Senior Village Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Opelousas, Louisiana.
- Location
- 315 Harry Guilbeau Road, Opelousas, Louisiana 70570
- CMS Provider Number
- 195318
- Inspections on file
- 28
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Senior Village Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions had a physician's order for oxygen saturation checks every shift, with instructions to administer oxygen if levels fell below 92%. Review of the MAR and staff interviews confirmed that these checks were not performed or documented, resulting in a failure to follow the physician's order.
A resident with severe cognitive impairment was found with an unexplained shoulder dislocation, which was not immediately reported to the State Survey Agency as required. Nursing staff and administration did not recognize the need to report the injury, believing only fractures required notification, resulting in a failure to comply with reporting regulations.
The facility failed to submit accurate PBJ staffing data, showing low weekend staffing levels. Weekdays had 3-6 RNs and 7-9 LPNs, while weekends had only 1 RN and 4 LPNs. Administrative staff were counted in weekday staffing but not on weekends, leading to discrepancies. The DON and Administrator were unaware of the issue, which was due to problems with inputting contract/agency staff and misclassification of administrative duties.
The facility failed to transmit MDS assessments within the required 14-day timeframe for several residents. For example, a resident's Quarterly MDS was completed in early August but not transmitted until early September. Similarly, multiple residents' Discharge MDS assessments completed between March and May were all transmitted in September. These delays were confirmed by staff during interviews.
The facility failed to ensure food safety standards were met, as dietary staff did not maintain proper holding temperatures for food on the steam table. S13Cook did not verify or record most food temperatures, with some items observed below the required 135 degrees Fahrenheit. This deficiency potentially affected 111 residents receiving meals from the kitchen.
A resident's personal equipment, including a CPAP machine and mask sanitizer, was found covered with dust and lint, indicating a failure by the facility's housekeeping staff to maintain a clean and sanitary environment. This was confirmed by both an LPN and a housekeeper, with the DON acknowledging the responsibility of the housekeeping staff in ensuring cleanliness.
A facility failed to accurately complete a resident's MDS assessment by incorrectly coding the use of an anticoagulant. A review of the resident's MAR and physician orders showed no order for such medication, and an interview confirmed the error.
A resident with urinary retention and a Foley catheter did not receive consistent catheter care as required by the facility's policy. Despite having an intact cognitive status, the resident reported infrequent cleaning of the catheter site by staff, leading him to perform the task himself during showers. Staff confirmed the absence of catheter care documentation in the care plan, MAR, and TAR.
A resident with End Stage Renal Disease experienced significant weight loss due to the facility's failure to implement the RD's recommendation for nutritional supplementation. Despite the RD's assessment and recommendation for a 4-ounce house supplement, there was no evidence of the supplement being provided or a physician's order being obtained. Interviews with staff confirmed the oversight and lack of communication regarding the resident's nutritional needs.
The facility failed to ensure food was prepared according to standardized recipes, affecting meal quality for residents. A dietary manager/cook prepared nectar thickened milk without a recipe, resulting in an overly thick consistency. Additionally, an okra and tomatoes dish was made using unlisted ingredients and incorrect quantities, as the cook followed personal preferences instead of the recipe. The dietary manager confirmed that recipes were available and should be used.
A facility failed to maintain safe operating conditions for equipment, as an air conditioner in a resident's room was observed leaking a liquid substance on two occasions. Wet towels were found under the unit, and maintenance staff were initially unaware of the issue. Upon inspection, the maintenance staff confirmed the leak and the unsafe condition of the air conditioner.
Failure to Follow Physician's Orders for Oxygen Saturation Monitoring
Penalty
Summary
A deficiency was identified when the facility failed to follow a physician's order for a resident with severe cognitive impairment and multiple diagnoses, including severe protein-calorie malnutrition, anorexia, aphasia, and cognitive communication deficit. The physician's order required that the resident's oxygen saturation be checked every shift, and if the saturation was less than 92%, oxygen should be administered at 2 liters per minute via nasal cannula as needed. Review of the resident's medication administration record (MAR) for two consecutive months showed no evidence that these oxygen saturation checks were performed or documented. Interviews with the LPN responsible for the resident and the Director of Nursing confirmed that the required oxygen saturation checks were not documented in the task documentation, nurse's notes, or MAR. Both staff members acknowledged the existence of the physician's order and the lack of evidence that the order was followed, confirming the deficiency in care for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin involving a resident to the State Survey Agency within the required two-hour timeframe after discovery. The incident involved a resident with severe cognitive impairment who was found to have swelling in the right shoulder, hand, and arm, which was first noticed by the resident's sister and subsequently assessed by nursing staff. The injury was not witnessed, and the resident was unable to provide an explanation due to cognitive limitations. The resident was transferred to the hospital, where an X-ray confirmed an anterior shoulder dislocation. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the Director of Nursing and the Administrator did not report the incident to the State Survey Agency, as they believed only fractures required reporting. The facility was unable to determine how or when the injury occurred, and the event was not reported as required by regulation. This deficiency was identified through record review and staff interviews, and it had the potential to affect all residents in the facility.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. During the review of the PBJ Staffing Data Report for FY Quarter 3 2024, it was found that there were triggers for excessively low weekend staffing. The facility's staff reporting forms from April to June 2024 showed a significant discrepancy in staffing levels between weekdays and weekends. On weekdays, there were 3-6 RNs and 7-9 LPNs, while on weekends, there was only 1 RN and 4 LPNs for day shifts. This discrepancy was not accurately reflected in the PBJ system, leading to the deficiency. Interviews with the Director of Nursing (S3DON) and the Administrator (S10ADM) revealed that they were unaware of the low weekend staffing and believed that state staffing ratio requirements were met. The issue was attributed to problems with inputting contract/agency staff into the PBJ system. Additionally, administrative nursing staff were counted in weekday staffing hours but not on weekends, and these roles were not correctly categorized in the PBJ system. The Administrative Assistant (S9AA) confirmed that contract/agency staffing hours were manually inputted, and there was a misunderstanding about the classification of administrative duties as direct care staffing.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for several residents were transmitted within the required timeframe of 14 days after completion. This deficiency was identified through record reviews and interviews, revealing that eight residents had their MDS assessments transmitted late. For instance, Resident #45's Quarterly MDS, with an Assessment Reference Date (ARD) of July 25, 2024, was completed on August 8, 2024, but not transmitted until September 9, 2024. Similarly, Resident #10's Quarterly MDS, with an ARD of August 6, 2024, was completed on August 20, 2024, and transmitted on September 6, 2024. These delays were confirmed during an interview with S7MDS, who acknowledged that the assessments were not transmitted within the required timeframe. Further review showed that several residents' Discharge - return not anticipated MDS assessments were also transmitted late. For example, Resident #8's assessment, with an ARD of April 5, 2024, was completed on April 19, 2024, but not transmitted until September 10, 2024. Similar delays were noted for Residents #23, #122, #67, #105, and #112, with completion dates ranging from March to May 2024, but all transmitted on September 10, 2024. During an interview on September 10, 2024, S7MDS confirmed that these assessments were completed but not transmitted within the required 14-day period after completion.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. The dietary staff, specifically S13Cook, did not ensure that all foods on the steam table maintained adequate holding temperatures before being served. The facility's policy required potentially hazardous cooked foods to be held at a minimum of 135 degrees Fahrenheit or higher. However, during the observation, S13Cook was seen checking food temperatures but did not allow the surveyor to verify the thermometer readings. She recorded temperatures for only a few items and failed to check the temperature of several foods, including pureed beans and gravy. Some foods, such as pureed sausage and pureed vegetables, were observed at temperatures below the required 135 degrees Fahrenheit. S13Cook began serving food without verifying or recording most of the food temperatures, claiming that all were above 140 degrees Fahrenheit. When questioned, she removed food pans from the line and placed them back in the steamer. The Registered Dietician, S5RD, stated that the holding temperature should be 130 degrees Fahrenheit or above, which contradicts the facility's policy. The Dietary Manager, S11DM, confirmed that S13Cook did not conduct the food temperature checks correctly and should have recorded the temperatures as they were taken. This deficiency had the potential to affect 111 residents who received food from the kitchen.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, specifically regarding the cleanliness of personal equipment in the resident's room. The resident, who was admitted with diagnoses including Sleep Apnea and Insomnia, had a CPAP machine, mask sanitizer device, a small fan, and a multi-plug extension cord that were observed to be covered with dust and lint. These observations were confirmed by both a Licensed Practical Nurse and a Housekeeper, who acknowledged that it was the responsibility of the housekeeping staff to ensure the cleanliness of the resident's personal equipment and room. The Director of Nursing also confirmed that the housekeeping staff should have maintained the cleanliness and sanitation of the resident's environment.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accurate completion of a resident's Minimum Data Set (MDS) assessment. Specifically, the Quarterly MDS assessment for Resident #9 inaccurately indicated the use of an anticoagulant under Section N, Medications. Upon review of the resident's Medication Administration Record (MAR) and physician orders for May 2024, it was found that there was no order for an anticoagulant. During an interview on September 10, 2024, with S1MDS, it was confirmed that Resident #9 was not on an anticoagulant, and the MDS was incorrectly coded.
Failure to Implement Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing catheter care for a resident diagnosed with Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Urinary Retention. The resident, who had an intact cognitive status as indicated by a BIMS score of 14, had a physician's order for a Foley catheter. However, the care plan, Medication Administration Record (MAR), and Treatment Administration Record (TAR) did not include catheter care instructions, which should have been performed every shift according to the facility's policy. Interviews with staff and the resident revealed that catheter care was not consistently provided. The resident reported that staff only cleaned around the catheter site following bowel movements and not on a daily basis. The resident also mentioned that he had to clean the area himself during showers. Staff members, including the Director of Nursing, confirmed the absence of catheter care documentation in the care plan, MAR, and TAR, acknowledging that it should have been included and performed regularly.
Failure to Implement Nutritional Supplementation for Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with End Stage Renal Disease and other significant health conditions. The resident experienced a significant weight loss of 24.26% over two months, dropping from 175.6 pounds to 133 pounds. The Registered Dietician (RD) had recommended nutritional supplementation to address the resident's poor intake, which was documented as 25% of most meals, occasionally reaching 75%. Despite these recommendations, there was no evidence in the resident's clinical record that the suggested 4-ounce house supplement was provided, nor was there a physician's order for the supplement. Interviews with facility staff, including an LPN, the RD, and the Director of Nursing (DON), confirmed the oversight. The LPN was unaware of the RD's recommendations, and the RD stated that she had communicated the need for supplementation to the staff, who were responsible for forwarding the recommendations to the physician. The DON confirmed that the RD's recommendations should have been sent to the physician for an order, but acknowledged that there was no evidence that the resident received the recommended supplement, nor was there an order in place for it.
Failure to Follow Standardized Recipes in Food Preparation
Penalty
Summary
The facility failed to ensure that food was prepared according to standardized recipes, which compromised the palatability and attractiveness of meals served to residents. During an observation, a dietary manager/cook was seen preparing nectar thickened milk without following a recipe, adding undetermined amounts of milk and powdered thickener until the desired consistency was achieved. This method resulted in a liquid that was excessively thick and difficult to pour, contrary to the preparation instructions on the thickener container, which specified that the liquid should be thickened by the glass to achieve the correct consistency. Additionally, the preparation of an okra and tomatoes dish was observed, where the dietary manager/cook used ingredients not listed in the standardized recipe, such as tomato sauce, and significantly deviated from the specified quantity of okra. The dietary manager/cook admitted to preparing the dish according to personal preference rather than following the recipe. The dietary manager confirmed that all recipes for the weekly menus were available in a binder and should be used by the staff when preparing meals, indicating a failure to adhere to established procedures.
Leaking Air Conditioner in Resident's Room
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, as evidenced by an air conditioner leaking a liquid substance in a resident's room. On two separate occasions, surveyors observed the air conditioner attached to the wall leaking, with multiple towels placed underneath the unit, all of which were wet. During an interview and inspection, the maintenance staff member stated he was unaware of the leaking air conditioner in the resident's room. Upon inspection, he confirmed the presence of wet towels under the air conditioner and acknowledged that the unit was leaking and not in safe operating condition.
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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