Pointe Coupee Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in New Roads, Louisiana.
- Location
- 1820 False River Road, New Roads, Louisiana 70760
- CMS Provider Number
- 195620
- Inspections on file
- 28
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Pointe Coupee Healthcare during CMS and state inspections, most recent first.
A resident with diabetes was given an incorrect dose of insulin due to a transcription error by an LPN, and nursing staff failed to implement or clarify blood glucose monitoring orders. The resident received a higher dose of insulin without any blood glucose checks, and when the resident showed signs of a change in condition, staff did not obtain a blood glucose level. Emergency services later found the resident to be severely hypoglycemic, requiring immediate intervention and hospitalization.
A resident with diabetes was admitted with a hospital order for Lantus 5 units daily, but an LPN transcribed the order as 30 units daily in the electronic record. Multiple nurses administered the incorrect dose over several days, resulting in the resident experiencing severe hypoglycemia and requiring emergency intervention.
A facility failed to manage pain for a cognitively impaired resident with a Left Humerus Fracture at the Elbow. Despite orders for an immobilizing brace and pain medication, staff did not consistently apply the brace or administer pain interventions. The resident showed signs of pain during ADL care, but staff did not report these to the nurse, assuming awareness of the fracture. The LPN and NP were not informed of the resident's ongoing pain or noncompliance with the splint, leading to inadequate pain management.
The facility failed to provide sufficient nursing staff, particularly on Hall B, where only one CNA was assigned despite high resident acuity. This led to delays in responding to residents' requests for ADLs, with a resident frequently waiting twenty to forty minutes for incontinence care. Staffing was based on minimum state standards rather than resident acuity, contributing to the deficiency.
A resident with a severe cognitive impairment frequently removed an immobilizing splint for a left humerus fracture, and the nursing staff failed to notify the physician of this non-compliance and the resident's signs of pain. Despite the facility's policy requiring prompt reporting of condition changes, the CNAs did not inform the nurses, and the nurses did not notify the physician, leading to an immediate jeopardy situation.
The facility failed to implement care plans for two residents, leading to deficiencies. A resident with a left humerus fracture frequently removed an immobilizing splint, and staff did not consistently reapply it, causing pain and potential injury. Additionally, the resident missed a follow-up orthopedic appointment due to a lack of scheduling and communication. Another resident did not attend a rheumatology appointment for fibromyalgia due to a failure in scheduling and referral follow-up.
A facility failed to ensure safe medication administration when an LPN left medications at a resident's bedside, as the resident preferred to take them later. The resident was cognitively intact, and the DON confirmed that staff were instructed to leave medications at the bedside to accommodate the resident's preference.
A resident with cognitive impairment and physical limitations did not receive necessary hair hygiene services, resulting in oily and flaky scalp conditions. Despite being scheduled for regular bathing assistance, there was no evidence of hair washing, and staff indicated that only the beautician could wash the resident's hair. The DON confirmed the resident's dependency on staff for personal hygiene and the need for hair washing with each bed bath.
A resident with Hemiplegia and Cerebral Vascular Accident, dependent on staff for mobility, was not repositioned every two hours as required by the facility's policy. Despite being at high risk for skin breakdown, observations and interviews confirmed the resident remained in the same position for extended periods, leading to a deficiency in care.
A facility failed to maintain a sanitary environment for a resident who was always incontinent of bladder. The resident's mattress had multiple brown rings and a strong urine odor, which persisted for months without being documented in the maintenance log or addressed by staff. Interviews revealed a lack of communication and procedure, as the CNA did not report the issue, and the maintenance supervisor was unaware of the problem until the day of the survey.
A facility failed to accurately assess a resident's PASARR status in their MDS assessment. Despite the resident having a Level II PASARR due to Bipolar Disorder and Major Depressive Disorder, the MDS was incorrectly coded, indicating no Level II PASARR. Staff interviews confirmed the error, acknowledging the MDS should have reflected the correct PASARR status.
A resident in an LTC facility, who was cognitively intact and enjoyed daily activities, was unable to attend morning activities on time due to delayed assistance from staff. Despite requesting help to put on pants after breakfast, the resident was left waiting, missing her preferred time to socialize before activities. Staff interviews confirmed the resident's enjoyment of activities and acknowledged delays in assistance.
The facility failed to designate an IDT member to coordinate hospice care and did not maintain updated hospice records for a resident. The resident's hospice binder contained outdated documents, and there was no system to ensure updates. Staff interviews revealed a lack of awareness about the need for a designated liaison with the hospice agency.
A resident with multiple health issues, including COPD and reduced mobility, was left in a non-functioning bed for several days due to a severed bed controller cord. The facility lacked a replacement bed, leaving the resident unable to be moved to a wheelchair as needed.
A resident with a cognitive communication deficit and a left distal humerus fracture was observed without a required elbow brace, despite the MAR indicating it was applied. Staff interviews revealed a lack of awareness and understanding of the brace requirement, leading to inaccurate documentation. The DON confirmed the MAR entries were incorrect, failing to meet professional standards for medical record accuracy.
A resident with severe cognitive impairment was treated without dignity by a CNA, who used profane language and handled the resident roughly during care. The CNA's actions were confirmed by video footage and acknowledged by facility management as unprofessional and undignified.
Failure to Accurately Transcribe Insulin Order and Monitor Blood Glucose Leads to Hypoglycemic Event
Penalty
Summary
The facility failed to ensure that nursing staff provided services in accordance with professional standards of quality for a resident with diabetes who was receiving insulin. Upon admission from a local hospital, the resident had a physician's order for Lantus insulin at 5 units daily. However, an LPN inaccurately transcribed this order into the electronic medical record and medication administration record (MAR) as 30 units daily. This error was not identified or corrected, and the resident received the incorrect, higher dose of insulin for several days. Additionally, the nursing staff did not clarify or implement blood glucose monitoring orders for the resident, despite the resident being diabetic and receiving insulin. The hospital discharge orders included a discontinuation of blood glucose checks, but the facility's standing orders required blood glucose monitoring for residents on insulin. Staff did not seek clarification from the physician regarding this discrepancy, nor did they refer to the facility's standing orders. As a result, no blood glucose levels were monitored or documented for the resident during the period in question. On the day of the incident, the resident exhibited a change in condition, including sleepiness and drooling. Despite these symptoms, the nurse on duty did not obtain a blood glucose level. It was only after the resident's family intervened that emergency services were called, at which point a paramedic found the resident's blood glucose to be critically low. The resident was treated for hypoglycemia and transferred to the hospital. Interviews and record reviews confirmed that the errors in transcription, lack of blood glucose monitoring, and failure to respond appropriately to a change in condition directly led to the resident's hypoglycemic event.
Significant Insulin Transcription Error Leads to Hypoglycemic Event
Penalty
Summary
A significant medication error occurred when a resident with Type 2 Diabetes Mellitus and Diabetic Chronic Kidney Disease was admitted from a local hospital with a physician's order for Lantus insulin 5 units subcutaneously daily. The order was incorrectly transcribed into the electronic medical record by an LPN as Lantus 30 units subcutaneously daily. This error was not identified during the order entry or subsequent reviews, resulting in the resident receiving six consecutive doses of 30 units of Lantus instead of the prescribed 5 units. Multiple nursing staff administered the incorrect insulin dose as documented in the Medication Administration Record (MAR), with each nurse following the erroneous order in the electronic record. The error persisted from the resident's admission until the resident experienced a hypoglycemic episode. On the day of the incident, the resident was found lethargic and unresponsive, with a blood glucose level of 23 mg/dL. Emergency medical services were called, and the resident was treated with intravenous dextrose and transferred to the hospital, where hypoglycemia was confirmed as the diagnosis. Interviews with the involved LPNs, the Clinical Data Coordinator, the DON, and the Nurse Practitioner confirmed that the original hospital order was for 5 units, and the error in transcription led to the administration of 30 units. Staff acknowledged the mistake and confirmed that the MAR reflected the incorrect dose, which was administered as ordered. The incident was recognized as a significant medication error that resulted in immediate jeopardy to the resident's health.
Failure in Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident who suffered a Left Humerus Fracture at the Elbow following a fall. Despite being treated by an Orthopedic Specialist and receiving an order to wear an immobilizing brace to prevent further injury and decrease pain, the staff did not apply the brace consistently from the time it was ordered. Observations indicated that the resident exhibited signs of pain during activities of daily living (ADL) care, yet no pain interventions were administered from the onset of symptoms. The resident, who was severely cognitively impaired, had a history of falls and was diagnosed with Alzheimer's Disease, among other conditions. After the fall, the resident was initially treated with Tylenol and later Tramadol, but the latter was discontinued shortly after. The resident's care plan included administering pain medications as ordered and monitoring for signs of nonverbal pain, but there were no updates or interventions added after the initial assessments. Staff failed to report the resident's signs of pain to the nurse, assuming the nurses were already aware of the fracture. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain management. The CNAs did not report the resident's pain symptoms, and the LPN did not notify the Orthopedic Specialist or the NP about the resident's removal of the splint or continued pain. The NP was unaware of the resident's ongoing pain and lack of pain medication administration. The Orthopedic Specialist's representative confirmed that the MD was not notified of the resident's noncompliance with the splint or unresolved pain, which could lead to further complications.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, particularly on Hall B, where only one CNA was assigned per shift despite the high acuity of residents requiring extensive assistance. This staffing inadequacy led to delays in responding to residents' requests for assistance with activities of daily living (ADLs), such as incontinence care. Resident #59, who required two staff members for assistance, frequently experienced delays of twenty to forty minutes before receiving care, as reported by both the resident and the CNAs assigned to Hall B. Interviews with the CNAs revealed that they were often unable to provide timely care due to the need to find additional staff from other halls to assist with residents requiring two-person assistance. This process was time-consuming, as other CNAs had their own assignments and tasks to complete, leading to significant wait times for residents like Resident #59. The CNAs confirmed that the acuity of Hall B was too high for a single CNA to manage effectively, resulting in delays in care provision. The facility's staffing practices were based on the minimum state-required standard of 2.35 hours per patient per day, rather than the acuity and specific needs of the residents. The Director of Nursing (DON) and the CNA Supervisor acknowledged the staffing challenges and the resulting delays in care but indicated that the facility had to work within the existing staff-to-resident ratios. The administrator confirmed that staffing was not based on resident acuity, which contributed to the deficiency in meeting residents' needs in a timely manner.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's physician of significant changes in the resident's condition, which required an alteration in treatment. The resident, who had a severe cognitive impairment, was ordered to wear an immobilizing splint for a left distal humerus fracture. Despite the resident's repeated removal of the splint and exhibiting signs of pain during activities of daily living (ADL) care, the nursing staff did not inform the treating physician of these issues. This lack of communication created an immediate jeopardy situation, as the resident was at risk of further bone displacement, improper healing, and additional pain. The resident's clinical records indicated a history of Alzheimer's disease, cognitive communication deficit, and a left humerus fracture sustained after a fall. The resident was assessed with a severe cognitive impairment and had orders to wear an immobilizing splint at all times, except during bathing. However, the resident frequently removed the splint, and the nursing staff failed to reapply it consistently or notify the physician of the resident's non-compliance and signs of pain. Interviews with CNAs and LPNs revealed that they assumed the nurses were aware of the resident's condition and did not report the resident's removal of the splint or signs of pain. The facility's policy required that any change in a resident's condition be promptly reported to the nurse, who would then notify the physician. However, this protocol was not followed, as the CNAs did not report the resident's signs of pain or removal of the splint to the nurses, and the nurses did not notify the physician. The Director of Nursing (DON) and the Nurse Practitioner (NP) were also not informed of the resident's ongoing issues, leading to a failure in managing the resident's pain and ensuring the proper use of the immobilizing splint.
Failure to Implement Care Plans and Ensure Follow-Up Appointments
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, leading to significant deficiencies. One resident, who was severely cognitively impaired, had a physician's order for an immobilizing splint to treat a left humerus fracture. Despite the order, the resident frequently removed the splint, and the nursing staff did not consistently reapply it. Observations revealed that the resident was often without the splint, and staff interviews confirmed that they were aware of the resident's non-compliance but did not take adequate steps to ensure the splint was worn as ordered. This failure resulted in the resident experiencing pain and the potential for further injury. Additionally, the facility did not ensure that the resident attended follow-up appointments with the orthopedic physician as ordered. The resident missed a scheduled appointment, and there was no documentation of efforts to reschedule or ensure the resident received necessary follow-up care. Interviews with staff responsible for scheduling and transporting residents to appointments revealed a lack of communication and follow-up, contributing to the missed appointment. Another resident, who was cognitively intact, also did not attend a follow-up appointment with a rheumatologist as ordered. The facility failed to schedule the appointment and did not follow up on the referral process, resulting in the resident not receiving the necessary evaluation and treatment for fibromyalgia. This oversight was confirmed through staff interviews, which highlighted a breakdown in the process of scheduling and tracking medical appointments for residents.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered safely, as evidenced by an incident involving a resident who was cognitively intact with a BIMS score of 13. During an observation, a cup of medications was found at the resident's bedside. An LPN admitted to leaving the medications there, stating that the resident preferred to take them at a later time. The Director of Nursing confirmed that staff were instructed to leave medications at the bedside to accommodate the resident's preference.
Failure to Provide Adequate Hair Hygiene for Resident
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the staff did not provide adequate hair hygiene for a resident who required maximum assistance for personal hygiene. The resident, who had a diagnosis of difficulty in walking, muscle wasting, atrophy, lack of coordination, and dementia, was observed with oily hair pinned to her scalp and a dry, crusted scalp with thick yellow flakes. Despite being scheduled for bathing assistance three times a week, there was no documented evidence that staff washed her hair during the period reviewed. Interviews with the resident and staff revealed that the resident desired her hair to be washed at least once a week, but staff informed her that only the beautician could wash her hair. The CNA confirmed the resident's dependency on staff for personal hygiene and acknowledged the need for hair washing with each bed bath. The facility's beautician reported that the resident was not a regular customer and required multiple washes to clean her hair due to the buildup of flakes. The Director of Nursing confirmed the resident's dependency on staff for personal hygiene and acknowledged that her hair should be washed with each scheduled bed bath.
Failure to Reposition Resident as Required
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including Hemiplegia and Cerebral Vascular Accident, was assessed as totally dependent on staff for bed mobility and transfers. The facility's policy required residents at risk for skin impairment to be turned and repositioned every two hours. However, observations and interviews revealed that the resident was not repositioned as required, remaining in the same position for extended periods. The resident's care plan and physician orders both indicated the necessity for repositioning every two hours due to the high risk of skin breakdown. Despite this, staff interviews and observations confirmed that the resident was not turned according to the prescribed schedule. The Director of Nursing acknowledged the resident's high risk for skin breakdown and the need for regular repositioning, yet the deficiency persisted, as evidenced by the resident's prolonged positioning without change.
Failure to Maintain Sanitary Mattress for Incontinent Resident
Penalty
Summary
The facility failed to maintain a sanitary environment for a resident, specifically regarding the condition of a mattress. The resident, who was always incontinent of bladder, had a mattress with multiple brown rings and a strong urine odor in the room. The facility's maintenance log showed no entries for the resident's mattress, indicating a lack of documentation and follow-up on the issue. The resident's mattress was observed to be in this condition for months, as confirmed by a CNA who stated that the mattress had been soiled with urine for an extended period. Interviews with facility staff revealed a breakdown in communication and procedure. The CNA acknowledged the persistent urine odor and the condition of the mattress but did not document the issue in the maintenance log or notify maintenance staff. The maintenance supervisor confirmed that he was not informed of the problem, and the mattress was not listed in the log. The administrator was only made aware of the situation on the day of the survey, indicating a failure in the facility's internal reporting and response systems to address the unsanitary condition in a timely manner.
Inaccurate PASARR Status in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's PASARR status, leading to a deficiency. A review of the facility's policy on MDS assessments revealed that all MDS should be completed according to the most current Resident Assessment Instrument manual. However, the admission MDS for a resident with Bipolar Disorder and Major Depressive Disorder, who was approved for admission by Level II Authority, inaccurately reflected the resident's PASARR status. The MDS was coded as if the resident did not have a Level II PASARR, despite documentation indicating otherwise. Interviews with facility staff confirmed the inaccuracy, acknowledging that the MDS should have accurately reflected the resident's Level II PASARR status.
Failure to Support Resident's Activity Participation
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting a resident's choice to participate in activities. A resident, who was cognitively intact and enjoyed participating in daily activities, was unable to attend morning activities on time due to a lack of assistance from staff. The resident, who had difficulty with balance and required help to put on pants, requested assistance from a CNA after breakfast but did not receive help in a timely manner. As a result, the resident was unable to join the activities at her preferred time, which was important to her for socializing with friends before the activities began. Observations and interviews confirmed that the resident was left waiting for assistance, pressing the call light, and eventually only managed to leave her room fully dressed after a significant delay. Staff interviews corroborated that the resident enjoyed participating in activities and that there were instances when she was not ready in time due to delays in receiving assistance. The Director of Nursing confirmed that staff should accommodate residents' preferences to be up and dressed at certain times, especially when they wish to attend activities.
Failure to Coordinate Hospice Care and Maintain Updated Records
Penalty
Summary
The facility failed to meet hospice care requirements by not designating a member of the interdisciplinary team (IDT) to coordinate care with hospice representatives. This deficiency was identified for a resident receiving hospice care, who was admitted to the facility and had been under hospice care for several certification periods. The facility's hospice care policy and the signed agreement with the hospice agency required the designation of a liaison to facilitate cooperative efforts, but the facility did not have such a designated member. Additionally, the facility did not maintain an updated system for the hospice resident's records. The hospice binder for the resident did not contain the most current hospice orders, plan of care, or recertification of terminal illness. The most recent documents in the binder were outdated, and the facility's Director of Nursing (DON) confirmed that the hospice binder was the only location for these records within the facility. The hospice nurse was responsible for updating the binder, but there was no system in place to ensure this was done. Interviews with facility staff revealed that the resident had experienced a decline in health, and the hospice nurse had increased the frequency of visits. However, the facility did not have a designated IDT member to manage the relationship with the hospice agency, and staff were unaware of the requirement to have one. This lack of coordination and record-keeping could potentially affect other residents receiving hospice services in the facility.
Failure to Maintain Safe Bed Equipment
Penalty
Summary
The facility failed to maintain a resident's bed equipment in safe operating condition, affecting a resident who was admitted with multiple diagnoses including generalized muscle weakness, muscle atrophy, abnormalities of gait and mobility, COPD, and reduced mobility. The resident's care plan required the head of the bed to be elevated due to difficulty breathing. However, the resident was observed lying flat in bed, unable to get out of bed for two days because the bed was not functioning properly. The bed's remote control had been cut off by maintenance after it became tangled in the bed frame, rendering the bed inoperable. Interviews with staff revealed that the bed controller cord was severed on a specific date, and the facility did not have a functioning bed available to replace it until several days later. During this period, the resident remained in bed, unable to be moved to a wheelchair as desired. The facility administrator confirmed that residents should always be provided with safely operating equipment, acknowledging that the resident was not provided with a safe operating bed during this time.
Inaccurate Documentation of Orthopedic Device Use
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's Medication Administration Record (MAR) concerning the use of an orthopedic device. Resident #76, who was admitted with a cognitive communication deficit and a left distal humerus fracture, had a physician's order for a left elbow brace to be applied every shift. However, observations on multiple occasions revealed that the resident was not wearing the brace, despite the MAR indicating it was in place. Specifically, on December 2nd and 3rd, 2024, the resident was observed without the brace, contradicting the MAR entries that marked the brace as applied. Interviews with facility staff further highlighted the discrepancy. A Certified Nursing Assistant (CNA) assigned to the resident for a month was unaware of the brace requirement and had never seen the resident wearing it. Additionally, a Licensed Practical Nurse (LPN) admitted to marking the MAR with a '1' but was unsure of its meaning and confirmed not applying the brace on the specified dates. The Director of Nursing (DON) confirmed that the MAR entries were inaccurate, as they indicated the brace was in place when it was not, highlighting a failure in maintaining accurate medical records in accordance with professional standards.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by the actions of a Certified Nursing Assistant (CNA) identified as S3CNA. On the morning of September 3, 2024, video footage provided by the resident's family showed S3CNA entering the resident's room and reacting inappropriately to the resident's soiled condition. S3CNA was observed yelling and using profane language while providing care, including bathing the resident with a towel and bottle of water. The CNA's behavior included making derogatory comments about the resident's condition and expressing frustration loudly, which was overheard by others outside the room. The resident, who had severe cognitive impairment due to unspecified dementia, was subjected to rough handling during a transfer to a wheelchair, causing her discomfort. Interviews conducted with the CNA, the Director of Nursing (DON), and the Administrator confirmed the inappropriate and undignified treatment of the resident. The CNA admitted to being unprofessional and having a poor attitude while caring for the resident. The DON and Administrator were made aware of the situation by the resident's family, who showed them the video footage. Both confirmed that the CNA's actions, including cursing and yelling, were undignified and unprofessional, failing to honor the resident's right to a dignified existence as outlined in the facility's Resident Rights document.
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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