The Encore Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crowley, Louisiana.
- Location
- 19110 Crowley-eunice Hwy, Crowley, Louisiana 70526
- CMS Provider Number
- 195426
- Inspections on file
- 18
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at The Encore Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairments was allegedly physically abused by a CNA, witnessed by another CNA who delayed reporting the incident. The LPN informed did not notify the resident's family, assuming they would be informed post-investigation. The family learned of the incident via social media, not from the facility, leading to concerns voiced in a meeting with the administrator.
A facility failed to report an alleged staff-to-resident physical abuse incident within the required 2-hour timeframe. A resident with severe cognitive impairment was allegedly handled roughly by a CNA. The incident was reported internally the day after it occurred, but the Administrator delayed reporting it to the state agency for 10 days, resulting in a deficiency.
The facility failed to ensure a Discharge MDS assessment was completed timely for a resident with multiple diagnoses, including Cord Compression and Diabetes Mellitus. The resident was discharged, but the required MDS assessment was not transmitted until several months later, as confirmed by an LPN.
The facility failed to ensure accurate documentation for two residents, including an incorrect entry about a PEG tube and multiple errors in medication administration records, leading to uncertainty about the care provided.
The facility failed to inform a resident's representative of their right to choose a hospice provider, leading to the representative signing up for hospice services without being fully aware of their options. The representative later revoked hospice care and filed a grievance upon learning of their right to choose a different provider.
The facility failed to accurately code all applicable diagnoses on two consecutive comprehensive MDS assessments for a resident. Despite documented diagnoses of Dementia and Schizoaffective Disorder, these were not included in the resident's MDS assessments, as confirmed by the Regional Clinical Educator and the MDS LPN.
The facility failed to refer a resident with a newly diagnosed serious mental disorder for a Level II PASARR evaluation as required by policy. Despite being diagnosed with Schizoaffective Disorder shortly after admission, the necessary paperwork was not submitted, resulting in the resident not receiving timely behavioral health services.
A resident with chronic edema in both lower extremities did not have a comprehensive care plan addressing her condition. Despite documented observations of worsening edema and the need for leg elevation, no interventions were included in the care plan. Interviews with staff and the resident confirmed the lack of assistance and monitoring for leg elevation, contrary to the facility's policy.
A resident with chronic respiratory conditions did not receive oxygen at the ordered rate due to a knot/kink in the tubing, which was confirmed and corrected by an LPN.
The facility failed to ensure medications were labeled to reflect physician-ordered adjustments for a resident with Hypertensive Heart Disease and other conditions. The resident received incorrect dosages of Tramadol on multiple occasions due to improper labeling, as confirmed by an LPN and the Regional Clinical Specialist.
The facility failed to ensure medication was labeled as per physician orders for a resident. During a medication administration observation, it was found that the medication card for Potassium Chloride 20meq was incorrectly labeled, instructing to take 1 & 1/2 tablets (30meq) by mouth once now, then resume 1 tablet by mouth once daily, whereas the physician's orders and MAR indicated to give 2 tablets (40meq) daily. This discrepancy was confirmed by the LPN and DON.
Failure to Report and Notify Family of Alleged Abuse
Penalty
Summary
The facility failed to implement its policy for incident investigation and reporting when staff did not immediately report alleged staff-to-resident physical abuse to administrative staff and failed to notify the resident's responsible party. The incident involved a resident with severe cognitive impairments and multiple diagnoses, including dementia and Parkinson's disease. The alleged abuse occurred when a CNA was observed by another CNA to be rough while combing the resident's hair and slapping the resident's hand. The witnessing CNA did not report the incident until the following day, and the LPN who was informed did not notify the resident's family, assuming they would be informed after the investigation. The incident was discovered a day after it occurred, but it was not entered into the Statewide Incident Management System until several days later. The resident's family learned about the alleged abuse through a social media post rather than being informed by the facility. The facility's administrator confirmed that the witnessing CNA and the LPN did not follow the policy of immediate reporting and family notification. The family expressed their concerns during a meeting with the facility's administrator, highlighting the failure to communicate the incident promptly.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the State Survey Agency within the required 2-hour timeframe. The incident involved a resident with multiple diagnoses, including malignant neoplasm of the endometrium, unspecified dementia, and Parkinson's disease, who was unable to participate in a mental status interview due to severe cognitive impairment. The alleged abuse occurred when a CNA was observed handling the resident roughly and slapping the resident's hands. The incident was discovered the following day, but the facility did not report it to the state agency until 10 days later. Interviews with facility staff revealed that the CNA who witnessed the incident reported it to an LPN, who then informed the CNA Supervisor. The CNA Supervisor confirmed that the Administrator was notified of the allegation on the same day it was reported by the LPN. Despite this chain of communication, the Administrator did not report the incident to the state agency until several days after the required reporting period, resulting in a deficiency for failing to adhere to the mandated reporting guidelines.
Failure to Timely Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for one resident out of 35 sampled residents. The resident was admitted with diagnoses including Cord Compression, Aural Vertigo, Spinal Stenosis, Diabetes Mellitus, Hypertension, and a Displaced Fracture of the Right Femur. The resident was admitted on [DATE] and discharged on 02/19/2024. However, the Discharge MDS assessment, which should have been completed and transmitted within 7 days of discharge, was not transmitted until 06/20/2024. This delay was confirmed during an interview with an LPN who reviewed the resident's record and acknowledged the failure to meet the required timeline.
Documentation Errors in Resident Records
Penalty
Summary
The facility failed to ensure the accuracy of documentation in the resident's records for two residents. For Resident #35, the nursing progress notes inaccurately documented the presence of a PEG tube, which the resident did not have. This error was confirmed by both the resident and the LPN who reviewed the records. The Director of Nursing also confirmed the mistake and noted that the incorrect entry needed to be retracted. For Resident #71, there were multiple documentation errors related to the administration of medication. The resident, who had a UTI and was prescribed Rocephin, did not receive a scheduled dose on one occasion. The LPN responsible for administering the medication documented an incorrect reason for the missed dose, stating it was due to the resident's transfer to the emergency room. However, there was no documentation that the dose was administered upon the resident's return from the hospital. Another LPN later confirmed that the dose was administered but failed to document it in the resident's record. These documentation inaccuracies were confirmed through interviews with the involved staff and a review of the resident's records. The errors led to uncertainty about the administration of critical medications and the presence of medical devices, highlighting significant lapses in maintaining accurate and reliable medical records for the residents.
Failure to Inform Resident's Representative of Hospice Provider Choice
Penalty
Summary
The facility failed to ensure that a resident's representative was fully informed of their right to choose a hospice provider. The resident, who had severe cognitive impairment and multiple serious health conditions, was placed under hospice care by her daughter, who was her responsible party (RP). The RP was not informed of her right to choose a hospice provider and was only presented with the facility's contracted hospice provider. This led to the RP signing up for hospice services without being fully aware of her options or understanding the paperwork involved. The RP later became dissatisfied with the hospice provider's services and revoked hospice care, only to learn from a friend that she had the right to choose a different provider. She filed a grievance with the facility, expressing her frustration that she was not informed of her rights initially. The facility's Social Services Director (S3SSD) and other staff confirmed that there was no documented evidence that the RP was informed of her right to choose a hospice provider. Interviews with the facility's staff, including the Social Services Director, Administrator, and Director of Nursing, revealed that the facility had a policy to inform residents and their representatives of their rights, including the right to choose a hospice provider. However, in this case, the policy was not followed, and the RP was not provided with the necessary information to make an informed decision. This oversight led to the deficiency identified in the report.
Inaccurate Coding of Diagnoses on MDS Assessments
Penalty
Summary
The facility failed to accurately code all applicable diagnoses on two consecutive comprehensive Minimum Data Set (MDS) assessments for one resident. The resident was admitted with diagnoses including Dementia and was later diagnosed with Depression, Dementia without behavior disturbances, and Schizoaffective Disorder. However, the admission MDS assessment and the subsequent quarterly MDS assessment did not include the diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder, despite these being documented in the resident's records and billing diagnosis code report. Interviews with the Regional Clinical Educator and the MDS Licensed Practical Nurse confirmed the discrepancies. The Regional Clinical Educator verified that the resident was diagnosed with Schizoaffective Disorder shortly after admission, and the MDS Licensed Practical Nurse acknowledged that the resident's MDS assessments were inaccurate, failing to include the correct diagnoses. This oversight resulted in two of the resident's MDS assessments being incomplete and inaccurate.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly evident serious mental disorder to the appropriate state designated authority for a Level II PASARR evaluation and determination. The resident, who was admitted to the facility without a prior diagnosis of a serious mental disorder, was later diagnosed with Schizoaffective Disorder by a psychiatrist. Despite this new diagnosis, the facility did not submit a Level II request to the Office of Behavioral Health (OBH) as required by their policy and state regulations. This oversight was confirmed during interviews with the Social Services Director and the Regional Clinical Educator, who acknowledged that the necessary paperwork had not been submitted. The resident's records revealed that the diagnosis of Schizoaffective Disorder was made shortly after admission, and the facility's policy mandated a Level II evaluation for such diagnoses. However, a review of the resident's file showed no evidence that a Level II request was ever submitted. The Social Services Director confirmed that the facility had not complied with the policy, and the resident currently required an evaluation for services. This failure to follow protocol resulted in the resident not receiving the necessary behavioral health services in a timely manner.
Failure to Develop Comprehensive Care Plan for Resident with Edema
Penalty
Summary
The facility failed to develop a comprehensive resident-centered care plan for a resident with chronic edema in both lower extremities. Despite the resident's admission assessment noting significant swelling and the need for leg elevation, the care plan did not include any interventions to address the edema. The resident's medical history included Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic Congestive Heart Failure (CHF), Atrial Fibrillation, and Hypertensive Heart Disease with Heart Failure, all of which contributed to her condition. The resident's progress notes documented varying degrees of pitting edema over several days, with the severity increasing to +4 on multiple occasions. Despite these observations, there were no documented interventions such as leg elevation or other measures to manage the edema. Interviews with the resident, her responsible party, and facility staff revealed that the resident was not assisted in elevating her legs, and no specific instructions were given to the staff to monitor or ensure leg elevation. The facility's policy required a comprehensive person-centered care plan upon admission, but this was not followed. The Director of Nursing (DON) and other staff confirmed that the care plan did not address the resident's edema, and no interventions were implemented to manage the condition. The oversight was acknowledged by the facility's Regional Clinical Educator, who confirmed that nursing interventions should have been included in the care plan based on the resident's initial assessment.
Failure to Ensure Proper Oxygen Delivery
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards by not ensuring that oxygen was delivered at the ordered rate for a resident. Resident #42, who has diagnoses including Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease, had an order for oxygen at 2 liters per nasal cannula (NC) continuously. During an observation, it was noted that the oxygen tubing had a knot/kink, obstructing the oxygen flow. This was confirmed by an LPN who observed the resident and removed the knot/kink from the tubing, acknowledging that it was obstructing the oxygen flow.
Failure to Ensure Proper Medication Labeling and Administration
Penalty
Summary
The facility failed to ensure medications were labeled to reflect medication adjustments as ordered by the physician for one resident. The resident, who had diagnoses including Hypertensive Heart Disease with Heart Failure, Cognitive Communication Deficits, and Unspecified Pain, had a physician's order for Tramadol ER 100mg to be taken every 12 hours as needed for pain. However, the medication card was labeled incorrectly, indicating Tramadol 50mg, and the resident received incorrect dosages on multiple occasions. Specifically, the resident received only 50mg of Tramadol instead of the prescribed 100mg on several dates, as confirmed by the LPN and the Regional Clinical Specialist during the review of the narcotic records and medication card. The deficiency was identified during a review of the resident's electronic health record and individual narcotics record, which showed discrepancies between the physician's order and the medication administered. The LPN and Regional Clinical Specialist confirmed that the resident should have received 100mg of Tramadol each time the medication was administered, but the resident only received 50mg on multiple occasions. This failure to properly label and administer the medication as ordered by the physician had the potential to affect the resident's pain management and overall health condition.
Incorrect Medication Labeling
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflected current standards of practice. Specifically, the facility did not ensure that medication was labeled as per physician orders for one resident. During an observation of medication administration, it was found that the medication card for Potassium Chloride 20meq was incorrectly labeled. The label instructed to take 1 & 1/2 tablets (30meq) by mouth once now, then resume 1 tablet by mouth once daily, whereas the physician's orders and the Medication Administration Record (MAR) indicated to give 2 tablets (40meq) daily. This discrepancy was confirmed by the LPN and the Director of Nursing (DON) during a review of the physician orders and MAR. The incorrect labeling of the medication card was identified during a medication administration observation. The LPN reviewed the Electronic Medical Record (EMR) and confirmed that the physician's order dated 05/17/2024 was for Potassium Chloride 20meq to be given as 2 tablets daily. However, the medication card in the storage bin for the resident was labeled incorrectly, and there was no other medication card with the correct label available. This deficiency had the potential to affect the care of 69 residents in the facility.
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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