Southwind Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crowley, Louisiana.
- Location
- 804 Crowley-rayne Hwy, Crowley, Louisiana 70526
- CMS Provider Number
- 195563
- Inspections on file
- 28
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Southwind Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident receiving Dabigatran Etexilate Mesylate was not monitored for bruising and/or bleeding as required by the facility's policy. Despite the policy mandating daily assessments for side effects, there was no documentation of such monitoring in the resident's MAR. Interviews with an LPN and the DON confirmed the oversight, highlighting a deficiency in the resident's care.
A resident with moderate cognitive impairment was verbally and physically abused by another resident with severe cognitive impairment in the dining room. The incident involved arguing, pushing with a wheelchair, and slapping, as witnessed by visitors and confirmed by facility staff. No injuries were reported, but the facility failed to adhere to its abuse and neglect policy.
A facility failed to report an abuse incident within the required timeframe. An altercation between two residents, one severely and one moderately cognitively impaired, resulted in physical abuse. Despite being documented by staff, the incident was not reported to the state agency as required by facility policy.
The facility failed to submit Level II PASARR evaluations for two residents with new mental illness diagnoses. One resident was diagnosed with Unspecified Psychosis Disorder, and another with Bipolar Disorder, but neither was referred for the necessary evaluation. The Social Service Director confirmed the oversight.
The facility failed to provide food in a form that met the needs of residents on pureed diets. Observations showed that the cook did not follow the correct recipe for pureeing rice, resulting in a product with whole grains. Additionally, pureed turnip greens contained visible bacon bits and stems. A dietary staff member placed regular textured beans and sausage on a resident's pureed meal, despite the resident being on a pureed diet. The Dietary Manager confirmed these inconsistencies.
A resident with multiple health issues and moderately impaired cognition was unable to reach their call bell, which was placed behind them under an incontinent pad. The facility's policy requires call lights to be within reach, but this was not adhered to, as confirmed by an LPN during an observation.
A facility failed to secure a resident's toilet, compromising safety. The resident, who was cognitively intact and required assistance for toilet transfers, reported using the bathroom without help. The maintenance supervisor was unaware of the issue, despite monthly checks and maintenance being performed when notified. The administrator confirmed that daily QA checks should include room inspections, but a QA check was not conducted on the day the issue was first observed.
A resident with moderate cognitive impairment repeatedly pulled her call bell station off the wall, making it unreachable. Despite staff awareness, the issue was not addressed in her care plan until surveyors identified the deficiency.
The facility failed to properly store medications, as loose pills were found in the bottom of medication cart drawers. During an inspection, an LPN confirmed the presence of two yellow oblong pills and one and a half white oblong pills loose in Cart #4. The DON also confirmed the loose pills and stated they should not have been there.
The facility did not provide the correct portion sizes for pureed meals, affecting two residents. During a lunch observation, pureed food items were served with a 1/2 cup scoop instead of the required 3/4 cup or 6 oz spoodle. The Dietary Manager confirmed the error, noting that staff should have followed the recipe spreadsheets for appropriate serving sizes. The cook reported being instructed to use a half cup scoop for all pureed items, indicating a miscommunication or misunderstanding of the facility's policy.
The facility failed to obtain hospice recertification for three residents receiving hospice care. A resident with Senile Degeneration of Brain, another with end-stage Parkinson's, and a third with Cardiovascular Disease did not have current recertification statements in their EHR. The DON confirmed the absence of these documents, which were not maintained in any other form. This deficiency was identified through a review of the EHR and an interview with the DON.
A resident with severe cognitive impairment and multiple diagnoses experienced nausea and refused medications for two days. The facility failed to notify the resident's physician and representative, contrary to policy. The oversight was confirmed through interviews with staff and the resident's representative.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring of a resident who was prescribed an anticoagulant medication, Dabigatran Etexilate Mesylate. The resident, who had been admitted with diagnoses including atrial fibrillation and heart failure, was not monitored for signs of bruising and/or bleeding from the start of the medication on February 13, 2025, through February 18, 2025. The facility's policy required daily or as-needed assessments for such side effects, but there was no documentation of this monitoring in the resident's Medication Administration Record (MAR) or comprehensive plan of care. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the lack of monitoring and documentation for the resident receiving the anticoagulant. Both staff members acknowledged that the resident should have been monitored for bruising and/or bleeding, and the findings should have been documented in the MAR. The absence of this monitoring and documentation represents a failure to adhere to the facility's policy on anticoagulant therapy, resulting in a deficiency in the resident's care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse, as evidenced by an incident involving two residents. Resident #R1, who was moderately cognitively impaired with a BIMS score of 8, was subjected to verbal and physical abuse by Resident #3, who was severely cognitively impaired with a BIMS score of 6. The incident occurred in the dining room, where Resident #3 approached Resident #R1, began arguing, and physically assaulted her by pushing her with a wheelchair and slapping her in the face. This altercation was witnessed by family members of another resident and was documented in the facility's incident reports. The incident was confirmed through interviews with visitors and facility staff, including the Administrator and Director of Nursing. The visitors reported that Resident #3 initiated the confrontation by telling Resident #R1 to move and subsequently threatened and hit her when she refused. Despite the physical altercation, no injuries were reported for either resident. The facility's policy on abuse and neglect, which emphasizes the residents' right to be free from abuse, was not adhered to in this situation, resulting in a deficiency in ensuring a safe environment for Resident #R1.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical and verbal abuse to the state survey agency within the required two-hour timeframe. This deficiency involved an incident between two residents, where one resident, who was severely cognitively impaired, engaged in an argument with another resident, who was moderately cognitively impaired. The incident escalated to physical abuse when the severely impaired resident hit the moderately impaired resident in the face. Despite the altercation being witnessed and documented by staff, the facility did not report the incident to the state survey agency as mandated by their policy. The facility's policy on abuse and neglect clearly outlines the requirement for immediate reporting of abuse allegations to the state agency. However, in this case, the facility's administrator and director of nursing confirmed that the incident was not reported. The failure to report the incident in a timely manner represents a breach of the facility's policy and state guidelines, which are designed to protect residents from abuse and ensure prompt investigation and intervention.
Failure to Submit Level II PASARR Evaluations for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that residents with qualifying mental disorders were referred for a Level II PASARR evaluation and determination. Specifically, two residents, identified as Resident #6 and Resident #76, were not referred to the appropriate state-designated authority for evaluation despite having new diagnoses that qualified them for such a review. Resident #6 was admitted with diagnoses including Depression and Unspecified Psychosis, and on a later date, was diagnosed with Unspecified Psychosis Disorder. However, there was no evidence that a Level II PASARR evaluation was submitted for this resident. Similarly, Resident #76 was admitted with diagnoses including Depression and Wernicke's Encephalopathy and was later diagnosed with Bipolar Disorder. Again, there was no evidence of a Level II PASARR evaluation being submitted. The Social Service Director, identified as S13SSD, confirmed during interviews that she was responsible for submitting these reviews and acknowledged that she failed to do so for both residents, despite being aware of their new qualifying mental illness diagnoses.
Failure to Provide Properly Pureed Diets
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form that met the individual needs of residents on pureed diets. Specifically, the facility did not puree food items to the appropriate consistency for residents requiring pureed diets. Observations revealed that the cook, S10Cook, did not follow the correct recipe for pureeing rice, using parboiled rice instead of the required instant rice mix, resulting in a product with whole grains and a sticky texture. Additionally, the pureed turnip greens contained visible bacon bits and stems, indicating they were not pureed to the appropriate consistency. The Dietary Manager, S8DM, confirmed these inconsistencies and acknowledged that the correct recipe was not used. Furthermore, the facility failed to ensure that regular textured food items were not placed on a resident's meal tray who was on a pureed diet. During the preparation of a resident's lunch meal tray, dietary staff member S11Dietary placed regular textured beans and sausage on top of the resident's pureed beans and sausage, despite the resident being on a pureed diet. S11Dietary stated that this was done because the resident wanted extra juice/gravy from the regular textured beans. The Dietary Manager confirmed that this was inappropriate for a resident on a pureed diet.
Failure to Ensure Call Bell Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs by not ensuring the call bell was within reach. The resident, who was admitted with multiple diagnoses including dysphagia, shortness of breath, protein-calorie malnutrition, major depressive disorder, anxiety, dependency on dialysis, cervical disc disorder, lumbar vertebra fracture, encephalopathy, and pain, had a BIMS score indicating moderately impaired cognition. The resident required extensive assistance with bed mobility and toileting, and total dependence with two-person assistance for transfers. During an interview and observation, the resident stated that the staff placed the call bell too far for him to reach. At the time of observation, the resident was sitting in a geri-chair, and the call bell was found laying across the bed behind him, under an incontinent pad, making it inaccessible. An LPN confirmed the call bell was not within reach for the resident, which was a failure to adhere to the facility's policy that requires call lights to be placed within reach of residents.
Facility Fails to Secure Resident's Toilet, Compromising Safety
Penalty
Summary
The facility failed to ensure that all areas and equipment were in good repair, specifically failing to secure a resident's toilet to the floor. This deficiency was identified during an investigation involving eight residents, with the issue being observed in the bathroom of a resident who was cognitively intact and required supervision or assistance for toilet transfers. The resident's toilet was found to be loose and easily moved with a gentle nudge, and the resident reported using the bathroom without assistance. The maintenance supervisor stated that room checks were conducted monthly and maintenance was performed when notified by residents or staff, but he was unaware of the loose toilet. The facility administrator confirmed that daily quality assurance checks were supposed to include room inspections, but a review of the QA document revealed that maintenance issues, including loose toilets, were noted, and a QA check was not conducted on the day the issue was first observed.
Failure to Implement Person-Centered Care Plan for Call Bell Issue
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who repeatedly pulled her call bell station off the wall. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 8, was observed with her call bell bed station dislodged and hanging off the wall, making it unreachable from her bed. Despite the resident's ability to call for help, she was unable to reattach the call bell station herself, and the issue was not addressed in her care plan. Multiple staff members, including the Director of Nursing, Registered Nurse Supervisor, Administrator, and Maintenance personnel, were aware of the ongoing problem with the call bell station. The maintenance staff had previously replaced the call bell station, but the issue persisted. The Administrator acknowledged that the resident should have been care planned for this behavior, but it was not done until surveyors highlighted the deficiency.
Improper Storage of Medications in Cart #4
Penalty
Summary
The facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers. During an inspection of Cart #4, two yellow oblong pills were observed loose on the bottom of the second drawer on the left side, and one white oblong pill along with half of a white pill were found loose on the bottom of the second to last drawer on the right side. These pills were located underneath resident medication blister packages. The Licensed Practical Nurse (LPN) confirmed the presence of the loose pills and acknowledged that they should not have been there. The Director of Nursing (DON) also confirmed the loose pills in the drawers and stated that they should not have been present in the medication cart.
Failure to Provide Correct Portion Sizes for Pureed Meals
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not providing the correct portion sizes for pureed meals. During an observation of the food service line, it was noted that pureed food items, including rice, turnip greens, beans and sausage, and cornbread, were being served with a 1/2 cup scoop instead of the required 3/4 cup or 6 oz spoodle for the pureed beans and sausage. This discrepancy was confirmed by the Dietary Manager (S8DM), who acknowledged that the staff should have followed the recipes and recipe spreadsheets that list the appropriate serving sizes. The cook (S10Cook) stated she was instructed to use a half cup scoop for all pureed food items, indicating a miscommunication or misunderstanding of the facility's policy on portion sizes.
Failure to Obtain Hospice Recertification for Residents
Penalty
Summary
The facility failed to obtain the recertification of terminal illness for three residents who were receiving hospice care. Resident #1, diagnosed with Senile Degeneration of Brain, had her last recertification signed on 03/04/2024 for the period ending 05/01/2024. Resident #2, with a diagnosis of end-stage Parkinson's, had her initial certification period from 09/01/2023 to 11/29/2023, but no subsequent recertifications were documented. Resident #3, diagnosed with Cardiovascular Disease, had her last recertification signed on 02/16/2024 for the period ending 05/19/2024. These deficiencies were identified through a review of the facility's electronic health records (EHR) and confirmed by the Director of Nursing (S1DON). The S1DON acknowledged that she was responsible for ensuring all hospice documents were current and scanned into the EHR. However, during an interview, she confirmed that there were no current recertification statements for the three residents in question. The hospice documents were only maintained in the EHR and not in any other form, such as hospice binders. Despite checking her emails, the S1DON was unable to locate the necessary recertifications for the residents, indicating a lapse in maintaining up-to-date hospice documentation as required by the facility's agreement with the Contracted Hospice Agency.
Failure to Notify Physician and Resident Representative of Medication Refusal
Penalty
Summary
The facility failed to ensure that a resident's physician and resident representative (RP) were immediately notified of a change in the resident's condition. Specifically, the resident experienced nausea and refused to take her medications over two days. Despite the facility's policy requiring medication refusals to be reported to the prescriber, the resident's physician and RP were not informed of the situation. This oversight was identified for one of the three sampled residents in the report. The resident in question had severe cognitive impairment and multiple diagnoses, including constipation, nausea with vomiting, dementia, overactive bladder, muscle weakness, protein-calorie malnutrition, and atrial flutter. The resident's medication administration record showed that several medications and supplements were not given on two consecutive days due to the resident's refusal. Progress notes indicated that the resident continued to experience nausea during this period, but there was no documentation that the physician or RP were notified of the medication refusals. Interviews with the resident's RP, an LPN, the nurse practitioner, and the Director of Nursing confirmed that the physician and RP were not informed of the resident's condition and medication refusals. The RP only became aware of the situation when visiting the resident and subsequently requested that the resident be sent to the emergency room for evaluation. The resident was hospitalized for four days before returning to the facility. Both the Director of Nursing and the regional nurse acknowledged that the RP and NP should have been notified of the resident's change in condition.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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.
