Riviere De Soleil Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansura, Louisiana.
- Location
- 7408 Hwy 1, Mansura, Louisiana 71350
- CMS Provider Number
- 195489
- Inspections on file
- 27
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Riviere De Soleil Community Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was not groomed according to her preferences, as she was observed with long chin hair despite being bathed. Additionally, the resident's dislike for ice cream was not honored, as she continued to receive it with her lunch tray despite staff awareness of her preference against dairy products.
A resident with severe cognitive impairment and multiple medical conditions did not receive necessary grooming and hygiene care, as observed by a CNA and confirmed by an LPN. The resident was found with a dried brown substance around her mouth and long fingernails, despite having just been bathed. The facility failed to notify the resident's responsible party of any refusal of nail care.
Two residents experienced significant weight loss due to the facility's failure to adhere to its Weight Assessment and Intervention policy. A resident with severe cognitive impairment was not weighed upon readmission from the hospital, resulting in a 4.9% weight loss over 16 days. Another resident with moderate cognitive impairment was not weighed weekly as required, leading to a 5.9% weight loss over 36 days. The facility's Director of Nursing confirmed these oversights.
A resident with a history of diabetes, hypertension, and hemiplegia was not provided with routine dental services as required by facility policy. Despite having intact cognition and needing assistance with oral hygiene, the resident had not seen a dentist since admission. Multiple scheduled appointments were missed due to conflicts, and staff confirmed the resident should have been seen.
The facility failed to store and label food items properly, leading to expired items being found in the kitchen. Expired cans of plate scraper, tomato paste, potato salad, and garlic in water were discovered, along with an unlabeled pitcher of gravy. The Dietary Manager confirmed these findings, acknowledging that the items should have been disposed of according to the facility's policies.
A CNA in the facility removed plates from a dining table while other residents were still eating, which was confirmed by an LPN. A resident with intact cognition felt rushed due to this action.
A resident with moderately impaired cognition did not receive a quarterly personal funds statement as required by facility policy. The facility lacked a systematic process for distributing these statements to residents managing their own funds, leading to a deficiency in compliance with their policy.
A facility failed to maintain a resident's Pommel cushion in good repair, which had a 3-inch tear exposing the inner foam. The cushion, used to prevent slipping from the wheelchair, had been in disrepair for 2 1/2 to 3 weeks. An LPN confirmed that the cushion should be inspected daily and replaced if defective, as per facility policy.
The facility failed to document critical care details for two residents. One resident was hospitalized for fecal impaction due to inconsistent documentation of bowel movements, despite a history of constipation and diarrhea. Another resident's verbal order to hold oral medications was not recorded, leading to a lack of formal documentation for the physician's directive.
The facility failed to maintain the confidentiality of resident-identifiable information for four residents receiving dialysis outside the facility. A sheet with their full names and dialysis schedules was visible to the public at the front desk, confirmed by the DON.
Failure to Honor Resident's Dignity and Food Preferences
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by their policy on dignity. The resident, who had severe cognitive impairment and required substantial assistance with personal hygiene, was observed with long chin hair, indicating a lack of grooming as per her preferences. Despite being bathed by a CNA, the facial hair was not addressed, and the LPN confirmed the presence of the long chin hair. Additionally, the facility did not honor the resident's food preferences. Although the resident had a physician's order for ice cream to be served with her lunch tray for weight loss, it was revealed through interviews that the resident did not like ice cream or dairy products. Despite this knowledge, the DON continued to serve different flavors of ice cream based on the Registered Dietician's recommendation, who was unaware of the resident's dislike. This resulted in the resident receiving food that she did not consume, as confirmed by the CNA.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide trimmed nails and oral care to a resident who required substantial assistance with these tasks. The resident, who had severe cognitive impairment and multiple medical conditions including Type 2 Diabetes Mellitus and a Stage 3 Pressure Ulcer, was observed with a dried brown substance around her mouth and fingernails approximately one inch long. This observation was made after a CNA had reportedly just bathed the resident. During an interview, the CNA acknowledged the presence of the dried substance, which might have been food, and the long fingernails. An LPN confirmed these observations and offered to clean and trim the resident's nails, to which the resident agreed. Additionally, a telephone interview with the resident's responsible party revealed that the facility had not notified her of any refusal of nail care by the resident.
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable parameters of nutritional status, as evidenced by significant weight loss that was not adequately monitored or addressed. Resident #1, who had severe cognitive impairment and required assistance with eating, was not weighed upon readmission from a hospital stay as per the facility's policy. The resident experienced a 4.9% weight loss over 16 days, but the facility did not conduct the required weekly weigh-ins following her return from the hospital. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that the resident should have been weighed within 24 hours of readmission and weekly thereafter. Similarly, Resident #3, who had moderate cognitive impairment and required setup or clean-up assistance with eating, was not weighed weekly for four weeks following admission, as required by the facility's policy. The resident experienced a 5.9% weight loss over 36 days, which was not identified until a significant weight loss trigger was noted by the Registered Dietician. The DON confirmed that the facility's procedure was not followed, resulting in the resident not being weighed weekly as mandated. These failures indicate a lack of adherence to the facility's Weight Assessment and Intervention policy, leading to unmonitored and significant weight loss in both residents.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that a resident received routine dental services as required by their policy. The policy mandates that each resident undergo a dental assessment within 90 days of admission and be offered dental services as needed. However, a resident with a history of Type 1 Diabetes Mellitus, Hypertension, and Hemiplegia following a cerebral infarction, who was admitted to the facility, had not been seen by a dentist since admission. Despite having intact cognition and requiring assistance with meals and oral hygiene, the resident expressed a desire to see a dentist for dentures but had not been provided with the necessary dental services. The resident had multiple scheduled dental appointments that were either rescheduled or not attended due to various conflicts, such as therapy sessions and time constraints. Interviews with facility staff, including a registered nurse, a social worker, and the Director of Nursing, confirmed that the resident had not received a dental assessment within the required timeframe and should have been seen by a dentist. The staff were unable to provide a clear reason for the repeated rescheduling and failure to provide the necessary dental care.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and labeling of food items. During an observation of the facility's kitchen, several expired items were found in the pantry and reach-in refrigerator, including two cans of plate scraper, twenty cans of tomato paste, one gallon of potato salad, and two jars of garlic in water. Additionally, there was an unlabeled and undated pitcher of prepared brown gravy. The Dietary Manager confirmed these findings and acknowledged that the items should have been disposed of but were not. The facility's policies require that foods be labeled with the date and time they were prepared and discarded if they exceed maximum storage time, which was not followed in this instance.
Failure to Respect Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal times, as observed in the dining room. A Certified Nursing Assistant (CNA) was seen removing plates from the dining table while other residents at the same table were still eating. This action was confirmed through an interview with the CNA, who admitted she was unaware that she should wait until all residents had finished eating before clearing the table. Further confirmation came from an LPN, who acknowledged that the CNA should have waited. A resident with intact cognition expressed feeling rushed when the CNA began removing plates while she was still eating.
Failure to Provide Quarterly Personal Funds Statement
Penalty
Summary
The facility failed to provide a quarterly personal funds statement to a resident, as required by their policy. The policy mandates that a written statement be provided quarterly to each resident or their authorized representative, detailing the balance at the beginning of the period, total deposits and withdrawals, interest earned, and the ending balance. The statement should be signed and dated by the Administrator and two witnesses, with a copy filed in the resident's trust fund folder. However, the facility did not adhere to this policy for a resident with moderately impaired cognition, who had been admitted approximately six months prior and had not received any quarterly account statement. Interviews with the facility's administrative staff revealed a lack of a systematic process for distributing quarterly statements to residents who manage their own funds. The Administrative Assistant responsible for sending out statements indicated that she provided account balances only when residents requested money, but did not have a system for ensuring that residents received their quarterly statements. The Administrator acknowledged signing the Trust Fund Quarterly Statement Distribution Form but admitted it was not a verification of distribution to residents. The Administrator confirmed that the resident wanted to receive her statements quarterly but lacked documentation to prove that the statement had been provided.
Failure to Maintain Resident Equipment in Good Repair
Penalty
Summary
The facility failed to ensure that a resident's equipment, specifically a Pommel cushion, was in good repair. The Pommel cushion, used to prevent the resident from slipping out of the wheelchair, had a 3-inch tear along the seam with the inner foam exposed. This condition was observed on two separate occasions, and the resident reported that the cushion had been in this state for 2 1/2 to 3 weeks. The facility's policy requires that assistive devices and equipment be maintained according to the manufacturer's instructions and replaced if defective or worn. An LPN responsible for the resident's care confirmed that the cushion should be inspected and cleaned daily and replaced if in disrepair, indicating that the cushion should have been replaced.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident #26, the facility did not consistently document the size and consistency of bowel movements as required by the care plan, which was crucial given the resident's history of constipation and diarrhea. This lack of documentation contributed to the resident being hospitalized for fecal impaction. Interviews with the Director of Nursing (DON), a Licensed Practical Nurse (LPN), and a Certified Nursing Assistant (CNA) confirmed the failure to document bowel movement details, which was a requirement for monitoring the resident's condition. For Resident #46, the facility did not properly document a verbal order from the physician to hold oral medications due to swallowing difficulties. Although the physician gave the order during rounds, the LPN who received the order failed to record it in the resident's chart, as required by the facility's policy on medication and treatment orders. This oversight resulted in the absence of a formal order to hold medications, despite the resident not receiving any oral medications since the verbal order was given.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of resident-identifiable information for four residents who were receiving dialysis outside of the facility. During an observation at the facility's front desk, a sheet attached to a clipboard was found to contain the full names and dialysis schedules of these residents. This information was visible to the public, as visitors were observed at the front desk multiple times during the survey process. The Director of Nursing (DON) confirmed that the list with residents' full names and dialysis times was visible to visitors and acknowledged that it should not have been.
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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