Ruston Nursing And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ruston, Louisiana.
- Location
- 3720 Hwy 80 East, Ruston, Louisiana 71270
- CMS Provider Number
- 195510
- Inspections on file
- 27
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ruston Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia, repeated falls, and severe cognitive impairment was care planned to receive total assistance with ADLs, including whirlpool baths three times weekly, shaving on bath days, and eating lunch and supper meals in the dining room. However, surveyors repeatedly observed the resident eating lunch in bed and having long, untrimmed facial hair. An LPN and the DON both confirmed that the resident’s facial hair needed trimming and that the resident was supposed to be bathed and shaved per the care plan and to eat meals in the dining room, confirming that the documented care plan interventions were not implemented.
A resident with dementia and a history of exit-seeking behaviors was able to leave the secured unit through an exterior door with a malfunctioning locking mechanism. The door did not have a functioning wander guard system and could be opened by pushing, allowing the resident to exit unsupervised and reach a nearby highway before being located and returned by staff. The resident's care plan documented the need for supervision and use of a wander guard, and staff interviews confirmed the door's security failure.
A resident with significant mobility and communication impairments, fully dependent on staff for ADLs, was left unsupervised during a bed bath when a CNA turned away to retrieve clothing, having removed a fall mat and used excessive lotion. The resident rolled over a bed bolster and fell, sustaining a head laceration, and was later found to have a right humerus and hip fracture as a result of the incident.
Surveyors found that several residents used wheelchairs or a scooter that were missing armrests or padding, had cracked parts, or had malfunctioning brakes. These issues were confirmed by staff, including an LPN and the DON, and affected residents with conditions such as dementia, Parkinson's, and diabetes. The lack of timely maintenance and repair of this essential equipment was observed over multiple days.
A resident with multiple chronic conditions, including atrial fibrillation, was prescribed Apixaban and identified as being at risk for abnormal bleeding. Although the care plan and physician orders required monitoring for bleeding or bruising, there was no documented evidence that such monitoring was performed or recorded, as confirmed by facility staff.
A resident with severe cognitive impairment and multiple medical conditions, who required substantial assistance with bathing and grooming, was repeatedly observed with poorly groomed and unshaven facial hair. Staff interviews confirmed that shaving should have been included in daily care, but this was not consistently performed.
Nursing staff did not maintain an active wound care order or document tracheostomy stoma care for a resident with severe cognitive impairment and multiple diagnoses. Although staff changed the stoma dressing daily, there was no documentation of the care provided, and the respiratory therapist confirmed the omission. This reflects a failure to ensure staff had the necessary competencies and skills for proper resident care.
A resident with multiple chronic conditions, who was cognitively intact, reported that the food provided was of poor taste, texture, and lacked variety or substitutions. A test tray meal was observed to be tough, overcooked, flavorless, and served cool, confirming the resident's complaints through direct observation and interview.
A resident with flaccid hemiplegia, right hand contracture, and moderate cognitive impairment did not receive required set-up assistance with meals, as staff failed to open food items and beverages or assist with chopping meat, despite care plan interventions. The resident was observed struggling to open items independently and reported that staff do not provide the necessary help, which was confirmed by staff interviews and direct observation.
A resident with multiple chronic conditions was found lying on a draw sheet without bed linen, a situation confirmed by both the resident and a CNA as a frequent issue, especially for those with bariatric beds. The resident had previously reported the problem to nursing staff, but no changes had been made.
A resident with moderate cognitive impairment and a history of falls was unable to self-release a wheelchair seatbelt that was documented as 'self-releasing.' The seatbelt was used as a fall intervention, but the resident could not unbuckle it when asked, and there was no documentation of restraint reduction attempts or reassessments. This resulted in the facility failing to identify and address the seatbelt as a restraint, as required by policy.
A resident with multiple diagnoses and moderate cognitive impairment was using a self-releasing alarming seatbelt as a fall intervention, per physician's orders. The care plan did not address the use of this device as a restraint, and there was no documentation of required quarterly reassessment for restraints, as confirmed by the DON.
The facility failed to protect residents from the misappropriation of their trust fund accounts, with unauthorized withdrawals and suspected forged signatures affecting 32 residents. Discrepancies were identified through a review of trust fund receipt books, revealing irregularities such as forged signatures, unauthorized withdrawals, and altered receipt amounts. This indicates a systemic issue within the facility's management of resident trust funds.
A resident discovered a $490 discrepancy in his trust fund account and reported it to the administrator, suspecting misappropriation. The facility failed to report the suspicion of a crime to law enforcement within the required 24-hour period, instead notifying authorities only after completing an internal investigation, which was not in compliance with section 1150B of the Act.
Failure to Implement Person-Centered Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident with Alzheimer’s disease, dementia with mood disturbance, repeated falls, hypothyroidism, and hyperlipidemia. The resident’s Quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with showering/bathing and personal hygiene. The resident’s care plan identified an actual fall with minor injury related to poor balance and included an intervention for the resident to eat lunch and supper meals in the dining room. The ADL care plan documented that the resident required total care with all ADLs, including bathing, and specified that the resident was to receive a bed bath on Monday, Wednesday, and Friday, as needed, and be shaved on bath days. Despite these documented interventions, surveyor observations on multiple dates showed the resident in bed eating lunch rather than in the dining room, and with long facial hair that had not been shaved or trimmed. An LPN reported that the resident had received a whirlpool bath the previous day, and during a joint observation with the surveyor, confirmed that the resident’s facial hair needed trimming. The DON also confirmed, during observation and care plan review, that the resident was care planned to receive a whirlpool bath three times per week, be shaved on bath days, and eat lunch in the dining room, and acknowledged that these care plan interventions were not being implemented for this resident.
Failure to Maintain Secured Unit Door Results in Resident Elopement
Penalty
Summary
The facility failed to maintain the door locking mechanism on an exterior door in the secured unit, which resulted in a resident with a known history of dementia, behavioral disturbances, and high elopement risk being able to exit the building unsupervised. The resident had a documented pattern of exit-seeking behaviors and had previously followed staff out of the secured unit on multiple occasions. Despite these behaviors and the resident's care plan indicating the use of a wander guard and the need for supervision, the door in question did not have a functioning wander guard locking mechanism and could be opened by pushing on it, as confirmed by staff interviews and direct observation. On the day of the incident, the resident was able to push open the door, which did not sound an alarm or prevent exit, and left the facility grounds. Staff members did not immediately realize the resident had left, and the resident was only discovered missing after being seen outside by a staff member returning from an appointment. The resident was ultimately found on a nearby highway, out of sight from the facility, and was returned by a staff member who located him in her car. Interviews with staff confirmed that the door's magnetic locking mechanism was loose and not functioning properly at the time of the incident. The resident involved had a history of psychiatric symptoms, including hallucinations, delusions, and agitation, and had been assessed as a high risk for elopement. Documentation showed repeated incidents of exit-seeking and confusion, with multiple notations in the medical record of the resident attempting to leave or expressing intent to do so. The failure to ensure the security of the door and to provide adequate supervision directly contributed to the resident's ability to elope from the secured unit.
Resident Fall Due to Inadequate Supervision During Bed Bath
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to conditions including functional quadriplegia, aphasia, and impaired mobility, was not provided adequate supervision during a bed bath. The resident's care plan required one-person assistance for bathing, bed bolsters, and fall mats on both sides of the bed due to a high risk for falls. Despite these interventions, the assigned CNA removed the fall mat from the left side of the bed and raised the bed to provide care. After completing the bed bath, the CNA turned away from the resident to retrieve clothing from the closet, leaving the resident unsupervised and unsecured in bed. While the CNA was turned away, the resident rolled over the bed bolster and fell from the left side of the bed onto the floor, resulting in a laceration to the forehead. The resident was not moved until EMS arrived and was subsequently transferred to the emergency room for treatment of the head injury. The resident returned to the facility with staples in place for the laceration. Several days later, after the responsible party noticed swelling and discoloration in the resident's right leg and foot, the resident was sent to the hospital again and diagnosed with a right humerus fracture and a right hip fracture, both attributed to the fall. Interviews and documentation confirmed that the CNA acknowledged turning away from the resident during care and admitted to using excessive lotion, which made the resident slippery. The CNA also recognized that all necessary items should have been within reach before starting the bed bath and that the resident should not have been left unsupervised. Staff interviews and record reviews further corroborated that the required fall prevention measures were not maintained at the time of the incident, directly leading to the resident's fall and subsequent injuries.
Failure to Maintain Safe and Functional Wheelchairs and Mobility Equipment
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically regarding wheelchairs and a scooter used by five residents. Observations revealed that several wheelchairs were missing armrests or armrest padding, had cracked armrests, or had malfunctioning brakes. For example, one resident's wheelchair was missing the right armrest, another had both armrests missing, and a third had a cracked armrest. Additionally, one resident reported that the wheelchair brakes did not work properly, which was confirmed by demonstration. Another resident's electric scooter had a torn seat cushion. These deficiencies were confirmed through multiple observations by surveyors and interviews with facility staff, including LPNs and the DON. The residents affected had various medical conditions, including Parkinson's disease, Alzheimer's disease, dementia, quadriplegia, hemiplegia, end stage renal disease, and diabetes. Some residents were cognitively intact, while others were cognitively impaired, and their levels of assistance required for activities of daily living varied. The deficiencies were identified over several days through direct observation and staff confirmation, indicating a lack of timely maintenance and repair of essential mobility equipment for these residents.
Failure to Monitor for Bleeding in Resident on Anticoagulant
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring for active bleeding or bruising in a resident receiving an anticoagulant. The resident had diagnoses including chronic kidney disease, chronic diastolic congestive heart failure, and atrial fibrillation, and was prescribed Apixaban (Eliquis) for atrial fibrillation. The care plan specifically identified the resident as being at risk for abnormal bleeding and/or bruising due to anticoagulant use, with interventions requiring monitoring for signs of active or internal bleeding and prompt physician notification if such symptoms were observed. Despite these documented orders and care plan interventions, a review of the resident's medical record revealed no evidence that monitoring for active bleeding, bruising, or symptoms of internal bleeding was performed or documented. This lack of documentation was confirmed during an interview with the facility's clinical operations/regional support staff, who acknowledged the absence of monitoring records for the resident in question.
Failure to Provide Necessary ADL Assistance for Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including unspecified psychosis, end stage renal disease, right hand contracture, type 2 diabetes mellitus, and dependence on renal dialysis, did not receive necessary assistance with activities of daily living (ADL) to maintain good personal hygiene. The resident was documented as requiring substantial to maximal assistance with bathing and grooming, as indicated in the quarterly Minimum Data Set (MDS) assessment. Despite this, repeated observations over several days showed that the resident's facial hair was poorly groomed and unshaven while seated in a wheelchair at the nurses station and while lying in bed. Interviews with facility staff, including an LPN and a CNA, confirmed that the resident was supposed to receive a bed bath daily, which included shaving, and that the resident should have been shaved during the night shift bath. However, the observations indicated that this aspect of care was not consistently provided, resulting in the resident not being neatly groomed or shaved as required.
Failure to Ensure Competent Tracheostomy Stoma Care and Documentation
Penalty
Summary
Nursing staff failed to ensure appropriate competencies and skills in caring for a resident with a tracheostomy stoma. The resident, who had a history of depression, schizoaffective disorder, diabetes, chronic cough, and an old tracheostomy, was admitted with severe cognitive impairment. The care plan indicated that the neck stoma dressing should be changed per treatment order. However, review of the resident's physician orders revealed there was no active wound care order for the tracheostomy stoma, and the order had been removed from the active orders and electronic treatment administration record in late February. Despite the absence of an active order, observations showed the resident had a dressing over the anterior throat, and interviews confirmed that staff were changing the stoma dressing daily. There was no documentation in the electronic medical record of the tracheostomy stoma care being performed. The respiratory therapist acknowledged providing the care but confirmed that she failed to document the treatments. This lack of orders and documentation demonstrated a failure to ensure staff had the necessary competencies and skills to meet the resident's needs.
Unpalatable Food and Inadequate Serving Temperature
Penalty
Summary
The facility failed to ensure that food was palatable and served at an appetizing temperature. A cognitively intact resident with multiple medical diagnoses, including type 2 diabetes, cerebral vascular disease, and chronic obstructive pulmonary disease, reported that the food was terrible, citing poor taste, texture, and lack of choices or substitutions. A test tray was requested and observed to leave the kitchen at 12:02 p.m. and was served at 12:23 p.m. The meal consisted of BBQ pork loin, beans, vegetable medley, corn bread, and cake. The pork loin was found to be tough, and the vegetable medley was overcooked, mushy, lacked flavor or seasoning, and the food was cool to taste. These findings were based on direct observation, record review, and resident interview.
Failure to Provide Meal Set-Up Assistance for Resident with Mobility and Cognitive Impairment
Penalty
Summary
A deficiency was identified when staff failed to provide necessary set-up assistance with meals for a resident with flaccid hemiplegia, right hand contracture, and moderate cognitive impairment. The resident's care plan, based on occupational therapy recommendations, required staff to assist with meal tray set-up, including opening seasoning packets and beverages. Observations revealed that a CNA delivered the resident's lunch tray but did not provide the required set-up assistance, leaving items unopened. The resident was seen repositioning the tray and opening a pepper packet with his teeth, and he reported that staff do not help him open items or chop his meat, which he finds difficult. Further observation during breakfast showed that the resident's milk carton and other fluids remained unopened after he had consumed part of his meal. When notified, an LPN confirmed that while the resident feeds himself, staff are supposed to open his drinks. The deficiency was reported to the facility's executive director, as the staff did not follow the care plan interventions for meal set-up assistance, resulting in the resident not receiving reasonable accommodation for his needs.
Failure to Provide Bed Linen for Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses of type 2 diabetes, cerebral vascular disease, and chronic obstructive pulmonary disease was observed lying on a draw sheet without bed linen on their bed. The resident, who was cognitively intact and required two-person physical assistance for bed mobility, transfers, and toilet use, reported that the lack of bed linen was a frequent problem and that previous reports to nursing staff had not resulted in any change. A certified nursing assistant confirmed that the absence of bed linen was a recurring issue, particularly for residents using bariatric beds. The executive director was notified of the situation after the observation.
Failure to Identify and Address Wheelchair Seatbelt as a Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. Specifically, a resident with moderate cognitive impairment and a history of falls was observed using a wheelchair seatbelt that was documented as 'self-releasing.' However, during an observation with the Director of Nursing Services (DNS), the resident was unable to unbuckle the seatbelt when asked, and stated he could not complete the task. The seatbelt was being used as a fall intervention, and the resident's medical record included diagnoses such as chronic obstructive pulmonary disease, osteoporosis, and schizoaffective disorder. Despite the facility's policy stating that only seatbelts which can be easily unfastened by the resident are not considered restraints, there was no documentation of restraint reduction attempts or reassessments for this resident. The lack of documentation and the resident's inability to self-release the seatbelt resulted in the facility failing to identify and address the seatbelt as a restraint, contrary to their own policy and regulatory requirements.
Failure to Revise Care Plan for Resident Using Restraint
Penalty
Summary
The facility failed to ensure that the care plan was revised for a resident who was using a restraint. According to the facility's Restraint Evaluation and Restraint Reduction Policy, all residents using a restraint are to be evaluated and re-evaluated approximately every quarter, and care plan updates should occur quarterly or when there is a change in goals or approaches. For one resident with diagnoses including chronic obstructive pulmonary disease, history of falling, osteoporosis, and nicotine dependence, the quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and the use of a chair alarm, but did not document the use of a wheelchair seatbelt. Physician's orders specified the use of a self-releasing alarming seatbelt for this resident due to unawareness of physical limitations and a diagnosis of schizoaffective disorder. However, the current plan of care only addressed the seatbelt as a fall intervention and did not address its use as a restraint. The Director of Nursing Services confirmed that there was no supporting documentation available regarding reassessment for restraints for this resident.
Misappropriation of Resident Trust Funds
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically their trust fund accounts. The investigation revealed discrepancies in the trust fund accounts of 32 residents, with unauthorized withdrawals and suspected forged signatures. The facility's policy required that all disbursements from the trust fund be authorized by the resident or their designated representative, and that transactions be documented with signatures. However, the review of records showed multiple instances where these procedures were not followed, leading to significant financial discrepancies. Several residents, including those with cognitive impairments, were affected by these unauthorized transactions. For example, one resident discovered a $490 shortfall in their account, while another resident's account was missing $972. Interviews with residents and the Regional Financial Consultant confirmed that many of the signatures on the trust fund receipts were forged, and in some cases, the amounts on the receipts were altered. This indicates a systemic issue within the facility's management of resident trust funds, as the discrepancies were widespread and involved significant sums of money. The facility's failure to adhere to its own policies and procedures regarding the management of resident trust funds resulted in financial losses for the residents. The discrepancies were identified through a review of the trust fund receipt books, which showed irregularities such as forged signatures, unauthorized withdrawals, and altered receipt amounts. These findings highlight a lack of oversight and control in the facility's financial management practices, leading to the misappropriation of resident funds.
Failure to Timely Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This deficiency was identified during a review of a case involving a resident who reported a discrepancy in his trust fund account. The resident, who was cognitively intact, discovered that his account was $490 short and suspected that someone had taken his money. He reported this to the administrator the following day. However, the facility did not report the allegations to a law enforcement entity within the required 24-hour timeframe. The facility's abuse prevention policy, last revised in August 2017, required reporting the results of all investigations to the administrator and other officials within five working days, but did not ensure compliance with the 24-hour reporting requirement to law enforcement. The administrator was informed of the alleged misappropriation on 05/31/2024 but only notified the Attorney General's office and the local sheriff's department on 06/13/2024 and 06/14/2024, respectively, after completing an internal investigation. This delay in reporting to law enforcement entities constituted a failure to adhere to the mandated reporting requirements.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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