St. Francisville Nursing And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Francisville, Louisiana.
- Location
- 15243 La Hwy 10, Saint Francisville, Louisiana 70775
- CMS Provider Number
- 195508
- Inspections on file
- 24
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St. Francisville Nursing And Rehab, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and psychiatric diagnoses struck another resident on the head, resulting in the victim expressing fear and choosing to remain in her room to avoid further harm. Staff and another resident confirmed the incident and the affected resident's subsequent fear, indicating psychosocial harm despite no physical injury. Facility policies prohibiting abuse were not effectively implemented, leading to a failure to protect the resident from abuse by another resident.
The facility did not submit accurate direct care staffing data to CMS, resulting in triggers for low staffing ratings, no RN hours, and lack of licensed nursing coverage for 24 hours per day. The administrator confirmed that staffing codes were not correctly transferred to the PBJ report, and a final validation report was not available for the affected month.
Two residents with active diagnoses of PTSD were not accurately coded for this condition in their MDS assessments. The staff member responsible for MDS completion confirmed the omission after reviewing the residents' records, and the DON stated that assessments are expected to reflect all active diagnoses.
A resident with a history of traumatic subdural hemorrhage and dysphonia did not receive a timely ENT specialist appointment as ordered by a physician and nurse practitioner. The referral was initially denied based on internal guidelines, and staff failed to notify the appropriate clinical leaders or schedule the appointment until the resident developed shortness of breath. Lack of a system to reconcile NP progress notes with physician orders contributed to the delay in care.
Two residents with PTSD were not care planned for their diagnosis, and staff were unaware of necessary trauma-informed interventions. One resident displayed agitated and aggressive behaviors without appropriate care plan interventions, and trauma assessments did not capture essential details for individualized care.
Surveyors found that a multi-dose insulin vial for a resident was opened and stored in the medication room refrigerator without being dated, as required by facility policy. An LPN confirmed the vial should have been dated upon opening. In a separate incident, another LPN left a medication cart unlocked and unattended in a hallway while providing resident care. The DON confirmed expectations for proper labeling and securing of medications.
Surveyors found that kitchen staff failed to properly label and date opened food items, did not sanitize food thermometers between uses, served ground beef at temperatures below the required 160°F, and did not maintain the kitchen air conditioner in a sanitary condition. These deficiencies were confirmed by dietary and administrative staff.
A resident with paraplegia and a urinary catheter was observed multiple times with an uncovered urinary drainage bag, despite facility policy requiring such bags to be covered to maintain dignity. Staff confirmed the bag should have been covered, and the cover was found on the floor next to the resident's wheelchair.
A resident with a broken tooth and recent dental infection did not receive a timely referral to an oral surgeon and endodontist for extraction and root canal, despite physician orders and care plan interventions. The staff member responsible for scheduling was unaware of the order due to a missed communication step, resulting in the appointment not being made.
Staff failed to follow proper hand hygiene and glove-changing protocols during perineal care for two residents with incontinence. CNAs did not perform hand hygiene before care, did not change gloves when moving from dirty to clean tasks, and touched clean items and room surfaces with soiled gloves, contrary to facility policy.
A resident with severe cognitive impairment and known behavioral issues physically assaulted two other residents, causing harm. The facility failed to provide adequate supervision, allowing the resident to engage in physical altercations. This resulted in one resident being hospitalized for injuries and another experiencing a fall.
A resident with severe cognitive impairment and known behavioral issues was not properly supervised, leading to an assault on another resident. The assigned CNA failed to maintain line of sight supervision, allowing the resident to enter a peer's room and cause harm. Despite being in-serviced on supervision requirements, the CNA admitted to taking his eyes off the resident, resulting in the incident.
A facility failed to ensure a cognitively impaired resident received timely treatment and care after a fall. An LPN did not transcribe or implement new orders for Tylenol and an X-Ray, nor did she communicate the resident's change in status to oncoming staff. This resulted in a delayed diagnosis of a displaced left femoral neck fracture, requiring surgical intervention.
The facility failed to accurately document the administration of Tylenol for a resident with severe cognitive impairment and multiple diagnoses. Despite the medication being administered on two occasions, it was not recorded in the MAR or transcribed into the electronic medical record.
The facility failed to accurately code the MDS for PASRR for two residents, despite having Level II PASRR approvals. The Director of Nursing and Chief Compliance Officer confirmed the inaccuracies during interviews.
The facility failed to update a resident's care plan to include interventions for removing the water pitcher from the room, despite the resident's tendency to replace thickened liquids with regular water. Staff interviews confirmed this oversight.
The facility failed to ensure a clean and safe environment for a resident, as the air conditioner cover was detached and a nightstand drawer was missing. Staff did not report these issues to maintenance, and they were only discovered during an observation.
The facility failed to post the required nurse staffing information on a daily basis. An observation revealed that the posted staffing data was outdated and lacked documentation of the facility name, resident census, and actual hours worked. The ADON confirmed the staffing report was not posted as required and was missing critical information.
Failure to Protect Resident from Physical Abuse and Psychosocial Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse and psychosocial harm when one resident struck another on the head. Specifically, a resident with severe cognitive impairment and diagnoses including Paranoid Schizophrenia, Bipolar Disorder, and Dementia approached another resident from behind and hit her on the head while she was sitting on a couch. The incident was witnessed by staff and another resident, and was documented in both the clinical record and state agency report. The resident who was struck immediately expressed fear of the other resident and was observed holding her head after the incident. Following the event, the resident who was hit reported to staff and her roommate that she was afraid of the resident who struck her and did not feel safe in her environment. She chose to remain in her room out of fear and expressed concern when the other resident returned from the hospital. Interviews with staff and another resident confirmed that the affected resident verbalized her fear and desire to avoid the individual who had hit her. The facility's own policies prohibit all forms of abuse, including physical and psychological harm, and require protection of residents from abuse by anyone, including other residents. Despite the absence of physical injury or significant decline in mental or physical functioning, the resident experienced psychosocial harm as evidenced by her expressed fear and change in behavior following the incident. The facility's documentation and staff interviews confirmed that the resident was initially fearful and that being hit on the head constituted physical abuse. The event demonstrated a failure to ensure the resident's right to be free from abuse and to feel safe in her living environment.
Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report for the first quarter of fiscal year 2025 revealed multiple triggers, including a One Star Staffing Rating, excessively low weekend staffing, no Registered Nurse (RN) hours, and lack of licensed nursing coverage for 24 hours per day. The infractions for no RN hours and lack of licensed nursing coverage occurred throughout December 2024. During an interview, the administrator responsible for PBJ uploads confirmed that the PBJ Final Validation Report for December 2024 was not available and acknowledged that the codes for direct care staffing were not accurately transferred to the PBJ report for that month.
Failure to Accurately Code PTSD Diagnoses in Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current diagnoses of two residents with Post-Traumatic Stress Disorder (PTSD). Review of the clinical records for both residents showed that each had an active diagnosis of PTSD upon admission. However, examination of their respective Quarterly Minimum Data Set (MDS) assessments revealed that the PTSD diagnosis was not marked as present in Section I: Active Diagnoses. During interviews, the staff member responsible for completing the MDS assessments confirmed that the PTSD diagnosis should have been indicated for both residents but was not. The Director of Nursing stated that MDS nurses are expected to complete assessments that accurately reflect each resident's active diagnoses and current status.
Failure to Arrange Timely ENT Referral Following Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by not arranging a timely appointment with an ENT specialist as ordered. The resident, who had a history of traumatic subdural hemorrhage and dysphonia, had a physician order dated 02/18/2025 requesting referral to a private physician for evaluation of persistent hoarseness. This referral was denied based on internal guidelines, and there was no documented notification to the DON or NP regarding the denial. Subsequently, a nurse practitioner noted on 03/05/2025 that a referral to a local ENT should be made, but there was no evidence that this appointment was scheduled at that time. Interviews revealed that the staff responsible for scheduling appointments was not aware of the need for an ENT referral until 04/10/2025, when the resident presented with shortness of breath. The DON confirmed that there was no system in place to cross-check nurse practitioner progress notes with physician orders, which contributed to the delay in scheduling the necessary specialist appointment. The lack of communication and follow-through on the referral orders resulted in the resident not receiving timely evaluation and care as directed by medical professionals.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and services in accordance with professional standards of practice for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Both residents had an active diagnosis of PTSD documented in their clinical records, but their care plans did not address this diagnosis. One resident exhibited aggressive and agitated behaviors, including responding to internal stimuli and yelling at staff and peers, yet there were no care plan interventions in place to address or manage PTSD-related symptoms. Interviews with staff revealed a lack of awareness regarding the residents' PTSD diagnoses and the absence of trauma-informed interventions. The LPN assigned to one resident was unaware of the PTSD diagnosis and confirmed that no interventions had been established. The staff member responsible for MDS assessments and care plans acknowledged that both residents should have been care planned for PTSD but were not. Additionally, the social services designee admitted to not knowing the specific trauma histories of the residents and confirmed that trauma assessments did not include details necessary for appropriate care planning.
Failure to Properly Label Insulin Vial and Secure Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to comply with accepted professional principles for the storage and labeling of drugs and biologicals. During an observation in the medication room, an opened multi-dose vial of insulin labeled for a specific resident was found in the refrigerator without a date indicating when it was opened. The LPN present confirmed that the vial should have been dated upon opening, in accordance with facility policy, but was not. Additionally, surveyors observed that Medication Cart #3 was left unattended and unlocked in a hallway for several minutes while the responsible LPN was performing resident care in a closed room. The LPN acknowledged that the cart should have been locked before leaving it unattended. The Director of Nursing confirmed that staff are expected to label and date multi-dose vials upon opening and to keep medication carts locked when not under direct observation.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. During an inspection, opened food items in the refrigerator and freezer, such as green grapes, pancakes, dough, ice cream, pie dough sheets, beef patties, green onions, chocolate syrup, and waffles, were found unsealed, unlabeled, and undated. Staff interviews confirmed that all opened food products should have been sealed, labeled, and dated according to facility policy, but this was not done. Additionally, the kitchen's air conditioning unit was observed to be covered in a thick, gray substance and a plastic piece next to it was covered in a spotted black substance, both of which were confirmed by staff to be unsanitary and not properly maintained. Further observations revealed that a cook failed to properly sanitize a food thermometer between checking the temperatures of different food items, specifically between ground beef patties and mashed potatoes, which was acknowledged by staff as a risk for cross-contamination. The same cook also served ground beef patties at an internal temperature of 142 degrees Fahrenheit, below the required 160 degrees Fahrenheit, and admitted that the food should not have been served at that temperature. These deficiencies were confirmed by both dietary and administrative staff during interviews.
Failure to Maintain Resident Dignity by Leaving Urinary Drainage Bag Uncovered
Penalty
Summary
The facility failed to ensure that a resident's urinary drainage bag remained covered, as required by facility policy to maintain dignity. Observations revealed that the resident, who was cognitively intact and had diagnoses including paraplegia, chronic kidney disease, neuromuscular dysfunction of the bladder, and a cervical spinal cord injury, was seen in his room and later on the smoking patio with an uncovered urinary drainage bag. The drainage bag cover was observed on the floor next to the resident's wheelchair during one of the observations. Staff interviews confirmed that the urinary drainage bag should have been covered to maintain the resident's dignity, in accordance with the facility's policy. The Director of Nursing and a CNA both acknowledged that the standard of care was not met in this instance, as the resident's urinary drainage bag was left uncovered during multiple observations.
Failure to Arrange Dental Referral as Ordered
Penalty
Summary
The facility failed to ensure a referral was made to an oral surgeon as ordered for a resident who required dental services. The resident, who was moderately cognitively impaired and had a history of a bacterial infection and a broken tooth, had a physician's order dated 03/31/2025 for appointments with an oral surgeon and endodontist for a tooth extraction and root canal. The care plan included coordinating dental care and transportation as needed. Nurse's notes and a nurse practitioner note confirmed the need for referral following a dental abscess and antibiotic treatment. Despite these orders and documentation, the staff member responsible for scheduling appointments was not aware of the referral order, as she had not received the printed order report from the DON. As a result, the appointment for the necessary dental procedures was not made. Interviews with the staff confirmed the breakdown in communication and process, with the DON acknowledging that the order report should have been provided to the scheduler to ensure the referral was completed.
Failure to Follow Hand Hygiene and Glove Protocols During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene and glove use during perineal care for two residents with bowel and bladder incontinence. In both cases, certified nursing assistants (CNAs) did not perform hand hygiene before care, did not change gloves when moving from dirty to clean tasks, and touched clean items and room surfaces with soiled gloves. Specifically, one CNA performed perineal care, handled clean briefs, opened drawers, applied barrier cream, and adjusted the resident's environment without changing gloves or performing hand hygiene. The other CNA similarly failed to change gloves or sanitize hands while cleaning the resident, handling clean briefs and clothing, and changing bed linens. Both residents involved were care planned for incontinence and required assistance with perineal cleansing. The CNAs confirmed during interviews that they did not follow proper hand hygiene and glove-changing protocols as outlined in the facility's policy. The Director of Nursing also acknowledged that staff are expected to perform hand hygiene before care, when moving from dirty to clean, and after care, and to avoid touching items in the resident's room with soiled gloves.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving two residents who were victims of physical abuse by a third resident known for physically abusive behaviors. Resident #2, who had severe cognitive impairment and a history of behavioral disturbances, physically assaulted Resident #1 by punching him in the face and neck multiple times. This incident resulted in Resident #1 experiencing physical pain, facial swelling, and bloody drainage from the nose, necessitating evaluation and treatment at a local hospital. Prior to this incident, Resident #2 had a documented history of behavioral issues, including confusion, wandering, and previous altercations with peers. On a previous occasion, Resident #2 had pushed Resident #3, causing her to fall and sustain pain to her right hip, which required an x-ray. Despite these known behaviors, Resident #2 was left unattended by a CNA, which allowed the altercation with Resident #1 to occur. The facility's failure to maintain adequate supervision and implement effective interventions for Resident #2's known behaviors directly contributed to the incidents of abuse. The lack of continuous line-of-sight supervision, as required by Resident #2's care plan, allowed the resident to engage in physical altercations with other residents, resulting in harm.
Failure to Maintain Line of Sight Supervision Results in Resident Harm
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident with known physical behaviors towards others. The resident, who had severe cognitive impairment and a history of behavioral disturbances, was supposed to be under line of sight supervision as per their care plan. However, on the day of the incident, the assigned CNA did not maintain the required supervision, allowing the resident to enter another resident's room and physically assault them. The incident occurred when the resident entered a peer's room and hit them in the face and neck, resulting in the peer being sent to the hospital for evaluation and treatment. The CNA assigned to supervise the resident admitted to taking his eyes off the resident to assist another resident, which led to the failure in maintaining line of sight supervision. This lapse in supervision was despite the CNA having been in-serviced on the requirements of line of sight supervision prior to the shift. Interviews with staff revealed that the LPN on duty had to redirect the CNA multiple times regarding the supervision requirements, but did not report these issues to the Director of Nursing. The failure to maintain the required supervision as outlined in the care plan directly led to the physical altercation and subsequent harm to another resident.
Failure to Transcribe and Communicate Orders
Penalty
Summary
The facility failed to ensure a cognitively impaired resident received treatment and care in accordance with professional standards of practice. Specifically, an LPN did not transcribe new telephone orders for Tylenol and an X-Ray for the resident after a fall and complaint of pain. Additionally, the LPN did not implement the new telephone order for an X-Ray and failed to communicate the resident's change in status, fall, or new orders to oncoming staff before leaving the facility at the end of her shift. The resident, who had a history of falling and severe cognitive impairment, was found on the floor in the bathroom by her roommate. The LPN on duty at the time received orders from the on-call nurse practitioner to administer Tylenol and obtain an X-Ray. However, the LPN did not notify the X-Ray company or transcribe the orders into the resident's chart. The LPN documented the fall and X-Ray order in the 24-hour report book but did not verbally communicate this information to the oncoming staff. As a result, the resident's condition was not properly addressed until later in the day when another LPN and a nurse practitioner assessed the resident and ordered an X-Ray. The X-Ray revealed a displaced left femoral neck fracture, which required surgical intervention. The delay in treatment and communication resulted in actual harm to the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure a resident's medical record was maintained accurately and systematically in accordance with accepted professional standards and practices. Specifically, the facility did not transcribe and document the administration of Tylenol on the Medication Administration Record (MAR) for one resident. The resident, who had severe cognitive impairment and multiple diagnoses including a displaced intertrochanteric fracture of the left femur and dementia, experienced a fall and complained of pain. Despite receiving Tylenol for pain management, the administration of the medication was not documented in the resident's MAR or transcribed into the electronic medical record as per standard procedures. Interviews with the involved Licensed Practical Nurses (LPNs) confirmed that Tylenol was administered to the resident on two separate occasions on the same day, but neither instance was documented in the MAR. The Director of Nursing (DON) reviewed the records and confirmed the absence of documentation for the Tylenol administration. This failure to document medication administration accurately and systematically represents a deficiency in maintaining medical records in accordance with professional standards.
Inaccurate Coding of PASRR in MDS Assessments
Penalty
Summary
The facility failed to ensure residents' assessments accurately reflected their status by not properly coding the Minimum Data Set (MDS) for PASRR (Pre-admission Screening and Resident Review) for two residents. Resident #27 was admitted with a Level II PASRR approval dated 02/07/2013, but the Annual MDS assessment dated 05/10/2023 incorrectly coded Section A1500 as 'No' and left Section A1510 blank. Similarly, Resident #52, admitted with a Level II PASRR approval dated 10/11/2017, had an Annual MDS assessment dated 09/07/2023 that also incorrectly coded Section A1500 as 'No' and left Section A1510 blank. These inaccuracies were confirmed by the Director of Nursing (S3DON) and the Chief Compliance Officer (S2CCO) during interviews conducted on 03/20/2024. Both S3DON and S2CCO verified that the residents' Form 142 indicated approval for nursing home admission by the Level II authority, and they confirmed that the MDS assessments should have been coded as 'Yes' in Section A1500. The failure to accurately code the MDS assessments for these residents indicates a lapse in ensuring that the residents' assessments accurately reflected their status, specifically regarding their PASRR evaluations.
Failure to Update Care Plan for Hydration Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered plan of care for a resident diagnosed with dysphagia. The resident was admitted with a requirement for nectar thick liquids, but the care plan did not include interventions to remove the water pitcher from the resident's room. Interviews with staff members, including a CNA, LPN, and MDS coordinator, revealed that the resident would dump out thickened liquids and replace them with regular water, which was not reflected in the care plan. The Director of Nursing confirmed that all care plans should accurately reflect the care being provided.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a clean and safe environment for Resident #36. During observations on 03/18/2024 and 03/19/2024, it was noted that the front cover of the air conditioner/heater unit in Resident #36's room was detached and laying on the floor. Additionally, the nightstand on the left side of the resident's bed was missing the third drawer. These issues were confirmed by the Director of Nursing (S3DON) during an observation on 03/19/2024, who acknowledged that staff should have reported these concerns to maintenance but had not done so. Interviews with the Director of Nursing (S3DON) and the Maintenance Director (S10MD) revealed that staff are expected to write environmental concerns in a maintenance log book to notify maintenance of any issues. However, no entries had been made in the log book regarding the detached air conditioner cover and the missing drawer in Resident #36's room. The Maintenance Director stated that he checks the log book every other day and also performs random room checks in the mornings. He was only made aware of the issues in Resident #36's room the day before the interview and did not know how long they had been present.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis. An observation on 03/18/2024 at 8:10 a.m. revealed that the posted staffing data near the nurse's station was dated 03/17/2024 and lacked documentation of the facility name, resident census, and actual hours worked. During an interview on 03/18/2024 at 9:18 a.m., the Assistant Director of Nursing (ADON) confirmed that the staffing report for 03/18/2024 was not posted as required and was missing critical information such as the facility name, census, and total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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