Sterling Place Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 3888 North Blvd, Baton Rouge, Louisiana 70806
- CMS Provider Number
- 195473
- Inspections on file
- 22
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sterling Place Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow professional standards for food service safety, as surveyors found expired and unlabeled food items in storage. Staff confirmed that these items were available for resident use and acknowledged the need for proper labeling and disposal of expired foods.
The facility failed to accurately reflect residents' PASRR evaluations in their MDS assessments. Four residents with approved Level II PASRR evaluations were incorrectly documented as not evaluated. Staff responsible for the assessments confirmed the oversight, and the DON acknowledged the need for accurate MDS assessments.
The facility failed to implement PASRR Level II recommendations for three residents, including medication education, training in ADLs, independent living skills, structured leisure activities, and specialized psychiatric services. Residents expressed willingness to participate, but services were not offered or documented in care plans. Staff claimed services were refused but lacked evidence, and the administrator confirmed expectations for offering and documenting recommended services.
The facility failed to maintain proper grooming and hygiene for two residents with cognitive impairments, as their fingernails were observed to be long and dirty. Despite physician orders for regular nail care, staff members did not clean or trim the residents' nails, with CNAs and nurses unclear about their responsibilities. The DON confirmed that CNAs should clean nails during ADL care, and nurses should assess them weekly.
The facility failed to maintain a safe and sanitary environment in five rooms, with issues such as water damage, stained ceiling tiles, and unsanitary conditions. A resident reported ongoing water leaks in Room b, which were not addressed due to pending remodeling. Staff confirmed awareness of these issues, but corrective actions were delayed, resulting in an unsafe environment.
The facility failed to maintain an effective pest control program, with multiple observations of roaches and other pests in critical areas like the kitchen and food storage rooms. Staff confirmed pest sightings had been reported, yet issues persisted, and the administrator acknowledged the need for increased pest control services.
A resident with severe cognitive impairment was involved in a verbal altercation with an LPN after touching the LPN's hair in an elevator. The situation escalated as both parties used inappropriate language, attracting other staff members' attention. Despite attempts to deescalate, the LPN continued to engage in the argument, leading to a substantiated finding of verbal abuse by the facility.
A verbal altercation between a resident with dementia and an LPN was not reported to the state agency within the required two-hour timeframe. The incident involved inappropriate language and escalating agitation, requiring staff intervention. Despite immediate notification to the administration, the report was delayed, violating the facility's abuse reporting policy.
An inspection revealed multiple environmental deficiencies in 12 rooms of the facility, including gaps in air conditioner units, peeling paneling, broken controls, and missing wall socket covers. Additionally, issues such as stained ceiling tiles, holes in walls, and improperly attached bed components were observed. These conditions were confirmed by facility staff as unacceptable.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and labeling of food items. During an inspection, surveyors observed several deficiencies in the facility's food storage practices. In the walk-in refrigerator, six 8 oz plastic containers of whole milk were found with an expiration date that had passed. In another refrigerator, an opened package of turkey was found without a discard date. Additionally, in the dry food storage room, an open plastic bag of yellow cake mix, an unsealed bag of powdered sugar, and a container of chili powder were all found without discard dates or readable open dates. Interviews with staff confirmed these observations. S10AM, a staff member, acknowledged that the food items were available for resident use and confirmed that expired food items should have been discarded and all opened food items should have been labeled with both opened and expiration dates. S1ADM, another staff member, also confirmed that all food storage items should be labeled and checked for both opened and expiration dates, indicating a lapse in following the facility's policy on food storage.
Inaccurate MDS Assessments for PASRR Evaluations
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of residents regarding their Pre-Admission Screening and Resident Review (PASRR) evaluations. Specifically, for four residents, the MDS assessments did not correctly indicate that the residents had been evaluated for PASRR, despite having approved Level II PASRR evaluations. This discrepancy was identified during a review of the clinical records and MDS assessments of the residents. Interviews with staff members responsible for the MDS assessments confirmed the oversight. The staff acknowledged that the comprehensive MDS assessments should have included the state Level II PASRR evaluations for the residents in question. The Director of Nursing (DON) also confirmed that the MDS assessments should be accurate for all residents, indicating a lapse in the facility's assessment process.
Failure to Implement PASRR Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II Determinations into the assessment, care planning, and transitions of care for three residents. Resident #14, who was severely cognitively impaired, had recommendations for medication education, training in ADLs, training in independent living skills, structured leisure activities, and an evaluation for a diagnosis of dementia. However, these services were not documented in the care plan, and the resident stated he was willing to participate but was never offered these services. The staff member responsible for ensuring these services were offered could not provide evidence of the resident's refusal. Resident #100, who was cognitively intact, had recommendations for training in independent living skills, structured leisure activities, Community Psychiatric Support and Treatment (CPST), and Psychosocial Rehabilitation (PSR) - Group. The resident expressed interest in these services but confirmed they were not offered. The staff member claimed the services were refused but lacked documentation to support this claim. The care plan did not reflect the recommended services or any refusal. Resident #109, who was moderately cognitively intact, had recommendations for structured leisure activities and CPST. The resident did not recall being offered these services and stated she would not have refused them. Again, the staff member responsible for offering these services claimed they were refused but could not provide documentation. The care plan did not include the recommended services or any indication of refusal. The facility administrator confirmed the expectation that all recommended services should be offered and documented, especially if refused.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services for maintaining good grooming and personal hygiene for two residents who were unable to perform activities of daily living (ADLs) independently. Resident #40, who has moderate cognitive impairment and is dependent on staff for ADLs, was observed with long and dirty fingernails on multiple occasions. Despite having physician orders to assess and trim fingernails monthly and as needed, the staff did not clean or trim the resident's nails. Interviews with the CNA and LPN revealed a lack of clarity regarding responsibility for nail care, with each assuming it was the responsibility of another staff member. Similarly, Resident #119, who has severe cognitive impairment and requires supervision for ADLs, was also observed with long and dirty fingernails. The resident expressed a desire to have his nails trimmed and cleaned, but this was not done. The CNA assigned to the resident did not clean the nails during morning ADL care, believing it was the responsibility of the wound care nurse. The wound care nurse stated that CNAs should clean under the nails during baths, and the floor nurse should assess and provide nail care weekly. The Director of Nursing confirmed that CNAs were responsible for cleaning under the fingernails during morning ADL care, and nurses were to assess fingernail care weekly.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in five rooms, leading to various environmental concerns. In Room a, observations revealed a hanging ceiling tile, black spotty staining at the top of the walls, and green fuzzy staining on the door frame. Water appeared to have dripped around the door and walls, and the DON confirmed these findings during an interview. Room b exhibited significant water damage, with water lines on the walls, warped bead board, and rusted metal trim around the window. Resident #66 reported ongoing issues with water entering the room during rain, which had been reported but not addressed due to pending floor remodeling. Room c had five water-stained ceiling tiles, with one tile showing green/black discolorations and sagging. The maintenance staff acknowledged the ongoing challenge with ceiling tiles. In Room d, a piece of vinyl wood floor plank was missing, and the wall had black and greenish circles, which were painted over without addressing the underlying issue. Room e had a large amount of debris in the sink, a foul-smelling drain with black sludge, and missing ceiling tiles exposing wiring. Housekeeping staff confirmed the long-standing issues, and the administrator was aware of the sanitation problems but had not taken corrective action. Interviews with staff and residents highlighted a lack of awareness and delayed responses to maintenance issues. The administrator acknowledged the deficiencies in maintaining a safe and comfortable environment, particularly in Rooms a and b, where water damage was evident. Despite being informed of these issues, the facility had not taken timely action to address the environmental concerns, resulting in an unsafe and unsanitary living environment for the residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of pests and insects within the premises. On several occasions, surveyors observed roaches, both alive and dead, in critical areas such as the main kitchen food preparation area and the food storage room. Additionally, small black particles resembling grains of rice were noted on the kitchen floor, indicating possible pest activity. Interviews with staff confirmed that these pest sightings had been reported to the administration, yet the issue persisted. Further observations included a cockroach crawling on a dirty linen bin in close proximity to a clean linen cart, a large cockroach on the ceiling near the dry food storage room, and a fly hovering over a steam table during food service. Staff members were seen attempting to shoo the fly away from the food. The facility's administrator acknowledged awareness of the pest problem and the need for increased pest control services, indicating a lapse in the current pest management efforts.
Verbal Abuse Incident Involving Resident and LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a resident with severe cognitive impairment, diagnosed with anxiety disorder, dementia, cognitive communication deficit, and unspecified psychosis. The resident had a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The incident occurred when the resident touched the hair of an LPN while they were alone in an elevator. This led to a verbal altercation between the resident and the LPN, with both parties using inappropriate language and curse words. The situation escalated as the LPN and the resident continued to argue loudly, attracting the attention of other staff members. Despite attempts by staff to deescalate the situation by separating the LPN from the resident, the LPN continued to engage in the argument, further agitating the resident. Witness statements confirmed that the LPN shouted profanities at the resident, which was considered verbal abuse by the facility's policy. The incident was substantiated as verbal abuse by the facility's investigation. Interviews with various staff members, including the Assistant Director of Nursing (ADON) and the Administrator, confirmed that the LPN's actions were inappropriate and constituted verbal abuse. The facility's policy clearly states that residents have the right to be free from abuse, including verbal abuse, and that staff should remain calm and avoid engaging in arguments with residents. The failure to adhere to these guidelines resulted in the substantiated finding of verbal abuse against the resident.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident and a staff member to the state survey agency within the required two-hour timeframe. The incident involved Resident #98, who has a medical history including anxiety disorder, dementia, cognitive communication deficit, and unspecified psychosis. The altercation occurred when the resident touched the hair of a staff member, S23LPN, leading to a verbal confrontation with inappropriate language and curse words exchanged between them. The situation escalated as both parties became increasingly agitated, requiring intervention from other staff members to separate them and attempt de-escalation. The facility's policy mandates immediate reporting of abuse allegations to the state survey agency and local law enforcement, but this was not adhered to in this case. The incident was documented in an incident report, which noted the altercation began at 7:27 a.m. and was reported to the state survey agency at 1:11 p.m., well beyond the two-hour requirement. Witnesses, including S13ADON and S22LPN, confirmed the details of the altercation, noting that S23LPN's actions contributed to the escalation rather than de-escalation of the situation. Interviews with staff, including S13ADON and S1ADM, confirmed the timeline of events and the failure to report the incident promptly. S13ADON, who was present during the altercation, immediately informed the administration, including S1ADM, S2AADM, and S12DON, of the incident. However, S1ADM, responsible for submitting incident reports, acknowledged the delay in reporting the verbal abuse allegation to the state agency, which constitutes a deficiency in adhering to the facility's abuse prevention and reporting policy.
Environmental Deficiencies in Facility Rooms
Penalty
Summary
The facility was found to have multiple environmental deficiencies during an inspection, affecting 12 rooms. Observations revealed various issues such as gaps between air conditioner units and wall mount harnesses, with outside light visible in some cases, indicating potential breaches in insulation and security. Additionally, there were several instances of peeling bead board/paneling, broken or missing air conditioner controls, and damaged or missing wall socket face plate covers. These deficiencies were confirmed by S2MAIN during an environmental tour. Further issues included stained and drooping ceiling tiles, holes in walls, and broken or missing components of bathroom vanities. In one room, a headboard was improperly attached to the bed frame, missing necessary brackets and bolts for secure attachment. These findings were acknowledged by S1ADM, who confirmed that the conditions were not acceptable and should not have been present.
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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