Plantation Oaks Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wisner, Louisiana.
- Location
- 110 Maple Street, Wisner, Louisiana 71378
- CMS Provider Number
- 195504
- Inspections on file
- 19
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Plantation Oaks Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not post the most recent state inspection results for resident review. While the annual survey results from October 2023 were displayed, the complaint survey results from July 2024 were missing. This was confirmed by the administrator.
The facility failed to maintain a clean and safe environment, as observed in several resident rooms and bathrooms, where air conditioner vents contained dirt, grime, and black substances. Additionally, feces and mold were found in a resident's bathroom, and the laundry room had mold and improperly stored cleaning supplies. These issues were confirmed by the facility's administrator.
A resident with a suprapubic urinary catheter was observed twice with his catheter bag exposed while in his wheelchair outside of his room, contrary to the facility's policy requiring catheter bags to be covered. The resident, who had no cognitive impairment, was admitted with multiple diagnoses. The DON confirmed the catheter bag should have been covered, indicating a failure to implement the care plan.
A facility failed to provide appropriate services and assistance to a resident with limited mobility, as observed when the resident was improperly positioned in a wheelchair with feet dangling. The resident, who has severe cognitive impairment and requires assistance with all ADLs, was not given adequate support to maintain or improve mobility, as confirmed by the DON.
A resident with a colostomy did not receive appropriate care due to the facility's failure to provide the correct size colostomy bags for over a week. The resident, who had no cognitive impairment, resorted to using a makeshift bag. The DON confirmed the unavailability of new colostomy bags, indicating a failure to follow the care plan.
The facility failed to assess two residents for entrapment risk from bed rails and did not obtain informed consent before installation. Both residents had severe cognitive impairments and required assist bars for bed mobility, but there was no documented evidence of risk assessment or consent. The DON confirmed these deficiencies.
The facility failed to maintain sufficient nursing staff with the necessary competencies and skills during weekends from April to June 2024. The PB&J Staffing Data Report highlighted extremely low staffing levels, confirmed by the Business Office Manager. Specific weekends in April, May, and June were identified as having insufficient staff, not meeting required staffing hours.
The facility did not post daily nurse staffing information in a visible area accessible to residents and visitors. The staffing data was found in a binder behind the nurses' station, as confirmed by the DON, which was not accessible to residents or visitors.
A pharmacist did not identify or report irregularities in the administration of Midodrine for a resident with chronic conditions. The medication was given outside prescribed parameters, despite the resident's systolic blood pressure being above the limit. This oversight was confirmed by the DON.
A resident with multiple health conditions was administered Midodrine Hydrochloride outside of prescribed parameters, despite instructions to hold the medication if systolic blood pressure exceeded 120. The Director of Nursing confirmed the medication was improperly administered on several occasions.
The facility failed to follow professional standards for food preparation by using hot water to thaw frozen sausage. A dietary staff member confirmed the use of hot water, which was against USDA guidelines that recommend thawing in the refrigerator, cold water, or microwave. The facility administrator acknowledged that this method should not have been used.
A resident with multiple health conditions was physically abused by a CNA, who bent the resident's finger and foot and slapped them in the chest. The incident was witnessed by other staff but not reported immediately, allowing the CNA to continue working. The facility failed to follow its abuse policy and did not initiate monitoring or interviews to prevent further abuse.
A resident with multiple health issues was physically abused by a CNA, witnessed by another CNA and an LPN, but the incident was not reported to administration or law enforcement in a timely manner. The facility's policy required immediate reporting and suspension of the accused employee, but these procedures were not followed, and the CNA continued to work additional shifts before being terminated.
Failure to Post Recent State Inspection Results
Penalty
Summary
The facility failed to ensure that the most recent state inspection results were available for resident review. During an observation on September 9, 2024, it was noted that while the results of the last annual survey from October 4, 2023, were posted by the front entrance, the results from the last complaint survey dated July 8, 2024, were not displayed. An interview with the administrator on September 10, 2024, confirmed that the most recent inspection results from July 8, 2024, were not posted for residents to review.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as evidenced by observations of unclean conditions in multiple resident rooms and bathrooms. Specifically, the air conditioner vents in the rooms of residents #7, #22, and #55 were found to contain dirt, grime, and a black substance. Additionally, a washcloth and a paper towel were found lodged in the vents of residents #7 and #22, respectively. Resident #55's bathroom door frame also had a black substance on it. These observations were confirmed by the facility's administrator. Further deficiencies were noted in the room and bathroom of resident #46, where feces were observed on the toilet seat and brown splatter stains on the walls. The air conditioning unit in this room was surrounded by black mold and dirt. Additionally, the laundry room was found to have black mold on the wall behind the washing machine, and cleaning supplies were improperly stored directly on the floor. These conditions were also confirmed by the facility's administrator during an interview.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to implement the care plan for a resident with a suprapubic urinary catheter, as evidenced by the resident's catheter bag not being covered with a privacy bag when outside of his room. The resident, who was admitted with multiple diagnoses including hemiplegia, epilepsy, and cognitive communication deficit, was observed on two separate occasions propelling himself in his wheelchair with the catheter bag exposed. The facility's policy requires catheter drainage bags to be covered at all times when the resident is out of their room. The resident, who had a Brief Interview of Mental Status score indicating no cognitive impairment, was seen on two occasions with his catheter bag hanging exposed under his wheelchair. The Director of Nursing confirmed that the resident's catheter bag should have been covered with a privacy bag while he was in his wheelchair outside of his room. This oversight indicates a failure to adhere to the facility's policy regarding catheter bag coverage, leading to the deficiency noted in the report.
Failure to Provide Proper Mobility Support
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Resident #53, who has severe cognitive impairment and requires assistance with all Activities of Daily Living, was observed on two separate occasions sitting in a high back wheelchair with both feet dangling and not touching the floor. This improper positioning was confirmed by the Director of Nursing during an interview, indicating a deficiency in providing adequate care to maintain or improve the resident's range of motion and mobility.
Failure to Provide Colostomy Care as Per Care Plan
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident who required such services, as evidenced by the lack of availability of colostomy bags in accordance with the resident's care plan. The resident, who was admitted with multiple diagnoses including hemiplegia, epilepsy, and a colostomy, was observed using a makeshift colostomy bag made from a gallon-sized plastic storage bag secured with tape. This was due to the facility not having the correct size colostomy bags available for over a week, despite the care plan requiring a new colostomy bag to be applied daily. The resident, who had a BIMS score indicating no cognitive impairment, reported that the facility had been using the same bag for over a week, prompting him to create his own solution. The Director of Nursing confirmed the unavailability of new colostomy bags for the past week, highlighting a failure to adhere to the resident's comprehensive person-centered care plan. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
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 review the risks and benefits of bed rails with the residents or their representatives, nor did they obtain informed consent prior to installation. This deficiency was identified for two residents who were reviewed for accident hazards. Resident #7, who had severe cognitive impairment and multiple medical conditions, had an assist bar installed on the left side of the bed without documented evidence of an assessment for entrapment risk or informed consent. Observations confirmed the presence of the assist bar, and the Director of Nursing acknowledged the lack of assessment and consent. Similarly, Resident #44, who also had severe cognitive impairment and required extensive assistance with activities of daily living, had two assist bars installed for bed mobility. There was no documented evidence of an assessment for entrapment risk or informed consent for this resident either. Observations confirmed the presence of the assist bars, and the Director of Nursing confirmed the absence of necessary assessments and consent. These actions and inactions led to the deficiency noted in the report.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skill sets to provide necessary nursing and related services. This deficiency was particularly evident during weekends from April 1, 2024, through June 30, 2024. The Payroll-Based Journal (PB&J) Staffing Data Report indicated extremely low weekend staffing levels for the third quarter of 2024. Interviews with the Business Office Manager confirmed the low staffing levels during this period. Specific dates in April, May, and June 2024 were identified where the staffing was insufficient, failing to meet the required staffing hours as per the facility's records and timesheets.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily in a prominent location accessible to residents and visitors. On September 9, 2024, at 8:00 a.m., a surveyor observed that the daily staffing information was not visible in the facility. Later, at 11:00 a.m., the Director of Nursing (DON) disclosed that the staffing data was kept in a binder behind the nurses' station, which was not accessible to residents or visitors. An observation at 11:05 a.m. confirmed that the staffing data was indeed located in a black binder behind the nurses' station. On September 16, 2024, the DON acknowledged that the staffing data should have been posted in a visible area for residents and visitors.
Pharmacist Fails to Identify Medication Administration Irregularity
Penalty
Summary
The pharmacist failed to identify and report irregularities in the administration of Midodrine Hydrochloride for a resident with multiple diagnoses, including chronic kidney disease and orthostatic hypotension. The resident's medication was administered outside the prescribed parameters, which specified that the medication should not be given if the systolic blood pressure was above 120. Despite this, the medication was administered multiple times in August and September when the resident's systolic blood pressure exceeded the specified limit. The Consultant Pharmacist conducted a Medication Regimen Review for the resident in early September but did not document any issues regarding the inappropriate administration of Midodrine in August. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the pharmacy consultant did not identify the irregularity in the medication administration for the resident.
Unnecessary Drug Administration Due to Non-Adherence to Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. A review of the records for a resident with chronic kidney disease, orthostatic hypotension, fibromyalgia, type 2 diabetes mellitus, chronic atrial fibrillation, and hypertension revealed that Midodrine Hydrochloride was administered outside of the prescribed parameters. The medication was ordered to be given three times a day for orthostatic hypotension, with instructions to hold the dose if the systolic blood pressure was above 120. However, the August and September Medication Administration Records showed that Midodrine was administered multiple times despite the resident's systolic blood pressure being above 120, which was against the prescribed parameters. An interview with the Director of Nursing confirmed that the medication was administered on the specified dates in August and September, even though it should not have been given due to the blood pressure readings being outside the set parameters.
Improper Thawing of Meat Using Hot Water
Penalty
Summary
The facility failed to adhere to professional standards for food preparation by using hot water to thaw frozen meat. During an observation in the kitchen, it was noted that a dietary staff member was thawing frozen sausage in a sink with hot running water. Upon interview, the dietary staff member confirmed the use of hot water for thawing the sausage. Further interview with the facility administrator confirmed that the staff should not have used hot water for thawing meat. According to the United States Department of Agriculture (USDA) Safe Defrosting Methods, there are three safe ways to thaw food: in the refrigerator, in cold water, and in the microwave. The USDA guidelines explicitly state that perishable foods should never be thawed on the counter or in hot water.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident occurred when the CNA, identified as S4CNA, physically abused a resident by bending the resident's finger and foot back and slapping the resident in the chest. This incident was witnessed by another CNA, S5CNA, and a Licensed Practical Nurse (LPN), S6LPN, who entered the room during the altercation. Despite witnessing the abuse, the staff did not immediately report the incident to the facility's administration, allowing the abusive CNA to continue working for several days following the incident. The resident involved in the incident had a history of chronic obstructive pulmonary disease, type 2 diabetes, heart failure, schizoaffective disorder, major depressive disorder, mood disorder, and cerebrovascular disease. The resident was known to be resistant to daily care, and the care plan included instructions to leave and approach the resident later if they became combative. On the day of the incident, the resident became upset during care, leading to the altercation with S4CNA. The facility's policy required immediate reporting and suspension of any staff involved in abuse allegations. However, this policy was not followed, as the CNA continued to work shifts after the incident. The facility also failed to initiate a quality assurance or performance improvement process to monitor for ongoing abuse and did not interview other residents to ensure no further abuse occurred. This oversight had the potential to affect all residents in the facility.
Failure to Report Resident Abuse and Implement Policies
Penalty
Summary
The facility failed to ensure that staff reported the physical abuse of a resident to administration immediately and did not implement policies and procedures for reporting a reasonable suspicion of a crime within 24 hours to law enforcement. The incident involved a resident with multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes, heart failure, schizoaffective disorder, and moderate cognitive impairment. The resident was physically abused by a CNA, witnessed by another CNA and an LPN, but the abuse was not reported to the administration or law enforcement in a timely manner. On the day of the incident, the resident became combative during care, leading to an altercation with the CNA, who physically abused the resident by bending his finger, slapping him, and bending his toes. Despite witnessing the abuse, the other CNA and LPN did not report the incident immediately to the administration. The abuse was only reported three days later, and the CNA involved continued to work additional shifts before being terminated. The facility's policy required immediate reporting of abuse to a supervisor and the suspension of the accused employee. However, the staff involved did not follow these procedures, and the administration was not informed until several days later. Additionally, the facility did not notify law enforcement within the required 24-hour period after becoming aware of the abuse, further compounding the deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
