Sage Rehabilitation Hospital Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 8000 Summa Avenue, Baton Rouge, Louisiana 70809
- CMS Provider Number
- 195621
- Inspections on file
- 27
- Latest survey
- October 29, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sage Rehabilitation Hospital Snf during CMS and state inspections, most recent first.
A facility failed to accurately code a resident's discharge MDS, specifically in Section A0410, which was incorrectly marked as 'Unit is neither Medicare nor Medicaid certified.' Interviews with MDS coordinators and the administrator confirmed the error, acknowledging it should have been coded as 'Unit is Medicare and/or Medicaid certified.'
A facility failed to adhere to its infection control policy by not using Enhanced Barrier Precautions (EBP) during a PICC line dressing change for a resident with a central line. Despite the policy requiring gowns and gloves for high-contact activities to prevent multidrug-resistant organism transmission, a nurse did not wear a gown during the procedure. Interviews with nursing leadership confirmed the expectation for gown use, highlighting a lapse in protocol adherence.
The facility did not post the required list of names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, including the State Survey Agency and others. This deficiency was confirmed during observations and a facility tour with S1ADM.
The facility did not ensure that the survey results were accessible to residents and their families. Observations revealed the absence of the survey results binder in the designated area, and it was found behind the nurse's station, which was not easily accessible. The DON and Administrator acknowledged the issue, noting the missing holder where the binder was supposed to be.
The facility did not post daily nurse staffing data in a prominent location accessible to residents and visitors, as required by its policy. Observations and interviews confirmed the absence of staffing data sheets, which should include details like the facility name, date, resident census, and staff hours worked.
A resident with diabetes refused blood sugar checks and diabetic medications over several days, but the facility failed to notify the nurse practitioner of these refusals. Interviews with staff confirmed the lack of communication, highlighting a deficiency in meeting professional standards of care.
The facility failed to ensure that seven staff members completed required training on abuse, neglect, exploitation, and dementia care. Personnel files lacked documentation of these trainings, which are mandated by the facility's policy for new and existing staff. An interview confirmed the absence of training records.
A cognitively intact resident reported being raped by an LPN during a catheter procedure, with a CNA present. The incident was reported internally but not to the state agency until 11 days later, violating the facility's policy to report such allegations within 2 hours. The Administrator confirmed the delay in reporting, acknowledging the deficiency in compliance with abuse reporting regulations.
The facility failed to provide necessary medications for two residents, resulting in missed doses. One resident, with serious conditions, missed multiple doses of Zyvox due to unavailability, extending their stay. Another resident missed doses of Omeprazole because staff misplaced the medication provided by family, causing discomfort. Staff interviews confirmed these deficiencies in medication management.
A resident with a Stage 4 Pressure Ulcer and MRSA experienced significant medication errors due to missed doses of the antibiotic Zyvox. The pharmacy entered an incorrect stop date, leading to a shortage of medication. Despite notifying the pharmacy and on-call NP, the issue was not resolved promptly, resulting in four consecutive missed doses. The resident had to stay an additional two days to complete the treatment. Staff confirmed the error as significant and preventable.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure an accurate discharge assessment for a resident, specifically in the coding of the Minimum Data Set (MDS). The resident was admitted to the facility on an unspecified date, and upon discharge, the MDS was completed with an Assessment Reference Date (ARD) of 05/23/2024. The error was identified in Section A0410, which was incorrectly coded as '2. Unit is neither Medicare nor Medicaid certified.' Interviews with two MDS coordinators and the facility administrator confirmed that the section should have been coded as '3. Unit is Medicare and/or Medicaid certified' to accurately reflect the resident's discharge status. This incorrect coding was acknowledged by all interviewed staff members, indicating a failure in the assessment process.
Failure to Adhere to Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The deficiency was identified during an observation where a registered nurse (S5RN) did not wear a gown while performing a peripherally inserted central catheter (PICC) line dressing change for a resident who was on EBP. This was contrary to the facility's policy, which mandates the use of gowns and gloves during high-contact resident care activities, such as device care or use, to prevent the transmission of multidrug-resistant organisms. The resident involved was admitted with a diagnosis of Cervical Spine Osteomyelitis and had a central line, necessitating the use of EBP. The facility's policy, revised in March 2024, clearly outlines the requirement for staff to wear appropriate personal protective equipment (PPE) during such procedures. Interviews with the Assistant Director of Nursing (S3ADON) and the Director of Nursing (S2DON) confirmed that staff should have worn a gown during the dressing change, indicating a lapse in adherence to the established infection control protocols.
Failure to Post Required Agency Information
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting a list of names, addresses, and telephone numbers of pertinent state agencies and advocacy groups. This includes the State Survey Agency, the State licensure office, adult protective services, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. On two separate occasions, observations and a tour of the facility confirmed the absence of this required information. The deficiency was acknowledged by S1ADM during the facility tour, confirming that the necessary information was not posted as required.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were posted in a location that was readily accessible to residents, family members, and legal representatives. During observations on multiple occasions, it was noted that there was no facility binder with survey results available in the designated area. On a tour of the facility, the Director of Nursing (S2DON) was unable to locate the survey results binder, acknowledging that the holder on the wall where it was supposed to be was missing. An interview with another staff member (S4US) revealed that the binder labeled 'SNF Survey Results' was located behind the nurse's station, which was confirmed by the Administrator (S1ADM) to be an inappropriate location as it was not readily accessible to residents and their families.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. The facility's policy, revised in June 2024, mandates that a Nurse Staffing Sheet be posted at the beginning of each shift, containing specific information such as the facility name, current date, resident census, and the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides. However, during an observation on October 28, 2024, no staffing data sheets were found posted in the facility. Interviews with the Director of Nursing (S2DON) and the Administrator (S1ADM) confirmed that the facility did not adhere to the policy of posting daily staffing data sheets in a prominent location accessible to residents and visitors.
Failure to Notify Nurse Practitioner of Resident's Refusal of Diabetic Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident with diabetes. The resident, who was admitted with a diagnosis of Diabetes Mellitus, had specific physician's orders for regular blood sugar checks and administration of diabetic medications, including Glimepiride and Insulin Lantus. However, the resident refused these blood sugar checks and medications on multiple occasions over several days. Despite these refusals, there was no documentation indicating that the nurse practitioner was notified of the resident's non-compliance, which is a critical step in managing the resident's diabetes effectively. Interviews with various staff members, including LPNs and the Director of Nursing, confirmed that the nurse practitioners were not informed of the resident's refusals, even though they acknowledged that they should have been. This lack of communication and failure to notify the appropriate medical personnel of the resident's refusals represents a deficiency in the facility's adherence to professional standards of care. This oversight had the potential to affect all residents in the facility, as it indicates a systemic issue in the communication and management of residents' medical needs.
Failure to Complete Required Staff Training on Abuse and Dementia
Penalty
Summary
The facility failed to ensure that required trainings on abuse, neglect, exploitation, and dementia care were completed for seven staff members. The personnel files of these staff members, including the Administrator, Director of Nursing, two Licensed Practical Nurses, a Certified Nursing Assistant, a Recreational Therapist, and a Learning and Development staff member, lacked documentation of the necessary training. The facility's policy mandates that new employees receive education on these topics during orientation and that existing staff receive annual education through planned in-services. Upon review, it was found that two staff members, an LPN and a Recreational Therapist, did not complete the required training on abuse, neglect, and dementia. Additionally, the Administrator, Director of Nursing, another LPN, a CNA, and a Learning and Development staff member did not complete the required dementia training. An interview with the Administrator confirmed the absence of documentation for these trainings, acknowledging that the facility should have maintained such records.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving a resident to the state survey agency within the required 2-hour timeframe. The facility's policy mandates that all allegations of abuse, including sexual abuse, be reported to the appropriate agencies immediately. However, in this case, the allegation was not reported until 11 days after the incident was first brought to the attention of the staff. The resident, who was cognitively intact, reported being raped by an LPN during a catheter procedure, with a CNA present, to a nurse practitioner during morning rounds. The nurse practitioner immediately informed the Administrator and the Director of Nursing about the allegation. Despite the immediate internal reporting, the facility did not notify the state agency until much later. Interviews with the Assistant Director of Nursing and the Administrator confirmed that the allegation should have been reported within 2 hours as per the facility's policy and federal regulations. The delay in reporting was acknowledged by the Administrator, who was responsible for submitting the required reports to the state agency. This failure to report in a timely manner constitutes a deficiency in the facility's compliance with abuse reporting regulations.
Medication Unavailability Leads to Missed Doses
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for its residents. Specifically, the facility did not have the prescribed medication Zyvox available for Resident #3, who was admitted with serious conditions including a Stage 4 Pressure Ulcer and MRSA. Despite having a physician's order for Zyvox to be administered every 12 hours, the medication was unavailable on multiple occasions, leading to missed doses on 08/21/2024, 08/22/2024, and 08/23/2024. This resulted in Resident #3 remaining in the facility for an additional two days to complete the antibiotic course. Similarly, Resident #6 experienced missed doses of Omeprazole due to the facility's inability to locate the medication, which was provided by the resident's family. Despite an order allowing the use of home medication, staff misplaced the medication, causing Resident #6 to miss doses and experience acid reflux. The facility's incident log and interviews with staff confirmed these medication errors, highlighting a failure in the facility's medication management system. Interviews with the facility's staff, including the pharmacist, LPNs, and nurse practitioners, confirmed the unavailability of medications and the resulting missed doses. The facility's Assistant Director of Nursing acknowledged the deficiencies, confirming that the medications were not available for administration as ordered, which should not have occurred. These incidents reflect a significant lapse in the facility's responsibility to ensure the availability and administration of prescribed medications to meet the needs of its residents.
Significant Medication Error Due to Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of the antibiotic Linezolid (Zyvox) for a resident with a Stage 4 Pressure Ulcer, Sepsis, and MRSA. The resident was admitted to complete a full course of IVPB antibiotics. However, due to an error in the stop date entered by the pharmacy, the facility did not have the necessary doses of Zyvox on hand for several days, resulting in missed doses on multiple consecutive occasions. The incident log and interviews revealed that the pharmacy had initially sent enough doses to last until an incorrect stop date, leading to a shortage of medication. Despite the facility contacting the pharmacy and notifying the on-call nurse practitioner, the issue was not resolved promptly, and the resident missed four consecutive doses of the antibiotic. This significant medication error was acknowledged by the facility's staff, including the LPN and RN involved, as well as the nurse practitioners who were not made aware of the issue during rounds. The deficiency resulted in the resident having to remain in the facility for an additional two days beyond the planned discharge date to complete the antibiotic course. Interviews with the facility's staff confirmed that the missed doses constituted a significant medication error, which should not have occurred. The error was attributed to a breakdown in communication and documentation, as well as the incorrect entry of the medication stop date by the pharmacy.
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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