The Care Center Of Dequincy
Inspection history, citations, penalties and survey trends for this long-term care facility in Dequincy, Louisiana.
- Location
- 602 North Division, Dequincy, Louisiana 70633
- CMS Provider Number
- 195527
- Inspections on file
- 23
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Care Center Of Dequincy during CMS and state inspections, most recent first.
The facility failed to protect residents from physical abuse, resulting in incidents involving two residents. A resident with dementia was physically abused by another resident, leading to skin tears. Another incident involved a resident with mild cognitive impairment being hit in the face by a fellow resident. The facility's policy on abuse prevention was not effectively implemented, resulting in these deficiencies.
The facility failed to implement and maintain an effective QAPI program, as evidenced by the lack of documented measurement or tracking of actions taken to address quality deficiencies. There was also no evidence of data collection and analysis from July 2024 to January 2025. This deficiency had the potential to impact the care and quality of life for 61 residents.
The facility failed to report two incidents of resident-to-resident abuse within the required timeframe. A resident with cognitive and mood disorders was involved in a physical altercation, and another resident sustained a skin tear in a separate incident. Both incidents were not reported to the state agency within the mandated two-hour window, as confirmed by the facility's administrator.
A facility failed to investigate an incident where a resident was struck multiple times by another, resulting in a skin tear. Despite the facility's policy requiring immediate investigation of abuse, no investigation or documentation was conducted. The Administrator confirmed the oversight during interviews.
The facility failed to properly store schedule IV controlled medications, as observed in Room A where a black refrigerator and a safe box containing Valium suppository and diazePAM Rectal Gel were found unlocked. The DON confirmed these medications should have been double locked, violating the facility's policy.
The facility failed to ensure that dietary staff followed recipes for pureed foods, as observed when a Dietary Cook prepared pureed white beans with ham and cornbread muffins without using the provided recipes. The Dietary Manager confirmed that recipes had not been followed since the menu rotation, potentially affecting six residents on a pureed diet.
A resident's dignity was compromised when their urine collection bag was left uncovered and visible from the hallway. Despite the care plan's instructions to keep the bag private, it was observed hanging at the foot of the bed without a privacy cover. Staff confirmed the oversight and acknowledged the need for a privacy bag to maintain dignity.
A facility failed to accurately assess a resident's discharge status, resulting in a deficiency. The resident was transferred to another nursing home, but the Discharge MDS assessment incorrectly indicated a discharge to a short-term general hospital. This error was confirmed by the staff member responsible for MDS assessments.
The facility failed to provide appropriate respiratory care for two residents, with equipment improperly stored on the floor. One resident's oxygen storage bag and another's nebulizer machine and tubing were found on the floor, confirmed by an LPN as inappropriate. The facility lacked a policy for storing such equipment.
A facility failed to update the hospice documentation for a resident with senile degeneration of the brain and vascular dementia. The last certification of terminal illness and plan of care (POC) were outdated, ending on January 4, 2025. The Director of Nursing confirmed the absence of updated documents, indicating a lapse in maintaining current hospice records.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in incidents involving two residents. Resident #8, who has a history of dementia with behavior disturbance and other mental health issues, was physically abused by Resident #3. On the date of the incident, Resident #8 backed his chair into Resident #3 while waiting to go outside to smoke, leading to Resident #3 hitting Resident #8 multiple times. This resulted in skin tears to Resident #8's left forearm and left lower leg. The facility's incident report confirmed the occurrence of resident-to-resident abuse. Resident #3, who has diagnoses including mild cognitive impairment and schizoaffective disorder, was involved in another incident of physical aggression. On a previous occasion, Resident #3 backed his wheelchair into Resident #63 multiple times, prompting Resident #63 to hit Resident #3 in the face three times. Although no injuries were observed at the time, the incident was documented as resident-to-resident abuse. The facility's records indicate that Resident #3 has a history of potential physical aggression due to anger and poor impulse control. The facility's policy on abuse prevention and investigation emphasizes the prohibition and prevention of abuse, including physical abuse such as hitting and slapping. Despite this policy, the facility failed to protect the residents involved from physical harm, as evidenced by the incidents of abuse. The facility's records and interviews with staff confirm these deficiencies, highlighting a failure to ensure the safety and well-being of the residents.
Failure to Implement and Track QAPI Program
Penalty
Summary
The facility failed to effectively implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a review of the facility's QAPI program and an interview with the Director of Nursing (DON). The facility did not provide documented evidence of measuring or tracking the success of actions implemented to address quality deficiencies from July 1, 2024, through January 12, 2025. Additionally, there was no evidence of data collection and analysis during this period. The lack of these critical components in the QAPI program had the potential to affect the care and quality of life for a census of 61 residents.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of abuse to the State Survey Agency within the required timeframe for two residents. The facility's policy mandates that any allegations of abuse must be reported immediately, but not later than two hours after the allegation is made. However, the incidents involving Resident #3 and Resident #8 were not reported as required. Resident #3, who has a history of cognitive and mood disorders, was involved in an incident where he was physically aggressive towards another resident, resulting in a physical altercation. Despite the incident being recognized as abuse, it was not reported to the state agency within the mandated timeframe. Resident #8, who also has a history of cognitive and mood disorders, was involved in a separate incident where he was physically aggressive towards Resident #3. This resulted in Resident #8 sustaining a skin tear. Similar to the previous incident, this was recognized as an incident of resident-to-resident abuse but was not reported to the state agency within the required two-hour window. The facility's records show that no Critical Incident Reports were created during the last six months, indicating a systemic issue in reporting such incidents. Interviews with the facility's administrator confirmed the failure to report these incidents in a timely manner. The administrator acknowledged that the incidents should have been reported immediately, as per the facility's policy and state requirements. This oversight highlights a deficiency in the facility's adherence to its own policies and state regulations regarding the reporting of abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to initiate an investigation into an alleged incident of abuse involving two residents. According to the facility's policy on Abuse Prevention and Investigation, any suspicion or report of abuse requires an immediate investigation, which includes interviewing all involved parties and documenting the findings. On 11/17/2024, an incident occurred where one resident was struck multiple times by another resident, resulting in a skin tear to the victim's left forearm. Despite the incident being documented as physical aggression, no investigation was conducted or documented by the facility. The Director of Nursing (DON) and the Administrator were both involved in the aftermath of the incident. The Administrator, who was responsible for investigating all incidents and creating Critical Incident Reports, confirmed that no investigation was conducted for the incident on 11/17/2024. The lack of documentation and investigation was acknowledged by the Administrator during interviews conducted on 01/28/2025 and 01/29/2025. This failure to investigate and document the incident of resident-to-resident abuse constitutes a deficiency in the facility's adherence to its own policies and regulatory requirements.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional principles, specifically regarding the storage of schedule IV controlled medications. During an observation of medication storage in Room A, it was found that a black refrigerator containing medications was unlocked. Inside the refrigerator, a black safe box was also found to be unlocked, containing schedule IV controlled medications such as Valium suppository 10 mg and diazePAM Rectal Gel 10 mg. The Director of Nursing (S2DON) confirmed that both the refrigerator and the safe box were unlocked and that the medications stored inside were schedule IV controlled substances that should have been double locked. This failure to secure controlled medications properly is a violation of the facility's policy, which mandates that patient-specific controlled substances be stored under double lock until administered to the patient.
Failure to Follow Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure that recipes for pureed foods were followed by the dietary staff, specifically by the Dietary Cook (S6DC). During an observation, S6DC was seen preparing pureed white beans with ham and cornbread muffins without using the provided recipes. Instead of measuring ingredients according to the recipes, S6DC used a large scoop with no marked measurements and added ingredients such as water, juice, milk, or thickener based on personal judgment. This practice was confirmed by S6DC during an interview, where she admitted to not following recipes and adjusting the consistency of the food as she deemed necessary. The Dietary Manager (S3DM) intervened during the observation, stopping S6DC from proceeding with the puree process and ensuring that the correct measurements were used. However, S3DM admitted that the dietary staff had not been following recipes for pureed foods since the rotation of the menu, and she could not recall when this practice began. S3DM acknowledged that the dietary staff should be following recipes and had only recently printed and organized the recipes into a binder. This deficiency had the potential to affect the six residents in the facility who were on a pureed diet.
Failure to Maintain Resident Dignity by Not Covering Urine Collection Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that the resident's urine collection bag was covered and private. The resident, who was admitted with acute kidney failure and urine retention, had an indwelling catheter as part of their care plan. The care plan specified that the catheter bag should be positioned below the bladder and away from the entrance room door. However, during an observation, the urine collection bag was found hanging at the foot of the resident's bed without a privacy cover, making it visible from the hallway. Interviews with the Certified Nursing Assistant Supervisor and the Director of Nursing confirmed that the urine collection bag should have been covered with a privacy bag to maintain the resident's dignity. Both staff members acknowledged the oversight and confirmed that the visibility of the urine collection bag from the hallway was not in line with the facility's standards for resident dignity.
Inaccurate Discharge Status in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's discharge status, leading to a deficiency. A review of the discharge transfer summary for a resident revealed that he was transferred to another nursing home. However, the Discharge Minimum Data Set (MDS) assessment inaccurately reflected that the resident was discharged to a short-term general hospital. This discrepancy was confirmed during an interview and record review with the staff member responsible for MDS assessments, who acknowledged the error in coding the discharge status.
Inappropriate Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for two residents, potentially affecting 23 residents receiving oxygen therapy. Resident #34, who was admitted with diagnoses including Dyspnea, COPD, and CHF, had an order for oxygen therapy to maintain oxygen saturation above 90%. However, during an observation, the oxygen storage bag was found on the floor with the tubing running through it, which was confirmed by an LPN to be inappropriate storage. Similarly, Resident #58, admitted with Acute and Chronic Respiratory Failure with Hypoxia, COPD, and Pneumonia, had orders for nebulizer treatments. An observation revealed that the nebulizer machine and tubing were stored on the floor at the head of the resident's bed. The resident expressed concern about the cleanliness of the equipment, and an LPN confirmed that the equipment should not be stored on the floor. The facility did not provide a policy for the storage of oxygen/nebulizer equipment by the time of the survey exit.
Failure to Update Hospice Documentation for Resident
Penalty
Summary
The facility failed to obtain the most recent recertification of terminal illness and the most recent plan of care (POC) for a resident receiving hospice services. The resident, who was admitted with diagnoses including senile degeneration of the brain and vascular dementia, was under hospice care as indicated in the Minimum Data Set (MDS) and physician's orders. However, the hospice documents in the contracted hospice binder showed that the last certification of terminal illness and POC were signed for a period ending on January 4, 2025. During a record review and interview with the Director of Nursing (DON), it was confirmed that there was no updated recertification of terminal illness or POC in the resident's hospice binder beyond the period ending January 4, 2025. This oversight indicates a lapse in maintaining current hospice documentation, which is essential for ensuring the resident's care aligns with their current medical needs.
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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