St Joseph Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 2301 Sterlington Road, Monroe, Louisiana 71203
- CMS Provider Number
- 195359
- Inspections on file
- 34
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at St Joseph Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not use cleaning products effective against C. difficile in contact isolation rooms, and staff were unclear about proper procedures and product efficacy. Infection surveillance documentation was incomplete, with missing signs and symptoms and no documented surveillance plan, resulting in ineffective identification and tracking of communicable diseases. These failures had the potential to impact a large number of residents.
The facility did not document that residents or their representatives received education on the benefits and potential side effects of the COVID-19 vaccine, as required by facility protocols. This deficiency was confirmed through interviews and record reviews for several residents.
Two residents were found to be self-administering medications at their bedside without the required facility assessment or documentation. One resident was using a Ventolin inhaler independently, while another had a prescription oral rinse at bedside and confirmed self-use. Staff and the DON confirmed that neither resident had been assessed for self-administration as required by facility policy.
Two residents were not given the required SNF ABN (CMS-10055) before their Medicare Part A services were discontinued and they were discharged home, despite having benefit days remaining. Staff confirmed that the necessary notification was not provided to the residents or their responsible parties.
The facility did not send required discharge notices to the State Long-Term Care Ombudsman for two residents who were discharged, as confirmed by missing documentation and staff interviews. Emergency transfer logs were incomplete, only covering a single month, and prior records were not accessible.
A resident receiving medications and nutrition via PEG tube was found with a bedside syringe containing yellowish fluid, which was not cleaned or stored according to facility policy. The syringe and plunger were not separated and the syringe was not properly rinsed or dried after use, as confirmed by the DON.
Two residents with multiple medical conditions were provided bed rails without documented assessments for entrapment risk, despite facility policy requiring such evaluations before installation. Observations and record reviews confirmed the absence of necessary documentation, and facility administration acknowledged the deficiency.
A resident with multiple complex medical conditions was prescribed anticoagulant and anticonvulsant medications, but staff failed to consistently document required monitoring for side effects as ordered. Review of records and staff interviews confirmed that documentation was missing on several occasions while the resident was receiving these medications.
A resident's responsible party reported the theft of a phone charger to the ADON, but the facility failed to investigate or document the grievance, and no follow-up was conducted, despite the resident having severe cognitive impairment and the facility's policy requiring prompt resolution of grievances.
A resident with a Foley catheter and a history of UTIs was observed on multiple occasions with the catheter bag lying on the floor, contrary to facility policy requiring catheter bags to be kept off the floor. Staff confirmed the improper storage, and the resident's care plan did not specify this requirement, despite recent treatment for UTIs.
Nurses did not start a physician-ordered medication, Naltrexone, for a resident with severe dementia and hypersexual behavior, despite clear recommendations in the psychiatric evaluation and documentation in the medical record. The DON confirmed the medication was never initiated as ordered.
Three residents with complex medical and psychiatric needs were not permitted to return to the facility after hospitalization for psychiatric evaluation, despite being deemed stable for discharge. The facility did not document inability to meet their needs or provide required written notifications to the residents, their representatives, or the Ombudsman regarding the transfer/discharge and appeal rights.
A resident was admitted without documentation that they or their responsible party received information on resident rights and the temporary leave-bed hold policy. The administrator confirmed the absence of this documentation after being unable to locate the admission packet.
A resident was found with Fluticasone nasal spray at her bedside without an assessment or physician's order for self-administration, as required by facility policy. The resident, who was cognitively intact, stated she self-administered the spray daily. Facility staff, including an LPN and the DON, were unaware of the resident's possession and use of the medication, indicating a failure to adhere to the facility's procedures for self-administration of medications.
The facility failed to maintain clean and properly dated respiratory equipment for three residents. Observations showed dirty oxygen concentrator filters and undated nebulizer equipment. Despite multiple observations, these issues persisted, and the DON confirmed the deficiencies.
The facility failed to ensure residents were free from unnecessary medication use, as physicians did not provide rationale for continuing psychotropic medications without attempting gradual dose reductions (GDR). This deficiency was identified for multiple residents, including those with anxiety, depression, and dementia, where physicians disagreed with pharmacist recommendations for GDR but did not document their reasoning. This lack of documentation was confirmed by the DON.
A resident was found to have a bottle of Fluticasone nasal spray on the bedside table without a physician's order or assessment for self-administration. The facility's policy requires medications for self-administration to be stored in a locked area. Staff were unaware of the medication's presence, and the resident admitted to self-administering it.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident's meal intake was not documented as required, another resident had medications at their bedside without proper assessment or orders, and a third resident had persistent hygiene issues without a care plan. These issues highlight lapses in care planning and monitoring.
The facility failed to provide adequate personal hygiene and ADL care for several residents, resulting in untrimmed and dirty fingernails and missed scheduled baths. Observations and interviews confirmed these deficiencies, affecting residents with varying levels of cognitive and physical impairments.
A resident with a history of falls and multiple medical conditions was found sitting on the floor in their room, but the required Accident/Incident report was not completed by the nursing staff. The facility's policy mandates immediate documentation of such incidents, which was not adhered to in this case, as confirmed by the DON.
The facility failed to assess residents for bed rail risks and did not obtain informed consent before installation. Multiple residents, including those with cognitive impairments and dependencies, had bed rails installed without proper documentation or consent. Observations and interviews confirmed these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, as required by their policy. A resident with a Foley catheter did not have EBP signage, and staff did not wear gowns when emptying the catheter bag. Two other residents with a hemodialysis line and tube feeding also lacked EBP signage. Another resident's room had EBP signage, but staff did not follow the policy, wearing only gloves instead of both gloves and a gown. The DON confirmed the policy was not followed.
A facility failed to maintain a record of a resident's personal belongings, including clothing, due to the absence of a system to document these items. The resident, who had multiple medical conditions and was dependent on staff, did not have an inventory of personal possessions in their medical record. Interviews with nursing staff confirmed the lack of an inventory sheet for the resident's belongings.
A resident on psychotropic medications missed a psychiatric appointment due to late transportation by the facility. The transportation driver reported the resident was not ready on time, leading to a delayed departure. Consequently, the resident arrived late and the appointment had to be rescheduled.
The facility did not have the most recent complaint survey results available for residents or families to review. The survey binder only contained the last annual survey results, and the absence of the latest complaint survey was confirmed by the DON.
A resident with multiple health conditions did not receive necessary lab tests, including hemoglobin A1C and lipid panel, despite orders from a Nurse Practitioner. The facility failed to follow through with the required monitoring, as confirmed by the DON.
A facility failed to provide timely care and treatment for a resident with a surgical wound from a hip fracture. The resident's surgical site was not assessed during admission, and there were no physician's orders for its care. The resident's staples were removed two months later, and the first orthopedic follow-up was delayed by ten weeks, beyond the typical 4 to 6 weeks post-surgery.
A resident in a LTC facility engaged in inappropriate sexual behavior towards two other residents, leading to a deficiency in protecting residents from abuse. The incidents involved sexual advances and misconduct, with one resident being cognitively intact and the other having moderately impaired cognitive skills. The facility's failure to prevent these incidents highlights a deficiency in their abuse prevention protocols.
The facility failed to notify responsible parties of significant changes in two residents' conditions. One resident's responsible party was not informed of the resident's passing, while another resident's responsible party was not notified of rescheduled psychiatric appointments due to transportation issues. The lack of documentation and communication was confirmed by facility staff.
A facility failed to document that a resident, who required extensive assistance with personal hygiene due to multiple medical conditions, received scheduled baths. Despite being cognitively intact, the resident's care plan required assistance with personal hygiene. However, there was no documented evidence of baths being provided as scheduled, as confirmed by interviews with a CNA and the DON.
A resident with limited range of motion and multiple diagnoses, including dementia and chronic kidney disease, was not provided with the prescribed soft braces while in bed, as observed during a survey. Despite physician orders and care plan instructions, staff failed to ensure the resident wore the necessary braces, leading to a deficiency in care.
The facility failed to administer medications per physician orders and document insulin administration. A resident received Glipizide despite low blood sugar levels, and another resident's sliding scale insulin administration was not documented, as confirmed by the DON.
Failure to Implement Effective Infection Control for C. difficile and Surveillance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the management of residents with confirmed or suspected Clostridioides difficile (C. difficile) infection. Housekeeping staff reported using cleaning products in contact isolation rooms that required specific contact times, but review of product labels and staff interviews revealed that none of the products in use were documented as effective against C. difficile. Additionally, there was confusion among staff regarding which products to use and their required contact times, and the Director of Nursing (DON) was unable to confirm the efficacy of products used on direct patient care equipment. The facility administrator later confirmed that the products being used were not effective against C. difficile infection. The facility also failed to properly identify and document possible communicable diseases or infections before they spread. Review of the infection surveillance report showed incomplete documentation, with missing signs and symptoms for numerous entries and a lack of categorization for infections. There was no documented infection surveillance plan, and staff were unable to provide evidence that effective infection surveillance was being performed. These deficiencies had the potential to affect 85 residents in the facility.
Failure to Document COVID-19 Vaccine Education for Residents
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for five residents reviewed. Specifically, there was no documented evidence in the medical records that these residents or their representatives received education about the benefits and potential side effects of the COVID-19 vaccine. This lack of documentation was confirmed by staff during interviews and record reviews. The facility's own protocols required education and documentation for all residents and staff, but this was not completed for the residents in question.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration of medications as required by its policy. According to the facility's Self-Administration Medications policy, an assessment must be completed for each patient requesting to self-administer medications and repeated quarterly, with documentation kept in the medical record. For one resident with multiple diagnoses including polyosteoarthritis, morbid obesity, diabetes, COPD, and functional quadriplegia, observations revealed a Ventolin inhaler at the bedside, and the resident confirmed self-administration of the inhaler. Record review showed there was no facility assessment for this resident to self-administer medications, and the DON confirmed the absence of such an assessment. Another resident with diagnoses including aggressive periodontitis, anemia, type 2 diabetes with chronic kidney disease, and hemiplegia was observed with a prescription oral rinse at the bedside. The resident stated she used the mouthwash independently, and an LPN confirmed the oral rinse should not have been at the bedside. The DON also confirmed that this resident had not been assessed for self-administration of medication. In both cases, the facility did not follow its own policy to assess and document the appropriateness of self-administration for these residents.
Failure to Provide SNF ABN Prior to Discontinuation of Medicare Part A Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, to two residents prior to the discontinuation of their Medicare Part A services. For both residents, records showed that Medicare Part A skilled services were ended while benefit days remained, and each resident was discharged home. There was no documented evidence that either resident or their responsible party received the SNF ABN before discharge. Interviews with the social worker and business office manager confirmed that the required notification was not given to the residents or their responsible parties prior to the termination of Medicare Part A services.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that copies of discharge notices were sent to the Office of the State Long-Term Care Ombudsman for two residents who were discharged. For one resident, records showed an admission and subsequent voluntary discharge against medical advice, but the facility's emergency transfer log only included notifications for December 2025, and staff confirmed that logs prior to that month were unavailable. For the second resident, records indicated multiple admissions and discharges, including a discharge to the hospital and later to home, but again, the emergency transfer log only covered December 2025, with no access to earlier records. Interviews with facility staff confirmed the lack of documentation and notification for these discharges.
Improper Cleaning and Storage of Enteral Feeding Syringe
Penalty
Summary
The facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice by not properly cleaning and storing a piston syringe used for enteral feedings. Observation revealed that a resident's bedside syringe contained a yellowish fluid in the tip, was capped, and had the plunger inserted, contrary to facility policy. The policy required syringes used for liquids other than clear water to be rinsed, dried, and stored in a proper bag or approved container, with the syringe and plunger stored separately. The resident involved had multiple diagnoses, including diabetes, encephalopathy, muscle weakness, and communication deficits, and was receiving medications and nutritional support via a PEG tube. Interview with the DON confirmed that staff did not follow the proper cleaning and storage procedures for the syringe after use.
Failure to Assess Entrapment Risk Prior to Bed Rail Installation
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment prior to the installation of bed rails for two out of three residents identified as having side rails in use. According to the facility's own policy, an assessment should be conducted to determine the resident's symptoms, risk of entrapment, and the reason for using side rails. For both residents involved, there was no documented evidence that such an assessment was completed before bed rails were installed. One resident had multiple diagnoses, including acute and chronic respiratory failure, heart failure, COPD, dementia, and metabolic encephalopathy, and was observed with bilateral quarter rails in the up position. The resident's care plan and physician's orders indicated the use of assist rails as an enabler, but the medical record lacked documentation of an entrapment risk assessment. Another resident, with diagnoses including atrial fibrillation, muscle weakness, unsteadiness, dementia, and major depressive disorder, was also observed with quarter bed rails in use. Similarly, the record for this resident did not contain evidence of an entrapment risk assessment prior to bed rail installation. Interviews with facility administration confirmed the absence of required documentation for both residents.
Failure to Document Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not consistently documenting the required monitoring for side effects of anticoagulant and anticonvulsant medications. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, atrial fibrillation, atherosclerotic heart disease, hypertensive heart disease with heart failure, seizures, and diabetes mellitus, was prescribed Eliquis (an anticoagulant) and Levetiracetam (an anticonvulsant). Physician orders required monitoring for side effects of these medications every shift, and the resident’s care plan included interventions to monitor and document side effects and effectiveness of the medications. Record reviews revealed that the facility failed to document the required monitoring for side effects on multiple occasions in both November and December. Specifically, there was no documented evidence of monitoring for 13 instances in November and 5 instances in December, despite the resident receiving both medications during these periods. Interviews with nursing staff confirmed that the monitoring was not documented as ordered while the resident was on these medications.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance reported by the responsible party (RP) of a resident with severe cognitive impairment. The RP reported the theft of the resident's phone charger to the Assistant Director of Nursing (ADON) during a visit. Despite this report, there was no follow-up or investigation conducted by the facility, and the grievance was not documented in the facility's grievance or complaint logs. The ADON confirmed that the grievance was reported to her and acknowledged that she did not follow up with the RP or initiate an investigation. The resident involved had a history of schizophrenia, chronic kidney disease, depression, anxiety, dysphagia, and schizoaffective disorder, and was assessed as having severely impaired cognition. The facility's grievance policy required prompt investigation and resolution of grievances, including documentation and follow-up with the complainant. However, these procedures were not followed in this instance, resulting in the grievance not being addressed according to policy.
Failure to Maintain Proper Foley Catheter Bag Storage
Penalty
Summary
Surveyors observed that a resident with multiple medical conditions, including severe dementia, neuromuscular bladder dysfunction, and a history of urinary tract infections (UTIs), had a Foley catheter bag that was repeatedly found lying on the floor. The facility's own urinary catheter care policy, as presented by the DON, specifically requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated UTIs. Despite this, on two separate occasions, the resident's Foley catheter bag was observed on the floor, both times while the resident was under enhanced barrier precautions. Review of the resident's medical record confirmed the ongoing use of an indwelling catheter and documented recent treatment for UTIs, including one with E. coli. The resident's care plan included instructions to position the catheter bag and tubing below the bladder and away from the room entrance, but did not specify to keep it off the floor. During interviews, facility staff acknowledged that the catheter bag should not have been on the floor and confirmed the observations. The repeated failure to properly store the Foley catheter bag constituted a breach of infection control standards as outlined in the facility's policy.
Failure to Initiate Physician-Ordered Medication
Penalty
Summary
Nurses at the facility failed to initiate a physician-ordered medication, Naltrexone, for a resident with a history of severe dementia, psychotic disturbance, and hypersexual behavior, as documented in a psychiatric evaluation. The resident, who also had a PEG tube for nutrition and other significant diagnoses, was recommended to start a trial of Naltrexone 25 mg daily to address inappropriate behavior. Review of the resident's July 2025 medication administration record showed that the medication was never started as ordered. During an interview, the DON confirmed that the medication had not been initiated and acknowledged that it should have been.
Failure to Permit Return and Provide Required Discharge Notifications After Hospitalization
Penalty
Summary
The facility failed to ensure that three residents who were transferred to acute care hospitals for psychiatric evaluation were permitted to return to the facility after being deemed stable for discharge by hospital staff. In each case, the residents were not re-admitted to the facility, despite their readiness for return, and instead remained in the behavioral health facility or were transferred to other long-term care facilities. The facility required additional documentation and insurance authorization before considering re-admission, which resulted in the residents not being allowed to return. Additionally, there was no documentation in the medical records indicating that the facility was unable to meet the needs of these residents. The facility did not provide written notification to the residents, their responsible parties, or the Ombudsman regarding the transfer or discharge, nor did it inform them of their appeal rights as required by policy. Interviews with facility staff confirmed the absence of such documentation and notifications. The events involved residents with complex medical and psychiatric histories, including diagnoses such as acute kidney failure, dementia, schizophrenia, and behavioral disturbances. The lack of proper notification and failure to permit return after hospitalization were identified through record reviews and interviews with facility staff and external social workers.
Lack of Documentation for Resident Rights and Bed Hold Policy
Penalty
Summary
The facility failed to document that a resident or their responsible party received information regarding resident rights and the temporary leave-bed hold policy upon admission. Record review showed that the resident was admitted on a specific date, but there was no evidence in the medical records that the required information on resident rights and facility regulations was provided. During an interview, the administrator was unable to locate the resident's admission packet and confirmed that there was no documentation available to show that the resident or their responsible party had received the necessary information.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, specifically for a resident who was found to have a bottle of Fluticasone nasal spray at her bedside. The facility's policy requires an assessment to determine if a resident is capable of self-administering medications safely, and a physician's order must be obtained if self-administration is deemed appropriate. However, there was no such assessment or physician's order for this resident, who had been admitted with diagnoses including acute respiratory failure, disorder of the lungs, hypertension, and depression. The resident was cognitively intact, as indicated by a BIMS score of 15, and stated she self-administered the nasal spray daily. Observations over several days confirmed the presence of the nasal spray at the resident's bedside, and interviews with facility staff revealed a lack of awareness regarding the resident's possession and self-administration of the medication. The LPN and DON both confirmed that there was no order or assessment for the resident to self-administer the medication, and the nasal spray bottle was labeled from the hospital where the resident was previously admitted. This oversight indicates a failure to follow the facility's policy on self-administration of medications, as the necessary assessments and orders were not completed or documented.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents. Observations revealed that the oxygen concentrator filters for two residents were dirty, and the oxygen tubing and humidification bottles were not dated or initialed. Despite multiple observations over two days, the filters remained unclean, and the issues with the oxygen tubing and humidification bottles were not addressed. The Director of Nursing confirmed these deficiencies during an observation. Additionally, the facility did not ensure that nebulizer equipment and tubing were dated and stored appropriately for two residents. Observations showed that the nebulizer masks and tubing were not dated or covered, and these issues persisted over two days. The Director of Nursing confirmed that the nebulizer equipment should have been dated and covered, indicating a failure to adhere to proper respiratory care protocols.
Failure to Document Rationale for Continued Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication use, as evidenced by the lack of rationale provided by physicians for the continuation of psychotropic medications without attempting gradual dose reductions (GDR). This deficiency was identified for five residents who were sampled for unnecessary medication review. The physicians or prescribers did not document a rationale for disagreeing with the pharmacist's recommendations for GDR, which is a requirement when continuing psychotropic medications. Resident #3 was admitted with multiple diagnoses, including anxiety disorder, schizoaffective disorder, and dementia with behavioral disturbance. The resident was prescribed several psychotropic medications, including Seroquel, Haloperidol, Buspirone, and Lorazepam, which required GDR. Despite recommendations from the pharmacist to reduce the doses of these medications, the physician disagreed without providing a rationale. This lack of documentation was confirmed by the Director of Nursing (DON). Similarly, other residents, including those with diagnoses such as depression, anxiety disorder, and dementia, were prescribed psychotropic medications that flagged for GDR. For instance, Resident #43 was on Mirtazapine, and Resident #51 was on Sertraline and Clonazepam, among others. In each case, the physician marked 'disagree' on the pharmacist's notes recommending GDR but failed to provide a rationale for their decision. This pattern of inaction and lack of documentation was consistent across all sampled residents, as confirmed by interviews with the DON.
Failure to Securely Store Self-Administered Medication
Penalty
Summary
The facility failed to securely store medications in a resident's room according to its policy and procedure for self-administering medication. Resident #323 was observed to have a bottle of Fluticasone nasal spray on the bedside table over several days, without a physician's order or assessment to determine if the resident was safe to self-administer the medication. The facility's policy requires that all medications for self-administration be stored in a locked storage area in the resident's room, and narcotics must be under double lock. Interviews with the LPN and the Director of Nursing revealed that they were unaware of the medication being in the resident's room. The LPN confirmed that there was no order for the resident to have the medication at the bedside and no assessment had been conducted. The medication label indicated it was from the hospital where the resident was prior to admission to the nursing facility, and the resident admitted to self-administering the medication without the facility's knowledge.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to deficiencies in care. For one resident, there was no documentation of meal percentage intakes on multiple dates, despite the care plan requiring monitoring and documentation of food intake at each meal. This resident was dependent on staff for activities of daily living and had a significant change in their condition, including diagnoses of encephalopathy, epilepsy, and protein-calorie malnutrition. Another resident was observed to have medications at their bedside without a physician's order or an assessment to determine if they were safe to self-administer the medication. The facility's policy requires an assessment and a care plan for self-administration of medications, which was not completed for this resident. The resident had a nasal spray from a previous hospital stay, and the nursing staff was unaware of its presence in the room. Additionally, a resident with a BIMS score indicating cognitive intactness was found to have dirty fingernails over several days, with no care plan developed to address nail care. Despite observations and interviews confirming the need for nail cleaning, there was no documented evidence of a care plan to address this aspect of personal hygiene. These deficiencies highlight the facility's failure to ensure comprehensive care planning and implementation for its residents.
Deficiencies in Personal Hygiene and ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining personal hygiene. Observations, record reviews, and interviews revealed that seven out of eleven residents reviewed did not receive adequate care. Residents had issues with untrimmed and dirty fingernails, and some did not receive scheduled baths. For instance, resident #62, who was dependent on staff for ADLs, was observed with long fingernails that needed trimming. The Director of Nursing confirmed the need for nail care. Resident #45, who was cognitively aware and dependent on staff for various ADLs, reported not receiving baths as scheduled. Documentation showed that the resident missed scheduled baths multiple times over two months. Interviews with staff confirmed the lack of documentation and adherence to the bathing schedule. Similarly, resident #221, who required partial to moderate assistance with bathing, had no documented evidence of receiving baths for 22 days before discharge. Other residents, such as #16, #58, and #41, also exhibited issues with nail care. Resident #16, who was cognitively intact, had dirty fingernails despite receiving a bath. Resident #58, with severe cognitive impairment, had long, grimy fingernails, and resident #41, with moderate cognitive impairment, expressed dissatisfaction with the length of his nails. Staff interviews confirmed the responsibility for nail care and the need for attention to these residents' hygiene needs.
Failure to Complete Accident/Incident Report for Resident Found on Floor
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not completing an Accident/Incident report when a resident was found sitting on the floor. According to the facility's Accident/Incidents Policy, an Accident/Incident Report must be completed immediately upon staff becoming aware of an accident or incident involving a patient. However, when a resident was found sitting on the floor in their bedroom, no such report was completed, indicating a lapse in following the established protocol. The resident involved had a history of conditions including encephalopathy, hypertension, epilepsy, atrial fibrillation, malignant neoplasm, dehydration, and chronic pain. The resident's care plan noted a risk for falls due to weakness. Despite this, when the resident was found on the floor, the nurse assisted the resident without completing the necessary documentation. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the report should have been completed.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the risk of entrapment from bed rails and did not review the risks and benefits of bed rails with the residents or their representatives. Additionally, the facility did not obtain informed consent prior to the installation of bed rails for five out of six residents reviewed for accident hazards. The facility's policy requires that residents be assessed for potential risks associated with bed rails, and informed consent must be obtained after discussing the benefits and potential hazards with the resident or their representative. Resident #62, who was unable to complete a mental status interview and was dependent on staff for activities of daily living, had bed rails installed without a signed informed consent. Similarly, resident #31, with moderate cognitive impairment, had bed rails installed without a signed consent. Observations confirmed that both residents had bed rails raised and locked on multiple occasions, and interviews with the Director of Nursing (DON) confirmed the lack of signed consent. Resident #16, who was cognitively intact, and resident #40, also cognitively intact, both had bed rails installed without documented assessments or signed consents. Resident #9, who was cognitively intact but dependent on staff for assistance with activities of daily living, also had bed rails installed without an assessment or signed consent. Interviews with the DON confirmed the absence of necessary documentation and assessments for these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for four residents who required such precautions due to their medical conditions. Resident #45, who had a Foley catheter, did not have the required EBP signage on their door, and staff were observed not wearing gowns when emptying the catheter bag, contrary to the facility's policy. Interviews with staff, including the Director of Nursing (DON), confirmed that the resident should have been on EBP and that signage should have been posted. Similarly, residents #321 and #322, who had a hemodialysis line and tube feeding, respectively, also lacked EBP signage on their doors, and staff were unaware of the need for these precautions. Resident #7's room had EBP signage, but staff did not adhere to the policy. A Certified Nursing Assistant (CNA) was observed wearing only gloves, not a gown, while emptying the resident's Foley catheter, despite the posted instructions requiring both gloves and a gown for such activities. The CNA stated she was instructed to wear only gloves, indicating a lack of proper communication and training regarding the facility's EBP policy. The DON confirmed that the policy required both gloves and a gown for this procedure.
Failure to Record Resident's Personal Belongings
Penalty
Summary
The facility failed to retain a resident's personal possessions by not having a system in place to record personal belongings. This deficiency was identified for a resident with multiple diagnoses, including encephalopathy, hypertension, epilepsy, and others, who was dependent on staff for activities of daily living. The resident's medical record did not contain an inventory of personal belongings, and interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the absence of such a record. The staff did not complete an inventory sheet for the personal items the resident brought or acquired during their stay.
Resident Misses Psychiatric Appointment Due to Late Transportation
Penalty
Summary
The facility failed to ensure that a resident received timely transportation to a psychiatric appointment, resulting in the appointment being missed and rescheduled. The resident, who is on psychotropic medications for depression, anxiety, and insomnia, had an out-of-town appointment scheduled with a psychiatrist at 9:00 a.m. However, the transportation driver reported that the resident was not dressed and ready when she arrived at work at 6:45 a.m., leading to a delayed departure from the facility at 7:36 a.m. Due to traffic, parking, and the preadmission process, the resident arrived late for the appointment and was unable to see the psychiatrist. The Director of Nursing confirmed that the resident should not have been late for the appointment. The failure to transport the resident in a timely manner was acknowledged by both the Director of Nursing and the transportation driver, resulting in the need to reschedule the appointment for a later date.
Missing Recent Complaint Survey Results
Penalty
Summary
The facility failed to ensure that the most recent state inspection results were available for review by residents or their families. Upon entering the facility, it was observed that the survey binder only contained the results of the last annual survey dated 09/13/2023. The results of the most recent complaint survey dated 08/16/2024 were missing from the binder. This was confirmed during an interview with the Director of Nursing, who acknowledged that the survey binder did not include the latest complaint survey results.
Failure to Conduct Necessary Lab Tests for Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not obtaining necessary laboratory tests. Resident #49, who was admitted with multiple diagnoses including type 2 diabetes mellitus, hypertension, and bipolar disorder, was supposed to have routine lab tests to monitor their condition. A Consultant Pharmacist recommended monitoring specific labs, including hemoglobin A1C and lipid levels, to ensure appropriate medication management. Despite receiving a verbal order from the Nurse Practitioner to conduct these tests every three to six months, the facility did not complete the hemoglobin A1C and lipid panel for the resident. The Director of Nursing confirmed that these tests were not performed as ordered, indicating a lapse in following through with the necessary medical monitoring for the resident's condition.
Failure to Provide Timely Care for Surgical Wound
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident admitted with a surgical wound. The resident, who was cognitively aware and required assistance with mobility and toileting, had a surgical wound from a left hip fracture. Upon review, it was found that the nursing admission assessment did not document the surgical wound, and there were no physician's orders for its care. The Director of Nursing confirmed that the surgical site was not assessed during admission, and the resident's staples were not removed until two months later. Additionally, the resident's first orthopedic follow-up occurred ten weeks after admission, which was significantly delayed compared to the usual 4 to 6 weeks post-surgery.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, leading to a deficiency in safeguarding residents' rights to be free from abuse. Resident #1, who was cognitively intact, was involved in inappropriate sexual behavior towards Resident #2 and Resident #3. The incidents involved Resident #1 making sexual advances and engaging in inappropriate sexual conduct in front of these residents. Resident #2, who was also cognitively intact, reported that Resident #1 engaged in sexual misconduct by masturbating in front of him and making inappropriate sexual comments. This incident left Resident #2 feeling upset and violated. The facility's records indicate that Resident #2 was immediately moved to a different room following the incident. Resident #3, who had moderately impaired cognitive skills, reported a similar incident where Resident #1 made inappropriate sexual propositions. Despite Resident #3's cognitive impairment, he was able to recount the incident to the staff. The facility's failure to prevent these incidents highlights a deficiency in their abuse prevention protocols, as Resident #1 was able to engage in such behavior on more than one occasion before being discharged.
Failure to Notify Responsible Parties of Resident Changes
Penalty
Summary
The facility failed to inform the responsible parties of two residents about significant changes in their conditions, violating resident rights. For one resident, the facility did not notify the responsible party when the resident passed away. The resident had a history of heart disease, chronic kidney disease, and other conditions, and was on hospice care with a Do Not Resuscitate status. Despite the resident's critical condition and eventual passing, there was no documented evidence that the responsible party was informed, as confirmed by the LPN and the Director of Nursing. In another case, the facility did not notify the responsible party of a resident when two psychiatric appointments were rescheduled. The resident, who was cognitively intact and required assistance with daily living, missed an appointment due to transportation issues. The facility's transportation driver was given an incorrect address, causing a delay and necessitating a reschedule. Additionally, a facility van was out of commission, leading to another missed appointment. The Director of Nursing and the Administrator confirmed the lack of notification to the responsible party regarding these changes.
Failure to Document Scheduled Baths for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good grooming and personal hygiene. The medical record for the resident, who had diagnoses including anemia, acute bronchitis, edema, anxiety, chronic kidney disease, schizoaffective disorder, dementia, and dysphagia, showed that they required extensive assistance with personal hygiene. Despite being cognitively intact with a BIMS score of 13, the resident's care plan included interventions for assistance with showers, shaving, oral, hair, and nail care per schedule and as needed. However, a review of the ADL Verification Worksheet for a specified period revealed no documented evidence that the resident received baths as scheduled. Interviews with a CNA and the DON confirmed that the resident was scheduled for bed baths on specific days and partial baths on others, but there was no documentation to support that these baths were provided as scheduled.
Failure to Provide Appropriate ROM Treatment for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, leading to a deficiency in care. Resident #6, who was admitted with multiple diagnoses including anemia, chronic kidney disease, and dementia, was identified as having limited range of motion and required assistance with activities of daily living. The resident's care plan indicated a risk for skin integrity and specified the use of a soft brace while in bed. Physician orders dated 11/08/2022 instructed that a brace be placed on the resident every evening and removed when out of bed. However, during an observation on 06/18/2024, it was noted that the resident was not wearing the prescribed soft braces while in bed, despite having foot drop in both feet. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the resident should have been wearing the soft braces while in bed. The Therapy Director also stated that the resident should wear soft braces in bed and metal braces when in a wheelchair. The failure to ensure the resident was wearing the appropriate braces as per the care plan and physician orders resulted in a deficiency in the care provided to the resident, potentially impacting their range of motion and overall well-being.
Failure to Administer Medications Per Orders and Document Insulin Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, Resident #1, who had multiple diagnoses including diabetes mellitus, was administered Glipizide 5 mg a total of 15 times during November 2023 when the resident's blood sugar was less than 110 mg/dL, contrary to physician orders. This was confirmed by the Director of Nursing (DON) during an interview. The resident's medical record indicated that blood sugar checks were to be performed four times a day, and Glipizide was to be held if the blood sugar was less than 110 mg/dL, which was not adhered to on multiple occasions. Additionally, the facility failed to document the amount of sliding scale insulin administered to Resident #2, who had diagnoses including hyperglycemia and dementia. The resident's care plan indicated a risk for hypoglycemia or hyperglycemia and required medications to be administered as ordered. Despite blood sugar readings that necessitated sliding scale insulin administration, the April 2023 Medication Administration Record (MAR) lacked documented evidence of the insulin amounts given. This deficiency was also confirmed by the DON during an interview.
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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