Southern Oaks Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 1524 Glen Oaks Place, Shreveport, Louisiana 71103
- CMS Provider Number
- 195558
- Inspections on file
- 23
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Southern Oaks Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A CNA engaged in sexual intercourse with a resident who had cognitive and physical impairments. The incident was witnessed by another CNA and confirmed by the resident, who reported the act as consensual. Facility leadership failed to recognize and report the event as sexual abuse, despite policies prohibiting such conduct and defining it as an abuse of power.
A facility failed to implement policies requiring staff to provide immediate protection to a resident during an alleged sexual abuse incident. A CNA witnessed another CNA engaging in sexual activity with a resident and, following policy, left the scene to report to a nurse, leaving the resident unprotected. Leadership confirmed staff were trained only to report incidents, not to intervene directly.
A CNA was witnessed engaging in sexual intercourse with a resident who had aphasia but intact cognition. The witnessing CNA left the room to report the incident to a nurse, following facility policy, but did not intervene or provide immediate protection. The facility's abuse prevention program lacked guidance for immediate response, and staff were not trained to intervene directly, resulting in Immediate Jeopardy.
A resident with expressive aphasia was repeatedly assessed as severely cognitively impaired using the Staff Assessment for Mental Status, despite being cognitively intact and able to communicate needs through limited speech and gestures. Staff interviews and a recent BIMS assessment confirmed the resident's cognitive intactness, revealing that prior assessments did not accurately reflect the resident's true status.
A facility failed to notify law enforcement after a CNA was observed engaging in sexual intercourse with a resident who had significant neurological and psychiatric diagnoses. Although the incident was reported internally, the Administrator did not contact police, contrary to facility policy and federal requirements. Staff later acknowledged the event was sexual abuse and should have been reported.
The facility failed to follow care plans for two residents, resulting in missed medication doses and monitoring tasks. One resident did not receive prescribed doses of Humulin R, Lantus, and Gabapentin, while another missed doses of Insulin Aspart, Levothyroxine, Protonix, and Hydralazine, along with necessary monitoring. The DON confirmed the lack of documentation, indicating non-compliance with physician orders.
A cognitively impaired resident with communication deficits was verbally abused by a CNA during a whirlpool bath, where the CNA threatened the resident with physical harm. The incident was witnessed by an LPN who did not report it immediately. The resident later attempted to communicate the incident to the DON, and the situation was eventually reported by another CNA. The facility's investigation confirmed the abuse, leading to the termination of the CNA and the LPN.
A resident with cognitive deficits and multiple medical conditions was verbally threatened by a CNA during a whirlpool bath. An LPN intervened but did not report the incident immediately to the DON or administrator. The administrator was informed the next day but failed to report the incident to the State Survey Agency within the required two-hour window, resulting in a delay of two days before the report was made.
The facility failed to provide hand rolls for a resident with bilateral hand contractures, despite physician orders and a care plan requiring their use. Observations and interviews confirmed the absence of hand rolls over several days, leading to a deficiency in care.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and psychosocial harm by a staff member. A Certified Nursing Assistant (CNA), who was the primary caregiver for a resident with diagnoses including hemiplegia, hemiparesis, bipolar disorder, depression, and aphasia, engaged in sexual intercourse with the resident in his bed. The incident was directly observed by another CNA, who entered the room and witnessed the act taking place. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, confirmed during an interview that the sexual activity occurred and stated it was consensual. Despite the resident's cognitive status and his report of consent, the facility's staff failed to recognize that any sexual relationship between a staff member and a resident constitutes an abuse of power and is considered sexual abuse, regardless of apparent consent. The Administrator did not initially report the incident, stating he did not recognize it as abuse because it was consensual. The facility's abuse and neglect policy, which prohibits all forms of abuse including sexual abuse by staff, was not followed in this case. Interviews with staff confirmed that the CNA involved was immediately told to leave the facility after the incident was reported to nursing staff. The Director of Nursing and other administrative staff later acknowledged that the incident was sexual abuse and an abuse of power. The failure to recognize and report the incident as abuse, as well as the occurrence of the sexual act itself, constituted a deficiency in protecting residents from all forms of abuse as required by facility policy and federal regulations.
Removal Plan
- Review and update the facility's abuse and neglect policy to include statements clarifying that any sexual relationship between staff and residents is considered an abuse of power.
- Inservice the nursing facility staff on changes to the abuse and neglect policy and conduct baseline competency interviews.
- Remove the accused employee from the facility pending investigation.
- Examine the resident for injury and interview the resident.
- Interview the witness to the event.
- Interview the accused.
- Inservice all staff regarding abuse and neglect, including sexual abuse.
- Interview all interviewable residents to determine if they had witnessed or had a sexual encounter with a staff member.
- Physically examine all non-interviewable residents for any evidence of a sexual encounter.
- Conduct staff interviews to determine if they had witnessed or had knowledge of any staff sexual encounters.
- Assign two employees to care for the resident.
- Notify the resident's responsible party and nurse practitioner of the situation.
- Meet with the resident council to discuss concerns regarding the incident and encourage residents to report any issues.
- Make medication changes for the resident as indicated by the nurse practitioner.
- Terminate the accused from the facility.
- Have the facility psych nurse practitioner visit the resident and have the social services director reach out to in-house counseling services to determine eligibility for counseling related to the event.
- Implement monitoring of residents and staff using a post-event monitor and ask questions to determine if any inappropriate staff sexual behavior had been witnessed or suspected; continue monitoring until compliance is assured.
- Discuss the event and corrective actions at the QAPI meeting, and implement any corrective actions based on the interviews.
Failure to Provide Immediate Protection During Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to develop and implement written policies and procedures that ensured immediate protection of an alleged victim from physical and psychosocial harm during and after an investigation of abuse. The existing abuse/neglect prevention program required staff to report incidents to a supervisor or nurse but did not specify actions to provide immediate protection to the resident during an incident. This omission was evident when a CNA witnessed another CNA engaging in sexual intercourse with a resident and, following facility policy, left the room to report the incident to a nurse, leaving the resident and the alleged perpetrator alone. The incident involved a resident with aphasia, limited speech, but intact cognition, who was able to make his needs known. The resident later reported that the sexual activity was consensual. However, the report determined that a reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, given the expectation of safety in a healthcare facility. The CNA who witnessed the event did not intervene or provide immediate protection, as she was trained to report to the nurse and not to take direct action to protect the resident. Interviews with facility leadership confirmed that staff were trained according to the policy, which only required immediate reporting to a nurse, not direct intervention. The Director of Nursing and Corporate Nurse both stated that CNAs were taught to notify the nurse, who would then intervene. Upon review of regulations, facility leadership acknowledged that the policy lacked guidance on immediate protection for residents during incidents of alleged abuse.
Removal Plan
- Review and update the facility's abuse and neglect policy to include immediate physical and psychological protection of the alleged victim during and after the investigation, and to protect the integrity of the investigation.
- Implement procedures for the victim of abuse to be examined for physical and psychological injuries and medically treated as indicated.
- Establish increased supervision of the alleged victim and residents as necessary, depending on circumstances.
- Implement room and/or staffing changes as necessary to protect the resident from the alleged perpetrator.
- Require staff to protect the victim from retaliation and provide emotional support and counseling during and after the investigation, as needed.
- Initiate inservice training for all facility staff on the updated abuse and neglect policy, including immediate protection measures and intervention steps.
- Ensure all staff receive inservice training prior to starting their shift if not already trained, using a personnel roster to track completion.
- Conduct baseline competency interviews with each staff member following inservice to ensure understanding and retention of the new procedures.
- Require immediate reinservice for any staff member who answers competency interview questions incorrectly.
- Implement a QAPI monitor to assure sustained compliance by interviewing random staff members about sexual abuse definitions and immediate protection procedures.
- Discuss effectiveness of corrective actions at QAPI meetings, with findings added to QAPI minutes and additional inservices or corrective actions implemented as needed.
Failure to Protect Resident from Staff Sexual Abuse and Provide Immediate Protection
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to protect a resident from abuse and to ensure immediate protection following an incident involving a staff member. A certified nursing assistant (CNA) was witnessed by another CNA engaging in sexual intercourse with a resident who had aphasia but intact cognition. The witnessing CNA left the room to report the incident to a nurse, as per facility policy, but did not intervene or provide immediate protection to the resident while the act was ongoing. The facility's abuse prevention program did not include guidance for staff on immediate response to protect an alleged victim during and after an incident. Interviews with the administrator, DON, and corporate nurse revealed that staff had only been trained to report abuse to a nurse, not to intervene directly or remain with the resident to ensure their safety. The administrator did not initially recognize the incident as abuse due to the resident's apparent consent, and the facility did not report the incident as required. Further interviews confirmed that the CNA who witnessed the abuse followed existing policy, which was inadequate for immediate resident protection. The administrator and corporate nurse later acknowledged that staff should have been trained to intervene and stay with the resident in such situations. The lack of effective policies, staff training, and immediate protective actions led to the finding of Immediate Jeopardy.
Removal Plan
- Inservice training provided to the Administrator by the NHA Supervisor on the responsibilities of nursing facility staff to protect residents and recognize that any sexual relationship between staff and residents is considered abuse of power.
- All staff instructed to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation.
- Victims of abuse to be examined for physical and psychological injuries and medically treated as indicated.
- Increased supervision of the alleged victim and residents as necessary, depending on the circumstances.
- Room and/or staffing changes to be made as necessary to protect the resident from the alleged perpetrator.
- Staff instructed to protect the victim from retaliation and provide emotional support and counseling during and after the investigation, as needed.
- Baseline competency interview completed with the Administrator to ensure understanding and retention of the inservice content, with immediate reinservice if any questions are answered incorrectly.
- QAPI monitoring implemented by interviewing random staff members to ensure staff awareness of immediate protection procedures during and after an abuse investigation.
- Effectiveness of corrective actions to be discussed at the QAPI Meeting, with findings added to the QAPI minutes and additional inservices or corrective actions implemented as needed.
Inaccurate Cognitive Assessment Due to Misuse of Staff Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected the resident's cognitive status during the observation period. Record review showed that the resident, who had a history of cerebral infarction, aphasia, hemiplegia, hypertension, diabetes, and mood disorders, was consistently assessed using the Staff Assessment for Mental Status on multiple MDS (Minimum Data Set) assessments over the past year. These assessments indicated severe cognitive impairment, despite the resident's care plan and staff interviews confirming that the resident was cognitively intact but had expressive aphasia, limiting verbal communication to a few words, gestures, and head movements. Interviews with the ADON, Administrator, Corporate Nurse, NP, Social Services, and MDS Nurse all confirmed that the resident was able to communicate needs and was cognitively intact, despite expressive limitations. It was revealed that the BIMS (Brief Interview for Mental Status) was not conducted previously, as staff believed the resident was rarely or never understood. However, a recent BIMS assessment, using alternative communication methods such as words and pictures, resulted in a score indicating cognitive intactness. The use of the Staff Assessment for Mental Status instead of the BIMS led to inaccurate documentation of the resident's cognitive abilities.
Failure to Report Suspected Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically by not notifying local law enforcement of an alleged incident of sexual abuse involving a resident and a Certified Nursing Assistant (CNA). According to the facility's Abuse/Neglect Prevention Program, any evidence or suspicion of abuse, including sexual abuse, must be immediately reported to the Administrator and appropriate authorities, including law enforcement. However, after a CNA witnessed another CNA engaging in sexual intercourse with a resident, the incident was reported internally but not to the police, as the Administrator determined the act was consensual. The resident involved had a medical history including hemiplegia and hemiparesis following a cerebral infarction, bipolar disorder, recurrent depressive disorders, and aphasia. Interviews with facility staff confirmed that law enforcement was not notified of the incident, despite the facility's policy and later acknowledgment by the Administrator and a corporate nurse that the event constituted sexual abuse and should have been reported to the police.
Failure to Follow Care Plans for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that the care plans for two residents were followed, specifically regarding the administration of medications and monitoring as per physician orders. For Resident #2, the medical record indicated a failure to administer prescribed doses of Humulin R, Lantus, and Gabapentin on multiple occasions throughout July 2024. This resident had a medical history including rheumatoid arthritis, chronic venous insufficiency, long-term insulin use, and diabetes mellitus with hyperglycemia. The Medication Administration Record (MAR) lacked evidence of medication administration on specified dates, indicating non-compliance with the care plan. Similarly, for Resident #3, the facility did not adhere to physician orders for administering Insulin Aspart, Levothyroxine, Protonix, and Hydralazine, as well as performing necessary monitoring tasks such as changing nebulizer equipment, checking edema status, and documenting seizure activity. This resident's medical history included type 2 diabetes mellitus, acute and chronic respiratory failure, myocardial infarction, and other complex conditions. The Director of Nursing acknowledged the missing documentation in the MAR, confirming that the medications and monitoring tasks were not completed as required, which constitutes a deficiency in following the care plan.
Verbal Abuse Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse and psychosocial harm by a staff member. The incident involved a cognitively impaired resident with communication deficits who was verbally abused by a certified nursing assistant (CNA) during a whirlpool bath. The resident, who had a history of cerebral vascular accident, aphasia, and other medical conditions, became agitated during the bath and did not want his hair washed. In response, the CNA threatened the resident with physical harm, using derogatory language. The incident was witnessed by a licensed practical nurse (LPN) who heard the commotion and intervened by instructing the CNA to step away from the resident. Despite witnessing the verbal abuse, the LPN did not immediately report the incident to a supervisor. The resident later attempted to communicate the incident to the Director of Nurses (DON) but was unable to do so effectively due to his communication deficits. The situation was eventually brought to the attention of the DON by another CNA who had overheard the incident. The facility's investigation confirmed the verbal abuse through statements from staff members who were present during the incident. The CNA involved was placed on administrative leave and subsequently terminated. The LPN who witnessed the abuse but failed to report it was also terminated. The facility's failure to protect the resident from verbal abuse and the delay in reporting the incident constituted a deficiency in the care provided to the resident.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse by a certified nursing assistant (CNA) towards a resident in a timely manner, as required by their Abuse/Neglect Prevention program. The incident involved a resident with significant cognitive deficits and multiple medical conditions, including cerebral vascular accident with right-sided hemiplegia, aphasia, apraxia, dysphasia, diabetes, bipolar disease, and hypertension. During a whirlpool bath, the resident became frustrated and allegedly attempted to get the CNA to leave him alone. In response, the CNA verbally threatened the resident. A licensed practical nurse (LPN) nearby heard the commotion and intervened, instructing the CNA to step away from the resident. However, the LPN did not report the incident to the director of nurses (DON) or the administrator immediately, as required by the facility's policy. The director of nurses was informed of the incident the following day, and the administrator was notified thereafter. Despite being aware of the incident, the administrator failed to report the allegation to the State Survey Agency within the mandated two-hour window. The incident was eventually reported to the State Survey Agency two days after it occurred, which was not in compliance with the facility's policy and state regulations. This delay in reporting represents a deficiency in the facility's adherence to abuse reporting protocols.
Failure to Provide Hand Rolls for Resident with Bilateral Hand Contractures
Penalty
Summary
The facility failed to provide services to prevent further contractures and potential decline in range of motion for a resident with bilateral hand contractures. Resident #22, who was cognitively intact and had a BIMS score of 15, had physician orders and a care plan that required the application of hand rolls to both hands every morning and their removal every afternoon. However, observations on multiple occasions revealed that the resident did not have hand rolls in place, and interviews confirmed that the hand rolls had been removed for cleaning and not returned for several days. The resident's medical record indicated diagnoses including quadriplegia and multiple contractures. Despite the care plan's specific instructions, the resident was observed without hand rolls on three separate days. Interviews with the resident and staff confirmed the absence of the hand rolls, with the CNA and LPN acknowledging that the hand rolls should have been in place. The failure to provide the necessary hand rolls as per the care plan and physician orders led to the deficiency noted in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
