The Guest House Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 10145 Florida Blvd, Baton Rouge, Louisiana 70815
- CMS Provider Number
- 195537
- Inspections on file
- 26
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Guest House Care Center during CMS and state inspections, most recent first.
The facility failed to implement comprehensive care plans for two residents. One resident, with multiple diagnoses including dementia and a fractured femur, did not have wheelchair brake extenders as ordered by a physician. Another resident, dependent on assistance for ADLs, lacked a care plan addressing these needs. Staff confirmed these oversights, indicating a failure to follow physician's orders and properly plan for resident care.
A resident with a history of falls and multiple diagnoses, including a fractured femur and dementia, experienced an unwitnessed fall in the lounge area. The facility failed to update the resident's care plan with new fall interventions after the incident, as confirmed by the MDS nurse and DON, who acknowledged the oversight in care plan revision responsibilities.
A resident with chronic pain was prescribed Oxycodone, but an LPN failed to document its administration in the MAR at the time it was given. The LPN admitted to delaying documentation until later in the shift, leading to multiple instances of late entries over two months. The DON confirmed that immediate documentation was expected but not followed.
A resident experienced a significant change in condition, including pain and inability to ambulate, which was not reported to the on-call medical provider as required. This delay led to a diagnosis of a femur fracture and necessitated a hospital transfer for surgery. Interviews with staff confirmed the oversight in communication.
A resident in a long-term care facility experienced a significant change in condition, including new onset pain, swelling, and inability to bear weight, which was not adequately recognized, monitored, or documented by the nursing staff. Despite the resident's severe cognitive impairment and baseline of independent ambulation, the staff failed to notify the medical provider or document the changes, leading to a delay in treatment. The resident was later diagnosed with a femur fracture, requiring hospitalization and surgery.
A resident with a documented Do Not Resuscitate (DNR) order was found unresponsive with a belt around their neck. An LPN initiated CPR without checking the resident's code status, contrary to the facility's policy. The Director of Nursing confirmed the lapse in procedure, highlighting a failure to respect the resident's advance directive.
The facility failed to maintain accurate medical records for a resident with Major Depressive Disorder. An LPN documented sadness on the MAR due to system limitations, despite the resident not displaying such symptoms. The DON confirmed the inaccuracies.
The facility failed to provide timely incontinence care for two residents, leaving them in soiled conditions for an extended period. Both residents were found with saturated incontinence briefs, pads, and sheets, and one had stool on her buttocks. The assigned CNA did not perform the required care during her shift and did not seek assistance.
The facility failed to assess a resident for the risk of entrapment from bedrails and did not obtain informed consent prior to their installation. The resident had multiple diagnoses and required side rails for bed mobility, but there was no documentation of an entrapment risk assessment or consent from the resident's representative.
The facility failed to ensure that CNAs demonstrated competency in necessary skills and techniques, leading to inadequate care for two residents. One resident was not transferred out of bed as needed, and another received an inexperienced bed bath. The CNA's orientation was signed off without proper competency checks, and the CNA lacked computer access to review care plans.
The facility failed to ensure that a newly hired CNA was competent in assisting residents with ADLs, leading to inadequate care for two residents. The CNA did not receive proper training or supervision, and her competency was signed off without verification.
A resident with moderate cognitive impairment and requiring extensive assistance with transfers was not assisted out of bed at her requested time of 10:00 a.m. Staff were aware of her preference but failed to provide the necessary assistance, leaving the resident in bed until her family member arrived to help.
The facility failed to ensure residents received mail on Saturdays, affecting four residents. Staff responsible for mail distribution only worked Monday through Friday, resulting in weekend mail being held until Monday.
The facility failed to resolve a grievance regarding a missing phone charger for a resident with severe cognitive impairment. The issue was reported to a CNA and an LPN, but neither escalated it to the administration, resulting in the grievance not being documented or resolved as required by the facility's policy.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #2, who was admitted with diagnoses including muscle weakness, dementia, Alzheimer's disease, repeated falls, and a fracture to the right femur, had a physician's order for wheelchair brake extenders for safety. However, during an observation, it was noted that the brake extenders were not in place, and the Assistant Director of Nursing (S2ADON) confirmed this oversight. The Director of Nursing (S1DON) also acknowledged that staff were expected to follow physician's orders, which was not done in this case. Resident #3, admitted with diagnoses including a fractured right femur, dementia, pain, and insomnia, was found to be dependent on assistance for activities of daily living (ADLs) such as eating, oral hygiene, toileting, showering, dressing, and personal hygiene. Despite these needs, the resident's care plan lacked interventions for ADLs dependency deficits. The MDS Coordinator (S3MDS) confirmed that these deficits should have been addressed in the care plan, and the Director of Nursing (S1DON) also verified that the resident was not properly care planned for these needs.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a resident's care plan to include updated fall interventions after a fall incident. Resident #3, who was admitted with diagnoses including a fractured right femur, dementia, pain, and insomnia, experienced an unwitnessed fall in the common lounge area on 12/31/2024. The resident was found sitting half on the wheelchair footrest with her right leg hanging over it, having slid out of the wheelchair. Despite this incident, the resident's care plan was not updated to include new interventions to prevent future falls. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was responsible for updating care plans following incidents such as falls. Both the MDS nurse and the Director of Nursing (DON) confirmed that the care plan should have been revised to include interventions after the fall on 12/31/2024, but it was not. This oversight indicates a failure in the facility's process for ensuring timely updates to care plans following significant events affecting resident safety.
Failure to Document Timely Administration of Pain Medication
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality in the administration of pain medication for one of the residents reviewed. Specifically, the facility did not document the administration of Oxycodone in the Medication Administration Record (MAR) at the time of administration for a resident who was prescribed Oxycodone 10 mg four times daily for chronic pain. The resident had a medical history that included chronic pain, opioid use, peripheral vascular disease, and an acquired absence of the right leg above the knee. The Licensed Practical Nurse (LPN) responsible for administering the medication admitted to not documenting the administration of Oxycodone at the time it was given. Instead, the LPN would wait until later in the shift to enter all documentation, resulting in multiple instances of delayed documentation over a two-month period. The Director of Nursing (DON) confirmed that the expectation was for nurses to document medication administration immediately after it was completed, which was not adhered to in this case.
Failure to Report Significant Change in Condition
Penalty
Summary
The facility failed to ensure timely communication of a significant change in condition to a resident's physician, resulting in an Immediate Jeopardy situation. A resident, who was typically active and able to ambulate independently, experienced a significant change in condition on the morning of July 13, 2024. The resident complained of pain in the lower extremities, exhibited swelling in the left knee, and was unable to bear weight or ambulate. Despite these symptoms indicating a significant change in condition, the on-call medical provider was not notified immediately by the nursing staff. The resident's condition continued to decline over the following days, with no further documentation or notification to the medical provider until July 15, 2024. On this date, an x-ray was ordered, revealing an acute left proximal femur fracture and chondral irregularity of the left femoral head, which could indicate avascular necrosis (AVN). The delay in notification and subsequent medical intervention resulted in the resident being transferred to the hospital for a Left Hip Hemiarthroplasty on July 16, 2024. Interviews with facility staff confirmed that the resident's significant change in condition was recognized but not reported to the medical provider as required by the facility's policy. The LPNs and the Assistant Director of Nursing acknowledged the oversight and confirmed that the on-call nurse practitioner should have been notified immediately. The delay in reporting led to a decline in the resident's range of motion, mobility, and prolonged pain.
Failure to Recognize and Address Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for a resident who experienced a significant change in condition. The resident, who was severely cognitively impaired, was observed to have new onset pain in the lower extremities, swelling in the left knee, and was unable to bear weight or ambulate. Despite these symptoms, the nursing staff did not recognize, monitor, intervene, or document the resident's condition adequately, leading to a delay in treatment. The resident's medical records indicated that prior to the incident, the resident was ambulatory without assistance or pain and was continent. However, from the morning of the incident, the resident exhibited signs of pain, decreased mobility, and new onset incontinence. The nursing staff, including LPNs and CNAs, observed these changes but failed to notify the medical provider or document the resident's condition changes in a timely manner. The resident was eventually diagnosed with an acute left proximal femur fracture after an x-ray was ordered two days later, resulting in hospitalization and surgery. Interviews with the nursing staff revealed a lack of communication and documentation regarding the resident's condition. The staff assumed the resident's symptoms were related to a gout flare-up, which was not previously documented, and did not take appropriate action to address the significant change in condition. The delay in notifying the medical provider and the lack of documentation contributed to the resident's prolonged pain and decline in mobility.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's advance directive, specifically a Do Not Resuscitate (DNR) order. The resident, who had a documented DNR status in their clinical record and care plan, was found unresponsive with a belt around their neck. Despite the clear documentation of the resident's wishes, the Licensed Practical Nurse (LPN) who discovered the resident initiated Cardiopulmonary Resuscitation (CPR) without first checking the resident's code status. This action was contrary to the facility's policy, which requires staff to verify the resident's advance medical directive before initiating CPR. The Director of Nursing (DON) confirmed that the LPN did not follow the proper procedure, which mandates checking the chart for code status before performing CPR. The LPN admitted to panicking upon finding the resident unresponsive and starting CPR without verifying the DNR order. This failure to adhere to the resident's advance directive represents a significant deficiency in the facility's compliance with respecting residents' rights to refuse treatment.
Inaccurate Documentation of Medication Administration Record
Penalty
Summary
The facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices for one resident. Specifically, the nursing staff inaccurately documented the Medication Administration Record (MAR) for a resident diagnosed with Major Depressive Disorder. The MAR indicated that the resident exhibited sadness on multiple dates, signed by the same LPN. However, during an interview, the LPN admitted that the resident never displayed signs of sadness or depression and that she documented sadness because the electronic system did not allow her to select any other option. The Director of Nursing confirmed the inaccurate documentation upon review.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene. Specifically, the facility did not provide timely incontinence care for two residents, Resident #75 and Resident #88. Resident #75, who had severe cognitive impairment and was always incontinent of bowel and bladder, was observed with a strong urine odor in her room and was found with a saturated incontinence brief, incontinence pad, and fitted sheet, along with stool on her buttocks. Similarly, Resident #88, who had intact cognition but required assistance with ADLs and was at high risk for skin breakdown, was also found with a strong urine odor in her room and a saturated incontinence brief, incontinence pad, and top sheet. Both residents had not received incontinence care during the shift as required by their care plans, which specified care every two hours and as needed. Interviews with the CNA assigned to these residents revealed that she had not provided incontinence care to either resident during her shift and had not reported her inability to complete her duties or asked for assistance. Further interviews with other staff members and the Director of Nursing confirmed that the lack of timely incontinence care was unacceptable and that incontinence rounds should have been performed every two hours. The failure to provide timely incontinence care resulted in both residents being left in soiled conditions for an extended period, which was confirmed by multiple observations and staff interviews.
Failure to Assess Entrapment Risk and Obtain Consent for Bedrails
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bedrails and did not obtain informed consent for bedrails prior to their installation. Specifically, Resident #41, who had multiple diagnoses including movement disorders, dementia, and muscle weakness, was found to have quarter side rails in use without any documented entrapment risk assessment or consent from the resident's representative. The resident's clinical record showed physician orders for the use of side rails for bed mobility and repositioning, but there was no documentation of an entrapment risk assessment or consent for the use of these side rails. Observations and interviews confirmed that the side rails were in use whenever the resident was in bed. Staff interviews revealed that while the side rails were assessed for proper function, no assessment for entrapment risk was conducted. Additionally, the Director of Nursing was unable to provide any documentation indicating that the resident's representative had given consent for the use of the side rails. This lack of documentation and assessment led to the deficiency identified in the report.
Inadequate CNA Training and Competency Checks
Penalty
Summary
The facility failed to ensure that each nurse aide demonstrated competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. Specifically, two residents were affected by this deficiency. Resident #28, who has moderate cognitive impairment and requires extensive assistance with transfers, was not transferred out of bed as needed. The CNA assigned to her was unsure of the resident's transfer status and did not seek assistance from another staff member, despite being unable to perform the transfer alone. This resulted in the resident remaining in bed and feeling that the CNA was incompetent to assist with her transfer needs. Resident #34, who is cognitively intact and requires partial/moderate assistance with bathing, reported that the CNA assigned to her was inexperienced and asked for guidance on how to perform a bed bath. The CNA, who had only been working at the facility for a few days, had not received proper training or computer access to review the residents' care plans. The CNA's orientation was signed off as complete without a return demonstration of care tasks, leading to inadequate care being provided to the resident. Interviews with staff revealed that the CNA's orientation and competency checks were not thoroughly conducted. The CNA responsible for training and signing off on the orientation did not observe the new CNA performing care tasks to ensure competency. Additionally, the Director of Nursing and the Administrator confirmed that the CNA should not have been providing care without knowing the specific assistance each resident required. This lack of proper training and oversight resulted in the CNA being unprepared to meet the residents' needs effectively.
Failure to Ensure CNA Competency in Resident Care
Penalty
Summary
The facility failed to ensure that its resources were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for its residents. Specifically, the facility did not have an effective system in place to ensure that a newly hired CNA was competent in the necessary skills and techniques for assisting residents with activities of daily living (ADLs). This deficiency was identified through interviews and record reviews involving two residents who required assistance with ADLs. One resident, who had diagnoses including hemiplegia and generalized muscle weakness, required assistance with transfers and needed to be transferred on her strong side. The CNA admitted that she was unable to transfer the resident out of bed by herself and did not seek additional help, despite the resident's request. The CNA also stated that she was unsure how to identify a resident's transfer status or the level of assistance required for ADLs. Another resident, who had diagnoses including a fracture of the neck of the femur and morbid obesity, required extensive assistance with ADLs and preferred bed baths. The CNA, who had not received computer login or training on the facility's system, provided a bed bath to the resident without prior demonstration or supervision. The CNA's competency was signed off by a supervisor without proper observation or verification. The Director of Nursing and the Administrator confirmed that the CNA should not have provided care without knowing the specific assistance each resident required and that the supervisor should have ensured the CNA's competency before allowing her to work independently.
Failure to Support Resident's Choice for Transfer Time
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting Resident #28's choice of when to get out of bed. Resident #28, who has moderate cognitive impairment and requires extensive assistance with transfers, expressed a preference to be out of bed by 10:00 a.m. On the day of the incident, Resident #28 requested assistance from S5CNA to be transferred to her wheelchair at 10:00 a.m., but this assistance was not provided. S5CNA informed S4LPN that she could not assist Resident #28 independently, and S4LPN instructed her to get another CNA for help. However, this did not happen, and Resident #28 remained in bed until her family member arrived and transferred her to the wheelchair. Interviews with staff members confirmed that Resident #28's request to be out of bed by 10:00 a.m. was known and should have been honored. S4LPN and S3CNAS both acknowledged that Resident #28 should have been assisted out of bed when she requested. The Director of Nursing (S2DON) also confirmed that Resident #28 should have been transferred out of bed by staff and should not have had to wait for her family member to arrive. This failure to assist Resident #28 in a timely manner demonstrates a lack of support for the resident's right to self-determination and choice.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, affecting four residents (#6, #51, #53, and #66) out of 17 reviewed during a resident council meeting. The facility's General Admission & Financial Agreement states that residents have the right to promptly receive unopened mail. However, interviews with staff members S5AD and S4FIN revealed that mail delivered on weekends was held until the following Monday due to the absence of staff responsible for mail distribution on Saturdays. Both staff members confirmed that they only worked Monday through Friday, leading to a delay in mail delivery for residents over the weekend.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to initiate and resolve grievances for a resident with severe cognitive impairment. The grievance policy requires that grievances be documented and resolved promptly, but this was not followed in the case of a missing phone charger reported by the resident's responsible party (RP). The RP reported the missing item to a nurse, who searched for it but did not find it. The nurse did not report the missing item to the administration, and as a result, the grievance was not documented or resolved as per the facility's policy. Interviews with staff confirmed that the missing phone charger was reported to a CNA and an LPN, but neither took the necessary steps to escalate the issue to the administration. The Director of Nursing (DON) and the Administrator were unaware of the missing item until the surveyor's investigation. This failure to follow the grievance policy resulted in the resident's grievance not being addressed or resolved in a timely manner.
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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