 28
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pilgrim Manor Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CNA transferred a dependent resident using a stand and pivot method instead of the required Hoyer lift, as outlined in the care plan. The resident, who had significant physical limitations and was dependent for transfers, sustained a right humeral neck fracture after hitting her arm on the wheelchair armrest during the improper transfer. The CNA was unaware of the resident's transfer requirements and did not check the care plan or observe signage indicating the need for a Hoyer lift.
A resident with multiple diagnoses and total dependence for transfers was moved from bed to wheelchair by an agency CNA without the use of a Hoyer lift, contrary to the care plan and facility policy. The CNA used a stand and pivot method, despite being trained and having access to the care plan, and supervisory staff confirmed the required procedure was not followed. This failure to provide the necessary transfer assistance constituted neglect.
The facility failed to ensure safe medication administration practices for two residents by leaving medications at the bedside without orders for self-administration. Both residents, with intact cognition, were found with medication cups on their bedside tables. Interviews with staff confirmed the breach in protocol, as nurses acknowledged leaving medications unattended and not staying with residents until administration was complete.
The facility failed to provide proper respiratory care for two residents. One resident's humidification bottle and nasal cannula were not changed weekly as ordered, while another resident's oxygen setup lacked a humidification bottle and dated tubing. An LPN confirmed these deficiencies.
The facility failed to ensure safe and sanitary dietary services, as improper thawing practices for meat were observed. Meat was found submerged in standing water instead of being thawed under running water, as confirmed by staff members. The Dietary Manager reported that 121 residents were served meal trays from the kitchen during the observed days.
The facility did not submit accurate payroll information for direct care staffing to CMS, resulting in a One Star Staffing Rating and Excessively Low Weekend Staffing. The Regional President confirmed a PBJ system reporting error for the specified period.
A resident with multiple medical conditions, including Alzheimer's, was injured during a transfer when a CNA failed to use a Hoyer lift as required by the care plan. The resident suffered a severe leg injury, exposing bone and adipose tissue, necessitating surgical intervention. Video evidence contradicted the CNA's claim of leaving to get the lift, revealing a breach in protocol.
A resident with multiple health conditions, including Alzheimer's, was injured during a transfer when a CNA failed to use a Hoyer lift as required by the care plan. The CNA left the resident unattended, resulting in a severe leg injury. Video evidence contradicted the CNA's claim of retrieving the lift, highlighting a breach in protocol.
A cognitively impaired resident with a history of elopement was inaccurately assessed as not at risk and subsequently eloped from the facility. The resident exited through an unsecured front entrance after the evening receptionist, unaware of the resident's status, remotely opened the doors. The facility's lack of communication and security measures, including an unattended front desk and absence of a wander guard system, contributed to the incident.
A cognitively impaired resident eloped from the facility due to inadequate risk assessment and security measures. The resident exited through the front doors, which were remotely opened by the receptionist, and was not missed until 90 minutes later. The ADON failed to assess the resident's elopement risk accurately, missing key information from the family. The facility lacked a secure entrance and did not have a wander guard system, contributing to the incident.
A resident with severe cognitive impairment eloped from a facility due to an inaccurate elopement risk assessment by the ADON, who failed to interview the family and missed critical information about the resident's history of elopement. The resident exited the facility after the evening receptionist, unaware of the resident's risk status, released the doors. The DON confirmed the assessment was inaccurate, and the ADON later acknowledged changing answers on the evaluation post-elopement.
The facility failed to document and investigate a grievance reported by a resident's family member regarding the resident being repeatedly found in a soiled brief. The administrator admitted that quickly resolved issues were not logged, violating the facility's grievance policy.
Failure to Use Hoyer Lift During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from bed to wheelchair using a stand and pivot method instead of the Hoyer lift as specified in the resident's comprehensive care plan. The resident was care planned as totally dependent for transfers and required the use of a Hoyer lift with two-person assistance due to significant physical limitations, including generalized muscle weakness, muscle wasting and atrophy, and impaired range of motion in both upper extremities. The CNA did not utilize the Hoyer lift during the transfer, resulting in the resident hitting her right arm on the wheelchair armrest and experiencing acute pain. The resident's medical record indicated a history of cerebral infarction, rheumatoid arthritis, and generalized osteoarthritis, and she was admitted to hospice care. The care plan interventions specifically included the use of a Hoyer lift for all transfers, and this requirement was documented in the resident's chart and typically indicated by a sign over the resident's bed. On the day of the incident, the CNA was not aware of the resident's transfer requirements and did not check the care plan or observe a sign over the bed. The CNA later reported not knowing how to look up transfer abilities until after the incident. Multiple staff interviews confirmed that the resident was dependent on staff for transfers and that the standard practice was to use a Hoyer lift, with signage over the bed to indicate this need. The incident resulted in the resident sustaining an acute complex impacted fracture of the right humeral neck, requiring emergency evaluation and treatment. The CNA involved had received facility orientation and had worked at the facility on several occasions prior to the incident, but failed to follow the care plan during the transfer.
Failure to Use Hoyer Lift for Dependent Resident Transfer
Penalty
Summary
Nursing staff failed to follow the care plan for a resident who was assessed as requiring a Hoyer lift for all transfers. The resident, who had diagnoses including peripheral vascular disease, lumbar spondylopathy, vascular dementia, and anxiety, was documented as totally dependent on staff for transfers and at risk for falls. The care plan, therapy assessments, and facility policies all specified the use of a Hoyer lift with two-person assistance for transfers, and the resident was listed as a total lift on the facility's lift list. On the morning in question, the resident was observed in a wheelchair without a Hoyer lift pad, which is typically left in place after a mechanical lift transfer. Multiple staff interviews confirmed that the resident had been transferred from bed to wheelchair without the use of a Hoyer lift. The agency CNA assigned to the resident admitted to using a stand and pivot transfer method instead of the required Hoyer lift, despite being trained on the facility's procedures and having access to the resident's care plan in the electronic system. The CNA stated that the resident was able to assist with the transfer and that a Hoyer lift pad was not available in the room at the time. Supervisory staff, including the CNA supervisor, RN supervisor, and Director of Rehabilitation, all confirmed that the resident was care planned for Hoyer lift transfers and that the correct procedure was not followed. The agency CNA's personnel record showed she had completed facility orientation and acknowledged her responsibility to follow the care plan and report any concerns to management. The failure to use the Hoyer lift as required by the care plan and facility policy constituted neglect, as it did not provide the necessary services to avoid potential physical harm or distress to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for two residents. Resident #102, who was admitted with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was observed with a medicine cup containing pills left on the bedside table. The resident confirmed that the nurse left the medications for her to take after eating, despite not having an order for self-administration. Interviews with the LPN and RN confirmed that medications should not have been left at the bedside without a self-administration order. Similarly, Resident #105, diagnosed with malignant neoplasm of the right kidney, was found with a medicine cup containing pills on the bedside table. The resident identified the pills as Oxycodone and Lexapro, which were left from the morning medication pass. The LPN confirmed leaving the medications at the bedside and acknowledged that the resident did not have an order for self-administration. The Corporate Nurse also confirmed that medications should not have been left at the bedside, and a nurse should remain until the medication administration is complete.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. For one resident, the facility did not change the humidification bottle and nasal cannula weekly as ordered. Observations revealed that the humidification bottle and nasal cannula were dated over two weeks prior, and the LPN confirmed that the setup should have been changed weekly but was not. For another resident, the facility did not ensure that oxygen tubing was dated and that humidification was administered with oxygen. Observations showed that the resident was using oxygen without a humidification bottle and that the cannula tubing was not dated. The LPN confirmed the absence of humidification and the lack of a date on the tubing, acknowledging that these were required.
Improper Thawing Practices in Facility Kitchen
Penalty
Summary
The facility failed to ensure dietary services were provided in a safe and sanitary environment, which could prevent contamination and foodborne illness for the 121 residents served meal trays from the kitchen. Observations in the facility kitchen revealed improper thawing practices for meat. On two separate occasions, large tube-shaped chubs of ground beef and pork tenderloins were found submerged in standing water in the sink, rather than being thawed under running water as required by accepted practices. Staff members, including S7 and S8, confirmed the improper thawing method and acknowledged the meat should not be submerged in standing water. Additionally, S8 was unaware of how the sink was cleaned before the meat was placed in direct contact with it. The Dietary Manager, S6, confirmed the improper thawing practices and reported the number of residents served from the kitchen during the observed days.
Inaccurate Payroll Submission for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. A review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 4 2024 revealed issues, including a One Star Staffing Rating and Excessively Low Weekend Staffing. During an interview, the Regional President acknowledged that there was a PBJ system reporting error to CMS for the specified period.
Failure to Use Hoyer Lift Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from harm by not utilizing a Hoyer lift during a transfer, which was required as per the resident's care plan. The incident involved a resident with multiple medical conditions, including cerebral ischemia, polyosteoarthritis, and Alzheimer's disease, who was totally dependent on two staff members for transfers. On the day of the incident, the resident was transferred from a Geri chair to a bed without the use of a Hoyer lift, resulting in a severe injury to the resident's left leg. The incident occurred when a CNA, who was an agency staff member, wheeled the resident to their room and left them unattended, claiming to have gone to retrieve a Hoyer lift. However, video surveillance revealed that the CNA did not leave the room to get the lift but instead went directly to the nurse's station to report the resident's injury. The resident was found in bed with a significant laceration on the left leg, exposing adipose tissue and bone, which required surgical intervention. Interviews with staff confirmed that the resident was known to require a Hoyer lift and two-person assistance for transfers. The CNA involved had been in-serviced on the proper use of lifts but failed to follow the care plan, leading to the resident's injury. The facility's video surveillance and staff statements highlighted discrepancies in the CNA's account of the events, indicating a failure to adhere to established protocols for safe resident handling.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance and supervision for a resident during a transfer, leading to a significant injury. The resident, who had multiple diagnoses including cerebral ischemia, polyosteoarthritis, and Alzheimer's disease, was totally dependent on two staff members for transfers and required the use of a Hoyer lift as per their care plan. On the day of the incident, the resident was transferred from a Geri chair to a bed without the use of the Hoyer lift, resulting in a severe leg injury that exposed adipose tissue and bone. The incident occurred when a CNA, who had been in-serviced on the proper use of lifts, wheeled the resident to their room and left them unattended, claiming to have gone to retrieve the Hoyer lift. However, video surveillance revealed that the CNA did not leave the room to get the lift and instead went directly to the nurse's station to report the injury. The resident was found in bed with a significant laceration on their left leg, and the Geri chair was positioned perpendicular to the bed with the lift sling still in place, indicating that the proper transfer procedure was not followed. Interviews with staff confirmed that the resident was known to require a Hoyer lift and two-person assistance for transfers. The CNA involved in the incident provided a statement that contradicted the video evidence, claiming to have left the room to get the lift. The failure to follow the resident's care plan and utilize the necessary equipment for safe transfers directly led to the resident's injury, which required surgical intervention and resulted in the resident being transferred to a hospital and subsequently discharged to another facility.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to adequately supervise a severely cognitively impaired resident, leading to the resident's elopement. The resident, who had a history of elopement from home, was inaccurately assessed as not at risk for elopement upon admission. This assessment was conducted by the Assistant Director of Nursing, who did not interview the resident's family or responsible party, despite their presence during the evaluation. Consequently, the resident's care plan did not include necessary interventions to prevent elopement. On the day of the incident, the resident was able to exit the facility through the front entrance, which was not locked during the day. The evening receptionist, unaware that the individual was a resident, remotely opened the sliding doors, allowing the resident to leave. The staff did not realize the resident was missing until approximately 90 minutes later, at which point a search was initiated, and the local police and the resident's responsible party were notified. The resident was eventually found unharmed at a local restaurant, having crossed two four-lane roads. Interviews and video reviews revealed that the facility's front entrance was not secure, and there were times when the front desk was unattended. The receptionist on duty was not informed of the new admission or the resident's risk for elopement. Additionally, the facility lacked a lockdown unit or wander guard system to prevent such incidents. These oversights and failures in communication and security measures contributed to the resident's unsupervised departure from the facility.
Elopement of Cognitively Impaired Resident Due to Inadequate Risk Assessment and Security Measures
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the elopement of a cognitively impaired resident. The resident, who was ambulatory and severely cognitively impaired, managed to exit the facility unsupervised. This occurred when the evening receptionist remotely opened the front sliding doors, allowing the resident to leave. The staff did not realize the resident had eloped until approximately 90 minutes later, prompting a search and notification of local police and the resident's responsible party. The resident was eventually found unharmed at a local restaurant about a mile away, having crossed two four-lane roads. The deficiency was further compounded by the failure of the Assistant Director of Nursing (ADON) to accurately assess the resident's risk for elopement upon admission. The ADON did not interview the resident's family or responsible party to capture a history of elopement from home, nor did they note the resident's expressed desire to leave the facility. Additionally, the facility lacked a secure front entrance and did not have a lockdown unit or wander guard system in place to prevent such incidents. The front entrance was left unlocked during the day, and the reception desk was sometimes unmanned, allowing for potential elopement risks.
Failure to Assess Elopement Risk Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that the nursing staff possessed the necessary competencies to accurately assess a resident for elopement risk. This deficiency was identified when a severely cognitively impaired resident, who was ambulatory, eloped from the facility. The resident was able to exit the facility through the front entrance after the evening receptionist remotely released the doors, unaware that the resident was at risk for elopement. The staff did not realize the resident had eloped until approximately 7:30 p.m., indicating a significant lapse in supervision and risk assessment. The Assistant Director of Nursing (ADON) inaccurately assessed the resident as not at risk for elopement upon admission. The ADON failed to interview the resident's family or responsible party, missing critical information about the resident's history of elopement from home and expressed desire to leave the facility. This oversight resulted in the absence of protective measures for the resident, who had a documented history of wandering behaviors and severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 03. The Director of Nursing (DON) confirmed that the initial elopement risk evaluation was inaccurate and that the ADON should have conducted a more thorough assessment. The ADON later acknowledged changing answers on the initial evaluation after the resident's elopement, which should not have been done. The receptionist was not informed of the resident's risk status, contributing to the failure in safety processes. The personnel record of the ADON did not reveal completed nursing assessment competencies, highlighting a gap in staff training and competency verification.
Failure to Document and Investigate Grievances
Penalty
Summary
The facility failed to ensure grievances and complaints were documented and investigated according to their policy. Specifically, the facility did not follow their grievance policy for a resident who had multiple medical conditions, including hemiplegia, aphasia, and vascular dementia. The resident's family member reported to the administrator that the resident was repeatedly found in a soiled brief during visits. Despite this complaint, the administrator did not document the grievance or initiate an investigation as required by the facility's policy. The facility's grievance policy mandates that any grievances or complaints, whether oral or written, should be documented and investigated promptly. However, the administrator admitted that issues resolved quickly were not included in the grievance log. This led to the failure to document and investigate the family member's complaint about the resident's soiled brief, which was a clear violation of the facility's established grievance procedures.
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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