Regency House Of Alexandria
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 5131 Masonic Drive, Alexandria, Louisiana 71301
- CMS Provider Number
- 195637
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Regency House Of Alexandria during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not receive their prescribed PRN Hydrocodone-Acetaminophen due to the medication not being available. An LPN borrowed the same medication from another resident and administered it, contrary to facility policy and professional standards. The incident was observed by staff and family, and confirmed by the DON and RN Supervisor.
A resident with chronic pain and opioid dependence was left without prescribed Hydrocodone-Acetaminophen due to failures in medication ordering and communication among nursing staff. In response, an LPN administered Tylenol without a physician order and later borrowed pain medication from another resident, violating medication protocols. The resident's family raised concerns about pain management, and the resident was transferred to the hospital for pain control.
Two residents experienced injuries of unknown origin that were not reported to the state agency within the required two-hour timeframe. One resident had a suspected femoral fracture, and another had a fall resulting in a scalp laceration. The facility's policy on reporting such injuries was not followed, and the Administrator's misunderstanding of reportable incidents contributed to the delay.
A resident with a history of Alzheimer's and Osteoarthritis experienced a failure in pain management when a CNA did not report the resident's complaint of leg pain to the nurse, despite being trained to do so. The resident's care plan required CNAs to report any pain complaints, but the CNA did not comply, as the resident requested not to inform the nurse. The CNA later acknowledged the oversight, and the CNA Supervisor confirmed the expectation to report all pain complaints.
An LPN failed to administer and accurately document medications for a resident, administering only 14 out of 18 scheduled pills. The LPN did not administer certain medications due to claimed unavailability and forgot others, yet documented them as given. Investigation revealed that some medications were available on the cart, and the DON confirmed they should have been administered per physician's orders.
A facility failed to provide pharmaceutical services by not ensuring the timely acquisition and administration of Sacubitril-Valsartan for a resident with congestive heart failure. The medication was not available during a scheduled administration, and although it was documented as given, it was confirmed by an LPN that it was not administered. The medication was not found on the cart or in storage, and an order was not released due to insurance denial, leading to the resident running out of the medication.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.76%. An LPN administered only 14 out of 18 prescribed pills to a resident, missing Bactrim DS, Sacubitril-Valsartan, Sodium Bicarbonate, and Cyanocobalamin. The LPN documented these as administered despite admitting to not giving them due to unavailability and oversight. The DON confirmed the discrepancies, noting that the medications should not have been documented as given if not administered.
The facility failed to implement Enhanced Barrier Precautions for a resident with wounds and another with a PICC line, as staff did not wear appropriate PPE during care. Additionally, the facility did not test its water system for Legionella, as required by its infection control program.
A resident with a history of hemiplegia and irritable bowel syndrome requested an incontinent wipe from a CNA, which was refused. The CNA cited inappropriate behavior by the resident as the reason for refusal, despite the resident's frequent requests due to feeling unclean. The incident was reported by the resident's niece and confirmed by the resident's private sitter, highlighting a deficiency in respecting the resident's rights to dignity and self-determination.
A resident with intact cognition and multiple health conditions was found to be wearing the same pair of jeans for a week due to the facility's failure to return his other pants from the laundry. The resident's closet contained minimal clothing, and staff were unaware of the issue. The facility's administrator acknowledged the oversight, noting the absence of a Social Service Director may have contributed to the situation.
A resident with moderate cognitive impairment experienced an unwitnessed fall, and the facility failed to promptly notify the physician and responsible party. The LPN on duty assessed the resident but did not follow protocol to inform the necessary parties immediately, leading to a delay in notification until the following day. The facility's procedures for handling falls were not adhered to, as confirmed by the DON.
A facility failed to ensure proper wound care for a resident with a stage 3 sacral pressure sore. A CNA applied Zinc Oxide cream, a task reserved for nurses, contrary to the resident's care plan and physician's orders. The resident's care plan required specific wound management, but the cream was improperly left in the room and applied by unqualified staff, as confirmed by the DON.
A facility failed to adhere to professional standards for respiratory care by not changing a resident's oxygen tubing as per the prescribed schedule. The resident, who required continuous oxygen therapy due to respiratory failure and other conditions, had tubing dated over a week old, contrary to the facility's policy and physician's orders. An LPN confirmed the oversight during an interview.
A resident with moderate cognitive impairment and multiple medical conditions was found with a tube of Zinc Oxide ointment and a bottle of Nystatin powder left unattended on their bedside dresser. These medications were not currently prescribed, and staff confirmed they should have been secured in the medication cart. The resident did not have a physician's order to keep medications at the bedside, nor an assessment for self-administration.
The facility failed to properly dispose of garbage and refuse, as observed with a blue dumpster outside the kitchen surrounded by dirty gloves and debris. The Dietary Manager confirmed the findings, and the Maintenance Director stated the trash was left by sanitation employees. The Administrator confirmed the Maintenance Director's responsibility for maintaining cleanliness around the dumpster.
The facility failed to use proper signage for two residents on Transmission-Based Precautions due to COVID-19. Observations showed signage for Enhanced Barrier Precautions instead, confirmed by the RN Infection Preventionist. Both residents required isolation and substantial assistance with daily activities.
A facility failed to implement a care plan for monitoring the side effects and effectiveness of an anticoagulant medication for a resident with multiple diagnoses, including chronic atrial fibrillation and end-stage renal disease. Despite the care plan's directives, no monitoring was in place, as confirmed by interviews with staff.
The facility failed to follow physician's orders for weekly PT/INR tests and did not notify the physician of an abnormal PT/INR result for a resident on Coumadin. The resident had a history of gastrointestinal hemorrhage, chronic atrial fibrillation, and end-stage renal disease, making the monitoring of PT/INR levels critical.
Failure to Administer Ordered Controlled Medication and Improper Borrowing of Medication
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that controlled medications ordered for a resident were administered as prescribed. Specifically, the resident had a physician's order for Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for pain. However, due to the facility not having the resident's pain medication available, an LPN borrowed the same medication from another resident and administered it to the resident in need. This action was acknowledged by the LPN, who stated she knew it was not appropriate, and was confirmed by the Director of Nursing and RN Supervisor. The resident involved had multiple diagnoses, including COPD, Type II Diabetes Mellitus with neuropathy, severe dementia with agitation, opioid dependence, and anxiety disorder. The resident was cognitively intact and required some assistance with activities of daily living. The lack of medication availability was noted by staff over several days, and the improper administration of another resident's medication was observed and reported by staff and family members. The facility's policy required strict adherence to medication administration standards, including verifying the right resident and medication, which was not followed in this instance.
Failure to Ensure Timely Acquisition and Proper Administration of Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the timely acquisition and dispensing of a controlled medication, Hydrocodone-Acetaminophen, for a resident with multiple diagnoses including chronic pain conditions and opioid dependence. The resident was admitted with a prescription for Hydrocodone-Acetaminophen to be given as needed for pain, but the medication supply was depleted on 12/03/2025. The process for reordering the medication was not properly followed, as the empty medication card was left on the Assistant Director of Nursing's desk without direct communication, and the responsible staff did not ensure the order was placed or received. During the period when the resident was without his prescribed pain medication, staff attempted to manage his pain by administering Tylenol, for which there was no physician order, and later by borrowing Hydrocodone-Acetaminophen from another resident, which is a violation of medication administration protocols. Multiple staff interviews confirmed that the breakdown in communication and lack of clear responsibility for medication ordering led to the resident being without his PRN pain medication for several days. The resident's family became aware of the situation and expressed concern about neglect related to pain management. The resident ultimately required transfer to the hospital for pain management at the family's request. Documentation and interviews revealed that the facility's procedures for controlled substance administration and accountability were not followed, resulting in the resident not having access to his prescribed pain medication when needed. The failure to ensure the availability of the medication and the inappropriate borrowing of another resident's medication were directly observed and confirmed by staff and administrative personnel.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents within the required two-hour timeframe as mandated by state law. Resident #1, who had a history of Alzheimer's disease and osteoarthritis, was found to have a suspected minimally displaced femoral peri arthroplasty fracture after complaining of knee pain. Despite receiving the x-ray results confirming the fracture, the facility did not report the injury within the required timeframe. The Administrator acknowledged the oversight, stating that the report should have been submitted immediately upon reviewing the x-ray results. Resident #2, who had diagnoses including protein calorie malnutrition and a history of falls, experienced an unwitnessed fall resulting in a laceration to the scalp and a subsequent emergency room visit. The RN on duty reported the incident to the Administrator shortly after it occurred, but the Administrator did not consider the fall a reportable injury at the time. It was only after the injury was revealed to be a fracture that the Administrator recognized it as a reportable incident. The facility's policy on reporting suspicious injuries of unknown origin was not followed in these cases, leading to a delay in notifying the state agency. The policy requires that all instances of serious bodily injury, such as fractures or head injuries, be reported within two hours. The Administrator's misunderstanding of what constitutes a reportable injury contributed to the failure to comply with state reporting requirements.
Failure to Report Resident's Pain Complaint
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, specifically in the area of pain management. The resident, who has a history of Alzheimer's Disease, Fibromyalgia, Osteoarthritis, and other conditions, was noted to have moderate cognitive impairment and required assistance with daily activities. The care plan included an intervention for Certified Nursing Assistants (CNAs) to monitor, record, and report any complaints of pain to the nurse. However, during an incident, a CNA did not report the resident's complaint of leg pain to the nurse, as the resident requested not to inform the nurse. The CNA, despite being trained to report any signs of pain regardless of the resident's request, failed to notify the nurse about the resident's pain complaint. This was confirmed during an interview with the CNA, who acknowledged the oversight. The CNA Supervisor also confirmed that the expectation was for all pain complaints to be reported to the nurse, even if the resident advised otherwise. This failure to report the pain complaint was a deviation from the established care plan and facility policy on pain management.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring medications were administered and accurately documented for a resident during medication administration. An LPN administered 14 pills to a resident, while the Medication Administration Record (MAR) indicated that 18 pills were scheduled to be administered. The LPN confirmed that she did not administer Bactrim DS, Sacubitril-Valsartan, or Sodium Bicarbonate due to their unavailability and forgot to administer Cyanocobalamin. Despite this, she documented the medications as administered, intending to correct the documentation later. Further investigation revealed that the Bactrim DS and Sodium Bicarbonate were available on the medication cart, contradicting the LPN's claim of unavailability. The Director of Nursing confirmed that these medications, along with Cyanocobalamin, should have been administered according to the physician's orders. Additionally, there was a discrepancy in the documentation of Bactrim DS administration, as the blister pack indicated fewer pills were removed than documented in the MAR.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition, receipt, and administration of Sacubitril-Valsartan, a non-controlled medication prescribed for congestive heart failure. During a medication administration observation, it was noted that the medication was not available and was not administered to the resident, despite being documented as given. The Licensed Practical Nurse (LPN) involved confirmed that the medication was not administered because it was unavailable and admitted to documenting it as administered by mistake. Further investigation revealed that the medication was not present on the medication cart, in the resident's cubby, or in the Pixus. The facility's records showed that the last supply of the medication was received on January 20, 2025, and the resident would have run out by February 3, 2025. An order for the medication was created on January 30, 2025, but was not released due to an insurance denial. The facility's Director of Nursing (DON) and other staff confirmed the medication was not available and that there was no follow-up to address the missing medication, despite it being documented as administered by nursing staff.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 11.76% during a survey. Specifically, the facility did not administer all prescribed medications to a resident as per the physician's orders. During a medication administration observation, an LPN administered only 14 out of the 18 prescribed pills to a resident. The missing medications included Bactrim DS, Sacubitril-Valsartan, Sodium Bicarbonate, and Cyanocobalamin. The LPN admitted to not administering these medications due to unavailability and oversight, yet documented them as administered. Further investigation revealed that the Bactrim DS and Sodium Bicarbonate were available on the medication cart, contradicting the LPN's claim of unavailability. The Sacubitril-Valsartan was not found on the cart or in storage, and the resident had reportedly run out of this medication days prior, despite it being documented as administered. The DON confirmed the discrepancies and acknowledged that the medications should not have been documented as given if they were not administered. This series of actions and inactions led to the facility's failure to adhere to its medication administration policy and maintain an acceptable medication error rate.
Infection Control Deficiencies in EBP and Water Testing
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer and a diabetic ulcer, as required by their policy. Despite the resident's condition necessitating EBP, there was no order for these precautions, and no signage or personal protective equipment (PPE) was available in or outside the resident's room. The resident's wife was not educated on infection control precautions, and staff did not wear appropriate PPE during toileting care, as observed by surveyors. Another resident, who had a PICC line and required EBP for high-contact care activities, did not receive proper care as staff failed to wear gowns during incontinent care. Although the resident's room had a red dot indicating the need for EBP, staff did not comply with the PPE requirements. Interviews with staff confirmed that they were aware of the EBP requirements but failed to adhere to them during care. Additionally, the facility did not maintain an infection prevention and control program as it failed to test the water system for Legionella. The facility's water management program required measures to minimize the risk of Legionella, but there was no documented evidence of testing since September 2024. The administrator confirmed that the facility had not conducted the necessary testing, which is a critical component of their infection control program.
Failure to Honor Resident's Request for Incontinent Wipe
Penalty
Summary
The facility failed to honor a resident's right to request an incontinent wipe, which is a violation of the resident's rights to dignity and self-determination. The incident involved a resident with a history of hemiplegia, major depressive disorder, anxiety disorder, and irritable bowel syndrome, who was dependent on assistance for toileting hygiene. The resident, who had a BIMS score indicating intact or mildly impaired cognition, requested an incontinent wipe from a CNA, which was refused. The CNA stated that the resident had already been cleaned and did not provide the wipe, citing inappropriate behavior by the resident with the wipe as the reason. The incident was reported by the resident's niece to the facility administrator, who confirmed the refusal of the request. The resident's private sitter corroborated the account, stating that the CNA told the sitter to provide the wipe if desired. The refusal to provide the wipe was confirmed by the CNA during an interview, acknowledging that the resident often requested wipes because she did not feel clean. This failure to provide the requested wipe was identified as a deficiency in treating the resident with respect and dignity, as required by federal and state law.
Resident Lacks Adequate Clothing Due to Facility Oversight
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #205, was treated with respect and dignity by not providing adequate clothing. Resident #205, who was admitted with diagnoses including Major Depressive Disorder, Type 2 Diabetes Mellitus, Acute Respiratory Failure, and Unspecified Protein Calorie Malnutrition, had a BIMS score of 15, indicating intact cognition. The resident required assistance with dressing and had been wearing the same pair of jeans for a week, as his other pair of pants, provided by the facility, had not been returned from the laundry. The resident expressed feeling bad about not having clothes and had informed two employees about the missing joggers but received no response. Observations and interviews revealed that the resident's closet contained only a pack of white t-shirts, socks, underwear, and a coat, with no other clothing items. The LPN providing care for the resident was unaware of the situation, and the Acting Social Service Director was also not informed about the resident's lack of clothing. The facility's administrator acknowledged purchasing some basic clothing items for the resident but confirmed that the facility should have assisted further in obtaining appropriate outerwear. The absence of a Social Service Director at the time may have contributed to the oversight.
Failure to Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician and responsible party after a change in a resident's condition, specifically following an unwitnessed fall. Resident #49, who was admitted with diagnoses including vascular dementia and moderate cognitive impairment, experienced a fall on 02/08/2025. The fall was reported to S10 Medical Records LPN by S8 CNA, who found the resident sitting upright on the floor with his back against his wheelchair. Although S10 Medical Records LPN conducted a head-to-toe assessment and documented the incident in the progress notes, she did not notify the physician or the resident's responsible party immediately as required. The delay in notification was confirmed during interviews with the staff, including S10 Medical Records LPN, who admitted to not notifying the necessary parties due to being overwhelmed with other tasks. The Director of Nursing (S2 DON) confirmed that the facility's protocol requires immediate notification of the physician and responsible party following a fall, which was not adhered to in this case. The notification was eventually made by another LPN the following day, and the incident report was back-dated, indicating a lapse in the facility's adherence to its own procedures for handling resident falls.
Improper Wound Care by CNA
Penalty
Summary
The facility failed to ensure that services provided to Resident #206 were delivered by individuals with the appropriate skills and qualifications, as outlined in the resident's plan of care. Specifically, S6 CNA applied Zinc Oxide cream to Resident #206's stage 3 sacral pressure sore, which was against the facility's protocol that only nurses are allowed to perform wound care. Resident #206, who was cognitively intact and required various levels of assistance for daily activities, had a care plan that included specific interventions for a stage 3 pressure ulcer. The physician's orders required cleansing the ulcer and applying Zinc Oxide, but this task was improperly performed by a CNA instead of a nurse. Observations and interviews revealed that the Zinc Oxide cream was left in Resident #206's room, and S6 CNA confirmed applying it during toileting care. The Director of Nursing (S2 DON) acknowledged that CNAs are not permitted to apply Zinc to wounds and confirmed that the cream should not have been left in the resident's room. Further observation of Resident #206's care showed a reddened, uncovered stage 3 pressure ulcer, indicating a lack of proper wound management as per the care plan and physician's orders.
Failure to Adhere to Oxygen Equipment Change Schedule
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident, identified as Resident #156, who required continuous oxygen therapy. The facility's policy mandated that oxygen tubing and mask/cannula be changed weekly and as needed if soiled or contaminated. However, observations revealed that Resident #156's oxygen tubing, dated 01/29/2025, had not been changed as per the physician's orders, which specified a change every Wednesday night shift and as needed. This oversight was confirmed during an interview with an LPN, who acknowledged that the tubing should have been changed but was not. Resident #156 was admitted with diagnoses including acute and chronic respiratory failure, chronic systolic heart failure, depression, anxiety disorder, and dependence on enabling machines and devices. The resident's medical record indicated intact cognition with a BIMS score of 14 and a requirement for continuous oxygen administration at 3 liters per minute. Despite these needs, the facility did not adhere to the prescribed schedule for changing the oxygen equipment, leading to a deficiency in the standard of care provided to the resident.
Medications Left Unsecured at Resident's Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by medications being left at the bedside of a resident. During an observation, a tube of Zinc Oxide ointment and a bottle of Nystatin powder were found unattended on the bedside dresser of a resident with moderate cognitive impairment and multiple medical conditions, including a stage 4 pressure ulcer and bipolar disorder. These medications were not prescribed for current use, as the orders for Zinc Oxide had been discontinued months prior, and the Nystatin powder order had been completed weeks before the observation. Interviews with facility staff confirmed that the medications should not have been left at the bedside and should have been secured in the medication cart when not in use. The resident did not have a physician's order to keep medications at the bedside, nor was there an assessment to determine if the resident was safe to self-administer medications. The Director of Nursing acknowledged that the medications should have been disposed of properly and confirmed that the resident does not self-administer medications.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed and confirmed by staff. During an inspection, a blue dumpster located outside the facility's kitchen was found surrounded by dirty gloves and debris, including old cardboard boxes. This observation was confirmed by the Dietary Manager at the time. The Maintenance Director indicated that the trash was left by sanitation employees, and the Administrator confirmed that the Maintenance Director was responsible for ensuring the area around the dumpster was kept clean.
Inadequate Signage for Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of proper signage for residents on Transmission-Based Precautions. Two residents, identified as Resident #2 and #R1, were placed in isolation due to positive COVID-19 tests. However, observations revealed that the signage on their doors indicated Enhanced Barrier Precautions instead of the appropriate Transmission-Based Precautions. This discrepancy was confirmed by the RN Infection Preventionist during the survey. Resident #2 was admitted with diagnoses including COVID-19, a disorder involving the immune mechanism, atherosclerotic heart disease, and an acquired absence of the right leg below the knee. The resident required varying levels of assistance with daily activities. Similarly, #R1 was admitted with diagnoses including COVID-19, rhabdomyolysis, cerebral infarction, unspecified dementia, and unspecified atrial fibrillation, and also required substantial assistance with daily activities. Despite their isolation status due to COVID-19, the incorrect signage was observed multiple times on their doors, indicating a failure in the facility's communication and implementation of appropriate infection control measures.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medication. Resident #3, who had diagnoses including gastrointestinal hemorrhage, anal fissure, chronic atrial fibrillation, end-stage renal disease, and dependence on renal dialysis, was admitted with a care plan that required monitoring for side effects and effectiveness of Warfarin therapy every shift. However, a review of Resident #3's medical record revealed no such monitoring was in place, despite the care plan's directives. Interviews with S2 RN and S1 DON confirmed that no monitoring had been implemented to assess for possible side effects and effectiveness of Resident #3's anticoagulant therapy. This lack of monitoring was a direct violation of the resident's care plan, which specified the need for such assessments to be conducted every shift. The deficiency was identified during a review of the resident's significant change MDS, which indicated intact cognition and various dependencies for daily activities.
Failure to Follow Physician's Orders for Lab Tests and Notify Physician of Abnormal Results
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of practice for Resident #3. Specifically, the facility did not follow physician's orders for obtaining labs for a medication that required a drug level. Resident #3 had orders for a weekly PT/INR test due to being on Coumadin for Atrial Fibrillation. However, the PT/INR test was not conducted weekly as ordered, with a gap from 02/01/2024 to 02/20/2024. Additionally, an abnormal PT/INR result was obtained on 12/06/2024, but there was no documentation that the Medical Director was notified when the attending physician did not immediately respond to the abnormal result. Interviews with the nursing staff confirmed that Resident #3's weekly PT/INR tests were not consistently obtained and that there was a failure to follow up with the physician regarding the abnormal test result. The Director of Nursing also confirmed that the orders for the weekly PT/INR were not followed and that there was no follow-up with the physician for the abnormal test result. Resident #3 had a history of gastrointestinal hemorrhage, chronic atrial fibrillation, and end-stage renal disease, making the monitoring of PT/INR levels critical for their care.
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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