Riverbend Nursing And Rehabilitation Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Belle Chasse, Louisiana.
- Location
- 13735 Highway 23, Belle Chasse, Louisiana 70037
- CMS Provider Number
- 195481
- Inspections on file
- 24
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Riverbend Nursing And Rehabilitation Center, Inc during CMS and state inspections, most recent first.
A resident with impaired cognition and a urinary catheter did not have a privacy cover on the catheter drainage bag as required by their care plan. Observations showed the bag was visible in public and private areas, and staff interviews confirmed it should have been covered at all times.
A resident with an indwelling Foley catheter did not have documented evidence that their catheter was changed as ordered by the physician and outlined in the care plan, which required monthly changes by urology. The facility was unable to provide records confirming the catheter change, and the DON confirmed the absence of documentation.
A resident with lung cancer and COPD was unable to control the temperature in his room due to a locked air conditioning control panel. Despite his preference for a warmer environment, the facility staff confirmed the lock was in place to accommodate his roommate's preference for cooler temperatures. The facility lacked documentation or a care plan intervention to justify this action.
A facility failed to complete a Level II PASARR for a resident with Major Depressive Disorder and Bipolar Disorder. Despite the resident's diagnoses and daily use of antipsychotics and antidepressants, there was no documentation of a Level II evaluation. Staff interviews confirmed that a referral should have been made but was not.
A resident with post-operative and acute conditions did not receive the full prescribed dosage of Ceftriaxone due to a failure in following physician's orders. The resident was supposed to receive two doses of the antibiotic, but only one was administered. Interviews confirmed the oversight, and facility staff acknowledged the error.
A resident with severe vascular dementia and other conditions was found with untrimmed, dirty fingernails, despite being dependent on staff for personal hygiene. The resident had requested nail trimming, but staff failed to provide this care, contrary to the facility's policy requiring daily cleaning and regular trimming.
A resident's LaPOST form indicating a DNR status was not signed by a physician, leading to a failure in accurately reflecting the resident's medical treatment wishes. Despite the resident's responsible party confirming the DNR preference, the facility's reliance on the incomplete form resulted in the resident being treated as a Full Code. Staff interviews confirmed the oversight and the need for a physician's signature to implement the resident's wishes.
A facility failed to maintain ongoing communication with a dialysis center regarding a resident's condition. The Dialysis Communication sheets, used to document communication, were incomplete or missing information on multiple occasions. Interviews with the ADON and DON confirmed the communication method, but the facility could not provide evidence of communication on several specified dates.
The facility failed to reconcile controlled drugs on two medication carts, as required by policy. Reviews of records for three months showed multiple instances of incomplete reconciliation, with missing signatures from nurses responsible for verifying narcotic counts at shift changes. Interviews confirmed the expectation for signatures, but numerous undocumented areas indicated a systemic issue.
The facility failed to properly label and dispose of insulin pens and secure heparin, leading to deficiencies in medication management. Insulin pens were either not labeled or not discarded after 28 days, and a heparin syringe was found unsecured in a resident's room. LPNs and the DON confirmed these lapses in policy adherence.
A resident with specific dietary needs due to malnutrition and weight loss was served an incorrect meal, contrary to physician orders for a NAS, mechanical soft diet with chopped meat. The facility's policy requires nursing staff to ensure correct meal delivery, but the resident received a regular diet tray, confirmed by both a CNA and the Dietary Supervisor.
The facility failed to properly label and date opened food products, maintain food and refrigeration temperature records, and ensure dishwashing practices met required standards. Observations revealed undated food items in the cooler, incomplete temperature logs for food and refrigeration, and missing entries in dish machine and sanitizer logs. These deficiencies were confirmed by interviews with the Dietary Supervisor and Administrator.
A facility failed to document the administration of midline flushes for a resident as per medical orders. Despite the LPNs administering the required flushes, there was no evidence in the EMR for several days. The DON and Administrator confirmed the absence of documentation.
The facility failed to provide prescribed wound care for two residents with pressure injuries. One resident with a stage 4 sacral ulcer did not receive daily treatment as ordered, while another resident at risk for pressure ulcers did not receive scheduled care for a heel injury. The e-TARs showed inconsistencies in treatment administration, and interviews confirmed the lack of adherence to physician orders.
The facility failed to conduct and document weekly wound assessments for two residents, leading to a deficiency in wound management. One resident's scalp incision and another's right calf venous ulcer were not properly assessed or measured as required.
The facility failed to respect a resident's right to choose healthcare services by not scheduling an appointment with a dermatologist despite the resident's representative's request. The resident's worsening skin condition was later diagnosed as scabies upon hospital admission.
The facility failed to conduct quarterly care plan meetings for two residents. One resident's responsible party reported attending only two meetings since admission and none in the last three months. The facility could not provide evidence of care plan meetings for this resident between January and March. Similarly, another resident was scheduled for a meeting in February, but no documentation was found, with the last recorded meeting in November.
The facility failed to follow the menu for a resident, serving fried meat instead of roasted pork loin as listed. The resident expressed dissatisfaction, and the Dietary Supervisor confirmed the discrepancy.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
The facility failed to provide a privacy cover for a urinary catheter drainage bag for one resident with a documented need for such an intervention. The resident's care plan, revised on 01/26/2025, specifically included an intervention to keep the catheter drainage bag in a privacy cover due to urinary retention. Despite this, multiple observations on 05/27/2025 revealed that the resident's catheter drainage bag was visible both in the dining area and in the resident's room, with yellow urine clearly visible in the bag. The bag was attached under the wheelchair seat and to the bed railing, and was visible from the doorway, including in the presence of a roommate. Interviews with facility staff confirmed that the resident's catheter drainage bag was not covered during the observed periods. Both a Licensed Practical Nurse and a Certified Nursing Assistant acknowledged that the catheter drainage bag should have been covered at all times, and the Director of Nursing confirmed this expectation. The resident involved had impaired cognition, as indicated by a Brief Interview for Mental Status score of 5 on the most recent assessment.
Lack of Documentation for Monthly Foley Catheter Change
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of urinary retention and an indwelling Foley catheter did not have documented evidence that their catheter was changed according to physician's orders. The physician's orders and the resident's care plan both specified that the Foley catheter was to be changed every month by urology. However, a review of the electronic medical record for March 2025 revealed no documentation that the catheter was changed or replaced during that month. The facility was unable to provide any evidence to confirm that the catheter change occurred as ordered. The Director of Nursing confirmed the lack of documentation and was unable to dispute the findings. This deficiency was based on interview and record review, focusing on the facility's failure to ensure appropriate catheter care and adherence to physician's orders for catheter changes for the resident in question.
Resident's Right to Control Room Temperature Denied
Penalty
Summary
The facility failed to ensure a resident's right to maintain a homelike environment, specifically regarding the control of room temperature. Resident #94, who was admitted with diagnoses including malignant neoplasm of the lung, COPD, nicotine dependence, weakness, anxiety, and major depressive disorder, was unable to adjust the air conditioning in his room. The resident's Minimum Data Set indicated a BIMS score of 12, suggesting some cognitive impairment. Despite the resident's preference for a warmer room due to his condition, the air conditioning control panel was locked, preventing him from adjusting the temperature. Interviews with staff revealed that the lock was placed on the air conditioning unit to prevent the resident from making the room warmer, as his roommate preferred a cooler temperature. The Maintenance Supervisor confirmed that only maintenance personnel had the keys to adjust the thermostat. The Social Services Director and the Administrator acknowledged the lock's presence but provided no documented evidence or care plan intervention justifying this action. This lack of documentation and failure to address the resident's preferences and needs led to the deficiency.
Failure to Complete Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for a resident diagnosed with mental illness. The resident was admitted with diagnoses of Major Depressive Disorder and Bipolar Disorder and was taking antipsychotics and antidepressants daily. However, the resident's Level I determination did not document these mental illnesses, and there was no evidence of a Level II PASARR evaluation being completed. Interviews with facility staff confirmed that a Level II referral should have been made to the appropriate state-designated authority based on the resident's diagnoses, but it was not.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident who was admitted with diagnoses including post-operative left knee replacement, pyogenic arthritis, and acute pancreatitis. The physician's telephone orders dated 10/08/2024 specified that the resident was to receive 1 gram of Ceftriaxone intramuscularly twice per day for one day. However, the electronic medical record indicated an order for only two doses of Ceftriaxone 1 gram IM, and the electronic medication administration record showed that only one dose was administered on 10/08/2024 at 12:45 p.m. Interviews conducted on 10/10/2024 revealed that the resident reported receiving only one of the two ordered doses of Ceftriaxone. The LPN responsible for the resident during the 6 p.m. to 6 a.m. shift on 10/08/2024 confirmed that she did not administer the second dose. Both the Director of Nursing and the Administrator acknowledged the failure to administer the second dose as ordered, and the facility could not provide any documented evidence that the second dose was given.
Failure to Provide Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene needs. The resident, who was admitted with severe vascular dementia, psychotic disturbance, lack of coordination, and cerebral palsy, was observed with fingernails extending past the tips of her fingers and visible dirt underneath. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident was reliant on staff for nail care, as outlined in her care plan. Observations and interviews revealed that the resident's nails had not been trimmed since her admission, and she had requested staff assistance for nail trimming. A CNA confirmed that nails should be trimmed if they extend past the nail bed, and a CNA Supervisor acknowledged that the resident's nails were too long and should have been cleaned and trimmed. These findings indicate a failure to adhere to the facility's policy on nail care, which includes daily cleaning and regular trimming.
Incomplete LaPOST Form Leads to Miscommunication of Resident's DNR Wishes
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected their medical treatment wishes following a cardiopulmonary arrest. Specifically, the deficiency involved a resident whose LaPOST form, indicating a Do Not Resuscitate (DNR) status, was not signed by a physician, rendering it incomplete. This oversight meant that the resident's wishes for a DNR code status were not officially documented in the physician's orders, despite the resident's responsible party confirming the DNR preference. Interviews with facility staff, including the Director of Nursing and Licensed Practical Nurses, revealed that the facility relied on the LaPOST form to determine a resident's code status. However, due to the lack of a physician's signature, the resident was treated as a Full Code, meaning CPR would be performed in the event of cardiac arrest. The staff acknowledged the incomplete LaPOST form and the necessity for a physician's signature to implement the resident's DNR wishes, highlighting a critical gap in the facility's process for honoring advance directives.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure ongoing communication regarding a resident's condition with the dialysis facility. This deficiency was identified for a resident who required dialysis services. The facility used a Dialysis Communication sheet as the method to communicate with the dialysis center. However, upon review, there was no documented evidence of communication from the dialysis center regarding the dialysis treatment provided and the resident's response to the treatment on several dates. Specifically, the facility's Dialysis Communication sheets for the resident were incomplete or missing information on multiple occasions, including dates in June, July, August, and September 2024. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the use of the Dialysis Communication sheet for communication with the dialysis center. The DON acknowledged that the communication sheets for the resident should have been completely filled out for each dialysis treatment, but they were not. The facility was unable to present any documented evidence of communication with the dialysis center regarding the resident's condition before and after dialysis on several specified dates.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to maintain a system for the periodic reconciliation of controlled drugs on two medication carts, Medication Cart a and Medication Cart b. The facility's policy required that controlled medications be counted at the end of each shift by both the nurse coming on duty and the nurse going off duty. However, a review of the Controlled Drugs-Count Records for August, September, and October 2024 revealed multiple instances where this reconciliation was incomplete, with missing signatures from the nurses responsible for verifying the narcotic counts at shift changes. Interviews with staff, including an agency LPN and the Director of Nursing, confirmed that the Controlled Drugs-Count Records were supposed to be signed by both the off-going and on-coming nurses. Despite this requirement, there were numerous undocumented signature areas on the records, indicating a failure to adhere to the facility's policy for controlled substance reconciliation. This deficiency was observed across several shifts over the three-month period, highlighting a systemic issue in the facility's medication management practices.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin pens and secure storage of heparin, leading to deficiencies in medication management. Observations revealed that insulin pens on two medication carts were either not labeled with an opened date or were not discarded after the recommended 28-day period. Specifically, an insulin pen for one resident was not labeled with an opened date, while another resident's insulin pen was dated over a month past its discard date. Interviews with LPNs and the Director of Nursing confirmed these lapses in adherence to the facility's policy on medication storage and handling. Additionally, the facility did not secure heparin as required, with a syringe found on a resident's bedside table. The resident, who was moderately cognitively impaired, indicated that the syringe had been there for several days. This was confirmed by an LPN and acknowledged by the Director of Nursing and the Administrator, who stated that the heparin should not have been left unsecured in the resident's room. These findings highlight a failure to follow the facility's policy on medication pass administration, which mandates that medications should not be left in residents' rooms.
Failure to Provide Correct Diet to Resident
Penalty
Summary
The facility failed to provide a resident with the correct diet as per the physician's orders, leading to a deficiency in dining services. The resident, who was admitted with diagnoses including moderate protein-calorie malnutrition, nutritional deficiency, and abnormal weight loss, had a specific diet order for No Added Salt (NAS), mechanical soft with chopped meat. However, during an observation, it was noted that the resident was served a regular diet tray instead of the prescribed mechanical soft diet with chopped meat. This discrepancy was confirmed by both a Certified Nursing Assistant (CNA) and the Dietary Supervisor, who acknowledged that the turkey pot roast served to the resident was not chopped as required. The facility's Resident Nutrition Services Policy mandates that nursing personnel inspect food trays to ensure the correct meal is delivered, and any incorrect meals should be reported to dietary services for correction. Despite this policy, the resident received an incorrect meal, which was not aligned with the dietary needs specified in the physician's orders and the dietary manager's notes. The failure to adhere to the prescribed diet could potentially impact the resident's nutritional status, given their existing health conditions.
Deficiencies in Food Storage, Temperature Monitoring, and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to its food storage and labeling policies, as evidenced by multiple observations of opened food products in the walk-in cooler that were neither sealed nor labeled with the date of opening. Specifically, an opened package of sliced turkey breast and a jar of slaw dressing were found without opening dates, and a similar issue was noted with a bag of sliced ham. Interviews with the Dietary Supervisor and the Administrator confirmed these findings, acknowledging that the items should have been dated according to the facility's policy. Additionally, the facility did not maintain proper records of food and refrigeration temperatures, which are crucial for preventing foodborne illnesses. The Prepared Food Temperature Record for October 2024 and the refrigeration temperature logs for September and October 2024 were incomplete, with no documented evidence of temperature monitoring. Furthermore, the Dish Machine Temperature Log and Sanitizer Test Log for September and October 2024 were also incomplete, indicating a failure to ensure that dishes were cleaned at the correct temperatures with appropriate sanitizer levels. These lapses were confirmed by the Dietary Supervisor and the Administrator, who acknowledged the absence of necessary documentation.
Failure to Document Midline Flushes for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation in a resident's medical record, specifically for Resident #42, regarding the administration of flushes for a midline catheter. The admission orders for Resident #42, dated 09/13/2024, required the midline to be flushed every shift with 10 mL of normal saline followed by 3 cc of Heparin. However, there was no documented evidence in the Electronic Medical Record (EMR) that these flushes were administered on 10/04/2024, 10/05/2024, or 10/06/2024. Interviews with two LPNs, who were responsible for Resident #42 during the specified dates, revealed that they administered the flushes but failed to document them. One LPN stated she administered a 5 cc Heparin flush, while the other confirmed administering both the normal saline and Heparin flushes as per the orders. The Director of Nursing and the Administrator acknowledged the lack of documentation, confirming that the facility could not provide any evidence of the flushes being recorded in the resident's medical record.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to administer wound care treatments as ordered for two residents with pressure injuries. Resident #1, who was admitted with a stage 4 pressure ulcer on the sacral region, did not receive daily wound care as prescribed by the physician. The treatment plan included cleaning the ulcer with normal saline, applying santyl, and covering it with an appropriate dressing once a day. However, the electronic Treatment Administration Order (e-TAR) for June, July, and August 2024 showed that the treatment was not administered daily. Resident #1 confirmed that the wound was treated only once a week, on Wednesdays. Similarly, Resident #3, who was at risk for developing pressure ulcers due to immobility, did not receive wound care for a right lateral heel injury as ordered. The physician's orders required treatment every Monday, Wednesday, and Friday, but the e-TAR for July and August 2024 indicated that these treatments were not consistently administered. Interviews with the Director of Nursing and the Administrator confirmed that the wound care treatments for both residents were not completed as ordered, and the facility lacked a dedicated Treatment Nurse prior to late August 2024.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to assess and measure wounds weekly for two residents, leading to a deficiency in wound management. Resident #1 returned from the hospital with a wound dehiscence on the left side of his head, but there was no documented evidence of weekly wound assessments or measurements from his return in December 2023 until his discharge in March 2024. This was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the lack of documentation for the required weekly assessments. Similarly, Resident #2 had a physician's order for wound care to a right calf venous ulcer from February to April 2024. However, the clinical record showed no documented evidence of weekly wound assessments or measurements, except for one instance on April 2, 2024, which also lacked the necessary wound measurements. Both the ADON and the Director of Nursing (DON) confirmed the absence of proper documentation and acknowledged that the assessments should have included wound measurements.
Failure to Respect Resident's Right to Choose Healthcare Services
Penalty
Summary
The facility failed to respect a resident's right to choose healthcare services, specifically for a resident who had a worsening skin rash. The resident's representative had requested that the resident see a dermatologist due to continued itching and worsening of the skin condition. Despite this request, no appointment was made, and the facility staff did not follow up with the resident's representative regarding the request. The resident was later diagnosed with scabies upon admission to the hospital, indicating that the condition had not been properly addressed by the facility. Interviews with the Social Services Director revealed that the facility's protocol involved notifying the resident's physician and scheduling an appointment if a resident chose to see a specialist. However, the Social Services Director admitted that no evidence could be produced to show that an appointment with a dermatologist was scheduled or that the resident had seen a dermatologist. This failure to act on the resident's representative's request led to a deficiency in respecting the resident's right to choose healthcare services.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings with the interdisciplinary team for two of the three sampled residents investigated for care plans. Resident #1's responsible party reported that she had only been invited to two care plan meetings since the resident's admission and had not attended any meetings in the last three months of the resident's stay. The facility could not provide documented evidence of a care plan meeting for Resident #1 between January 1, 2024, and the resident's discharge on March 12, 2024. The Social Services Director confirmed the absence of documentation for any care plan meetings during this period. Similarly, Resident #2 was scheduled to have a care plan meeting on February 15, 2024, but there was no documented evidence that this meeting occurred. The last recorded care plan meeting for Resident #2 was on November 2, 2023. The Social Services Director could not find any documentation of a care plan meeting for Resident #2 between January 1, 2024, and April 11, 2024. This lack of documentation indicates that the facility did not hold the required quarterly care plan meetings for these residents.
Failure to Follow Menu for Resident's Meal
Penalty
Summary
The facility failed to follow the menu for a resident on 04/11/2024. The regular diet menu indicated that residents were to be served roasted pork, au gratin potatoes, sliced zucchini, a dinner roll, a brownie, margarine, salt packet, pepper packet, a choice of a beverage, and water. However, the posted lunch menu showed a slight variation with mashed potatoes and California blend vegetables. Observation revealed that a resident's lunch tray contained a piece of battered and/or fried meat instead of roasted pork loin. The resident expressed dissatisfaction with the meal, stating that she would have preferred the roasted pork loin as listed on the menu. The Dietary Supervisor confirmed the discrepancy, acknowledging that the meal served did not match the menu.
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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