The Guest House Skilled Nursing Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 9225 Normandie Drive, Shreveport, Louisiana 71118
- CMS Provider Number
- 195380
- Inspections on file
- 30
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Guest House Skilled Nursing Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment eloped from the facility by crawling out of a window, highlighting the facility's failure to perform required visual checks on high-risk residents. Video surveillance showed staff did not conduct checks on other residents at risk for elopement, violating facility policy. Interviews confirmed the resident had a history of exit-seeking behaviors, yet effective preventive measures were not in place.
The facility failed to supervise residents at risk for elopement, leading to a resident eloping and being found a mile away. The resident, moderately cognitively impaired, exited through a window and was not missed until a call from a responsible party. Video review showed staff did not perform required checks on other at-risk residents. Interviews confirmed the lack of supervision, highlighting a deficiency in monitoring procedures.
A resident with multiple health issues, including dementia, eloped from the facility through a window and was found at a gas station. The facility failed to report this incident to the State Survey and Certification Agency and did not complete an investigation as required by their policy.
A resident with dementia eloped from the facility and was found at a gas station. The staff failed to conduct a thorough investigation into the incident, despite facility policies requiring such actions. The DON and Administrator acknowledged the lack of investigation.
The facility failed to conduct weekly skin assessments and implement wound care plans for residents with a history of wounds. A resident with a resolved unstageable pressure ulcer, another with a resolved sacral DTI, and a third with a chronic arterial ulcer did not receive necessary assessments or care planning. Staff confirmed these deficiencies, acknowledging the lack of adherence to the facility's procedures for pressure ulcer prevention and risk assessment.
A facility failed to document the destruction of 13 tablets of Sulfamethoxazole-Trimethoprim for a resident. The resident had two orders for the medication, with 32 tablets dispensed and only 19 administered. Interviews with the DON and a Corporate Nurse confirmed the discrepancy, and the facility's logs lacked documentation for the destruction of the remaining tablets.
The facility failed to verify the licensure of two staff members, S6 and S7, before allowing them to perform duties as licensed nurses. S6 was only licensed in Texas, not Louisiana, and S7's licensure status was not verified upon hire or annually, as required.
The facility failed to update the care plan for a resident admitted to Hospice. The resident's physician's orders indicated Hospice admission, but the care plan did not reflect this change or include related interventions. The MDS Coordinator confirmed the oversight during an interview.
The facility failed to ensure that a resident's oxygen concentrator filter was cleaned weekly as required, resulting in the filter being covered with a large amount of fluffy gray particles. The DON acknowledged the oversight.
Failure to Supervise High-Risk Residents Leads to Elopement
Penalty
Summary
The facility failed to adequately supervise cognitively impaired residents who were at high risk for elopement, resulting in an Immediate Jeopardy situation. Resident #1, who had a moderate cognitive impairment and was known for exit-seeking behaviors, managed to elope from the facility by crawling out of a window. The staff was unaware of the resident's absence until they received a call from the resident's responsible party, who found the resident at a gas station approximately one mile away. This incident highlighted the facility's failure to perform visual checks every two hours as required by their policy. Further investigation revealed that the facility's staff did not conduct the necessary visual checks on other residents identified as high risk for elopement, such as Residents #5 and #6. Video surveillance showed that staff failed to perform these checks during the night shift, which was a direct violation of the facility's policy. Both residents had severe cognitive impairments and were at risk for elopement, yet the staff did not enter their rooms to ensure their safety. Interviews with various staff members confirmed that Resident #1 had a history of exit-seeking behaviors, such as following staff and visitors out of the facility. Despite this, the facility did not implement effective measures to prevent the resident from leaving. The lack of supervision and failure to adhere to the facility's policies put multiple residents at risk, demonstrating a significant oversight in maintaining a safe environment for those at risk of elopement.
Failure to Supervise Residents at Risk for Elopement
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency related to the supervision of residents at risk for elopement. Specifically, the facility did not have an adequate system in place to ensure that three of six sampled residents who were at risk for elopement were adequately supervised. This lack of oversight led to an Immediate Jeopardy situation when a moderately cognitively impaired resident, who ambulated with a walker, was able to elope from the facility. The resident crawled out of a window and was found at a gas station approximately one mile away, having traversed a dark single-lane highway and a four-lane divided highway during the night. The resident had been assessed as at risk for elopement, but protective measures were not implemented despite a documented history of exit-seeking behaviors. Further review of the facility's video surveillance revealed that staff failed to perform visual checks on residents every two hours as required by the facility's policy. This was particularly evident on Hall A, where two other residents identified at risk for elopement were not adequately monitored. Interviews with the Corporate Nurse and Assistant Administrator confirmed that the night shift staff did not complete the required visual checks, which had the potential to adversely affect the remaining ten residents at risk for elopement. The facility's failure to ensure that nurses and CNAs were performing routine checks every two hours contributed to the deficiency.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an alleged violation involving neglect to the State Survey and Certification Agency. This deficiency was identified during a review of an incident involving a resident who eloped from the facility. The facility's policy requires that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. However, the facility did not adhere to this policy in the case of the resident's elopement. The incident involved a resident with a history of chronic obstructive pulmonary disease, heart failure, depression, insomnia, problems related to living alone, and a history of falling. The resident was found at a gas station by a responsible party after eloping from the facility through a window. The staff had previously observed what appeared to be the resident asleep in bed, but upon further inspection, it was discovered that the bed was stuffed with pillows and blankets to resemble a body. The facility's incident investigation reports did not document the resident's elopement, and the administrator acknowledged that an investigation was not completed as required.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation involving the elopement of a resident with dementia. The resident was found at a gas station by a responsible party after leaving the facility through a window. The staff had previously observed what appeared to be the resident asleep in bed, but upon further inspection, it was discovered that the bed was stuffed with pillows and blankets to resemble a body. The facility's policy required routine resident checks to ensure safety, but it is unclear if these checks were conducted as required. Interviews revealed that the Director of Nursing was notified of the incident the following day, but an investigation was not completed. The Administrator also acknowledged that an investigation should have been conducted but was not. The lack of a thorough investigation into the resident's elopement represents a failure to adhere to the facility's policy on abuse investigation and reporting, which mandates prompt reporting and thorough investigation of all alleged violations.
Failure to Conduct Weekly Skin Assessments and Implement Wound Care Plans
Penalty
Summary
The facility failed to provide necessary treatment and services to residents with wounds or a history of wounds, as required by professional standards of practice. This deficiency was identified for three residents who did not receive weekly skin assessments or have a written wound care plan implemented. The facility's procedures for the prevention of pressure ulcers and injury risk assessment were not followed, as evidenced by the lack of comprehensive skin assessments upon admission and the absence of weekly body audits to identify abnormal skin conditions. Resident 1, with a history of an unstageable pressure ulcer, did not have weekly skin assessments performed after the ulcer resolved, and there was no care plan for wound prevention. Resident 2, with a history of a resolved sacral deep tissue injury, also lacked weekly skin assessments and a care plan for wound history. Resident 3, who had a chronic arterial ulcer of the sacrum, did not receive weekly skin assessments. Interviews with facility staff confirmed these deficiencies, acknowledging that the required assessments and care planning were not conducted.
Failure to Document Medication Disposal
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of a resident by not accurately disposing of medications. Specifically, the facility did not document the destruction of 13 tablets of Sulfamethoxazole-Trimethoprim that were not administered to a resident. The facility's policy requires that unused medications be destroyed and documented, but this was not followed in this case. The resident had two separate orders for Sulfamethoxazole-Trimethoprim, with a total of 32 tablets dispensed, but only 19 tablets were documented as administered. Interviews with the Director of Nursing (DON) and a Corporate Nurse confirmed the discrepancy in the medication records. Both acknowledged that the pharmacy dispensed two separate orders for the medication, resulting in 32 tablets, but only 19 were administered according to the records. The facility's medication destruction logs did not show any documentation for the destruction of the remaining 13 tablets, indicating a failure to comply with the facility's policy for medication disposal.
Failure to Verify Nursing Licenses
Penalty
Summary
The facility failed to ensure that two staff members, identified as S6 and S7, were licensed in accordance with applicable state laws before performing duties as licensed nurses. S6 was hired without verification of a practical nurse license for the state of Louisiana, although they held a license for Texas that had expired. During an interview, S6 confirmed they had applied for a Louisiana multistate license but had not yet received it, indicating they only had a license to practice in Texas. Similarly, S7 was hired without verification of their licensure status. The facility provided evidence of a Louisiana practical nurse license that had expired and a registered nurse license with an alert from the Louisiana Registered Nurse Board of Nursing, indicating further verification was needed. The facility did not conduct a license verification for S7 upon hire and had not verified their licensure status annually since their date of hire. This was confirmed by S3 Corporate Nurse, who acknowledged the lack of documentation proving S7 had an active license in Louisiana.
Failure to Update Care Plan for Hospice Admission
Penalty
Summary
The facility failed to ensure the plan of care was revised for a resident who was admitted to Hospice. The resident's physician's orders indicated an admission to Hospice on 03/13/2024. However, a review of the resident's comprehensive care plan revealed that it had not been updated to include the Hospice admission or any related interventions and services. During an interview on 05/08/2024, the MDS Coordinator confirmed that the resident had been admitted to Hospice on 03/13/2024 and acknowledged that the care plan had not been updated accordingly.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident. Specifically, the facility did not ensure that the oxygen concentrator filter for a resident with chronic obstructive pulmonary disease and other medical conditions was cleaned weekly as required. The resident's physician's orders included instructions to clean the concentrator filter every Wednesday night shift and as needed for contamination. However, an observation revealed that the filter was covered with a large amount of fluffy gray particles, indicating it had not been cleaned. The Director of Nursing acknowledged that the filter was dirty and should have been cleaned during the scheduled maintenance.
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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