Villa Feliciana Chronic Disease
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Louisiana.
- Location
- 5002 Highway 10, Jackson, Louisiana 70748
- CMS Provider Number
- 195150
- Inspections on file
- 29
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Villa Feliciana Chronic Disease during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering did not have a functioning Wanderguard alarm, as required by physician orders. The alarm failed to sound when the resident exited a door, and staff confirmed the system had not been tested recently. No elopement risk assessment was completed, and facility leadership was unaware of the malfunction.
The facility did not maintain adequate nursing staff as required by its Facility Assessment, resulting in staff being unable to complete timely rounds or provide necessary care to all residents. Multiple staff members, including CNAs and LPNs, reported unmanageable workloads and confirmed that staffing levels were below the required numbers, impacting the ability to meet residents' needs.
Several residents who were physically able to use the call bell system did not have call bells accessible or within reach while in bed. Observations and staff interviews confirmed that call bells were either missing from the wall system or placed on the floor behind beds, contrary to facility policy. All affected residents had no upper extremity impairment and should have had access to the call system.
A urine-soiled brief was found on the floor between a resident's bed and their roommate's bed and remained there for at least five hours. Multiple staff, including an LPN, DON, and the director of housekeeping, confirmed the brief's presence and agreed it was unacceptable for it to remain on the floor.
The facility failed to provide sufficient CNA staff on Unit 2B, where only one CNA was assigned per shift instead of the required two. This led to delays in care for 20 residents, many of whom required two staff members for ADL assistance due to behaviors. Observations and staff interviews confirmed that the staffing was inadequate to meet the residents' needs, resulting in wait times of 20 to 30 minutes for assistance.
The facility failed to accurately document medication administration for two residents, compromising the reliability of their MARs. A resident with multiple diagnoses, including Diabetes Mellitus-Type 2, had no documented evidence of receiving or refusing medications over several days. Another resident also had missing documentation for medication administration. Staff interviews revealed issues with accessing the electronic MAR system and the absence of current paper MARs, affecting the facility's compliance with its medication administration policy.
An RN at a facility was observed misappropriating medications intended for two residents, placing them in her personal bag instead of administering them. The residents, both severely cognitively impaired, were prescribed critical medications for various conditions, including cardiac and psychiatric disorders. The RN falsely documented that the residents refused their medications, leading to an Immediate Jeopardy situation. Despite the potential for serious harm, the residents reportedly suffered no negative outcomes.
Two residents' medications were misappropriated by a nursing supervisor, who was observed placing the medications into her personal bag. Despite immediate discovery, the incident was not reported to the state survey agency until several days later, violating the facility's policy and state regulations.
The facility failed to ensure staff used appropriate PPE for residents on Enhanced Barrier Precautions, as observed in three residents with chronic wound care needs and indwelling medical devices. Staff did not wear gowns during high-contact care activities, and there was no signage indicating the need for EBP, leading to staff being unaware of the precautions required.
A facility failed to ensure a resident was assisted with meals in a dignified manner. A CNA was observed standing over a resident while feeding him, contrary to the facility's policy of sitting at the resident's level. The resident, dependent on staff for eating due to medical conditions, was not fed at eye level, and the CNA acknowledged not sitting during the process. The DON confirmed the CNA should have been seated.
A resident with Schizoaffective Disorder - Bipolar Type did not receive recommended specialized services, including outpatient therapy and a psychiatric evaluation, due to a lack of an effective system for implementing Level II PASARR recommendations. Staff interviews revealed a breakdown in communication and responsibility, resulting in the oversight.
A resident with pressure ulcers did not receive the prescribed wound care treatment, as the wound vacuum was not applied, and a dry dressing was used instead. Despite this, the treatment was inaccurately documented as completed per physician orders. Interviews with the involved LPNs and the DON confirmed the discrepancy, highlighting a failure to meet professional standards of quality in the facility.
A resident with pressure ulcers did not receive the physician-ordered wound vacuum treatment, as staff applied a dry dressing instead. Interviews and observations confirmed the wound vacuum was not in place on multiple occasions, despite orders for continuous use. This lapse in care was acknowledged by the LPNs, wound care nurse, and DON, highlighting a failure to follow the facility's wound care policy.
The facility failed to protect residents from physical abuse in three separate incidents involving residents with different levels of cognitive impairment. In one case, a resident was pushed out of a wheelchair by another resident over a drink dispute. In another, a resident was slapped on the head by another resident in the day room. The third incident involved a resident being physically assaulted over a cigarette disagreement, resulting in visible injuries. These incidents were confirmed by staff and documented in medical records.
A resident with Epilepsy, Bipolar Disorder, and Alcohol Abuse did not receive their prescribed Phenobarbital dose as ordered by the physician. The medication was not administered on a specific evening, and staff interviews confirmed the oversight. The DON acknowledged that medications should be administered and documented accurately.
A resident with a known allergy to Depakote was mistakenly administered the medication due to a failure in verifying allergies during a verbal order process. An LPN did not communicate the allergy to the psychiatrist, and an RN administered the medication without checking the MAR. The error was confirmed by the facility's nursing leadership.
A facility failed to limit PRN orders for psychotropic medications to 14 days, as required by policy. A resident with dementia, psychosis, and schizophrenia was prescribed Ativan without a stop date or duration, and it was administered multiple times. The DON confirmed the order exceeded 14 days without proper documentation.
The facility failed to notify the physician when three residents exhibited abnormal behaviors, including lethargy and unsteady gait, on the same day. Despite being reported to the RN, the physician was not informed. Additionally, over-the-counter sleep aids were found on the medication cart without the physician's knowledge.
The facility failed to report abuse allegations within the required timeframe for two residents. One resident experienced verbal abuse from a roommate, and another reported physical abuse by a CNA. Both incidents were not reported to the state survey agency within the required two-hour period, despite internal reporting. Staff interviews confirmed delays and inconsistencies in the reporting process, indicating lapses in communication and adherence to procedures.
The facility failed to limit PRN orders for psychotropic medications to 14 days and include stop dates for several residents. A resident with dementia and psychosis had a PRN order for Haldol without a stop date. Another resident with schizophrenia had PRN orders for Hydroxyzine and Olanzapine without specified durations. Additional residents with various psychiatric diagnoses had PRN orders for Haldol and Zyprexa without stop dates. The DON confirmed these medications should have had stop dates, indicating non-compliance with policy.
The facility failed to protect residents from physical abuse, with incidents involving three residents. A resident was pushed and hit by another in the dining room, confirmed by video and staff interviews. Another resident was pushed to the floor and punched in the dayroom, also confirmed by video. A third resident was forcefully pushed in a wheelchair into the hallway by a roommate, nearly hitting the railing, as observed by a CNA and confirmed by video.
A resident's care plan was not updated following a verbal altercation with another resident, despite facility protocol requiring such updates. The incident involved a threat of physical harm, and staff interviews confirmed the oversight in revising the care plan to include new interventions.
The facility failed to protect residents from abuse, resulting in three incidents. A resident was mentally abused by a CNA who made degrading comments about their bowel condition. Two residents with cognitive impairments were involved in a physical altercation, resulting in one resident being scratched. Another resident with severe cognitive impairment pushed a cognitively intact resident to the floor. These incidents were confirmed as abuse by the facility's staff.
A facility failed to provide necessary behavioral health care for a resident with severe cognitive impairment by not implementing and documenting increased behavior monitoring as required. Despite a physician's order for 15-minute checks, records showed multiple lapses in monitoring over several days. Staff interviews confirmed that the observations were not completed, indicating a failure to adhere to the facility's policy and provide the necessary care.
Failure to Maintain Functioning Wanderguard System for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a functioning assistance device for supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified psychosis, unspecified dementia, and schizophrenia, was assessed as severely cognitively impaired and required a wander/elopement alarm daily. Physician orders specified that the resident should have a Wanderguard bracelet checked every shift to ensure it was functioning and in place. However, no elopement risk assessment was completed for the resident. On multiple occasions, it was observed that the Wanderguard alarm did not sound when the resident exited a door with staff. Staff interviews confirmed that the resident frequently wandered and required the Wanderguard for safety, and that the malfunction had been reported to nursing leadership. The system had not been tested since a staff member responsible for testing was on leave, and facility leadership confirmed that elopement risk assessments were not conducted. The Wanderguard system was expected to alert staff if a resident exited the building, but it was not functioning as required.
Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents as outlined in its Facility Assessment. The assessment specified that each shift required 14 CNAs, 6 licensed nurses providing direct care, and 5 other nursing personnel with administrative duties. However, review of staff assignment sheets over several days showed that these staffing levels were not consistently met, with multiple shifts falling short of the required number of CNAs and licensed nurses. Staff interviews confirmed that these shortages resulted in unmanageable workloads, with CNAs and LPNs reporting that they were unable to complete 30-minute rounds or provide timely assistance to residents. Some staff were responsible for as many as 23 residents, and there were instances where units operated without a CNA, making it difficult to meet residents' needs and pass medications on time. Further interviews with staff, including the DON and administrative personnel, confirmed awareness of the staffing requirements in the Facility Assessment and acknowledged that the facility was not staffed according to these requirements during the reviewed period. Staff responsible for making assignments were unaware of the Facility Assessment's staffing requirements, leading to continued non-compliance. The deficiency had the potential to affect the entire resident census of 153, as the facility was unable to ensure that nursing and related services were provided to maintain the highest practicable well-being of each resident.
Failure to Ensure Accessible Call Bell System for Capable Residents
Penalty
Summary
The facility failed to ensure that residents who were physically capable of using the call bell system had call bells accessible and within reach. Observations on 04/28/2025 revealed that five residents were either lying in bed without a call bell available in the wall system or had the call bell placed behind the bed on the floor, making it inaccessible. Review of the facility's policy indicated that call lights should be kept within reach of residents, either clipped to sheets, tied to the side rail, or clipped to a bedside chair. Despite this policy, the call bells for these residents were not accessible as required. Record reviews showed that all five affected residents had no impairment of upper extremities, confirming their ability to use the call bell system. Interviews with facility staff, including an LPN, the program director, and the administrator, confirmed that these residents were physically able to use the call bell and that the call bells should have been accessible and within reach. The deficiency was identified through direct observation, record review, and staff interviews, all of which corroborated the lack of accessible call bells for these residents.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A urine-soiled brief was observed on the floor between a resident's bed and their roommate's bed during a morning observation. The soiled brief remained on the floor for at least five hours, as confirmed by subsequent observations. Staff interviews, including those with an LPN, the Director of Nursing, and the Director of Housekeeping, confirmed the presence of the soiled brief and acknowledged that it was not acceptable for it to remain on the floor in the resident's room. No information was provided regarding the resident's medical history or condition at the time of the deficiency.
Insufficient CNA Staffing on Unit 2B
Penalty
Summary
The facility failed to provide sufficient certified nursing assistant (CNA) staff to meet the needs of residents on Unit 2B, which was one of the two units reviewed for staffing. The facility's staffing pattern required two CNAs per shift for Unit 2B, but records and observations revealed that only one CNA was assigned during certain shifts. This staffing deficiency was observed on multiple occasions, with only one CNA present to care for 20 residents, leading to delays in care and assistance. Observations on Unit 2B showed residents tapping on the nurses' station glass windows, indicating a need for assistance. The lone CNA on duty struggled to manage the residents' needs, as multiple residents required two staff members for activities of daily living (ADL) assistance due to behaviors. Interviews with CNAs and LPNs confirmed that the acuity and behaviors of residents on Unit 2B were too much for one CNA to handle, resulting in residents waiting 20 to 30 minutes for assistance, which was deemed too long, especially for those with behavioral issues. Interviews with staff responsible for staffing decisions revealed a lack of a specific method to determine staffing needs, despite acknowledging that Unit 2B should be staffed with two CNAs due to the residents' behaviors and acuity. The staff confirmed that the current staffing was insufficient, and the deficiency had the potential to affect the well-being of the 20 residents residing on Unit 2B.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents, which was identified during a review of the Medication Administration Records (MAR) and interviews with staff. Resident #1, who had multiple diagnoses including Schizoaffective Disorder, Dementia, and Diabetes Mellitus-Type 2, did not have documented evidence of receiving or refusing medications from February 8 to February 10, 2025. Additionally, there was no documentation of insulin administration or blood glucose checks during this period. Interviews with nursing staff revealed that one nurse did not have access to the electronic MAR system and documented on paper MARs, which were not found in the resident's clinical record. Resident #2, who was diagnosed with conditions such as Diabetes Mellitus-Type 2 and Dementia, also had missing documentation for medication administration on February 13, 2025. The nurse responsible for administering the medications confirmed that she did not document the administration on the MAR as required. The facility's Director of Nursing (DON) acknowledged the lack of a current process for staff to follow if they could not access the electronic MAR system and confirmed that all medication administrations and glucose checks should have been documented. The facility's policy requires nurses to document medication administration immediately after administering medications and to use paper MARs if electronic access is unavailable. However, the review revealed that the binder containing paper MARs was outdated, and no current paper MARs were available for any residents. This deficiency in documentation practices had the potential to affect all 153 residents in the facility, as it compromised the accuracy and reliability of medication administration records.
Misappropriation of Resident Medications by RN
Penalty
Summary
The facility failed to prevent the misappropriation of resident property by a registered nurse (RN), identified as S4RN, which resulted in an Immediate Jeopardy situation. On the morning of February 1, 2025, two staff members observed S4RN placing medication packets belonging to two residents into her personal bag. These medications were due to be administered the previous evening, but S4RN falsely documented that the residents had refused them. The medications included critical prescriptions for conditions such as cardiac issues, hypertension, seizures, diabetes, and psychiatric disorders. Resident #1, who was severely cognitively impaired with a BIMS score of 00, had a range of diagnoses including Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder. Resident #2, also severely cognitively impaired with a BIMS score of 99, had diagnoses including Diabetes Mellitus-Type 2, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Essential Hypertension, Aphasia Following Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction. Both residents were unable to be interviewed due to their cognitive impairments. The incident was discovered during a shift change when S5LPN and another staff member noticed S4RN acting erratically and observed her placing medications into a crush bag and then into her personal bag. Upon further inspection, they found unopened medication packets with the residents' names and the scheduled administration time. Despite the potential for serious harm, both residents reportedly suffered no negative outcomes from the incident. The facility's policy on abuse and neglect, which prohibits the exploitation of residents, was clearly violated by S4RN's actions.
Delayed Reporting of Medication Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of property within the required timeframe for two residents. The incident involved a nursing supervisor who was observed placing medication packets belonging to two residents into her personal bag. This was witnessed by an LPN and a caregiver, who also found additional medication packets and a medication crush bag with white residue in the supervisor's personal bag. Despite the immediate discovery of the incident, the facility did not report it to the state survey agency until several days later. Resident #1, who has a history of Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder, was one of the residents affected. The incident was documented in the facility's records, but the notification to Adult Protective Services was delayed. Similarly, Resident #2, with diagnoses including Diabetes Mellitus-Type 2, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Essential Hypertension, Aphasia Following Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction, was also involved in the incident. Interviews with facility staff revealed a breakdown in communication and reporting procedures. The LPN who witnessed the incident reported it to a registered nurse supervisor, who then informed the Assistant Director of Nursing. However, the Director of Nursing and the Administrator were not informed of the full details, including the misappropriation of medications, until several days later. This delay in reporting violated the facility's policy and state regulations, which require immediate reporting of such incidents to the appropriate authorities.
Failure to Utilize PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff utilized appropriate personal protective equipment (PPE) during care for residents requiring Enhanced Barrier Precautions (EBP). This deficiency was observed in three residents who had chronic wound care needs and indwelling medical devices. The facility's policy required the use of gowns and gloves for high-contact resident care activities, such as dressing, bathing, providing hygiene, and device care. However, observations revealed that staff did not adhere to these guidelines. For instance, a nurse administered medications via a gastrostomy tube without wearing a gown, and a wound care nurse performed wound care on a resident with pressure ulcers without appropriate PPE. Additionally, there was a lack of signage indicating that the residents were on Enhanced Barrier Precautions, which contributed to staff being unaware of the need for PPE. Interviews with staff confirmed the absence of necessary signage and the failure to wear gowns during care activities. The Director of Nursing and other staff members acknowledged that the residents should have had signage on their doors and that staff should have worn gowns when performing care on residents with EBP in place.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain an environment that promotes quality of life through dignity and respect for a resident. Specifically, the facility did not ensure that residents were assisted with meals in a dignified manner. During an observation, a CNA was seen standing over a resident while feeding him, despite a chair being available. The resident, who was dependent on staff for eating assistance due to functional limitations in his upper extremities and other medical conditions, was not fed at eye level as per the facility's policy. The CNA admitted to not sitting while feeding the resident, and the Director of Nursing confirmed that the CNA should have been seated during the feeding process.
Failure to Implement Level II PASARR Recommendations
Penalty
Summary
The facility failed to incorporate Level II PASARR determination recommendations into the care planning for a resident diagnosed with Schizoaffective Disorder - Bipolar Type. The resident was admitted to the facility with recommendations for specialized services, including individual outpatient therapy and a psychiatric evaluation. However, a review of the resident's care plan and clinical records revealed no evidence that these recommendations were documented or implemented. Interviews with staff members confirmed that the necessary psychiatric evaluation had not been conducted, and outpatient therapy services were neither offered nor provided to the resident. The deficiency was attributed to a lack of an effective system to ensure the implementation of Level II PASARR recommendations. Staff interviews revealed a breakdown in communication and responsibility, with the social service counselor and medical records administrator each assuming the other was responsible for implementing the recommendations. The Director of Nursing and the Social Services Director confirmed the absence of a specific process to ensure that the recommendations were followed, leading to the oversight in the resident's care plan.
Inaccurate Documentation of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that nursing staff accurately documented pressure ulcer treatment for a resident with pressure ulcers, which did not meet professional standards of quality. The resident, who was cognitively intact and had diagnoses including pressure ulcers and paraplegia, had specific physician orders for wound care that included applying a non-adhering dressing and a wound vacuum to the left leg twice a week and as needed. However, on a specified date, the wound vacuum was not applied as ordered, and a dry dressing was used instead. Despite this, the treatment was documented as completed per the physician's orders. Interviews with the involved LPNs confirmed that the wound vacuum was not replaced as required, and a dry dressing was applied instead. The Director of Nursing also confirmed that the treatment was not completed as ordered and acknowledged the incorrect documentation. This deficiency had the potential to affect any of the 13 residents with pressure ulcers residing in the facility.
Failure to Implement Physician-Ordered Wound Vacuum Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a physician-ordered wound vacuum treatment. The resident, who was admitted with pressure ulcers and paraplegia, had a treatment plan that required a non-adhering dressing and a wound vacuum to be applied to a pressure injury on the left leg twice a week and as needed. However, during an interview and observation, it was noted that the wound vacuum was not in place, and a dry dressing was applied instead. This was confirmed by the resident and the LPNs involved in the treatment, who admitted to not replacing the wound vacuum as ordered. Further interviews with the wound care nurse and the Director of Nursing confirmed that the wound vacuum was not applied on the specified dates, despite being ordered to be in place at all times. The failure to implement the physician's orders for the wound vacuum treatment was observed over multiple days, indicating a lapse in following the facility's wound care policy and procedures. This deficiency had the potential to affect other residents with pressure ulcers in the facility.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by three separate incidents involving residents with varying levels of cognitive impairment. In the first incident, a resident with intact cognition was pushed out of his wheelchair by another resident with severe cognitive impairment over a dispute involving a drink. This incident was captured on video surveillance and confirmed by the facility's staff, who substantiated the allegation of resident-to-resident abuse. In the second incident, a resident with severe cognitive impairment was physically abused by another resident with moderate cognitive impairment. The aggressor approached the victim from behind and slapped him on the head while he was sitting in the day room. This incident was witnessed by staff members, who confirmed the occurrence of the abuse and the facility substantiated the allegation. The third incident involved a resident who was unable to complete a cognitive assessment and was physically assaulted by another resident with intact cognition. The aggressor admitted to hitting the victim over a disagreement about a cigarette, resulting in visible injuries including a skin tear and bruising. The facility's staff confirmed the occurrence of physical abuse, and the incident was documented in the resident's medical records.
Failure to Administer Medication as Ordered
Penalty
Summary
The provider failed to ensure that physician's orders were implemented for a resident, leading to a deficiency. Resident #13, who was admitted with diagnoses including Epilepsy, Bipolar Disorder, and Alcohol Abuse, had a physician's order for Phenobarbital 64.8 mg to be administered twice daily. However, a review of the Medical Administration Record (MAR) and the Individual Patient Controlled Drug Record revealed that the medication was not administered on the evening of September 4, 2024, as ordered. Interviews with the involved staff confirmed that the medication was not given, and it was acknowledged that it should have been administered according to the physician's orders. The Director of Nursing also confirmed that medications should be administered and documented accurately in compliance with physician's orders.
Medication Error Due to Allergy Oversight
Penalty
Summary
The facility failed to ensure that a resident did not receive a medication to which they were allergic, resulting in a medication error. Resident #10, who had a documented allergy to Depakote, was administered the medication despite this known allergy. The incident occurred when a verbal order for Depakote was given by a psychiatrist and received by an LPN, who failed to verify the resident's allergies before entering the order into the system. The allergy was documented on the resident's Medication Administration Record (MAR), but the LPN did not notice the absence of an allergy sticker on the resident's chart and did not communicate the allergy to the psychiatrist. Subsequently, an RN administered Depakote to the resident without checking the MAR for allergies, leading to the administration of a medication that the resident was allergic to. Interviews with the staff involved, including the LPN, RN, and the psychiatrist, confirmed the oversight in checking the resident's allergies before prescribing and administering the medication. The Director of Nursing and Assistant Director of Nursing acknowledged the error and confirmed that the proper protocol of verifying allergies was not followed, resulting in the medication error.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days, as required by their policy. Specifically, a resident with diagnoses including Unspecified Dementia, Unspecified Psychosis, and Schizophrenia was prescribed Ativan 1mg tablet by mouth every six hours as needed for agitation. This PRN order, written on December 11, 2023, did not include a stop date or duration, and was administered on multiple occasions in September 2024. During an interview, the Director of Nursing confirmed that the Ativan order was in place for longer than 14 days without an end date or documented duration, which is a violation of the facility's policy on psychotropic medications.
Failure to Notify Physician of Residents' Change in Condition
Penalty
Summary
The facility failed to notify the physician when three residents experienced a change in condition, which was identified during a review of abuse allegations. Resident #12, who had a history of Traumatic Brain Injury and severe cognitive impairment, exhibited abnormal behaviors such as lethargy, confusion, and unsteady gait on the morning of June 25, 2024. Despite these changes, the physician was not informed, although the RN on duty was notified of the resident's condition. Similarly, Resident #13, also with a history of Traumatic Brain Injury and severe cognitive impairment, showed signs of lethargy, unsteady gait, and repeated falls on the same day. The resident's abnormal behaviors were reported to the RN, but again, the physician was not notified. The resident continued to exhibit these behaviors throughout the day, requiring constant redirection and assistance. Resident #14, diagnosed with Schizoaffective Disorder and Vascular Dementia, was found to be very lethargic and unresponsive on June 25, 2024. The LPN on duty attempted to arouse the resident without success and reported the abnormal behavior to the RN. However, the physician was not made aware of the situation. Additionally, a box of Dollar General Sleep Aid and a bottle of Melatonin were found on the medication cart, which the physician confirmed he was not informed about.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for two residents, leading to a deficiency. For Resident #7, an incident occurred where another resident made a threatening and verbally abusive statement. The incident was discovered and reported internally, but the allegation of verbal abuse was not reported to the state survey agency within the required two-hour timeframe. Interviews with staff confirmed the delay in reporting, despite the facility's policy requiring immediate reporting of such incidents. For Resident #16, the resident was found with a bruise on the face and reported that a CNA had physically abused him the previous night. Although the incident was reported internally, it was not communicated to the state survey agency within the required two-hour period. Interviews with staff revealed inconsistencies in the reporting process, with some staff members denying knowledge of the abuse allegation or failing to report it to their supervisors. The facility's policies on abuse reporting were not followed, resulting in a failure to meet the regulatory requirement of reporting abuse allegations to the state survey agency within two hours. This deficiency highlights lapses in communication and adherence to established procedures among the facility's staff, as confirmed by multiple staff interviews.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days and included a specified duration for several residents. Resident #4 was admitted with diagnoses including Unspecified Dementia, Unspecified Psychosis, and Schizophrenia. The resident had a PRN order for Haldol, a psychotropic medication, without a stop date. Similarly, Resident #8, diagnosed with Schizophrenia, Panic Disorder Episodic, and Paroxysmal Anxiety, had PRN orders for Hydroxyzine and Olanzapine without specified durations or stop dates. The Director of Nursing (DON) confirmed these medications should have had stop dates. Resident #13, with diagnoses of Traumatic Brain Injury, Impulse Disorder, and Major Depressive Disorder, had PRN orders for Haldol in both injection and tablet forms, again without stop dates. Resident #14, diagnosed with Schizoaffective Disorder and Vascular Dementia, had a PRN order for Zyprexa without a stop date. The DON confirmed that these psychotropic medications should have been limited to 14 days and required a stop date, indicating a failure in adhering to the facility's policy and regulatory requirements.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving three residents. Resident #3, who was cognitively intact, was physically abused by Resident #4, who was severely cognitively impaired. The incident occurred in the dining room where Resident #4 forcefully pushed Resident #3's wheelchair against a table and struck him on the head. This was confirmed by video footage and interviews with the Director of Nursing (DON) and the Licensed Practical Nurse (LPN) who documented the incident. Another incident involved Resident #9, who was also cognitively intact, being physically abused by Resident #4. In the dayroom, Resident #4 approached Resident #9, pushed him to the floor, and began punching him. This altercation was witnessed by staff and confirmed through video footage. The DON acknowledged the incident as physical abuse after reviewing the footage and interviewing the involved parties. The third incident involved Resident #5, who had severe cognitive impairment, being pushed out of his shared room by Resident #6, who was moderately cognitively impaired. Resident #6 forcefully pushed Resident #5's wheelchair into the hallway, nearly causing it to hit the railing. This incident was observed by a Certified Nursing Assistant (CNA) and confirmed by video footage. The DON and other staff members considered this action to be a form of abuse due to the malicious intent behind it.
Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise the care plan for a resident following a verbal altercation with another resident. The incident occurred when one resident threatened another with physical harm, referencing a previous physical altercation between them. Despite the incident being documented in the nurse's notes and an incident report, the care plan for the threatened resident was not updated to include new interventions to address the behavior and prevent future incidents. Interviews with facility staff, including an LPN, the MDS coordinator, and the Director of Nursing, confirmed that the care plan should have been updated following the incident. The MDS coordinator acknowledged responsibility for updating care plans after incidents and confirmed that the care plan was not revised as required. The Director of Nursing also confirmed that the facility's protocol involves updating care plans with new interventions after incidents, which was not done in this case.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in three separate incidents involving different residents. In the first incident, a resident with a history of major depressive disorder and anxiety was subjected to mental abuse by a CNA. The CNA made degrading comments about the resident's bowel condition in a public area, causing the resident to feel embarrassed and degraded. This incident was witnessed by other staff members and led to the resident experiencing sadness and crying. In the second incident, two residents with severe cognitive impairments were involved in a physical altercation. One resident, who does not like noise and can become agitated, grabbed and scratched another resident's face after being bumped into several times. This incident was captured on surveillance video and confirmed as physical abuse by the facility's staff. The third incident involved a resident with severe cognitive impairment who physically pushed another resident to the floor. The resident who was pushed was cognitively intact and reported that they could not get out of the way fast enough. This altercation was also captured on video and confirmed as physical abuse by the facility's staff.
Failure to Implement and Document Increased Behavior Monitoring
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as outlined in their comprehensive care plan. Specifically, the facility did not implement and document increased behavior monitoring for a resident with diagnoses including Moderate Intellectual Disabilities, Schizophrenia, and Extrapyramidal Movement Disorder. The resident, who had a severe cognitive impairment, was supposed to be monitored every 15 minutes as per a physician's order. However, the facility's records showed multiple instances where this monitoring was not conducted or documented over a period of several days. Interviews with staff members, including LPNs and the Director of Nursing, confirmed that the required observations were not completed as per the facility's policy. The staff acknowledged that if the documentation was not completed, it indicated that the observations were not done. This lack of adherence to the observation protocol resulted in a failure to provide the necessary care and services to maintain the resident's highest practicable physical, mental, and psychosocial well-being.
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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