Southern Hills Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 9105 Baird Road, Shreveport, Louisiana 71118
- CMS Provider Number
- 195519
- Inspections on file
- 23
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Southern Hills Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident who was physically dependent and at high risk for falls was left unsupervised during incontinent care when a CNA turned away to retrieve supplies, leaving the bed in a high position. The resident lost grip on the side rail and fell, resulting in a fractured femur and transfer to the ER. Staff interviews confirmed the lack of supervision and improper bed positioning directly led to the incident.
A resident with severe cognitive impairment was subjected to unwanted sexual contact by another resident in an unlit dining room. The facility failed to implement protective measures or report the incident, resulting in Immediate Jeopardy. Staff interviews revealed a lack of communication and training on abuse policies.
A resident with cognitive impairments was subjected to unwanted sexual contact by another resident, and the incident was not reported to the necessary authorities within the required timeframe. The facility's staff, including the DON, were aware of the incident but failed to notify the administrator or report it to the state agency and law enforcement, resulting in an Immediate Jeopardy situation.
A facility failed to protect a resident from sexual abuse by another resident and did not report the incident to the state agency or law enforcement. The DON did not provide in-service training to all staff on abuse and neglect, and the Administrator was not informed of the incident until months later. No interventions were put in place to ensure resident safety, leading to an Immediate Jeopardy situation.
A resident with severe cognitive impairment was involved in a sexual abuse incident where another male resident inappropriately touched them. Despite the incident being reported by a CNA to an RN, the resident's representative and physician were not notified. The DON acknowledged the oversight and confirmed the lack of notification.
The facility failed to ensure physician orders were in place for two residents' care devices. A resident with Alzheimer's and impaired cognition had a wander guard alarm without a physician's order. Another resident with a PICC line for antibiotics lacked orders for its maintenance or discontinuation. These deficiencies were acknowledged by the DON.
The facility failed to assess the risk of entrapment for three residents using bed rails, as required by policy. Despite physician orders and care plans indicating the use of assist rails for bed mobility, there was no documentation of entrapment risk assessments. Observations confirmed the presence of raised rails, and staff interviews revealed that maintenance checks for entrapment risk were not conducted.
The facility failed to complete an annual performance review for a CNA, identified as S11, for the year 2024. S11's personnel record, reviewed by Human Resources, confirmed the absence of this required evaluation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a midline catheter and surgical wound, necessary for preventing infection transmission. Observations showed missing EBP signage and unavailable PPE, acknowledged by the DON, indicating a lapse in infection control practices.
A facility failed to update a resident's care plan following a resident-to-resident abuse incident. The resident, with moderate cognitive impairment and multiple psychiatric diagnoses, was involved in a sexual abuse incident. Despite this, the care plan was not revised to include increased monitoring or supervision. The DON confirmed the oversight during interviews.
A resident with a urinary catheter was observed with the Foley catheter bag placed on the floor, which is against basic care standards. The resident has multiple medical conditions, including dementia and hypertension, and is dependent on staff for toileting. The issue was confirmed by the DON and acknowledged by the Corporate Nurse.
A resident with multiple medical conditions, including malnutrition and dysphagia, was receiving enteral feeding at an incorrect rate. The physician's order specified a rate of 45 ml/hr, but observations showed the feeding pump infusing at 60 ml/hr. This discrepancy was confirmed by an LPN, indicating a failure to provide appropriate care for the resident's feeding tube.
The facility did not have the required members present for the quarterly QAA meetings since the last annual survey. A review of the QAA Committee Summary sign-in sheet showed that the meeting included the Administrator, DON, Medical Director, and a Nurse Practitioner, but the Administrator later confirmed that the required members were not present.
Failure to Provide Adequate Supervision During Incontinent Care Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but physically dependent on staff for activities of daily living (ADL) and at high risk for falls, was not provided adequate supervision during incontinent care. The resident had a history of impaired mobility, rheumatoid arthritis, and a previous femur fracture, and required extensive assistance with bed mobility. During the incident, a CNA was providing incontinent care with the resident's bed in a high position and turned away from the resident to retrieve an adult brief from the over bed table, leaving the resident unsupervised. While the CNA was turned away, the resident lost her grip on the side rail and fell from the bed, resulting in a fractured right femur. The resident was found on the floor by staff, complaining of significant pain, and was subsequently transferred to the emergency room where the fracture was confirmed. The incident report and staff interviews confirmed that the CNA did not ensure the resident was secure and safe in the bed before turning away, and the bed was left in a high position, increasing the risk of injury. Interviews with the resident and staff revealed that the resident was unable to hold onto the side rails for long due to arthritis, and the CNA was reportedly distracted, possibly using a cell phone during care. The failure to maintain supervision and ensure the resident's safety during care directly led to the resident's fall and injury. The deficiency was identified as immediate jeopardy due to the serious harm that resulted from the lack of supervision.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and psychosocial harm, resulting in an Immediate Jeopardy situation. A cognitively impaired resident was subjected to unwanted sexual contact by another resident in an unlit dining room. The incident was observed by a CNA, who reported it to an RN. Despite the resident's clear indication of discomfort and non-consent, the facility did not implement protective measures or report the incident to the appropriate state agency or law enforcement. The resident who committed the abuse had a history of moderate cognitive impairment and was on antipsychotic medication. However, the resident's comprehensive care plan did not include any interventions or monitoring following the incident. The victim, who had severe cognitive impairment, was not provided with protective measures in her care plan after the incident. The facility's failure to act increased the risk of further harm to all residents. Interviews with facility staff revealed a lack of communication and training regarding the incident. The Director of Nursing did not ensure all staff were in-serviced on abuse and neglect policies, and the Administrator was not informed of the incident until months later. The facility's reportable incident list did not include the sexual abuse incident, indicating a failure to comply with reporting requirements.
Failure to Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents in a timely manner. A Certified Nursing Assistant (CNA) observed one resident engaging in unwanted sexual contact with another resident in the facility's dining room. The incident was not reported immediately to the facility's administrator, the appropriate state agency, or local law enforcement as required by the facility's policy and federal regulations. The incident involved a resident with cognitive impairments who was subjected to unwanted sexual contact by another resident. Despite the resident's cognitive condition, the incident was not reported to the necessary authorities within the required two-hour timeframe. The facility's Director of Nursing (DON) and other staff members were aware of the incident but failed to notify the administrator or report it to the state agency and law enforcement. The failure to report the incident resulted in an Immediate Jeopardy situation, as it posed a high likelihood of additional harm to the residents. The facility's administrator was not informed of the incident until several months later, and no report was submitted to the appropriate authorities. This lack of action and communication within the facility led to a significant deficiency in ensuring the safety and well-being of the residents.
Failure to Protect Resident from Abuse and Report Incident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the protection of residents from abuse. Specifically, the facility did not have an effective system in place to protect a resident from sexual abuse by another resident. The incident occurred when a CNA observed one resident inappropriately touching another resident in the facility's dining room. The resident who was touched, who is cognitively impaired, confirmed the unwanted contact and expressed discomfort. Despite the absence of a significant decline in mental or physical functioning, the incident was determined to have caused severe psychosocial harm. The facility also failed to report the abuse to the appropriate state agency and law enforcement. The Director of Nursing (DON) did not provide in-service training to all staff on abuse and neglect following the incident and failed to notify the Administrator of the incident. The Administrator was not made aware of the incident until several months later and acknowledged that a report should have been submitted. The Corporate Nurse was informed of the incident the day after it occurred but did not ensure the Administrator was notified. Interviews revealed that no interventions were put in place to ensure the safety of the resident involved or other residents. The DON admitted responsibility for overseeing interventions and staff training but failed to ensure these were implemented. The facility's failure to implement protective measures created a high likelihood of additional harm to the residents. The Immediate Jeopardy was identified and later removed after the facility implemented a plan of removal.
Failure to Notify After Sexual Abuse Incident
Penalty
Summary
The facility failed to notify a resident's representative and physician following an incident of sexual abuse. A resident with severe cognitive impairment, including diagnoses of unspecified dementia, schizophrenia, Alzheimer's disease, and major depressive disorder, was involved in an incident where another male resident inappropriately touched them in the dining room. Despite the incident being reported by a CNA to an RN, there was no documentation indicating that the resident's representative or physician was informed of the event. The Director of Nursing acknowledged the oversight and confirmed the lack of notification to the resident's representative and physician.
Lack of Physician Orders for Resident Care Devices
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. Resident #22, who has Alzheimer's disease, anxiety disorder, and chronic kidney disease, was identified as an elopement risk with impaired safety awareness. Despite having a wander guard alarm device on their ankle, there was no physician's order for its use. This oversight was acknowledged by the Director of Nursing during an interview. Resident #326, admitted with spinal stenosis, fusion of the spine, Parkinson's disease, Type 2 diabetes, and a UTI, had a PICC line for one dose of antibiotic. However, there was no physician's order for the maintenance, monitoring, or discontinuation of the PICC line. This deficiency was also acknowledged by the Director of Nursing, indicating a lapse in ensuring proper medical orders were in place for the resident's care.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for three residents, leading to a deficiency in assessing the risk of entrapment. Resident #13, who was admitted with a diagnosis of unspecified glaucoma, had assist rails for bed mobility and positioning as per physician orders. However, the medical record did not contain any assessments for entrapment risk after the rails were applied, despite observations confirming the presence of raised assist rails on both sides of the bed. Similarly, Resident #50, with diagnoses including schizoaffective disorder and hypertension, also had assist rails for bed mobility and positioning. The care plan and physician orders supported the use of these rails, but like Resident #13, there was no documentation of entrapment risk assessments in the medical record. Observations confirmed the presence of raised assist rails on both sides of the bed. Resident #51, who had multiple medical conditions including cerebral infarction and dementia, was also found to have raised quarter side rails on both sides of the bed. Despite having a physician order for assist rails, the restraint necessity/positioning device form incorrectly indicated that no device was in use. Interviews with facility staff revealed that maintenance checks for entrapment risk were not performed for these residents, highlighting a systemic issue in the facility's assessment and documentation processes.
Failure to Complete Annual Performance Review for CNA
Penalty
Summary
The facility failed to ensure an annual performance review was completed for one of the Certified Nurse Assistants (CNA), identified as S11, out of a sample of five CNAs. S11 was initially hired on February 3, 2017, and rehired on October 28, 2021. Upon review of S11's personnel record, it was found that the 2024 annual performance review was not completed. This deficiency was confirmed during an interview with S9 from Human Resources, who acknowledged the absence of the 2024 performance review in S11's personnel file.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in implementing Enhanced Barrier Precautions (EBP) for a resident who was reviewed for antibiotic use. The resident, who was admitted with diagnoses including spinal stenosis, Type 2 Diabetes, and a urinary tract infection, had undergone neck surgery and was receiving intravenous antibiotics for an infection. Despite having a midline catheter and a surgical wound, which necessitated EBP, the facility did not have appropriate signage or readily available personal protective equipment (PPE) for staff. Observations revealed that the necessary EBP signage was missing, and PPE supplies were not accessible, which was acknowledged by the Director of Nursing. The resident had a midline catheter in the upper left arm and a surgical wound on the neck, conditions that required EBP to prevent the transmission of multidrug-resistant organisms. The lack of EBP implementation was confirmed during interviews with the resident and the Director of Nursing, highlighting a significant lapse in the facility's infection control practices.
Failure to Update Care Plan After Resident Abuse Incident
Penalty
Summary
The facility failed to revise the care plan for a resident following an incident of resident-to-resident abuse. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder with psychotic features, anxiety disorder, intellectual disabilities, and delusional disorders, had a moderate cognitive impairment as indicated by a BIMS score of 09 out of 15. Despite using antipsychotic medication routinely, the resident was involved in a sexual abuse incident with another resident. The comprehensive care plan was not updated to include increased monitoring or supervision after this incident. The Director of Nursing confirmed the oversight during interviews, acknowledging that the care plan should have been revised to address the increased risk following the incident.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency in preventing urinary tract infections. The resident, who has a history of cerebral infarction, essential hypertension, dementia with behavioral disturbance, and other conditions, was observed with a Foley catheter bag placed on the floor. This was noted during two separate observations on the same day, once in the morning and again in the afternoon, with confirmation from the Director of Nursing that the catheter bag should not be on the floor. The Corporate Nurse also acknowledged that keeping the catheter bag off the floor is a basic standard of care.
Incorrect Enteral Feeding Rate for Resident
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with a feeding tube, leading to a deficiency. The resident, who has medical diagnoses including moderate protein calorie malnutrition, dysphagia, atrial fibrillation, and Parkinson's disease, was observed to receive enteral feeding at an incorrect rate. According to the physician's order dated 12/17/2024, the resident's feeding should have been administered at 45 ml/hr for 20 hours to deliver the prescribed nutritional intake. However, observations on 02/03/2025 revealed that the enteral feeding pump was infusing at 60 ml/hr, which was confirmed by an LPN during an interview. This discrepancy between the ordered and actual infusion rate was not addressed, resulting in a failure to provide the appropriate care for the resident's feeding tube.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure the required members were present for the quarterly Quality Assessment and Assurance (QAA) meetings since the last annual survey. A review of the facility's QAA Committee Summary sign-in sheet revealed that during the meeting on October 9, 2024, the signatures of the Administrator, Director of Nursing (DON), Medical Director, and a Nurse Practitioner were present. However, during an interview on February 7, 2025, the Administrator confirmed that the required members were not present during this meeting.
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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