The Woodleigh Of Baton Rouge
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 14333 Old Hammond Hwy., Baton Rouge, Louisiana 70816
- CMS Provider Number
- 195472
- Inspections on file
- 22
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Woodleigh Of Baton Rouge during CMS and state inspections, most recent first.
The facility did not ensure that code status documentation was consistent across medical records for two residents. In both cases, discrepancies existed between the LaPost forms, physician orders, and EHRs, with staff confirming that they would follow the physical chart in emergencies, potentially leading to actions not aligned with the residents' wishes. Staff and leadership acknowledged that all records should match to honor resident preferences.
A resident with multiple chronic conditions requiring oxygen therapy was found to have oxygen tubing that was not labeled with the date it was last changed. Observations and staff interviews confirmed that the tubing should have been changed and labeled weekly, but this was not done, resulting in a deficiency in respiratory care.
Surveyors found that an expired medication was still available for use in one medication cart, and an opened bottle of Vitamin D tablets was not labeled with the date it was opened. Both an LPN and the DON confirmed these deficiencies during interviews.
Surveyors found an outdoor trash dumpster with its door open and a bag containing soiled briefs and gloves hanging out, along with scattered trash such as plastic cups, utensils, gloves, and other items on the ground. Staff confirmed the area should be kept clean and the dumpster doors closed, but maintenance did not ensure proper containment and disposal of waste.
A resident with an indwelling urinary catheter was not placed on Enhanced Barrier Precautions as required by facility policy, and an LPN performed catheter care using only gloves instead of both gown and gloves. Staff interviews confirmed that the necessary precautions and signage were not implemented for the resident, despite the presence of a urinary catheter and related diagnoses.
A resident with significant mobility impairments and a care plan requiring the call light to be within reach was repeatedly observed with the call light on the floor and inaccessible. Staff and the DON confirmed the call light should have been accessible at all times, in accordance with facility policy and the resident's documented needs.
A resident's unopened Ipratropium-Albuterol Solution was observed left on the bedside table on two occasions, rather than being stored in a locked medication cart as required by facility policy. Both an LPN and the DON confirmed that medications should not be left at the bedside and acknowledged the nurse's responsibility for proper storage.
A resident who returned from the hospital with a left arm in a sling was documented in the MDS as needing only setup or cleanup help for meals, but observations and staff interviews confirmed the resident was actually dependent on staff for feeding. The MDS coordinator and DON confirmed the assessment was based on documentation that did not accurately reflect the resident's true needs.
A resident with moderate cognitive impairment and a history of falls, who was always incontinent but aware of toileting needs, was not provided with a bowel and bladder program or scheduled toileting. Staff instructed the resident to use briefs instead of assisting with commode transfers, and no interventions were in place to promote continence, despite the resident's ability and preference to use the toilet.
A resident with significant physical limitations and moderate cognitive impairment was dependent on staff for eating, but ADL documentation inconsistently recorded the level of assistance provided. Staff interviews and observations confirmed the resident required total dependence for eating, yet records showed varying levels of assistance, resulting in inaccurate documentation.
A resident suffered fractures in both femurs after a CNA inappropriately used a slide board for a transfer. The CNA had received computer-based training but had not completed a return demonstration to ensure competency. The facility lacked consistent training and competency checks for slide board transfers, leading to the incident.
The facility failed to ensure all licensed nursing and CNA staff had documented new hire and annual competency demonstrations for their roles. Personnel files of five staff members showed no evidence of completed competencies, and interviews confirmed that CNAs did not demonstrate skills before working independently or annually. The DON acknowledged the lack of competency demonstrations despite regular in-service trainings.
The facility failed to ensure that nurse staffing data was posted in a prominent location accessible to residents and visitors. The daily nursing staff sheet was found behind the nurses' station in a restricted area, confirmed by the DON.
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days for four residents. Interviews with the pharmacist and DON confirmed that PRN Lorazepam orders for these residents had no stop dates, violating the 14-day limit requirement.
The facility failed to ensure accurate MDS assessments for two residents reviewed for PASRR. Both residents had approved Level II PASRRs, but their Annual MDS assessments incorrectly indicated they were not evaluated for PASRR. Staff confirmed the assessments should have included the state Level II PASRR but did not.
The facility failed to ensure medications were administered safely and timely by leaving medications at the bedside for a resident. The resident confirmed that the medications were his morning doses and that the LPN had left them for him to take when he was ready because he was feeling nauseated. The LPN verified that she did not observe the resident take his medications, which she acknowledged she should have done. The DON confirmed that medications should not have been left at the resident's bedside and that the nurse should have observed the resident taking his medications.
A resident with hemiplegia, hemiparesis, and type 2 diabetes mellitus did not receive necessary nail care, resulting in long, dirty fingernails despite multiple requests and observations by staff. Inconsistencies in staff responsibilities and communication contributed to the deficiency.
A resident with Unspecified Protein-Calorie Malnutrition did not consistently receive the prescribed House Shake Supplement with meals, as ordered by the healthcare provider. Observations and interviews confirmed that the supplement was often missing from the resident's meal trays, despite the dietary and nursing staff being aware of the order.
A resident reported missing clothing and a blanket, but the facility failed to log the grievance or resolve the issue promptly. Staff did not follow the facility's policy, resulting in the resident not being informed of any findings or corrective actions.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that all medical records accurately reflected residents' wishes regarding code status for two residents. For one resident, the physical chart contained a LaPost form signed by the resident's Power of Attorney and physician indicating Do Not Resuscitate (DNR), while the physician orders and electronic health record (EHR) listed the resident as Full Code. Staff interviews confirmed that the LaPost and EHR did not match, and the Director of Nursing acknowledged that all records should reflect the resident's end-of-life wishes but did not. For another resident, the physical chart's LaPost form indicated Full Code, while the hospice binder contained a LaPost signed by a family member and physician indicating DNR. The physician orders and EHR also listed DNR, but the physical chart did not match. Staff interviews revealed that in an emergency, staff would refer to the physical chart, which could result in actions inconsistent with the resident's wishes. The resident confirmed a desire for CPR, but documentation across records was inconsistent, and staff acknowledged that all records should be consistent.
Failure to Label and Change Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide necessary care and services for respiratory care in accordance with professional standards for one resident. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Diastolic Heart Failure, Ischemic Cardiomyopathy, and Asthma, had a physician's order for oxygen therapy at 2 liters per nasal cannula as needed. Observations on two consecutive days revealed that the resident's oxygen tubing was not labeled with the date it was last changed. Interviews with nursing staff, including an LPN and the Director of Nursing, confirmed that the tubing should have been changed and labeled weekly, and that it was the nurse's responsibility to do so. The failure to label and change the oxygen tubing as required constituted a deficiency in the provision of respiratory care.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications in accordance with accepted professional standards. Specifically, in one medication cart, a card containing 21 tablets of Hyoscyamine Sulfate Sublingual 0.125 mg for a resident was found with a discard after date that had already passed, indicating the medication was expired but still available for use. Additionally, a bottle of Vitamin D 10 mcg tablets was found opened without a label indicating the date it was opened. During interviews, both the LPN and the Director of Nursing confirmed these findings and acknowledged that the expired medication should have been discarded and the opened bottle should have been labeled with the open date.
Improper Containment and Disposal of Outdoor Garbage and Refuse
Penalty
Summary
Surveyors observed that one of the facility's two outdoor trash dumpsters had its door open, with a clear plastic bag containing soiled briefs and gloves hanging out of the lid. Additional scattered trash, including a plastic bag, plastic cups, plastic utensils, gloves, a green cloth, empty juice containers, and other unidentifiable paper items, was found on the ground around the dumpster. Multiple staff interviews confirmed these observations and acknowledged that maintenance staff were responsible for keeping the dumpster area clean and that the dumpster doors should be kept closed with the surrounding area free of trash.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically by not implementing Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. According to the facility's policy, residents with indwelling medical devices, such as urinary catheters, should be placed on EBP, which includes the use of gown and gloves during high-contact care activities. Observations revealed that there was no EBP signage on the resident's door, and the resident was not placed on EBP despite having a urinary catheter. Interviews with staff, including the Director of Nursing and the Infection Preventionist, confirmed that the resident should have been on EBP and that the required signage and precautions were not in place. Additionally, during an observation of catheter care, an LPN performed the procedure wearing only gloves and not a gown, contrary to the facility's policy for EBP. The LPN stated that only gloves were necessary for catheter care and confirmed that she did not use a gown. The Infection Preventionist also confirmed that staff should wear both gown and gloves when providing direct care to residents on EBP and acknowledged that the resident with the urinary catheter was not on the appropriate precautions. The resident in question had a history of benign prostatic hyperplasia with urinary retention and a urinary tract infection, and had an indwelling catheter in place at the time of the deficiency.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia, hemiparesis, left hand and elbow contractures, and a need for extensive assistance with activities of daily living was found to have their call light out of reach on multiple occasions. The resident's care plan specifically included interventions to keep the call light within reach due to their decreased mobility, history of falls, and self-care deficits. Despite these documented needs and interventions, observations on two consecutive days revealed the call light lying on the floor at the foot of the bed, not accessible to the resident while she was sitting up in bed. Interviews with the resident, a CNA, and the Director of Nursing confirmed that the call light was not within reach and that it should have been accessible at all times when the resident was in her room. The facility's policy also required that each resident be provided with a means to call staff for assistance from their bed. The failure to ensure the call light was within reach represented a lack of reasonable accommodation for the resident's needs and preferences as outlined in her care plan and the facility's policy.
Medication Storage Policy Not Followed
Penalty
Summary
The facility failed to ensure that medications were stored safely and in accordance with professional standards, as required by its own policy. During observations, an unopened package of Ipratropium-Albuterol Solution was found left on the bedside table of a resident on two separate occasions. The resident, who was cognitively intact and had diagnoses including wheezing and acute cough, confirmed that the medication belonged to her. According to the facility's policy, all medications are to be stored in locked compartments and only accessible to authorized personnel, with nursing staff responsible for maintaining safe storage practices. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the medication should not have been left at the bedside and should have been stored in the locked medication cart. Both staff members acknowledged that it was the nurse's responsibility to ensure proper storage of medications. The failure to secure the medication as per policy constituted a lapse in maintaining professional standards of quality for medication storage.
Inaccurate Resident Assessment for Eating Assistance
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual status of a resident regarding the assistance required for eating. A review of the clinical record for a resident who was readmitted to the facility with a left upper extremity sling revealed that the Quarterly MDS Assessment indicated the resident only required setup or cleanup assistance for meals. However, direct observation showed that the resident was being fed by staff, with one staff member feeding the resident and another holding a cup and placing a straw to the resident's lips. Multiple staff interviews confirmed that since the resident's return from the hospital with a sling, he had been dependent on staff for feeding due to limited range of motion. The MDS coordinator acknowledged that the assessment was based on electronic health record documentation, which should have accurately reflected the resident's needs, but was unaware of the resident's dependency for meals. The DON also confirmed that the MDS assessment relied on ADL documentation, which should accurately represent the resident's status.
Failure to Provide Bowel and Bladder Continence Services
Penalty
Summary
The facility failed to provide appropriate services to restore or maintain normal bowel and bladder function for a resident who was always incontinent of bowel and bladder. The resident, who had a history of septic arthritis, falls, hemiplegia, and required assistance with personal care, was assessed as moderately cognitively impaired but was aware of his need to use the toilet. Despite this, the care plan interventions were limited to the use of adult briefs, checking every two hours, and encouraging the resident to call for assistance. There was no evidence of a structured bowel and bladder program or scheduled toileting to promote continence. Multiple incident reports documented the resident's attempts to use the bathroom independently, resulting in falls and near-misses. Interviews with the resident, his responsible party, and several staff members revealed that staff routinely instructed the resident to use the brief and did not offer or implement a toileting schedule or regular assistance to the commode, despite the resident's expressed preference and ability to participate. Nursing staff confirmed that a bowel and bladder program had not been initiated for the resident, and there were no current interventions in place to promote continence.
Inaccurate ADL Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of Activities of Daily Living (ADL) care for one resident who required assistance with eating. The resident, who had a history of septic arthritis in the left shoulder, hemiplegia, and hemiparesis following a cerebral infarction affecting the right side, was admitted and readmitted with significant physical limitations. Clinical records and staff interviews confirmed that the resident had a sling on the left arm and limited movement in the right arm, resulting in total dependence on staff for eating. However, the ADL documentation for the resident inconsistently recorded the level of assistance provided, with entries ranging from limited assistance to total dependence, despite staff consistently reporting that the resident was dependent on staff for eating. Observations showed staff feeding the resident and assisting with drinking, further supporting the need for total dependence coding. Multiple staff members, including CNAs, LPNs, and therapy staff, confirmed the resident's inability to feed himself due to his physical condition. The MDS coordinator acknowledged that the ADL documentation was inaccurate and should have reflected total dependence for eating, as the resident was being fed by staff throughout the reviewed period.
Inadequate Training on Slide Board Transfers
Penalty
Summary
The facility failed to ensure that each nurse aide was competent in transferring a resident using a slide board, resulting in actual harm to a resident. On 04/02/2024, a CNA inappropriately used a slide board to transfer a resident, causing the resident to fall to the floor. The resident initially denied pain but later experienced severe pain, leading to the discovery of fractures in both femurs, which required surgical intervention. The resident was cognitively intact and dependent on staff for transfers, with a care plan that included the use of a slide board for transfers due to decreased mobility and other health conditions. Interviews and record reviews revealed that the CNA had received computer-based training on slide board transfers but had not completed a return demonstration to ensure competency. The facility's training materials indicated that caregivers should position themselves in front of the patient during transfers, but the CNA was standing behind the resident during the incident. Further interviews with staff indicated that there was no consistent training or competency checks for slide board transfers, and the physical therapy staff had not provided demonstrations or training to the CNAs. The Director of Nursing confirmed that new CNA employees did not complete a slide board/transfer competency skills check upon hire or annually. The facility had conducted an in-service on safe transfers in November 2023, but staff did not complete a return demonstration to ensure competency. The CNA involved in the incident had completed computerized training in December 2023 but did not attend the in-service training. This lack of proper training and competency checks led to the inappropriate use of the slide board and the subsequent injury to the resident.
Failure to Document Staff Competency Demonstrations
Penalty
Summary
The facility failed to ensure all licensed nursing and certified nursing assistant staff had documented new hire and annual competency demonstrations for all skills related to their expected roles. This deficiency was identified in the personnel files of five staff members, including CNAs and LPNs, who had no documented evidence of competencies being completed upon hire or annually. Interviews with staff confirmed that CNAs did not demonstrate competency skills before working independently or annually, and the Director of Nursing acknowledged that while in-service skills trainings were conducted, there were no competency demonstrations by the employees themselves.
Failure to Post Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data, including resident census and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. On 05/28/24 at 11:55 a.m., an observation revealed that the daily nursing staff sheet was located behind the nurses' station in the medical record room, which was restricted to staff only. This was confirmed during an interview with the Director of Nursing (DON) at 12:18 p.m., who acknowledged that the daily nursing staff sheet was not accessible for residents or visitors to view.
Failure to Limit PRN Orders for Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for four residents. Resident #17 was admitted with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, and Insomnia. The resident had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath, with no stop date. Similarly, Resident #35, admitted with Alzheimer's Disease, Schizoaffective Disorder, Unspecified Mood Disorder, and Anxiety, had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath, also without a stop date. Resident #58, with Vascular Dementia, Major Depressive Disorder, and Schizoaffective Disorder, had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for anxiety and/or shortness of breath, again with no stop date. Resident #69, diagnosed with Unspecified Dementia, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Anxiety Disorder, had a PRN order for Lorazepam 1 mg tablet every 4 hours as needed for shortness of breath, anxiety, and/or trouble sleeping, without a stop date as well. Interviews with the pharmacist and the Director of Nursing (DON) confirmed that all PRN antipsychotic medications, including Lorazepam, required an end date of no longer than 14 days following the start of the medication. The pharmacist responsible for completing the facility's pharmaceutical consultation reports for Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) stated that PRN antipsychotic medications should have an end date. The DON confirmed the presence of PRN Lorazepam orders without stop dates for Residents #17, #35, #58, and #69, indicating a failure to comply with the 14-day limit requirement for PRN psychotropic medications.
Inaccurate MDS Assessments for PASRR
Penalty
Summary
The facility failed to ensure that resident MDS assessments accurately reflected the residents' status for two residents reviewed for PASRR. Resident #13, who was admitted with diagnoses including Major Depressive Disorder, Bipolar Disorder, Persistent Mood Affective Disorder, and Generalized Anxiety Disorder, had an approved Level II PASRR. However, the Annual MDS with ARD of 12/21/2023 incorrectly indicated that the resident was not evaluated for PASRR. Similarly, Resident #18, admitted with Schizoaffective Disorder and Bipolar Disorder, also had an approved Level II PASRR, but the Annual MDS with ARD of 01/04/2024 incorrectly indicated that the resident was not evaluated for PASRR. Interviews with staff confirmed that the MDS assessments should have included the state Level II PASRR but did not.
Failure to Administer Medications Safely and Timely
Penalty
Summary
The facility failed to ensure medications were administered safely and timely by leaving medications at the bedside for a resident. During an observation, a plastic medication cup containing 7 pills was found on the bedside table of a resident who was awake and alert. The resident confirmed that the medications were his morning doses and that the LPN had left them for him to take when he was ready because he was feeling nauseated. The LPN verified that she did not observe the resident take his medications, which she acknowledged she should have done. The Director of Nursing confirmed that medications should not have been left at the resident's bedside and that the nurse should have observed the resident taking his medications. The resident's clinical record revealed multiple diagnoses, including Polyneuropathy, Acquired Absence of both legs above the knee, Benign Prostatic Hyperplasia, Moderate Protein Calorie Malnutrition, Peripheral Vascular Disease, and Unspecified Pain. The resident was cognitively intact with a BIMS score of 15, and his physician orders included several medications to be taken daily.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not trim the fingernails of a resident with hemiplegia, hemiparesis, and type 2 diabetes mellitus. The resident, who had intact cognition and required moderate assistance for ADLs, was observed with fingernails that were 1/2 to 1 cm long and had black debris underneath. Despite the resident's requests for nail trimming, the facility staff did not provide this care adequately. Interviews with various staff members, including CNAs and LPNs, revealed inconsistencies and misunderstandings regarding who was responsible for trimming the nails of diabetic residents. While CNAs were expected to clean nails, they deferred trimming to nurses due to the residents' diabetic status. However, the Director of Nursing stated that any staff member could trim fingernails, regardless of the resident's diabetic condition. This lack of clear protocol and communication led to the resident's nails being neglected, despite multiple opportunities for care during regular shower routines and daily assessments.
Failure to Provide Prescribed Nutritional Supplement
Penalty
Summary
The facility failed to ensure a resident was offered a therapeutic diet as ordered by the healthcare provider. Resident #3, who was admitted with a diagnosis of Unspecified Protein-Calorie Malnutrition, had a physician's order for a House Shake Supplement three times a day with all meals. Despite this order, observations and interviews revealed that Resident #3 did not consistently receive the prescribed Mighty Shake with her meals. On one occasion, it was noted that Resident #3's breakfast tray did not include the Mighty Shake, and she had only consumed approximately 25% of her meal. Interviews with CNAs and an LPN confirmed that the resident was supposed to receive the supplement with all meals but did not always get it. The CNAs and LPN acknowledged that the kitchen staff should have included the supplement on the meal tray, and if it was missing, the CNAs should have retrieved it from the kitchen. Further interviews with the Dietary Manager and the Director of Nursing revealed that the process for ensuring the supplement was provided involved updating meal tickets and notifying kitchen staff of new orders. The Dietary Manager confirmed that the order for the Mighty Shake was resumed due to the resident's weight loss after hospitalization, and the supplement should have been provided with each meal. The Director of Nursing verified that the kitchen staff were responsible for sending the supplements on the meal trays and confirmed that Resident #3 should have received the Mighty Shake with her breakfast. The failure to consistently provide the prescribed nutritional supplement contributed to the resident's ongoing nutritional issues and weight fluctuations.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances for a resident who reported missing clothing and a blanket. The resident, who was cognitively intact, reported the missing items to staff but did not receive a resolution. The facility's grievance log did not document the grievance, and staff interviews revealed that the missing items were not reported to the Administrator as required by the facility's policy. The resident reported the missing items to a CNA and the housekeeping supervisor, but neither took the necessary steps to log the grievance or inform the Administrator. The facility's policy requires grievances to be investigated and resolved within five working days, but this was not followed in the case of the missing items. The Director of Nursing and the Social Services Director confirmed that no grievance was filed for the missing items, and the Administrator stated that the grievance should have been logged and resolved within the specified timeframe. The failure to follow the grievance policy resulted in the resident not being informed of the findings or any corrective actions regarding the missing items.
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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