Pontchartrain Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mandeville, Louisiana.
- Location
- 1401 Highway 190, Mandeville, Louisiana 70448
- CMS Provider Number
- 195297
- Inspections on file
- 29
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pontchartrain Health Care Center during CMS and state inspections, most recent first.
The facility failed to follow its grievance policy when a resident with TBI, dementia with behavioral disturbance, and mood disorder complained during a care plan meeting about not receiving baths in a timely manner. Although the grievance officer acknowledged this was a grievance and reported it to the CNA supervisor, she did not complete a grievance form, did not enter it into the grievance log, and did not conduct follow-up with the resident to confirm resolution, as required by policy. Review of grievance logs showed no entry for this concern, and an observation later noted the resident in a room with a strong urine odor.
A resident’s Quarterly MDS assessment was inaccurately coded in Section C, question C0100, indicating that the resident was rarely/never understood and that a Brief Interview for Mental Status (BIMS) should not be conducted, despite the resident being able to hear, understand, and clearly answer questions during interview. The social worker who completed Section C later acknowledged the resident could be understood and that the coding was incorrect, and the DON confirmed the inaccuracy in the MDS coding.
A resident with hemiplegia and a history of cerebral infarction, who was cognitively intact and required substantial/maximal assistance for showering, did not consistently receive scheduled showers, and multiple shower days were left undocumented with no recorded refusals. Observation showed poor hair hygiene, and the resident reported rarely receiving the three weekly showers he was scheduled for. CNAs and supervisory staff stated that when the shower aide was pulled to work the floor, assigned CNAs often did not complete showers and did not fill out shower logs. The DON had previously identified shower provision as a problem and initiated a QAPI project, but staff confirmed that the corrective actions and monitoring outlined in the QAPI plan were not being implemented.
Two residents did not receive comprehensive, person-centered care as required. One resident with a history of brain injury and repeated falls was not consistently provided with 1:1 supervision or sitters at bedside, despite care plan directives and clinical recommendations, leading to multiple unwitnessed falls and further injury. Another resident with a seizure disorder did not have a neurology consult scheduled as ordered, due to a breakdown in the appointment scheduling process.
A resident with cognitive impairment, a history of falls, and recent brain injury experienced multiple unwitnessed falls when 1:1 supervision was not consistently provided as required by the care plan. Staff only implemented bedside supervision when extra personnel were available, and did not always ensure relief before leaving the resident unsupervised. This resulted in serious injury, including a new subdural hematoma, and demonstrated a failure to follow and monitor fall prevention interventions.
A resident with cognitive impairment, a history of falls, and a recent brain bleed was assessed to need continuous staff supervision at bedside, but this intervention was not consistently implemented. Staff only provided sitters when extra personnel were available, and there was no system to ensure ongoing supervision, resulting in multiple unwitnessed falls, including one causing a new subdural hematoma and ICU admission. Care plan interventions were inconsistently documented and not reliably followed, leading to repeated incidents.
The facility did not maintain accurate and consistent documentation of code status for two residents, resulting in conflicting information between LaPOST forms, physician orders, and advance directives. Staff interviews confirmed that these discrepancies could cause confusion during emergencies, as staff might rely on outdated or incorrect documentation.
Staff failed to follow infection prevention protocols, including not wearing a gown during PICC line care for a resident under Enhanced Barrier Precautions and not changing gloves or performing hand hygiene during incontinence care for another resident. These actions were inconsistent with facility policy and posted instructions, as confirmed by staff interviews.
A resident's MDS assessment was not accurately coded to reflect their Level II PASRR approval, despite documentation in the clinical record confirming the approval. Both the MDS coordinator and DON verified that the assessment should have indicated the resident's PASRR status, but it was incorrectly marked as not evaluated.
A resident with a history of Bipolar Disorder and newly diagnosed Major Depressive Disorder and Generalized Anxiety Disorder was not referred for a required PASRR Level II evaluation after acquiring these additional mental health diagnoses. Facility staff confirmed that the necessary referral was not submitted as required.
A resident with a history of seizures and other neurological conditions was not provided with physician-ordered seizure precautions, specifically the requirement to keep the bed in the lowest position. During observations, the bed was found in a high position, and both the DON and NP confirmed that seizure precautions were not in place as ordered.
A resident with multiple complex medical and psychiatric conditions had numerous instances where medication administration, behavioral monitoring, and clinical assessments were not documented as required in the MAR. Nursing staff and the DON confirmed that these omissions occurred and should have been recorded according to physician orders and facility protocol.
A resident receiving hospice care did not have the most recent Hospice Plan of Care or physician recertification of terminal illness in their Hospice Binder, as required by facility policy and hospice agreement. Review and interviews confirmed that only outdated documents were present, potentially affecting all hospice patients in the facility.
Surveyors found that the facility did not post the required names, addresses, and phone numbers of pertinent State agencies and advocacy groups, nor did it display a statement on how a resident may file a complaint with the State Survey Agency. The administrator confirmed these postings were missing and should have been accessible to all residents and their representatives.
Surveyors found that several resident rooms were not maintained in a sanitary or functional condition, including unclean floors, chipped paint, dirty bed parts, non-functional showers, and unclean air conditioner units. Staff and administration confirmed these deficiencies, and maintenance logs showed no requests for repairs or cleaning in the affected rooms.
The facility failed to maintain a safe and sanitary environment, with issues such as disrepair of ceiling tiles, unclean vents, broken gutters, and a long-standing non-functional toilet. Staff confirmed awareness of these issues, which had the potential to affect 114 residents.
A resident with severe cognitive impairment was found with a bruise on the forehead, raising concerns of potential abuse. The LPN reported the incident to the Supervisor and the resident's representative, who suspected another resident might have caused the injury. Despite the facility's policy requiring reporting to the state agency within 24 hours, the Administrator did not report the incident, believing an internal investigation sufficed.
A facility failed to document daily meal intake percentages for a resident with Non-Alzheimer's Dementia, Malnutrition, and Dysphagia, as required by the care plan. The care plan aimed to ensure adequate nutrition by having staff observe and document meal intake. However, several dates in February were left undocumented, which was confirmed by the DON as a failure to implement the care plan.
The facility failed to maintain a safe, clean, and homelike environment, as observed in Halls A, B, and C. Cracked and missing floor tiles with exposed subflooring were noted, along with stains and scuffs on walls. The administrator confirmed these conditions were unacceptable and posed a safety risk to residents.
The facility failed to maintain an effective pest control program, resulting in a fly infestation affecting residents and common areas. Observations revealed flies in resident rooms and hallways, with residents expressing discomfort. Staff confirmed the issue, and the administration acknowledged the failure to ensure a pest-free environment.
The facility failed to maintain accurate bath records for two residents, who were supposed to receive baths three times a week. The Bath/Shower Logs for these residents showed missing documentation on several occasions. Interviews with the ADON and DON confirmed the absence of records for the specified dates, indicating a failure to adhere to professional standards in maintaining accurate medical records.
The facility failed to ensure staff adhered to Enhanced Barrier Precautions for two residents with indwelling medical devices and wounds. Despite signs and gowns being available, staff were observed providing care without wearing gowns, which was confirmed in interviews with the staff involved.
A resident's MDS was inaccurately coded, failing to reflect the use of prescribed antipsychotic and antidepressant medications. Despite being administered Quetiapine Fumarate and Venlafaxine as per physician's orders, the MDS did not include these medications. The oversight was confirmed by the MDS coordinator and the DON.
A facility failed to meet professional quality standards by not accurately transcribing a physician's orders for a resident with Gastrostomy and Colostomy Status. Upon review, it was found that there were no orders for necessary care documented, and the MAR lacked entries for both Gastrostomy and Colostomy Care. Interviews with the facility's staff confirmed the incorrect transcription of the physician's orders.
A resident with dyspnea did not receive proper respiratory care as their oxygen tubing and humidifier bottle were not labeled with the date of last change, contrary to facility policy. Additionally, the resident was administered oxygen at 4 liters per minute instead of the ordered 2 liters per minute, as confirmed by the DON.
The facility failed to maintain accurate records for three residents regarding their activities of daily living, specifically the documentation of completed baths or showers. Despite the completion of these tasks by CNAs, the records lacked documentation, which was confirmed by the staff involved and the ADON.
The facility failed to store food under sanitary conditions by not labeling and dating food items in unit refrigerators and freezers. Additionally, the kitchen had unsanitary conditions, including black sludge and ice buildup around the standalone freezer door, which had been present for a week.
The facility failed to have a policy for the use and storage of foods brought by family and visitors, affecting 101 residents. This was confirmed through policy review and staff interviews.
The facility failed to properly dispose of garbage and ensure waste was contained in the outdoor dumpster. Observations revealed stagnant water with trash, a deteriorating mop head, and a metal cooking pan with spoiled food near the kitchen entrance. Additionally, bedframes and mattresses were left around the dumpsters, which the trash company had not picked up. S1ADM confirmed the unsanitary conditions.
The facility failed to inform residents of their right to rescind the arbitration agreement within 30 days. This was identified for three residents, as the admission packet did not include this information, confirmed by the facility administrator.
The facility failed to ensure resident assessments accurately reflected the residents' status for three residents. Diagnoses of Alzheimer's, Depression, and PTSD were not coded as active diagnoses in the MDS assessments. Interviews with the MDS coordinator and the DON confirmed these findings.
The facility failed to ensure a resident with Schizoaffective Disorder, Bipolar Type was referred for a PASARR Level II evaluation as required. Despite the new diagnosis, the necessary Resident Review was not submitted, as confirmed by the BOM, DON, and Administrator.
The facility failed to ensure PRN psychotropic medications had a stop date for two residents, resulting in the continued use of Lorazepam without a stop date. The oversight was confirmed by the hospice nurse, hospice company's administrator, and facility staff.
The facility failed to ensure staff used appropriate hand hygiene after providing incontinent care to a resident. A CNA did not perform hand hygiene after removing gloves and before touching clean linen, contrary to the facility's policy. The CNA and DON confirmed the lapse in protocol.
The facility failed to ensure all complaint surveys since the last annual survey were available for resident review. An observation revealed that the survey results binder only contained the annual recertification survey, missing complaint surveys from several dates. The administrator confirmed the omission.
The facility failed to post complete nurse staffing data, including resident census and total number and actual hours worked by nursing staff, on two consecutive days. This was confirmed by the facility administrator.
Failure to Document and Follow Up on Resident Grievance Regarding Bathing
Penalty
Summary
The facility failed to follow its grievance policy and procedure by not documenting and tracking a resident's care-related complaint as a formal grievance. The facility's written policy required that grievances about care and treatment, staff behavior, and other concerns be written on a grievance/complaint report form, entered into a grievance log with the disposition, and followed up after resolution to ensure effectiveness. A resident with diagnoses including unspecified focal traumatic brain injury, dementia with behavioral disturbance, and persistent mood affective disorder voiced a concern during a care plan meeting that he was not receiving baths in a timely manner. This concern was documented in a progress note, which indicated that the issue was addressed with the CNA supervisor. Review of the grievance logs for several months showed no entries for this resident, despite the grievance officer stating she considered the resident's bath concern to be a grievance. She acknowledged that she notified the CNA supervisor but did not complete a grievance form, did not log the grievance, and did not follow up with the resident to ensure the concern was resolved, contrary to facility policy. The administrator confirmed that issues with care, including bath concerns, were considered grievances and that the grievance officer should have completed the required documentation and follow-up. During observation, the resident was seen in his room eating breakfast in his wheelchair, and the room had a strong smell of urine, but there was no evidence in the grievance documentation that his earlier concern about bathing had been processed according to policy.
Inaccurate MDS Coding of Resident Communication and Mental Status
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the Quarterly MDS with an Assessment Reference Date of 01/12/2026 did not correctly reflect the resident’s communication and mental status. Record review showed that in Section C, question C0100, which asks whether the Brief Interview for Mental Status (BIMS) should be conducted, the resident was coded as 0 – no (resident is rarely/never understood). However, during an interview on 02/18/2026, the resident was able to hear and understand questions without difficulty and was able to clearly voice answers. In a subsequent interview, the social worker responsible for completing Section C of the MDS acknowledged that the resident was able to be understood and that coding C0100 as 0 was inaccurate, and the DON also confirmed that this MDS item was not coded accurately.
Failure to Implement QAPI Monitoring for Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its QAPI and QAA processes to ensure residents received scheduled showers and that refusals were properly documented. A Quality Improvement Corrective Action Plan dated 01/12/2026 identified that residents were not receiving showers consistent with their schedules and outlined actions such as CNAs notifying the floor nurse of refusals and submitting shower sheets for review. However, the plan’s objective measures for evaluating effectiveness were incomplete, and there was no sufficient evidence of ongoing monitoring or evaluation to ensure corrective actions were carried out. A cognitively intact resident with hemiplegia and cerebral infarction, who required substantial/maximal assistance for showering, was scheduled for showers three times weekly but had multiple dates on his Bath/Shower Log left blank, with no documentation of showers given or refusals. Nurse’s notes contained no entries indicating shower refusals. During observation, the resident’s hair appeared oily with white flakes, and he reported that he was supposed to receive showers three times a week but often only received one. CNAs and supervisory staff confirmed that on several dates no shower aide was assigned, the resident did not receive showers, and shower logs were not completed as required. The DON and other staff acknowledged that residents not receiving showers had been identified as an issue and that the QAPI corrective actions related to showers were not being implemented.
Failure to Implement Comprehensive Care Plans and Supervision
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents, resulting in significant deficiencies. For one resident with a history of traumatic subdural hemorrhage, repeated falls, cognitive impairment, and poor safety awareness, the care plan included interventions such as sitters at bedside and 1:1 staff supervision. However, staff did not consistently implement these interventions, and the resident experienced multiple unwitnessed falls when left unsupervised. Documentation and interviews revealed that sitters were only provided when extra staff were available, and there was no clear duration or end date for the intervention in the care plan. Staff often left the resident unsupervised, especially during breaks, and did not always ensure another staff member was present to supervise the resident, despite the resident's high risk for falls and recommendations from the nurse practitioner for continuous supervision. The resident suffered several falls, including incidents where staff stepped away from the bedside or were not assigned to supervise, resulting in the resident being found on the floor. One of these falls led to a new subacute subdural hematoma, requiring hospitalization and admission to the neurological intensive care unit. Upon return to the facility, the resident continued to be left unsupervised at times, and the care plan interventions were not reliably followed. Staff interviews confirmed that supervision was inconsistent and dependent on staffing availability, and that the care plan interventions were sometimes copied directly from incident reports without specifying implementation details or timeframes. For another resident with a seizure disorder, the facility failed to schedule a neurology consultation as ordered by the physician and indicated in the care plan. The staff member responsible for scheduling follow-up appointments was unaware of the order and did not arrange the necessary consultation. This failure to implement the care plan intervention left the resident without the required specialist evaluation for seizure-like activity. The process for scheduling appointments relied on an appointment slip system, which was not followed in this case, resulting in the omission.
Failure to Provide Consistent Supervision Results in Multiple Unwitnessed Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent avoidable falls for a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness. The resident was assessed to require staff supervision at bedside, but this intervention was not consistently implemented. Multiple unwitnessed falls occurred, including incidents where staff left the resident unsupervised, resulting in serious injury, including a new subacute subdural hematoma that required hospitalization and intensive care. The resident's care plan included interventions such as a fall mat, bed against the wall, helmet, non-skid footwear, and 1:1 supervision at bedside. Despite these interventions being documented, staff interviews and record reviews revealed that 1:1 supervision was only provided when extra staff were available. Staff members reported that they were not required to find relief before leaving the resident unsupervised, and there was confusion among the nursing administration regarding the necessity and implementation of continuous 1:1 supervision as outlined in the care plan. Incident logs and staff interviews confirmed that the resident experienced multiple unwitnessed falls when supervision was not maintained as required. Staff acknowledged that the presence of a sitter at bedside was effective in preventing falls, but this intervention was not reliably provided. The lack of consistent supervision placed the resident at risk for further injury and demonstrated a failure to implement and monitor care plan interventions as required.
Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently for a resident with a significant fall risk, resulting in a deficiency. A cognitively impaired resident with a history of repeated falls, recent brain bleed, poor safety awareness, and impulsiveness was assessed to require staff supervision at bedside. Despite this, the intervention of a sitter at bedside was not consistently implemented, and the resident experienced multiple unwitnessed falls while unsupervised. Documentation showed that the care plan included interventions such as sitters at bedside, helmet use, and frequent neurological checks, but these were not reliably carried out. Staff interviews revealed that sitters were only provided when extra staff were available, and there was no system to ensure continuous supervision as indicated in the care plan. Staff members reported that if a sitter needed to take a break, there was no requirement to find a replacement, leaving the resident unsupervised. The Assistant Director of Nursing acknowledged that interventions were copied from incident reports into care plans without specifying duration or end dates, leading to confusion about the ongoing need for supervision. The Director of Nursing and other staff confirmed that 1:1 supervision was not always provided, and the nurse practitioner’s recommendation for continuous supervision was not consistently followed. As a result of these lapses, the resident suffered several unwitnessed falls, including one that resulted in a new subacute subdural hematoma and required admission to the neurological intensive care unit. The lack of consistent implementation of care plan interventions and inadequate communication among staff contributed directly to the repeated incidents. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious injury, harm, impairment, or death for the resident and potentially for others requiring increased supervision.
Failure to Ensure Accurate and Consistent Documentation of Residents' Code Status
Penalty
Summary
The facility failed to ensure that all medical records accurately reflected the residents' wishes regarding code status for two residents. For one resident, the clinical record showed a LaPOST form indicating Full Code status, while the current physician orders and care plan documented Do Not Resuscitate (DNR). Multiple staff interviews confirmed the inconsistency between the LaPOST and the physician orders, and staff acknowledged that the documentation should have matched to reflect the resident's wishes. For another resident, the clinical record and care plan indicated Full Code status, but the physical hard chart contained both a LaPOST form indicating DNR and an advance directive form indicating Full Code. Staff interviews revealed that during an emergency, staff would refer to whichever form was on top in the chart, potentially leading to confusion. Staff responsible for updating code status documentation confirmed that only the most current code status should be present in the chart, and the presence of conflicting documents could result in staff not honoring the resident's actual wishes.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by policy and physician orders. In one instance, a resident with a peripherally inserted central catheter (PICC) line was observed receiving an intravenous medication infusion from an LPN who did not wear a gown, despite the presence of an Enhanced Barrier Precaution (EBP) sign and caddy with gowns and gloves at the resident's door. The facility's policy and posted instructions required staff to wear both gown and gloves during high-contact care activities involving central lines. The LPN confirmed awareness of the EBP signage but stated she did not believe a gown was necessary during the procedure. In another instance, a CNA providing incontinence care to a resident with neuromuscular dysfunction of the bladder failed to change gloves and perform hand hygiene after removing a soiled brief and before applying skin barrier cream and a clean brief. The CNA disposed of the soiled brief, cleaned the resident, and then, without changing gloves or performing hand hygiene, applied barrier cream and a clean brief. The CNA later confirmed the expected process was to change gloves and perform hand hygiene before these steps. The Director of Nursing also confirmed the expectation for staff to follow proper glove and hand hygiene protocols during such care.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected the resident's status by incorrectly coding the Minimum Data Set (MDS) regarding the Pre-admission Screening and Resident Review (PASRR). A review of the clinical record showed that the resident was admitted with a Form 142 indicating approval for admission by the state Level II Authority. However, the annual MDS assessment did not accurately document this, as Section A1500 was coded as 'No' for Level II PASRR evaluation, and Section A1510 was left blank. Both the MDS coordinator and the Director of Nursing confirmed upon review that the MDS should have indicated a Level II PASRR approval, but it was not properly coded.
Failure to Refer Resident for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with newly identified mental health diagnoses was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required. Record review showed that the resident was admitted with a diagnosis of Bipolar Disorder and subsequently acquired additional diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder. Despite these new diagnoses, there was no documentation of a Level II PASRR evaluation in the clinical record. Interviews with facility staff confirmed that a Resident Review form should have been submitted to the state agency for evaluation and determination for Level II services, but this was not done after the resident acquired the new mental health diagnoses.
Failure to Implement Physician-Ordered Seizure Precautions
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for seizure precautions for a resident with a history of cerebral palsy, extrapyramidal and movement disorder, and seizures. The resident had a physician's order for seizure precautions starting on 04/02/2025, which included keeping the bed in the lowest position. During observations, the resident was found resting in bed with the bed in a high position, and the Director of Nursing confirmed that seizure precautions were not in place as ordered. The Nurse Practitioner who ordered the precautions also confirmed that the bed should have been in the lowest position as part of the seizure precautions. The facility did not have a policy related to seizure precautions, and staff acknowledged that the required precautions were not implemented for the resident.
Failure to Accurately Document Medication Administration and Assessments
Penalty
Summary
The facility failed to ensure accurate and complete documentation of a resident's Medication Administration Record (MAR) for one resident. The resident, who had multiple diagnoses including bipolar disorder, PTSD, fibromyalgia, major depressive disorder, anxiety disorder, legal blindness, insomnia, and type 2 diabetes requiring long-term insulin use, had several physician orders for medications, behavioral monitoring, and clinical assessments. These orders included administration of various medications such as oxycodone-acetaminophen, trazodone, duloxetine, insulin, Jardiance, Prozac, gabapentin, and promethazine, as well as regular monitoring for side effects, pain, behavioral symptoms, and vital signs. Review of the resident's MAR for April and June revealed multiple instances where medication administration and required assessments were not documented as completed. Specific omissions included missing documentation for insulin injections, oral medications, behavioral and side effect monitoring, pain assessments, and vital sign checks across several shifts and dates. These gaps were identified for both scheduled and as-needed medications, as well as for required clinical observations and interventions. Interviews with nursing staff and the Director of Nursing confirmed that the medications, assessments, and observations in question should have been documented but were not. The staff members responsible for the resident's care on the identified dates acknowledged the lack of documentation, and the Director of Nursing verified the omissions upon review of the MARs for the relevant months.
Failure to Maintain Current Hospice Documentation
Penalty
Summary
The facility failed to maintain a system to ensure that a hospice resident's Hospice Binder contained the most recent Hospice Plan of Care and a current Recertification of Terminal Illness. Specifically, for one resident receiving hospice care, the binder did not include the latest physician recertification or an updated plan of care for the current certification period. The facility's agreement with the hospice agency required obtaining and maintaining these documents for each hospice patient. Record review showed that the most recent documents in the resident's Hospice Binder were outdated, corresponding to a previous certification period. Interviews confirmed that the current physician recertification and updated plan of care were missing from the binder. This deficiency had the potential to affect all residents in the facility receiving hospice services.
Failure to Post Required State Agency and Advocacy Group Information
Penalty
Summary
The facility failed to post the names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency, State licensure office, protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. During an initial tour of the facility, surveyors did not observe this required information posted anywhere in the facility. Additionally, there was no statement posted explaining how a resident may file a complaint with the State Survey Agency regarding suspected violations of state or federal nursing facility regulations. Further confirmation was obtained during a subsequent tour with the facility administrator, who acknowledged that the required list and complaint filing statement were not posted in a form and manner accessible to residents or their representatives. This deficiency had the potential to affect all 109 residents residing in the facility, as none of the required postings were available for review.
Failure to Maintain Sanitary and Functional Resident Rooms
Penalty
Summary
The facility failed to maintain a functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations over several days. In one resident room, surveyors noted a scattered brown/black substance and debris on the floor near the window and air conditioner unit, missing and chipped paint behind the bed, and a dried brown substance on the bed's mechanical parts, which was also missing a cover. The shower in this room was not functional, missing a shower head, and had chipped or missing tiles, a dried orange substance along the bottom, and no shower curtain. These conditions were observed repeatedly and confirmed by both housekeeping and maintenance staff, as well as the facility administrator, who acknowledged that the room had not been maintained in a sanitary or functional state. Additionally, in two other resident rooms, a fluffy gray substance was observed scattered on top of the air conditioner units over several days, with no change in condition. Staff interviews confirmed that housekeeping was responsible for daily cleaning of resident rooms, while maintenance was responsible for cleaning air conditioner units. However, there were no documented maintenance requests for these issues in the facility's maintenance log for the relevant period. The facility administrator and maintenance supervisor both confirmed the unsanitary and non-functional conditions in these rooms, including the prolonged lack of a functional shower.
Facility Environment and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During a tour of the facility, several deficiencies were observed. In multiple rooms, including Rooms b, c, d, and f, as well as Hall b, ceiling tiles were found to be in disrepair, with brown substances and tears present. Additionally, the vent above the ice machine on Hall c was covered in a gray fluffy substance, indicating a lack of cleanliness. The exterior of the facility also showed signs of neglect, with broken PVC pipes connected to the gutters, leaving jagged edges exposed. Furthermore, the bathroom toilet in Hall a was found to be wrapped in opaque plastic bags with a black unknown substance underneath, and upon removal of the bags, black water with sludge was noted in the toilet bowl. Interviews with staff members, including the Administrator (S1ADM), Maintenance Staff (S3MS), and Director of Nursing (S2DON), confirmed awareness of these issues, particularly the long-standing disrepair of the toilet, which had been out of order for years. These deficiencies had the potential to affect the 114 residents residing in the facility.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the state agency within the required 24-hour timeframe. The incident involved a resident who was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 00. On the morning of February 4, 2025, a Licensed Practical Nurse (LPN) documented a bruise on the resident's left forehead, which was reported by a Care Partner. The incident was unwitnessed, and the resident was unable to provide a description due to cognitive impairment. The LPN reported the bruise to the Supervisor and the Nurse Practitioner, and the resident's representative was notified. The representative expressed concern that the resident might have been hit by another resident, based on the bruise's size and location and a statement made by the resident. Despite these concerns, the Assistant Director of Nursing (ADON) and the Administrator did not report the allegation to the state agency. The ADON began an investigation by reviewing video surveillance, which took the entire day. The Administrator confirmed that she was aware of the unwitnessed and unexplained bruise and the representative's concerns but chose not to report the incident to the state agency. She believed that if her investigation found no signs of physical abuse, reporting was unnecessary. This decision was contrary to the facility's policy, which mandates reporting all allegations of abuse to the state agency within 24 hours of discovery.
Failure to Document Meal Intake for Resident with Nutritional Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, specifically in documenting daily meal intake percentages. The resident, who was admitted with diagnoses including Non-Alzheimer's Dementia, Malnutrition, and Dysphagia, had a care plan that required staff to observe and document meal intake percentages to ensure adequate nutrition. However, a review of the resident's nutrition intake records for February 2025 revealed multiple dates where the meal intake percentage was not documented. The Director of Nursing confirmed that these omissions were not in compliance with the care plan, indicating a failure to implement the required interventions for the resident's nutritional needs.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations conducted on three different halls. On Hall A, surveyors observed two busted and cracked floor tiles with exposed concrete subflooring near the double doors and another cracked tile across from the shower room. On Hall B, a cracked and uneven tile was noted at the beginning of the hall, along with two more cracked tiles with missing parts further down the hall. Hall C had a cracked tile with missing parts in the middle of the hall, as well as a dried blue substance on two separate walls, a brown stain on a wall, and multiple black scuffs on the bottom of the walls below the handrails. During a facility tour and interview, the administrator (S1ADM) confirmed that the conditions observed in Halls A, B, and C were not acceptable and acknowledged that the missing and cracked tiles posed a safety risk to residents. S1ADM also confirmed that housekeeping and maintenance services should ensure the facility remains a safe, clean, comfortable, and homelike environment at all times, which was not achieved in this instance. The deficient practice had the potential to affect the entire census of 110 residents residing in the facility.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent fly infestation affecting residents and common areas. Observations during the survey revealed flies flying around the facility, including hallways and resident rooms. Specific instances included flies in the rooms of two residents, with one resident having a fly trap and fly swatter in his room, indicating a personal attempt to manage the issue. Interviews with staff and residents confirmed the presence of flies throughout the facility, with multiple staff members acknowledging the ongoing problem. The deficiency was observed over multiple days, with flies noted in various locations, including resident rooms and hallways. Residents expressed discomfort due to the flies, with one resident stating that the flies were bothersome and made the environment feel dirty. Staff interviews corroborated the observations, with several CNAs and an LPN confirming the fly issue. The facility's administration was made aware of the observations, and the administrator acknowledged that the presence of flies was inappropriate and confirmed the facility's failure to maintain a pest-free environment.
Failure to Maintain Accurate Bath Records
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards for two of the three sampled residents reviewed for baths. Resident #2 was admitted to the facility and was supposed to receive a bath three days a week. However, the Bath/Shower Logs for September and October 2024 showed no documentation of a bath or shower on specific dates, including 09/21/2024, 09/24/2024, and 10/10/2024. Similarly, Resident #3, who was also admitted to the facility, was supposed to receive a bath three days a week. The Bath/Shower Logs for September 2024 revealed missing documentation for several dates, including 09/07/2024, 09/10/2024, 09/12/2024, 09/14/2024, 09/19/2024, and 09/28/2024. Interviews conducted with S3ADON and S2DON on 10/11/2024 confirmed the absence of documentation for the specified dates for both residents, acknowledging that there should have been records of baths or showers provided. This lack of documentation indicates a failure to adhere to professional standards in maintaining accurate medical records for the residents.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for two residents. Resident #2, who had an indwelling urinary catheter, colostomy, percutaneous endoscopic gastrostomy tube, and a stage 4 sacral pressure ulcer, was observed to have an EBP sign posted on her door with gowns available. However, S5CNA was seen performing peri-care and catheter care without wearing a gown, which was confirmed during an interview with S5CNA, who acknowledged the oversight. Similarly, Resident #3, who had an indwelling urinary catheter and an ostomy, was also on EBPs with a sign posted on her door and gowns available. Despite this, S6CNA was observed providing catheter care without wearing a gown. In an interview, S6CNA confirmed the failure to wear a gown, acknowledging the requirement. The Director of Nursing (S2DON) confirmed that both residents were on EBPs due to their medical conditions and that staff should have worn gowns while providing care.
Inaccurate MDS Coding for Medication Use
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically in the coding of the Minimum Data Set (MDS) for antipsychotic and antidepressant use. Resident #3, who was admitted with diagnoses including Depression and Hallucinations, was prescribed Quetiapine Fumarate and Venlafaxine, as per the physician's orders. The Medication Administration Record confirmed that these medications were administered as prescribed. However, the Quarterly MDS with an Assessment Reference Date of 09/24/2024 did not reflect the resident's use of these medications. Interviews with the MDS coordinator and the Director of Nursing confirmed the oversight in coding, acknowledging that the resident's MDS was not accurately completed to include the use of antipsychotic and antidepressant medications.
Failure to Transcribe Physician's Orders Correctly
Penalty
Summary
The facility failed to ensure that services were provided to meet professional quality standards by not accurately transcribing physician's orders for a resident. The resident was readmitted to the facility with diagnoses including Gastrostomy Status and Colostomy Status. However, upon review of the resident's clinical records, it was found that there were no physician's orders for Gastrostomy Care, and the order for Colostomy Care lacked a start date. Additionally, the Medication Administration Record (MAR) for the resident did not include entries for either Gastrostomy Care or Colostomy Care. Interviews with the facility's Quality Assurance Nurse (S7QAN) and Director of Nursing (S2DON) confirmed that the physician's orders dated 10/09/2024 were transcribed incorrectly, and no orders for the necessary care were documented after the resident's readmission. Both staff members acknowledged the oversight in the transcription of the physician's orders, which led to the deficiency in care provided to the resident.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident, as evidenced by two main deficiencies. Firstly, the oxygen tubing and humidifier bottle for a resident diagnosed with dyspnea were not properly labeled with the date of the last change. This was confirmed by an LPN and the Director of Nursing (DON), who acknowledged that the facility's policy required weekly changes and proper labeling by the night shift nursing staff. Secondly, the resident was observed receiving oxygen at a rate of 4 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the DON, indicating a failure to administer oxygen at the prescribed rate.
Failure to Document Resident Showers
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards and practices for three residents reviewed for activities of daily living. Specifically, the facility did not ensure that staff documented completed baths or showers in the residents' records. For Resident #1, there was no documentation of a completed bath or shower on two specific dates in July 2024, despite the shower aide confirming that the baths were completed but not documented. Similarly, for Resident #2, there was no documentation of completed showers over a week-long period from late June to early July 2024, even though the shower aide stated that multiple showers were completed but not recorded. For Resident #3, the facility's records lacked documentation of completed baths on three specific dates in July 2024. The shower aide confirmed that the baths were completed on those dates but were not documented. Interviews with the CNAs and the ADON revealed that the expectation was for shower aides to document the completion of baths or showers on the appropriate shower list, which was not adhered to in these cases. The lack of documentation was confirmed by the CNAS upon reviewing the shower lists for the three residents.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to store food under sanitary conditions by not ensuring that food items in unit refrigerators and freezers were properly labeled and dated. During a tour of Medication Storage Room A, it was observed that three to-go boxes, a frozen coffee drink, and a frozen fast food ice cream were not labeled or dated. Similarly, in Medication Storage Room B, a pitcher of cranberry juice, five plastic containers of frozen food, and an open plastic cup with pink liquid were found without labels or dates. Interviews with staff confirmed that all food items should have been labeled and dated, but they were not. Additionally, the facility failed to maintain kitchen equipment in safe operating condition. An observation of the kitchen revealed black sludge on the ground leading into the entrance of the standalone freezer door, a buildup of ice surrounding the freezer door frame, and a buildup of ice covering the plastic flaps in the entryway of the freezer. Staff confirmed that these unsanitary conditions had been present for a week and needed to be addressed and cleaned.
Lack of Policy for Food Storage and Handling
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors, which is necessary to ensure safe and sanitary storage, handling, and consumption. This deficiency was identified through a review of the facility's policies and confirmed during interviews with the Assistant Director of Nursing (S2ADON) and the Director of Nursing (S2DON). Both staff members acknowledged the absence of such a policy, which had the potential to affect 101 residents capable of storing and consuming food in the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and ensure waste was properly contained in the outdoor dumpster. On 05/06/2024 at 8:40 a.m., an observation and interview with S5DM revealed a pool of grey stagnant water containing loose trash and a deteriorating mop head near the kitchen entrance/exit door, which was used for food deliveries. Additionally, a metal cooking pan filled with black water and spoiled food was observed. At 8:45 a.m., further observation of the area surrounding the facility's two dumpsters showed multiple bedframes and mattresses waiting to be disposed of, which the trash company had not picked up. S5DM confirmed these items were trash. At 9:45 a.m., S1ADM confirmed all observations were unsanitary and needed to be addressed and cleaned.
Failure to Inform Residents of Right to Rescind Arbitration Agreement
Penalty
Summary
The facility failed to ensure residents were informed of their right to rescind the arbitration agreement within 30 calendar days. This deficiency was identified for three residents during a review of their clinical records and interviews. The facility's admission packet included an arbitration agreement within the Resident [NAME] of Rights form, but it did not document the residents' right to rescind the agreement within 30 days. This was confirmed by the facility administrator during an interview, who acknowledged the omission in the admission packet for all three residents reviewed.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected the residents' status for three of the sampled residents. Resident #50, diagnosed with Alzheimer's, had an admission MDS that did not code Alzheimer's as an active diagnosis. Resident #54, diagnosed with Depression, had a quarterly MDS that did not code Depression as an active diagnosis. Resident #78, diagnosed with Post Traumatic Stress Disorder, had an annual MDS that did not code Post Traumatic Stress Disorder as an active diagnosis. Interviews with the MDS coordinator and the Director of Nursing confirmed these findings and acknowledged that the MDS assessments should have been coded accurately with the residents' active diagnoses.
Failure to Submit PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a resident with an identified mental health diagnosis was referred for a PASARR Level II evaluation as required. Resident #72 was admitted to the facility and later diagnosed with Schizoaffective Disorder, Bipolar Type. Despite this new diagnosis, a Resident Review for PASARR Level II was not submitted. Interviews with the Business Office Manager (S6BOM), Director of Nursing (S2DON), and Administrator (S1ADM) confirmed that the required Resident Review for PASARR Level II should have been submitted following the new diagnosis but was not completed.
Failure to Ensure PRN Psychotropic Medications Have a Stop Date
Penalty
Summary
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for two residents. Resident #19 was admitted with diagnoses including Anxiety Disorders, Hallucinations, and Senile Degeneration of the Brain. The clinical record revealed an active physician order for Lorazepam 2mg/ml oral concentration, to be administered every 4 hours PRN for anxiety/agitation until death, without a documented stop date. Similarly, Resident #51, admitted with Bipolar Disorder and Schizoaffective disorder, had an active physician order for Lorazepam 2mg/ml oral concentration every 4 hours PRN for anxiety/agitation until death, also without a documented stop date. Interviews with the hospice nurse and hospice company's administrator confirmed that the Lorazepam medication is a PRN standing order for every hospice resident and does not have a stop date. The Director of Nursing (S2DON) and the Administrator (S1ADM) confirmed the oversight in not ensuring PRN psychotropic medications had a stop date and were limited to 14 days as required. The deficiency was identified during a review of the clinical records and interviews with the hospice nurse, hospice company's administrator, and facility staff. The facility's failure to adhere to regulations regarding PRN orders for psychotropic medications resulted in the continued use of Lorazepam without a stop date for both residents. This oversight was acknowledged by the Director of Nursing, who admitted to overlooking the requirement for a stop date on PRN psychotropic medications, and the Administrator, who confirmed the necessity of a stop date and the 14-day limit for such orders.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. Specifically, the facility did not ensure that staff used appropriate hand hygiene after providing incontinent care to a resident. The facility's policy on hand hygiene, revised in August 2015, mandates the use of alcohol-based hand rub or soap and water before and after direct contact with residents, after contact with bodily fluids, and after removing gloves. However, this policy was not followed during the observed incident involving Resident #101. During an observation on May 8, 2024, a CNA was seen providing incontinent care to Resident #101. After removing the resident's soiled brief and cleaning the perineal area, the CNA removed her gloves but did not perform hand hygiene before leaving the room to retrieve a clean sheet from the linen cart. The CNA confirmed in an interview that she did not use hand sanitizer or wash her hands after removing her gloves, which she acknowledged was against the facility's policy. The Director of Nursing also confirmed that staff are expected to perform hand hygiene immediately after direct contact care of residents.
Failure to Provide Complaint Survey Results for Resident Review
Penalty
Summary
The facility failed to ensure all complaint surveys since the last annual survey were available for resident review. An observation on 05/06/2024 at 8:35 a.m. revealed that the survey results binder near the entrance of the facility only contained the annual recertification survey dated 04/27/2023. There was no documented evidence of the complaint surveys dated 08/24/2023, 08/30/2023, 11/15/2023, and 02/15/2024 being available for review. During an interview on 05/06/2024 at 8:40 a.m., the administrator confirmed that the complaint surveys should have been included in the binder but were not.
Failure to Post Complete Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data, including resident census and total number and actual hours worked by licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. On two consecutive days, observations revealed that the staffing data sheets did not include the required information. Specifically, on 05/06/2024 and 05/07/2024, the staffing data sheets lacked documentation of the resident census and the total number and actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. This was confirmed during an interview with the facility administrator on 05/07/2024, who acknowledged the omission of the required information on the staffing data sheets.
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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