The Bradford Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 3050 Baird Road, Shreveport, Louisiana 71118
- CMS Provider Number
- 195513
- Inspections on file
- 38
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Bradford Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
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.
A resident with multiple chronic conditions was using bilateral hand assist rails without documented quarterly assessment for entrapment risk or informed consent, as required by facility policy. The DON confirmed that the necessary Side Rail Utilization Assessment and consent process had not been completed.
A facility failed to report an alleged abuse incident involving a resident to the State Agency, despite conducting an internal investigation. The resident, with severe cognitive impairment and other mental health conditions, was allegedly kicked and cursed at by a CNA. The facility's policy requires timely reporting of such incidents, but this was not done, resulting in a deficiency.
A resident with severe cognitive impairment and frequent bowel incontinence was not checked every two hours as required by their care plan. Video footage showed a CNA entered the resident's room at night and did not return until the next morning, which was confirmed by the facility's administrator and DON.
A resident with multiple diagnoses and a self-care performance deficit was found with long and dirty fingernails, despite having a care plan requiring assistance with personal hygiene. The resident, who was cognitively intact, had requested nail trimming a week prior, but the facility failed to provide this care. The DON confirmed the need for nail trimming.
A resident, who was cognitively intact and receiving hospice care, felt threatened and unsafe after an administrator threatened to notify APS over a payment issue. The resident expressed a desire to leave the facility due to the administrator's rude behavior, which was confirmed by multiple staff members.
A resident with severe cognitive impairment and high fall risk was found with side rails in use without a physician's order, assessment, or consent, effectively acting as a restraint. Facility staff confirmed the lack of necessary documentation and acknowledged the inappropriate use of side rails as a restraint.
The facility failed to ensure proper use and maintenance of bed rails for several residents, lacking assessments, consents, and physician orders. Residents with various medical conditions had side rails raised without necessary documentation, as confirmed by observations and interviews with the corporate nurse. This indicates a systemic issue in adhering to protocols for safe bed rail use.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. An LPN administered incorrect medications to two residents: one received the wrong inhalation medication, and another received half the prescribed dose of Metoprolol Succinate ER. Both errors were confirmed by the LPN, a Nurse Practitioner, and the DON.
The facility failed to submit accurate payroll information for direct care staffing to CMS. A review of the PBJ report indicated low weekend staffing. Interviews revealed that the corporate office handles report submissions, and late agency staffing hours can result in inaccurate staffing levels being reported, suggesting inadequate staffing.
A resident with severe cognitive impairment and multiple diagnoses was unable to reach their call light, which was placed on a bedside table. Despite requiring extensive assistance, the resident's call light was observed out of reach on multiple occasions, and a CNA confirmed it should not have been placed there.
A facility failed to investigate an incident of resident-to-staff violence, where a resident with a history of violent behavior pushed an LPN and used profanity. Despite the facility's policy requiring such incidents to be reported and investigated, the DON did not complete an incident report, and the Administrator did not review available camera footage. The incident was not reported to the Corporate Compliance Officer, as it was deemed a behavior rather than an incident, indicating non-compliance with regulatory requirements.
The facility failed to ensure that a resident with multiple diagnoses, including mobility issues, was free from accidents and hazards. The resident was repeatedly observed with their bed in a high position and the call bell out of reach, contrary to physician orders and the care plan. A Restorative Aide confirmed these deficiencies.
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 Obtain Informed Consent and Complete Quarterly Side Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails and did not conduct quarterly assessments for the risk of entrapment as required by its own policy. Specifically, for one resident with diagnoses including muscle wasting, chronic pain, osteoarthritis, and morbid obesity, the medical record did not contain evidence that a Side Rail Utilization Assessment had been completed quarterly. The facility's policy mandates that such assessments be performed upon admission, readmission, quarterly, or with significant changes, and that informed consent be obtained after discussing the risks and benefits with the resident or their representative. Observations confirmed that the resident was using bilateral hand assist rails during multiple surveyor visits, and interviews with the resident and the DON verified that the required assessment and consent process had not been completed as per policy. The resident, who was cognitively intact, reported using the rails for bed mobility, but documentation of the necessary assessment and consent was missing from the medical record.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the State Survey and Certification Agency. The facility's policy mandates timely reporting of suspected abuse to appropriate agencies, but this was not adhered to in the case of a resident who was allegedly kicked and cursed at by a CNA. The incident was reported internally on December 25, 2024, and an investigation was conducted, including interviews with the involved staff and witness statements. However, the facility did not notify the State Agency as required. The resident involved in the incident had a complex medical history, including severe cognitive impairment, neurocognitive disorder with Lewy Bodies, and other mental health conditions. The resident's MDS assessment indicated severely impaired cognition, which underscores the vulnerability of the resident. Despite the internal investigation and acknowledgment of the incident by the Director of Nursing, the failure to report the alleged abuse to the State Agency constitutes a deficiency in the facility's adherence to regulatory requirements.
Failure to Implement Incontinence Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and frequent bowel incontinence. The resident, who had a BIMS score of 2 indicating severely impaired cognition, was admitted with diagnoses including schizoaffective disorder bipolar type, Alzheimer's disease, history of falls, and osteoarthritis. The care plan required staff to check the resident every two hours for incontinence. However, a review of the facility's video footage revealed that a CNA entered the resident's room at 11:08 p.m. and did not return until 6:25 a.m. the following morning, indicating that the resident was not checked every two hours as required. Interviews with the facility's administrator and DON confirmed the lapse in care, acknowledging that no staff entered the resident's room during the specified time frame, thus failing to adhere to the care plan's intervention for incontinence management.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care for a resident who was unable to perform self-care due to a self-care performance deficit related to decreased vision and impaired balance. The resident, who was admitted with multiple diagnoses including muscle wasting, COPD, and anxiety, was cognitively intact with a BIMS score of 15. Despite having a care plan that required assistance with personal hygiene, the resident's fingernails were observed to be long and dirty. The resident expressed that he did not want long fingernails and had requested them to be trimmed a week prior. The Director of Nursing confirmed the observation that the resident's fingernails were dirty and needed trimming.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically in the case of one resident. The facility's Resident Rights Policy mandates that all residents be treated with kindness, respect, and dignity. However, the administrator's interaction with a resident did not adhere to this policy. The resident, who was cognitively intact and receiving oxygen therapy and hospice care, reported feeling fearful and threatened after an encounter with the administrator. The resident expressed a desire to leave the facility due to the administrator's rude behavior. The incident involved a discussion about the resident's payment process, during which the administrator threatened to notify Adult Protective Services (APS) if the resident's funds were not used to pay his bill. This threat left the resident visibly shaken and adamant about leaving the facility, as confirmed by multiple staff members. The administrator acknowledged making the statement about contacting APS if the payment was not made, which contributed to the resident's distress and feeling of unsafety.
Failure to Ensure Resident's Right to Be Free from Unnecessary Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. Specifically, the facility did not complete a side rail utilization assessment, obtain consent for the use of side rails, or secure a physician's order for the use of bedrails for Resident #360. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully and must be based on a physician's order with consent from the resident or their representative. Resident #360, who was admitted with severe cognitive impairment and a high risk for falls, was observed with bilateral upper side rails in use without the necessary assessments or orders. Despite the resident's dependency on staff for mobility and the absence of an indication for side rails for mobility assistance, the side rails were used, effectively acting as a restraint. Interviews with facility staff confirmed the lack of a physician's order, side rail assessment, and consent for the use of side rails, acknowledging that the side rails were used as a restraint.
Failure to Ensure Proper Use and Maintenance of Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for several residents, as evidenced by the lack of assessments, informed consents, and physician orders. The facility's policy requires a thorough assessment of residents for the use of side rails, obtaining informed consent, and ensuring physician orders are in place. However, for 11 out of 17 residents investigated, these steps were not followed, leading to deficiencies in compliance with the facility's guidelines and regulatory requirements. For instance, Resident #3, who has multiple diagnoses including hemiplegia and schizophrenia, had side rails raised without a documented assessment or consent. Similarly, Resident #17, diagnosed with Alzheimer's disease and a history of falls, had side rails raised without consent or documented checks for placement and functioning. These oversights were confirmed through observations and interviews with the facility's corporate nurse, who acknowledged the absence of necessary documentation and assessments. Other residents, such as Resident #23 and Resident #41, also had side rails raised without prior assessments or consents, and in some cases, without physician orders. The facility's failure to conduct quarterly assessments and obtain necessary consents and orders for the use of side rails was a recurring issue across multiple residents, indicating a systemic problem in adhering to the established protocols for the safe use of bed rails.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate during a medication pass observation. Two specific errors were identified. The first involved Resident #19, who was administered Fluticasone Propionate and Salmeterol 250mcg/50mcg by oral inhalation instead of the prescribed Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act. This discrepancy was confirmed by the LPN during an interview, who acknowledged that the medication administered did not match the physician's order. The second error involved Resident #93, who received one-half tablet of Metoprolol Succinate ER 25mg instead of the full tablet as prescribed for essential hypertension. The LPN and a Nurse Practitioner confirmed the error upon reviewing the medication card and physician's order. The Director of Nursing also verified that the medications administered to both residents did not align with the physician orders, contributing to the facility's medication error rate exceeding the acceptable threshold.
Inaccurate Payroll Submission for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. A review of the Payroll Based Journal (PBJ) report for the fiscal year 2024, 2nd quarter, revealed that excessively low weekend staffing was triggered. During interviews, the administrator and human resources personnel indicated that the corporate office is responsible for submitting the PBJ report. The administrator suggested that an agency invoice might have been missed or not available at the time of reporting. The human resources representative explained that when staffing agencies send staffing hours late, the reported staffing hours to the corporate office do not reflect the actual staffing levels, leading to an appearance of inadequate staffing.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring the call light was within reach. The resident, who was admitted with diagnoses including parkinsonism, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus, pain unspecified, restlessness and agitation, and insomnia, had a severe cognitive impairment as indicated by a BIMS score of 03. The resident required extensive assistance with bed mobility, transfer, and toilet use. On the morning of August 19, 2024, observations revealed that the resident's call light was placed on the bedside table, out of reach. During an interview, the resident confirmed the inability to reach the call light. Later, the resident was heard calling for help, and the call light was still observed to be out of reach. A CNA confirmed that the call light should not have been out of the resident's reach.
Failure to Investigate Resident-to-Staff Violence Incident
Penalty
Summary
The facility failed to comply with applicable Federal, State, and local laws, regulations, and codes by not investigating an incident involving resident-to-staff violence. The incident involved a resident who was cognitively intact and had a history of violent behavior, including bipolar disorder and anxiety disorder. On the night of the incident, the resident was observed yelling and using profanity in the hallway. When approached by an LPN, the resident pushed the LPN and slammed the door. Despite this, the facility did not complete an incident report or conduct an investigation as required by their Workplace Aggression/Violence Policy. The facility's policy mandates that all employees report any threats or violent acts, which include verbal or physical harassment and threats, to the appropriate supervisor or HR Director. However, the Director of Nursing (DON) did not consider it necessary to write an incident report after seeing the progress note in the resident's medical record. Additionally, the facility's Administrator did not review the camera recording of the incident, and the recording was no longer available. This lack of action and documentation indicates a failure to adhere to the facility's policy and ensure a safe environment for both staff and residents. Interviews with staff revealed that the incident was not reported to the facility's Corporate Compliance Officer, as it was not considered an incident but rather a behavior. The resident's behavior was notably above baseline, and the resident was later transferred to a Behavioral hospital with police assistance. The facility's failure to investigate and report the incident demonstrates non-compliance with their own policies and regulatory requirements, compromising the safety and well-being of both staff and residents.
Failure to Ensure Resident Safety and Accessibility
Penalty
Summary
The facility failed to ensure that Resident #3 was free from accidents and hazards. Resident #3, who has multiple diagnoses including muscle wasting, gait and mobility issues, anxiety disorder, and heart failure, was observed multiple times with their bed in a high position and the call bell out of reach, despite physician orders and a comprehensive care plan specifying the use of a low bed and fall mats. On several occasions, the call bell was found hanging off the side of the bed, wrapped around the assist rail, or on the floor, making it inaccessible to the resident. These observations were confirmed by a Restorative Aide who acknowledged that the bed should be lowered and the call bell should not be on the floor.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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