Resthaven Nursing & Rehab Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Charles, Louisiana.
- Location
- 1103 W Mcneese, Lake Charles, Louisiana 70605
- CMS Provider Number
- 195414
- Inspections on file
- 18
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Resthaven Nursing & Rehab Center, Llc during CMS and state inspections, most recent first.
The facility's kitchen was found to be unsanitary, with excessive food residue, black mildew-like residue, and pest infestations, posing a risk of foodborne illnesses to 110 residents. Equipment and surfaces were not properly cleaned, and food storage practices were inadequate. Additionally, dietary workers lacked proper hair restraints, and used gloves were improperly left in the drink service area. These deficiencies were confirmed by staff and observed during multiple visits.
The facility failed to maintain sanitary conditions in the kitchen, leading to an Immediate Jeopardy situation due to the risk of foodborne illness for 110 residents. Despite awareness of a gnat problem and previous cleanliness issues, the Administrator and Regional Administrator did not conduct thorough inspections, and the Dietary Manager did not report any problems. An email from the Administrator highlighted unresolved cleanliness issues, indicating a lack of effective oversight and communication.
The facility failed to maintain an effective pest control program, resulting in a gnat infestation and the presence of cockroaches in the kitchen. Despite pest control efforts, the issue persisted, affecting the facility's ability to provide a pest-free environment for meal preparation.
The facility failed to follow physician orders and update care plans for three residents. A resident received incorrect water flushes, another was not provided with a prescribed heel protector, and a third resident's care plan was not updated after a fall, despite staff being in-serviced on new interventions. These deficiencies were confirmed by the DON and other staff during observations and interviews.
A facility failed to ensure proper dialysis care for a resident by not assessing the resident's condition before treatments and lacking effective communication with the dialysis center. The resident's communication binder was often incomplete, and staff were unaware of communication procedures. A transporter took the resident to dialysis without a completed pre-dialysis assessment or communication sheet.
A facility failed to ensure proper labeling of a tube feeding container for a resident with Dysphagia and Multiple Sclerosis. The resident was observed receiving Jevity via a feeding pump, but the label lacked the date and time the feeding was hung. An LPN confirmed the omission during an interview and observation.
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in care. A resident with respiratory conditions had their nebulizer mask left exposed instead of being stored in a bag, as per facility policy. A nurse confirmed the improper storage, and the DON acknowledged the oversight.
The facility failed to maintain adequate staffing levels on weekends, as evidenced by low weekend staffing data. The facility's assessment indicated a need for above 2.35 nursing hours per resident, but on specific weekends, the nursing hours provided were at or just above this minimum requirement. Interviews with the ADON and DON confirmed that staffing levels were insufficient to meet resident needs, resulting in a high resident-to-nurse aide ratio and challenges in providing necessary care.
A nurse in an LTC facility failed to follow medication administration protocols by leaving a medicine cup with 10 pills at a resident's bedside without ensuring they were taken. The resident, who was cognitively intact, had no physician's order or care plan for self-administration. The facility's policy requires that medications be administered at the time they are prepared and that the nurse remains with the resident until all medication is swallowed. This breach was confirmed by the Clinical Care Coordinator and the Director of Nursing.
The facility failed to follow its medication storage policy, resulting in expired and unlabeled medications being found during an inspection. Expired medications were discovered in the refrigerator and on medication carts, and an unlabeled inhaler was found on a cart. The DON confirmed that these practices were against policy, potentially affecting the care of 111 residents.
A facility with 160 licensed beds failed to employ a qualified full-time social worker. The Administrator, lacking the necessary qualifications and experience, was acting as the social worker. The Human Resources representative, who assisted, also lacked the required qualifications. Despite efforts to hire a suitable candidate, the facility had not succeeded.
A facility failed to post required signage outside a COVID-19 positive resident's room, indicating the type of transmission-based precautions and necessary PPE, as per their infection control policy. This oversight was confirmed by a registered nurse and the infection preventionist, potentially affecting six residents on similar precautions.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which posed a risk of cross-contamination and foodborne illnesses to the 110 residents who consumed meals prepared there. During multiple visits, surveyors observed excessive food residue on kitchen equipment, including the stove top, oven, and fryer. There was also black residue under the ice machine's filter, and ice buildup on the floor of the walk-in refrigerator. Additionally, the dish and cookware storage areas were found to have dried food residue, and some clean dishes had food debris. Food storage practices were inadequate, with dented cans, unlabeled bags of cereal, and containers of tuna fish without preparation dates. The kitchen surfaces were also found to be unsanitary, with trash debris and dirt on the floors, black residue resembling mildew on walls and baseboards, and dried food particles on various surfaces. The dishwashing room had significant cleanliness issues, including a large area of black residue behind the dishwasher, dried brown splatter on walls, and a dirty towel hanging on the door. Pests were present, with gnats flying in the dishwashing room and cockroaches found in the kitchen and dry storage areas. Additionally, dietary workers were observed without proper hair and facial hair restraints, further compromising food safety. In another instance, the facility failed to adhere to professional standards for food service safety by leaving used soiled gloves in the residents' drink service area. During lunch service, a pair of used food gloves was found on the counter where residents' drinks were being poured and served. A registered nurse admitted to using the gloves for serving drinks and then placing them on the counter instead of disposing of them in the garbage can. The infection preventionist confirmed that the gloves should have been discarded properly to maintain hygiene standards.
Kitchen Oversight Failure Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to unsanitary and unsafe conditions in the kitchen, which posed a high likelihood of causing foodborne illness to 110 residents. The deficiency was identified as an Immediate Jeopardy situation on 08/18/2024. The Registered Dietician (RD) conducted a quarterly walkthrough of the kitchen on 06/19/2024 and reported no cleanliness issues, although she was aware of a gnat problem for several months. The facility had received a Retail Food Notice of Violations on 06/11/2024, indicating non-critical cleanliness issues, but the Administrator (ADM) believed these had been corrected. Despite being aware of the gnat issue since 08/09/2024, the ADM did not conduct a thorough inspection of the kitchen. The Regional Administrator (RA) and the Dietary Manager (DM) were also involved in the oversight of the kitchen. The RA conducted rounds and observed the kitchen on 08/12/2024, reporting no issues, while the DM was responsible for ensuring daily, weekly, and monthly cleaning tasks were completed. However, the ADM and RA were unaware of the ongoing cleanliness issues, and the DM did not report any problems. An email from the ADM to the DM on 06/05/2024 highlighted several cleanliness issues, but these were not addressed in a meeting. The lack of documentation of kitchen rounds by the ADM and RA further indicates a failure in oversight and communication regarding the kitchen's condition.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects in the kitchen area. During an inspection, a large swarm of gnats was observed in the dishwashing room, and live cockroaches were found behind the stove and in the dry food storage room. Additionally, three dead roaches were discovered in a bucket under the food prep counter. The Dietary Manager acknowledged that a bug light in the kitchen was out of order, which may have contributed to the pest issue. Interviews with facility staff revealed that the pest problem had been ongoing for several months. The Registered Dietician confirmed awareness of the gnat issue during her quarterly kitchen walkthrough. The Administrator was informed of the gnat problem and contacted pest control, but the treatment was ineffective. Both the Regional Administrator and the Administrator acknowledged the persistence of pest control issues despite previous treatments.
Failure to Follow Physician Orders and Update Care Plans
Penalty
Summary
The facility failed to adhere to physician's orders and update care plans for three residents, leading to deficiencies in care. For Resident #1, the facility did not follow the physician's order for water flushes at 45ml/hr, instead administering them at 40ml/hr, as confirmed by the Director of Nursing during observations. Resident #4 was not provided with the prescribed Prevalon heel protector for her right foot during multiple observations, despite the physician's order for it to be worn at all times. The Director of Nursing confirmed the absence of the heel protector during an observation. Resident #5 experienced a fall on 05/07/2024, but the care plan was not updated with new interventions to prevent further falls, such as toileting every two hours, until after a subsequent fall on 06/08/2024. The Assistant Director of Nursing and the Minimum Data Set coordinator confirmed that the care plan was not updated following the initial fall, despite staff being in-serviced on the new toileting schedule. This oversight in updating the care plan contributed to the resident's continued risk of falling.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. Specifically, the facility did not ensure the assessment of the resident's condition before dialysis treatments and failed to maintain an effective communication system between the facility and the dialysis center. The resident, who was dependent on renal dialysis, was admitted with diagnoses including surgical aftercare following circulatory system surgery and vitamin deficiency. The resident was scheduled for dialysis three times a week at an offsite center. However, the facility's communication binder, which was supposed to contain information communicated to the dialysis center, was found lacking entries on multiple dates. During the investigation, it was revealed that the communication binder was often misplaced, and the facility staff, including the LPN and the Director of Nursing, were unaware of a specific communication procedure with the dialysis center. The facility's policy on post-dialysis care did not address communication, and the corporate nurse was unfamiliar with any regulations regarding dialysis communication. Additionally, a transporter was observed taking the resident to dialysis without a completed pre-dialysis assessment or communication sheet, which was confirmed by an LPN who admitted to not assessing the resident or communicating with the dialysis center.
Failure to Label Tube Feeding Container
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a feeding tube by not ensuring the tube feeding container was properly labeled. Resident #4, who was admitted with diagnoses including Dysphagia and Multiple Sclerosis, was observed receiving Jevity via a feeding pump. However, the label on the tube feeding formula did not include the date and time it was hung, as required. This deficiency was confirmed during an interview and observation with an LPN, who acknowledged the omission of the necessary labeling information.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents, leading to a deficiency in respiratory care. Resident #31, who was admitted with diagnoses including Respiratory Failure and Chronic Obstructive Pulmonary Disease, had physician orders for multiple inhalation solutions to be administered via nebulizer. Observations on two separate occasions revealed that Resident #31's nebulizer mask was left exposed on top of the nebulizer machine and not stored in a closed plastic bag as required by the facility's policy. A registered nurse confirmed the mask should have been bagged and noted the absence of a storage bag in the resident's room. Similarly, Resident #27, admitted with conditions such as Shortness of Breath and Wheezing, had orders for inhalation solutions to be used as needed. An observation found Resident #27's nebulizer mask lying exposed on a nightstand without a storage bag. The registered nurse confirmed the mask was not stored properly. The Director of Nursing also acknowledged that the nebulizer masks should be stored in bags when not in use, confirming the facility's failure to adhere to its own policy.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels of skilled licensed nurses, nurse aides, and other nursing personnel on weekends, as evidenced by excessively low weekend staffing data. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2 of 2024 showed that the facility's weekend staffing was below the required levels. The facility's assessment indicated an average daily census of 117-125 residents, with a staffing plan aiming to provide above 2.35 nursing hours per resident. However, on specific weekends, the nursing hours provided were at or just above the minimum requirement, with a census of 122 to 124 residents. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the staffing levels were inadequate to meet the needs of the residents. The ADON stated that a minimum of 21 nurse aides per day was necessary, but on certain weekends, only 20 nurse aides were available, with one being an orientation nurse aide. This resulted in a high resident-to-nurse aide ratio, making it challenging to provide necessary care such as baths, showers, and meal services. The facility administrator acknowledged the low weekend staffing data and confirmed that the nursing hours provided were the minimum required, which did not meet the facility's assessment goals.
Medication Administration Protocol Breach
Penalty
Summary
The facility failed to ensure that nursing staff adhered to its policies and procedures for medication administration, as evidenced by a nurse leaving medications at a resident's bedside. The facility's policy mandates that medications be administered as prescribed and that the person administering the medication must remain with the resident until all medication has been swallowed. However, on the morning of August 18, 2024, a nurse prepared and left a medicine cup containing 10 pills on a resident's dresser without ensuring the medications were taken. This action was contrary to the facility's policy, which requires that medications be administered at the time they are prepared and that the nurse remains with the resident during administration. The resident involved, who was cognitively intact with a BIMS score of 15, had no physician's order or care plan for self-administration of medication. Despite this, the nurse left the medications unattended in the resident's room. The Clinical Care Coordinator and the Director of Nursing confirmed that the resident did not have an interdisciplinary team assessment for self-administration of medications and that the nurse should not have left the medications in the room. This incident highlights a lapse in following established medication administration protocols, potentially compromising the resident's care.
Medication Storage Deficiencies
Penalty
Summary
The facility's staff failed to adhere to the policy for medication storage, resulting in several deficiencies. During an inspection, expired medications were found in the refrigerator in Med Room A and on two medication carts. Specifically, an expired Bisacodyl suppository for a resident was found in the refrigerator, and expired medications, including Tamsulosin and Albuterol Sulfate Inhalation Aerosol, were found on the medication carts. Additionally, an unlabeled inhaler was discovered on one of the carts, with the LPN unable to identify the resident it belonged to. These findings indicate a failure to remove expired medications and ensure proper labeling, as required by the facility's policy. The facility's policy mandates that medications be stored safely and securely, with expired or unlabeled medications removed and destroyed according to procedures. However, the inspection revealed that these procedures were not followed, as evidenced by the presence of expired and unlabeled medications. The Director of Nursing confirmed that expired medications should not be stored on medication carts or in refrigerators, and that inhalers should be properly labeled. This oversight had the potential to affect the care of the facility's 111 residents.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility, which has 160 licensed beds and a census of 111 residents, failed to employ a qualified full-time social worker. The Director of Nursing (S2DON) revealed that the facility's Administrator (S1ADM) had been acting as the social worker for over a month. Despite efforts to hire a qualified social worker, the facility had not succeeded in finding a suitable candidate. A review of S1ADM's resume showed that she did not possess a bachelor's degree in social work or a related human services field, nor did she have the required one year of supervised social work experience in a healthcare setting. Additionally, the Regional Administrator (S3RA) mentioned that the Human Resources representative (S4HR) assisted the Administrator in social work duties. However, S4HR's resume indicated a Bachelor of Science in Mass Communication with a concentration in Journalism, lacking the necessary qualifications for a social worker role. S4HR confirmed her educational background and stated that she had no prior experience working with the geriatric population. This situation led to the facility's failure to meet the requirement of having a qualified full-time social worker.
Failure to Post Required Isolation Signage for COVID-19 Positive Resident
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not posting proper signage outside a resident's room to indicate the type of transmission-based precautions and the appropriate PPE required. This deficiency was observed in the case of a resident who was COVID-19 positive and on contact/droplet isolation. The facility's policy, last reviewed on February 14, 2024, required isolation rooms to have proper signage indicating the type of isolation. However, on August 18, 2024, it was observed that the resident's room door lacked any signage indicating the necessary precautions or PPE. The deficiency was confirmed during an observation with a registered nurse, who acknowledged the absence of the required signage. Further confirmation came from the facility's infection preventionist, who stated that the resident should have had a sign on the door as per the facility's policy. This oversight had the potential to affect six residents in the facility who were on transmission-based precautions, as it failed to communicate necessary infection control measures to staff and visitors.
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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