St. Margaret's Daughters Home
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 3525 Bienville St, New Orleans, Louisiana 70119
- CMS Provider Number
- 195437
- Inspections on file
- 25
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at St. Margaret's Daughters Home during CMS and state inspections, most recent first.
Surveyors found multiple unsecured hazardous chemicals accessible to residents in several areas, including a resident's room, dining room, and salon, with staff confirming these items should have been secured. Additionally, a resident with a history of falls who required two-person assistance for transfers was transferred by a single CNA, resulting in a fall, contrary to the resident's care plan.
Multiple black flying insects were repeatedly observed in the kitchen and dry storage areas, including inside a bottle of vinegar with an unsecured cap. The Dietary Manager confirmed the presence and increase of insects but did not notify administration or pest control, and the DON was unaware of the kitchen infestation. The administrator acknowledged the insects should not have been present and that staff failed to report the issue as required.
A resident with moderate cognitive impairment was found with Voltaren gel at their bedside on multiple occasions, despite not being assessed or care planned for self-administration of medications. Facility records showed no physician order for self-administration or for Voltaren gel, and staff confirmed the resident should not have had access to the medication.
A resident with a history of falls experienced two witnessed falls when staff failed to update the care plan after the first incident and did not follow the care plan's requirement for two-person assistance during a transfer, resulting in a second fall. The DON and MDS nurse confirmed that the care plan was not revised or properly implemented as required.
The facility did not submit required payroll information for direct care staffing for a specific quarter in 2024. A review of the PBJ Staffing Data Report showed a lack of submission for the period, with no documented evidence provided by the facility to confirm compliance.
A facility's medication error rate exceeded 5%, with errors involving two residents. One resident, cognitively intact, was prescribed Ferrous Gluconate 240 mg but was mistakenly given Ferrous Sulfate 325 mg, which they refused. Another resident with cognitive deficits was prescribed Ferrous Gluconate 324 mg but was given 240 mg instead. Both errors were acknowledged by the LPNs involved.
The facility failed to ensure proper hand hygiene during incontinence care for two residents, with CNAs not changing gloves or performing hand hygiene as required. Additionally, clean and dirty laundry were not properly separated in a laundry room, with unlabeled baskets and improper placement of soiled linen and clean laundry. Staff acknowledged these lapses, and the DON confirmed the failure to adhere to infection control standards.
A facility failed to perform a weekly skin assessment for a resident at high risk for pressure ulcers, as required by physician orders and facility policy. The resident, with a Braden Scale score indicating very high risk, did not receive the assessment on the specified date. Interviews with staff confirmed the oversight, and no documentation was found to indicate the assessment was completed.
A facility failed to accurately document a resident's medication administration record for Ferrous Gluconate 324 mg, as required by their policy. An LPN documented administering the medication on several occasions but later confirmed she did not administer it on those dates. This inaccuracy was confirmed by the DON, highlighting discrepancies in the resident's medication records.
The facility failed to maintain a clean and safe environment for residents, with two residents' rooms found unclean and three residents' equipment in disrepair. Observations revealed dried substances and food debris in rooms, and damaged rolling bedside tables. An LPN and the administrator confirmed these deficiencies.
The facility failed to ensure accurate documentation in Physician Progress Notes for two residents. An NP photocopied previous notes and reused them for subsequent visits, resulting in identical assessments across multiple visits. This practice was against facility policy, as confirmed by the DON, Administrator, and COO.
The facility did not conduct a performance review for a CNA within the last 12 months. The CNA's personnel file, with a hire date of 10/17/2018, showed no evidence of a recent review, and the COO confirmed the absence of such documentation.
The facility failed to prevent expired food from being available for consumption, maintain kitchen sanitation, and document temperature checks for food storage and preparation. Expired items like sauces and milk were found, and the kitchen had unsanitary conditions, including dirty equipment and leaks. Staff interviews confirmed the absence of temperature checks and documentation, which was acknowledged by the DON and Administrator.
The facility failed to document its Water Management Program for Legionella prevention and did not track or trend infections to identify clusters. Interviews revealed no evidence of monitoring water temperatures or other program components. Infection Logs for several months listed various infections, but no documentation showed plotting these infections to identify trends.
The facility failed to document education and refusal of influenza and pneumococcal vaccinations for four residents. The Quality Director noted verbal inquiries were made, but no proof of refusals or education was documented. Additionally, outdated educational materials were used, and the DON had no further information to address the deficiency.
The facility did not ensure CNAs received 12 hours of annual in-service education, as evidenced by a lack of documentation in personnel files for three CNAs. The Chief Operating Officer confirmed the absence of monitoring for the completion of these training hours.
The facility failed to protect residents from psychosocial abuse by a CNA, who made disparaging remarks and handled residents roughly, causing emotional distress and physical pain. The incidents were reported by three residents and corroborated by staff interviews, leading to the CNA's termination.
Unsecured Hazardous Chemicals and Inadequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to ensure that hazardous chemicals were not accessible to residents and did not provide adequate supervision to prevent accidents. Multiple unsecured chemicals were observed in various locations, including a spray bottle of floor cleaner on a housekeeper’s cart, plant food/fertilizer in a dining room, a spray bottle of sanitizer in an unlocked cabinet, and cleaning chemicals in an unsecured salon room. Additionally, a resident with sensory and perception alterations related to vision was found to have two cans of aerosolized insecticide in her room, which staff were unaware of and acknowledged should not have been accessible. Staff interviews confirmed that these chemicals should have been secured and not available to residents. The facility also failed to provide sufficient supervision to prevent a fall for a resident with a history of falls who required maximal assistance from two staff for transfers. Despite this care plan, a CNA attempted to transfer the resident alone, resulting in a witnessed fall. The DON confirmed that the resident’s fall care plan, which required two-person assistance for transfers, was not implemented at the time of the incident.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
Surveyors observed multiple black flying insects present in the facility's kitchen and dry storage room on several occasions. On two consecutive days, black flying insects were seen in the kitchen's dry storage area and around shelving units. Additionally, a gallon bottle of distilled vinegar was found with its cap ajar, containing several dead black insects floating in the liquid. These findings were confirmed by the Dietary Manager, who acknowledged the presence of the insects in both the dry storage room and the kitchen, and noted an increase in their number. Interviews with facility staff revealed a lack of timely communication and response regarding the pest issue. The Dietary Manager did not notify the facility administrator or pest control when the insects returned to the kitchen. The Director of Nursing was aware of the insects in the facility but was not informed that they were present in the kitchen. The facility administrator confirmed that the insects should not have been present and that it was the Dietary Manager's responsibility to monitor and report such issues. No residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Assess Resident Before Allowing Access to Medication at Bedside
Penalty
Summary
A resident with moderate cognitive impairment, as indicated by a Brief Interview for Mental Status score of 11, was found to have a tube of Voltaren gel at their bedside on multiple occasions. Review of the resident's records showed no physician order for self-administration of medications, no order for Voltaren gel, and no care plan addressing self-administration or bedside access to medications. The resident's electronic medication administration record documented that all medications were to be administered by facility staff. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident had not been assessed or care planned to self-administer medications and should not have had access to Voltaren gel. Despite this, the medication was observed at the resident's bedside on two separate days, indicating a failure to ensure the resident was properly assessed for safe self-administration prior to having access to the medication.
Failure to Revise and Implement Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise and implement a resident's care plan following a witnessed fall. According to the facility's Accidents/Incidents Policy, the charge nurse or nursing supervisor is required to initiate a care plan change to ensure the resident's welfare and safety before the end of the shift. However, after a resident with a history of falls experienced a witnessed fall with no injury, the care plan was not updated with new goals or interventions. Both the Director of Nursing and the MDS Nurse confirmed that the care plan was not revised as required after the incident. Additionally, the facility did not ensure that existing fall care plan interventions were implemented. The resident's Activities of Daily Living care plan specified the need for maximal assistance and required two staff members for transfers. Despite this, a CNA attempted to transfer the resident alone, resulting in another witnessed fall. The Director of Nursing confirmed that the care plan, which required two staff for transfers, was not followed during this incident.
Failure to Submit Payroll Information for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit payroll information for direct care staffing as required by CMS. A review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 4 2024 revealed that the facility did not submit staffing data for the period from July 1 to September 30, 2024. There was no documented evidence provided by the facility to show that the PBJ Staffing Data for this quarter was submitted as required.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.66% during a survey. This deficiency was identified through observations, interviews, and record reviews involving two residents. Resident #3, who was cognitively intact with a BIMS score of 15, was prescribed Ferrous Gluconate 240 mg daily for Iron Deficiency Anemia. However, an LPN attempted to administer Ferrous Sulfate 325 mg instead, which was refused by the resident. The LPN acknowledged the error, and the pharmacist confirmed that such a substitution should not occur without physician approval. Resident #R5, diagnosed with Anemia, Cognitive Deficit, and Dementia, was prescribed Ferrous Gluconate 324 mg daily. An LPN attempted to administer a 240 mg dose instead. The LPN recognized the mistake, and the DON confirmed the error in dosage. These incidents contributed to the facility's medication error rate exceeding the acceptable threshold, highlighting lapses in medication administration accuracy.
Infection Control Deficiencies in Hand Hygiene and Laundry Management
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by Certified Nursing Assistants (CNAs) during incontinence care for two residents. One resident, who was always incontinent of bowel and bladder and dependent on staff for toileting hygiene, was observed receiving care from a CNA who did not change gloves or perform hand hygiene after removing a soiled brief and before placing a clean one. The CNA also touched the resident's pillow and bed linens with the same gloves used during incontinence care. Another resident, who was incontinent and had a urinary tract infection, received peri-care from a CNA who did not perform hand hygiene before putting on gloves, did not change gloves or perform hand hygiene after completing peri-care, and did not perform hand hygiene before leaving the room. Both CNAs acknowledged their failure to follow proper hand hygiene protocols, and the Director of Nursing confirmed these lapses in infection control standards. Additionally, the facility failed to maintain separation between clean and dirty laundry in one of the observed laundry rooms. Observations revealed unlabeled baskets containing both clean and dirty laundry placed next to each other on the floor. A housekeeper and a CNA confirmed that the laundry was not labeled or separated as required. Further observations showed soiled linen placed in a handwashing sink and clean laundry directly on top of a dryer. Staff interviews confirmed that these practices were not in accordance with proper infection control procedures, as dirty linen should not be placed in handwashing sinks, and clean laundry should not be left on surfaces where contamination could occur.
Failure to Conduct Weekly Skin Assessment for High-Risk Resident
Penalty
Summary
The facility failed to adhere to a physician's order to conduct a weekly skin assessment for a resident identified as being at high risk for pressure ulcers. According to the facility's Wound Prevention and Skin Care policies, residents with a Braden Scale score greater than 12 are considered at risk and require weekly skin checks by a licensed nurse, which should be documented in the resident's Electronic Medical Record (EMR). Resident #2, who had a Braden Scale score of 8.0 indicating a very high risk for skin breakdown, did not receive the required skin assessment on 12/11/2024 as ordered by the physician. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the weekly skin assessment for Resident #2 was not completed on the specified date. The absence of documented evidence in the resident's assessment report further corroborated this oversight. The failure to perform the skin assessment as ordered represents a deficiency in the facility's care for residents at risk of developing pressure ulcers.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's medication administration record, specifically for a resident prescribed Ferrous Gluconate 324 mg to be taken daily with breakfast. The facility's Liberalized Medication policy requires that the date, time, dosage, and medication administered be recorded by the individual administering the medication. However, the Medication Administration History Report showed that an LPN documented administering the medication on several dates, but later confirmed that she did not actually administer the medication on those dates. This discrepancy was confirmed by the Director of Nursing, indicating inaccuracies in the medication administration records for the resident.
Deficiencies in Cleanliness and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations and interviews. Two residents' rooms and equipment were found to be unclean. Specifically, one resident's room had large areas of a dried tan substance on the floor and tube feeding pole, which was confirmed by an LPN to be unclean. Another resident's room had small and large pieces of food and splatters of dried liquids on the floor, side rail, bed frame, and rolling bedside table. The administrator confirmed that the room and equipment were dirty and should have been kept clean. Additionally, the facility did not ensure that residents' equipment was in good repair. Observations revealed that the rolling bedside tables of three residents had peeled and broken edges. The administrator confirmed that these tables were damaged and should have been replaced. These deficiencies indicate a failure to provide a safe, clean, and comfortable environment for the residents.
Inaccurate Documentation in Physician Progress Notes
Penalty
Summary
The facility failed to ensure complete and accurate documentation for Physician Progress Notes for two residents. For one resident, the Nurse Practitioner (NP) documented progress notes on several occasions, but the notes were identical, with the chief complaint, physical exam, diagnosis, problem list, and plan remaining unchanged across multiple visits. These notes were photocopies of an earlier note with only the date altered. Similarly, for another resident, the NP documented progress notes that were also identical across several visits, with vital signs, chief complaint, physical exam, laboratory results, diagnosis, problem list, and plan remaining the same. These notes were also photocopies of a previous note with the date changed. During interviews, the NP admitted to photocopying previous progress notes and using them for subsequent assessments, acknowledging that the assessments, including vital signs and physical exams, would not have been exactly the same for each visit. The Director of Nursing and the Administrator confirmed that it was not the facility's policy to photocopy previous progress notes and use them for future assessments, nor to document previous assessments as current and accurate. The Chief Operating Officer also confirmed that this practice was against facility policy.
Lack of Performance Review for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had a performance review within the last 12 months. Specifically, the personnel file of a CNA, hired on 10/17/2018, lacked documented evidence of a performance review being completed within the past year. During an interview, the Chief Operating Officer confirmed that there was no documented evidence of a performance review for this CNA.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that expired food was not available for resident consumption, maintain the kitchen in a sanitary manner, and document temperature checks for food storage and preparation equipment. Observations revealed several expired food items, including garlic parmesan wing sauce, ground ginger, vanilla syrup, cinnamon sauce, and regular milk, which were available for use. Both the Dietary Manager and the Administrator acknowledged that expired food should not have been available in the kitchen or food pantry. Additionally, the facility's kitchen was found to be unsanitary, with issues such as fuzzy, shriveled oranges, brown liquid substances on the floor, caked-on substances on the deep fryer, and dirty pots and pans. The steam table contained cloudy yellow water, and the handwashing sink had a leak. Furthermore, there was no documented evidence of temperature checks for the steam tables and refrigerator/freezers, as confirmed by interviews with staff members. The Director of Nursing and the Administrator acknowledged the lack of temperature checks and documentation.
Deficiencies in Water Management and Infection Tracking
Penalty
Summary
The facility failed to maintain documented evidence of its Water Management Program for Legionella prevention. The program, dated February 2024, outlined requirements such as maintaining water temperatures outside the ideal range for Legionella growth, preventing water stagnation, ensuring adequate disinfection, and maintaining plumbing to prevent conditions conducive to Legionella. However, interviews with the Quality Director, Director of Nursing, and Administrator revealed that the facility did not have documentation of monitoring water temperatures or any other components of the Water Management Program. Additionally, the facility did not accurately track and trend infections to identify clusters or trends. The Infection Logs for May, June, and July 2024 listed various infections among residents, including conjunctivitis, respiratory infections, urinary tract infections, and skin infections. Despite this, the facility's Tracking and Trending Maps for these months showed no documented evidence of plotting these infections to identify potential clusters or trends. Interviews with the Quality Director and Director of Nursing confirmed the lack of appropriate tracking and trending of infections.
Lack of Documentation for Vaccination Refusals and Education
Penalty
Summary
The facility failed to ensure that the medical records of four residents contained documentation of education and refusal of influenza and pneumococcal vaccinations. Specifically, the records for these residents did not have documented evidence of refusal or consent for the vaccinations. The facility's spreadsheet indicated that these residents had refused the vaccinations, but there was no proof of refusals or education provided prior to the date of the vaccination review. The Quality Director admitted to verbally asking the residents about vaccinations and documenting the outcomes on the facility's spreadsheet, but acknowledged the lack of documentation for refusals or education. Additionally, the facility did not provide current literature for educating residents on the risks and benefits of the vaccinations, as the education materials used were from 2022. The Director of Nursing confirmed that there was no further information available to address the areas of deficient practice.
Deficiency in CNA In-Service Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service education annually. This deficiency was identified through a review of personnel files for three CNAs, all of whom lacked documented evidence of completing the necessary in-service hours. Specifically, the personnel files for CNAs hired on 10/17/2018, 03/15/2019, and 11/10/2020 showed no documentation of the required training. During an interview, the Chief Operating Officer acknowledged the absence of documentation and admitted that the facility had not monitored the completion of the annual in-service training hours.
Failure to Protect Residents from Psychosocial Abuse
Penalty
Summary
The facility failed to protect the residents' rights to be free from psychosocial abuse by a Certified Nursing Assistant (CNA). This deficiency was identified for three residents who reported abusive behavior by S5CNA. Resident #1, who was cognitively intact, reported being told by S5CNA that she was in the nursing home because her family did not love her, which left her visibly upset and crying. Resident #2, who had moderate cognitive impairment, reported that S5CNA disregarded her request to be careful with her arthritic knee during incontinence care, causing increased pain. Resident #2 also reported that S5CNA responded dismissively when she mentioned that God was watching her. Resident #3, who had mild cognitive impairment, reported that S5CNA was rough when turning him in bed and told him he could turn himself, which he could not do, leading him to wait for the day shift CNA to get out of bed. Interviews with other staff members corroborated the residents' reports. S2CNA discovered Resident #1 crying and upset during morning rounds, and S3LPN and S4LPN both reported that residents had complained about S5CNA's behavior during the night shift. The facility's administrator was informed of the incidents and conducted interviews with residents and staff, leading to the immediate termination of S5CNA. The facility's policy on abuse recognition, reporting, and investigation was reviewed, revealing that residents should be protected from any physical and mental mistreatment, including verbal abuse, which was defined as the use of disparaging and derogatory terms to residents or their families.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
