St Joseph Of Harahan
Inspection history, citations, penalties and survey trends for this long-term care facility in Harahan, Louisiana.
- Location
- 405 Folse Drive, Harahan, Louisiana 70123
- CMS Provider Number
- 195374
- Inspections on file
- 46
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at St Joseph Of Harahan during CMS and state inspections, most recent first.
A resident's representative was not provided with the facility's written bed-hold policy within the required 24-hour period following an emergency hospital transfer. Although the policy was mailed, there was no documentation confirming timely receipt by the representative, and the policy was only included in the transfer packet sent to the hospital.
A resident experienced right arm immobility and pain, which was assessed by an LPN and led to an x-ray order from the physician. The resident's responsible party was not notified of the change in condition or new orders until several hours later, after the x-ray confirmed a fracture, rather than at the time of the initial assessment or intervention.
A resident sustained a fractured arm of unknown origin, and the facility did not conduct a thorough investigation as required by its abuse prevention policy. The Administrator reviewed surveillance footage at high speed and did not verify if the resident was left unattended in the shower room, missing key details before the footage became unavailable.
A resident with dementia and a history of wandering, who required supervision with ambulation, was not adequately supervised and wandered into another resident's room, resulting in a fall and a right femur fracture that required surgery. Staff had attempted redirection multiple times but did not provide higher-level supervision, despite the resident's known risk for falls and persistent wandering behavior.
Due to insufficient dietary staffing, meals were routinely served late and at improper temperatures. Staff and resident interviews confirmed that breakfast and lunch were often delayed, with some residents receiving cold food well after scheduled meal times. Observations and temperature checks showed that hot foods were not maintained at recommended temperatures, resulting in unpalatable meals for residents.
Two residents did not receive required care plan interventions: one resident with a recent hip fracture did not have a fall mat or bright colored tape on wheelchair brakes as ordered, and another resident with dementia and a history of wandering was not care planned for wandering, despite a fall resulting in injury. Staff interviews confirmed lack of awareness and documentation of these interventions.
A resident with heart conditions received both the newly prescribed and previous doses of Digoxin simultaneously after staff failed to discontinue the earlier order, resulting in a significant medication error and hospitalization for elevated Digoxin levels. The DON and an LPN confirmed the medication was not administered as ordered.
The facility did not report an allegation of physical abuse involving two residents to the State Survey Agency within the required two-hour window, as mandated by policy. The incident was reported several days after it occurred, and the administrator confirmed the delay.
The facility failed to secure electrical wall sockets in three resident rooms and two hallways, as observed during a survey. Unsecured sockets were found in Rooms a, b, and c, and Halls X and Y, with multiple staff members acknowledging the issue. This deficiency was noted during routine activities, indicating a lapse in maintenance.
The facility failed to implement new individualized interventions for three residents after multiple falls, despite having a policy requiring such measures. One resident, with severe cognitive impairment, fell while trying to move herself into a wheelchair. Another resident, with left-sided weakness post-CVA, frequently fell attempting to use the bathroom unassisted. A third resident, with schizophrenia, often threw herself on the floor. Staff acknowledged the lack of appropriate interventions.
A resident with Alzheimer's Dementia, exhibiting moderate cognitive impairment, was subjected to verbal abuse by a CNA who told the resident to "Shut the F*** up." This incident was overheard by the DON, who confirmed it as verbal abuse. The CNA admitted to the language used, citing the resident's prior cursing as the reason.
A CNA failed to perform hand hygiene before providing catheter care to a resident with an indwelling catheter, contrary to the facility's policy. The CNA changed gloves without washing hands after providing incontinent care. This was confirmed by the CNA, Wound Care Nurse, CNA Supervisor, and Infection Control Nurse.
A resident was not provided with restorative services as recommended by therapy staff. Discharge summaries from physical and occupational therapy indicated the need for participation in a restorative nurse program to maintain performance levels and prevent decline. However, interviews revealed that the resident was not enrolled in the program since admission, as confirmed by both the Restorative CNA and the Director of Nursing.
The facility failed to prevent falls for two residents by not updating care plans and not maintaining bed positions as required. One resident fell while trying to get out of bed, and their care plan was not revised with new interventions. Another resident's bed was not consistently kept in the lowest position despite being a fall risk, as confirmed by staff interviews.
A facility failed to provide necessary incontinence care for a resident with severe cognitive impairment, resulting in the resident being left in a heavily saturated brief for an extended period. Observations and interviews confirmed the neglect, and the facility administrator verified the deficiency through camera footage review.
Failure to Provide Timely Bed-Hold Policy Notification to Resident Representative
Penalty
Summary
The facility failed to provide the resident representative (RR) with the required written bed-hold policy within 24 hours of an emergency transfer of a resident to the hospital. According to the facility's own policy, written notification of the bed-hold policy must be given to the family, surrogate, or representative at the time of transfer, or within 24 hours in the case of an emergency. Record review and staff interviews confirmed that, following the resident's emergency transfer due to behavioral issues, the social services staff mailed the bed-hold policy to the RR but did not confirm receipt, and there was no documented evidence that the RR received the policy within the required timeframe. The administrator stated the policy was included in the transfer packet sent to the hospital, but acknowledged the resident would likely not understand the policy, and there was no evidence the RR was properly notified as required.
Failure to Timely Notify Responsible Party of Resident Injury and Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's responsible party of a significant change in the resident's condition, specifically an injury of unknown origin resulting in right arm immobility and pain. On the morning of the incident, an LPN assessed the resident and administered Tylenol for pain, later obtaining a physician's order for an x-ray in the afternoon. Despite these developments, the resident's responsible party was not informed of the change in condition or the new physician's orders at the time they occurred. Documentation review confirmed there was no evidence of timely notification. The responsible party was only notified in the evening, after the x-ray results confirmed a right arm fracture, several hours after the initial assessment and intervention. Interviews with staff and the responsible party corroborated the delay in notification.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition policy by not conducting a thorough investigation into an injury of unknown origin for one resident. According to the facility's policy, the Administrator is required to complete a comprehensive investigation following such injuries. In this case, the Administrator was notified of a resident's fractured right arm after an x-ray and initiated an investigation. The investigation included reviewing surveillance footage, which showed the resident ambulating without issue before being assisted into and out of the shower room by a shower aide. The resident was later left seated on her rollator in the hallway. However, the Administrator did not review the footage to determine if the resident was left unattended in the shower room or to observe when the certified nursing assistant entered and exited the shower room. The Administrator viewed the footage at a high speed, which may have resulted in missing critical details, and the footage was no longer available for further review. As a result, the investigation did not fully address whether the resident was left alone in the shower room, failing to meet the facility's policy requirements for a thorough investigation of injuries of unknown origin.
Failure to Supervise Wandering Resident Results in Serious Fall Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with dementia and cognitive communication deficits who was identified as a wanderer. The resident required staff supervision or assistance with walking and was known to wander, particularly at night. Despite being redirected multiple times by staff, the resident continued to walk into other residents' rooms. On the evening of the incident, the resident wandered into another resident's room and, during an interaction with that resident, fell and sustained a displaced fracture of the right femoral neck, which required surgical intervention. Staff interviews and record reviews revealed that the resident was frequently observed walking in and out of rooms and that staff attempted to redirect her several times without success. Staff acknowledged the difficulty in supervising the resident due to her persistent wandering behavior. The care plan and assessments documented the resident's risk for falls related to confusion and poor communication, as well as her need for supervision with ambulation. At the time of the incident, staff were engaged in routine rounds and preparing residents for bed. The resident was not under direct supervision when she entered another resident's room and fell. The incident report and staff statements indicated that the resident's wandering behavior was well known, and that staff interventions prior to the fall were limited to redirection and activity engagement, without the implementation of more intensive supervision measures.
Removal Plan
- Photos taken of all residents and made available at nurses' stations and the reception desk to identify residents 1-12 who are at risk for wandering.
- Additional staff, hall monitor, added to stay on the 2nd floor hall and visually observe and document observation of residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. During meal times, the monitoring of residents 1-12 will be handed off to CNA's and LPNs assigned to monitor the dining room and the hall monitor will remain on the hall to continue monitoring any of residents 1-12 that remain in their room for meals.
- Staff will be in-serviced on who the 12 residents are that are at risk for wandering, the need to visually observe residents 1-12 to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls, and methods for cueing, redirection, offering activities/snacks, and for what to do if a resident cannot be redirected.
- Hall monitor will be trained on residents 1-12 at risk for wandering. How to monitor residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. How to cue, redirect or offer activities/snacks, how to document on monitoring form, and how to handle meal time. Also trained on what to do if a resident cannot be redirected.
Inadequate Dietary Staffing Leads to Delayed and Improperly Served Meals
Penalty
Summary
The facility failed to maintain adequate dietary staffing levels, resulting in delayed meal service and food not being served at appropriate temperatures. Observations revealed that breakfast and lunch were consistently served later than the posted meal times, with breakfast trays often not reaching residents until after 9:00AM and lunch trays after 1:00PM. Staff interviews confirmed frequent call-ins and ongoing understaffing in the kitchen, which contributed to these delays. Residents reported that meals were regularly late, with some stating that breakfast would not arrive until 9:30AM or later and lunch closer to 2:00PM on multiple days each week. The posted meal times were not updated to reflect the actual service times, and both dietary management and administrative staff acknowledged the discrepancies. Additionally, food was not consistently served at palatable temperatures. Direct observation and temperature checks of meal trays revealed that hot foods, such as macaroni and okra, were served at temperatures significantly below the recommended 160-165 degrees Fahrenheit, with readings as low as 88-90 degrees Fahrenheit. Residents reported that late meals were often cold and unappetizing, with specific complaints about the texture and temperature of breakfast items. These findings were corroborated by both staff and resident interviews, as well as direct observation of meal service.
Failure to Implement and Develop Care Plan Interventions for Fall and Wandering Risks
Penalty
Summary
The facility failed to implement and document care plan interventions for two residents at risk for accidents. For one resident with a history of falls and a recent hip fracture, the care plan included the use of a fall mat and bright colored tape on wheelchair brakes as interventions. Despite physician orders and care plan revisions, repeated observations showed that the fall mat was not present in the resident's room and the wheelchair did not have the required tape. Interviews with staff, including a CNA and an LPN, revealed they were unaware of these interventions, and the resident herself confirmed she had never received them. The DON acknowledged that the interventions were not in place as specified in the care plan and physician orders. Another resident, admitted with dementia and a cognitive communication deficit, was a known wanderer and had a documented history of wandering at night. This resident experienced an unwitnessed fall in another resident's room, resulting in a hip fracture. Despite this known behavior and risk, there was no evidence in the medical record or care plan that wandering was addressed or that interventions were developed to mitigate this risk. Both the DON and the MDS nurse confirmed that the resident should have been care planned for wandering but was not.
Failure to Discontinue Previous Digoxin Order Led to Medication Overdose
Penalty
Summary
Nursing personnel failed to administer medication as ordered by the physician for a resident with diagnoses including congestive heart failure and hypertensive heart disease with atrial fibrillation. The physician had ordered an increase in Digoxin to 250 mcg three times a day and for the previous order of 125 mcg three times a day to be discontinued. However, the order for 125 mcg was not discontinued, resulting in the resident receiving both 250 mcg and 125 mcg of Digoxin three times a day over several days. This medication administration error led to the resident receiving a higher cumulative dose of Digoxin than prescribed, which was identified when the resident was found to have an elevated Digoxin level of 4.2 ng/ml (normal range: 0.9-2.0 ng/ml). The resident was subsequently transferred to a local hospital per physician orders due to the elevated Digoxin level. Interviews with the DON and an LPN confirmed that the resident did not receive the medication as ordered.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State Survey Agency within the required two-hour timeframe. According to the facility's Abuse Prevention and Prohibition Policy, the administrator is required to initiate a Statewide Incident Management System (SIMS) report to the Louisiana Department of Health immediately, but no later than two hours after forming a suspicion of a crime if the alleged violation involves abuse or results in serious bodily injury. The incident in question occurred at 11:14 PM, but the SIMS report was not entered until several days later at 4:40 PM. During an interview, the administrator confirmed that the allegation was not reported within the mandated timeframe.
Unsecured Electrical Sockets in Resident Rooms and Hallways
Penalty
Summary
The facility failed to ensure that electrical wall sockets were properly secured in several areas, including three out of four resident rooms and two out of four hallways. Observations conducted on October 28, 2024, revealed unsecured electrical sockets in Room a, Room b, and Room c, as well as in Hall X and Hall Y. In Room b and Room c, the unsecured sockets were located at the head of the bed, with two electrical plugs inserted into them, posing a potential safety hazard. Additionally, an unsecured socket was found on the wall opposite the head of the bed in Room c. Interviews with various staff members, including the Maintenance Supervisor, CNA, LPN, Administrator, Regional Maintenance Director, Electrical Contractor, and Regional Administrator, confirmed the unsecured condition of the electrical sockets. These staff members acknowledged that the sockets should have been secured to the wall, indicating a lapse in maintenance and oversight. The deficiency was noted by multiple staff members during routine activities, such as meal service, highlighting the widespread nature of the issue within the facility.
Failure to Implement Individualized Fall Interventions
Penalty
Summary
The facility failed to ensure that residents received adequate care and services to prevent falls, as evidenced by the lack of new individualized interventions after multiple falls occurred. This deficiency was identified for three residents who were reviewed for falls. The facility's Fall Prevention Program Policy and Procedure requires an individualized daily plan for residents identified as high risk for falls, with care plans addressing goals and approaches. However, the facility did not implement new interventions for the residents after each fall, which is contrary to their policy. Resident #1, a female with severe cognitive impairment, experienced a fall that resulted in hospital admission. Despite being added to the fall program, no new interventions were implemented in her care plan to prevent future falls. Interviews with staff indicated that Resident #1 was mostly independent and attempted to move herself into her wheelchair when she fell. Similarly, Resident #2, a male with left-sided weakness post-CVA, experienced multiple falls without new interventions being added to his care plan. Staff noted that he often attempted to go to the bathroom unassisted, despite his unrealistic expectations of his abilities. Resident #3, a female with a history of schizophrenia and heart failure, also experienced multiple falls without new interventions being implemented. Staff interviews revealed that she was often confused and had a tendency to throw herself on the floor. The Assistant Director of Nursing and the Director of Nursing acknowledged that the facility had not consistently implemented appropriate individualized interventions for each fall sustained by the residents, despite recent procedural changes intended to address this issue.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident diagnosed with Alzheimer's Dementia. The resident, who had a moderate cognitive impairment, was verbally abused by the CNA, who told the resident to "Shut the F*** up." This incident was overheard by the Director of Nursing (DON) while passing by the room. The CNA admitted to using the abusive language after the resident had cursed at her. The facility's policy clearly defines verbal abuse as the use of disparaging and derogatory language towards residents, which was violated in this instance.
Failure to Perform Hand Hygiene Before Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff prior to providing catheter care for a resident. The facility's policy on catheter care, dated August 24, 2016, mandates that hand hygiene should be performed and gloves put on before the procedure. However, during an observation on July 2, 2024, a Certified Nursing Assistant (CNA) was seen changing gloves without performing hand hygiene after providing incontinent care and before performing catheter care for a resident who had an indwelling catheter for urinary elimination. The resident involved was admitted with a diagnosis of neuromuscular dysfunction of the bladder and was always incontinent of bowel. The CNA confirmed the failure to perform hand hygiene during an interview, acknowledging that it should have been done. This observation was corroborated by the Wound Care Nurse, CNA Supervisor, and Infection Control Nurse, all of whom confirmed that hand hygiene should be performed when changing gloves between incontinent care and catheter care.
Failure to Provide Recommended Restorative Services
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as Resident #5, as recommended by therapy staff. According to the Physical Therapy Discharge Summary dated April 29, 2024, Resident #5 was discharged from physical therapy with a recommendation to participate in a restorative nurse program to maintain their current level of performance and prevent a decline in ambulation, bed mobility, and transfers. Similarly, the Occupational Therapy Discharge Summary dated April 30, 2024, recommended 24-hour care and participation in the restorative nurse program. However, during an interview on May 16, 2024, the Restorative CNA confirmed that Resident #5 was not enrolled in the restorative CNA program since admission. This was further corroborated by the Director of Nursing, who confirmed that the resident was not provided with the recommended restorative services.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to identify and implement interventions to prevent falls for two residents. Resident #4 experienced an unobserved fall in their room, which was discovered by a CNA after the resident was heard screaming. The resident attempted to get out of bed independently, leading to the fall. Despite being assessed as at risk for falls due to impaired mobility and weakness, the care plan for Resident #4 was not updated following the incident. Interviews with facility staff, including the MDS Nurse/LPN and the Director of Nursing, confirmed that the care plan should have been revised with new interventions after the fall. Resident #5's care plan included interventions such as keeping the bed in the lowest position due to a previous fall from the bed. However, observations revealed that the bed was not consistently maintained in the lowest position, as it was found halfway between the lowest and highest positions on multiple occasions. Interviews with the CNA Supervisor, an LPN, and a CNA confirmed that the bed should have been in the lowest position at all times due to the resident's fall risk. The Director of Nursing also acknowledged that the bed should have been kept in the lowest position.
Failure to Provide Incontinence Care
Penalty
Summary
The facility failed to provide necessary incontinence care for a dependent resident, Resident #2, who had severe cognitive impairment and was always incontinent of bowel and bladder. According to the Minimum Data Set (MDS) and the Potential for Bowel and Bladder Retraining assessment, Resident #2 required substantial assistance for toileting and pericare after each incontinent episode. However, camera footage and observations revealed that Resident #2 was not provided incontinence care for an extended period. Specifically, from 4:55 a.m. to 8:41 a.m., there was no evidence that Resident #2 received incontinence care, despite multiple entries and exits by staff members into the resident's room. Observations noted a strong urine smell and a heavily saturated brief, indicating neglect in providing necessary care. Interviews with staff confirmed that the expected care was not provided during this time frame. The CNA responsible for Resident #2 admitted to not providing incontinence care since the start of her shift at 6:00 a.m., and the CNA Supervisor acknowledged that the resident's brief would not have been saturated if changed every 2 hours as required. The facility administrator also confirmed the lack of incontinence care based on the review of camera footage.
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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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.
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