Village Health Care At The Glen
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 403 E. Flournoy Lucas, Shreveport, Louisiana 71115
- CMS Provider Number
- 195533
- Inspections on file
- 26
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Village Health Care At The Glen during CMS and state inspections, most recent first.
A cognitively impaired resident with hemiplegia, Alzheimer’s disease, and dependence for transfers was subjected to physical abuse and unsafe transfer techniques by a CNA. Video showed the CNA entering without greeting, ignoring the resident’s request about food, repeatedly yelling at the resident to “Get up,” and forcefully pulling the resident up by the left upper arm without a gait belt, despite the resident grimacing and saying “Wait.” The CNA roughly manipulated the resident’s arm, rammed the wheelchair into the bed, lifted the resident by the underarms, and dropped the resident into an unlocked wheelchair, after which the resident cried out in pain and rubbed her left arm. Skin assessments later documented multiple reddish-purple areas on the back of the resident’s left upper arm resembling fingerprints. The Administrator and DON confirmed that the CNA’s actions constituted physical abuse and caused psychosocial harm, with the resident appearing frightened during the incident.
A resident with hemiplegia, Alzheimer's disease, muscle weakness, and other coordination deficits had a care plan identifying them as a fall risk, with an intervention requiring fall mats on each side of the bed when in bed. On multiple observations, the resident was found in bed or in their room without fall mats in place, and both a CNA and the ADON confirmed that the room lacked the care-planned fall mats despite the documented intervention.
A resident with dementia, impaired balance and gait, and a history of multiple falls, assessed as high risk for falls and requiring partial assist for transfers and ambulation, was cared for in a room where the floor surface was repeatedly observed to be dry but shiny, slippery, and lacking traction along the entry, walkway, and around the bed and recliner. Staff including a CNA, housekeeping, an LPN, the ADON, the Administrator, and the housekeeping supervisor all acknowledged the floor was slippery and posed a fall risk after it was mopped with the facility’s standard cleaning solution, and the resident reported the floor sometimes felt slippery and at other times like glue, causing shoes to stick. Despite these observations and the resident’s documented fall risk and history of falls in the room and bathroom, the environment was not maintained free of this accident hazard.
A facility failed to evaluate a resident's fall risk and implement necessary interventions, leading to multiple unwitnessed falls. Despite having a high fall risk score, the resident's Baseline Care Plan lacked specific interventions for fall prevention. Interviews with facility staff confirmed that a fall risk assessment should have been conducted upon admission and interventions included in the care plan.
Two residents did not receive medications according to physician's orders or within the facility's liberalized time blocks. One resident's medications were administered late, between 10:45 a.m. and 10:55 a.m., while another's were given at 11:17 a.m. An LPN admitted to not adhering to scheduled times, indicating a failure to follow both physician's orders and facility policy.
A facility failed to implement fall prevention measures for a resident with severe cognitive impairment and a high risk of falls. Observations revealed only one fall mat was in place, contrary to physician orders for two mats. The resident's medical history includes Alzheimer's, impaired mobility, and a history of multiple falls.
Two residents with severe cognitive impairments were found with bed rails raised without a physician's order, risk assessment, or informed consent. Observations confirmed the continuous use of bed rails, and the facility's administrator acknowledged the lack of proper assessments and documentation.
A resident with severe dementia was improperly restrained with a self-releasing seatbelt in a wheelchair without written consent or documentation, contrary to facility policy. Staff interviews revealed a lack of awareness about the resident's ability to remove the seatbelt, and the seatbelt was not perceived as a restraint by the Administrator.
The facility failed to provide appropriate pain management for a resident after a fall, as no initial pain assessment was completed despite multiple injuries. The resident was later diagnosed with a displaced fracture causing significant pain.
The facility failed to comprehensively assess a resident using the CMS-specified Resident Assessment Instrument after the resident was hospitalized following a cerebral infarction and a right femoral head fracture. Despite the significant change in condition, the required significant change MDS was not completed.
The facility failed to ensure that resident assessments were transmitted to the State within the required 7-day timeframe for 10 residents. Multiple instances were found where assessments were either not completed, not submitted, or not accepted within the required timeframe. The Medicare Case Manager acknowledged these failures during an interview, confirming the facility's non-compliance with regulatory requirements.
The facility failed to maintain sanitary conditions in the kitchen, with issues including unlabeled and frostbitten meat, opened and unlabeled jars, unclean equipment, and grease and food residue on various surfaces. Staff confirmed these lapses, which affected food safety for 12 residents.
Physical abuse and unsafe transfer of a cognitively impaired resident by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse and psychosocial harm by a CNA. The resident, who resided on a locked memory care unit, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, other lack of coordination, Alzheimer’s disease, and muscle weakness. A quarterly MDS showed a BIMS score of 0, indicating severely impaired cognition, and the resident was dependent on staff for bed-to-chair transfers. The resident’s care plan identified her as a fall risk and required the use of a gait belt for all transfers with assistance from one staff member. On the morning of the incident, surveillance video with audio captured the events in the resident’s room. The video showed housekeeping staff initially conversing with the resident, who was seated on the side of the bed, smiling, laughing, and verbally interacting appropriately. After housekeeping exited, the CNA entered the room carrying linens and clothing, did not greet or acknowledge the resident, and failed to respond when the resident asked about getting something to eat. The CNA then approached the resident and, without using a gait belt, attempted to pull the resident up by her left arm. The CNA yelled “Get up!” and forcefully gripped and pulled the resident’s left upper arm multiple times in an upward motion. The resident was observed grimacing, saying “Wait,” and being unable to stand, while the CNA continued to hold and manipulate the resident’s left upper arm, swinging her back into the bed when she could not maintain a standing position. The video further showed the CNA dropping linens and clothing on the bed, forcefully tossing the resident’s shoes to the floor, and ramming the resident’s wheelchair into the wooden footboard, causing the bed to shake. When the CNA brought the wheelchair to the resident, the resident recoiled, appeared frightened, and verbally stated she could get up if the CNA did not mind, but the CNA did not respond. The CNA placed the unlocked wheelchair in front of the resident, lifted the resident by her underarms without a gait belt, and dropped her into the wheelchair, with an audible impact and the resident exclaiming “Ow!” The resident then rubbed her left arm, moaned, and appeared to express pain. The CNA proceeded to pull the resident backward in the wheelchair, again striking the footboard, and then rolled the resident into an unlit bathroom. Throughout the interaction, the CNA repeatedly yelled at the resident by her first name to “Get up,” handled her roughly, and failed to use safe transfer techniques. Subsequent documentation and interviews linked physical findings to this event. A late entry progress note by the Administrator described a nickel-sized irregular bright purple purpura on the lateral upper left arm near the antecubital space, and a later note documented multiple areas of bright purple purpura on the posterior left upper arm. A weekly skin review by an LPN on 01/11/2026 recorded four small reddish-purple areas on the back of the left upper arm just above the elbow, which the LPN described as looking like fingerprints; the DON reported these could have been from the CNA’s fingerprints. The Administrator and DON both confirmed, based on review of the video, that the CNA physically abused the resident by yelling, grabbing, lifting, twisting, and roughly transferring her without a gait belt, and that the resident appeared frightened during the event. The Administrator further stated that a reasonable person subjected to this physical abuse and verbal aggression would have experienced physical abuse and psychosocial harm, including dehumanization and humiliation.
Failure to Implement Care-Planned Fall Mats for a High Fall-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan intervention for a resident identified as a fall risk. The resident, admitted on 07/03/2025, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, other lack of coordination, Alzheimer's disease, and muscle weakness. The resident’s comprehensive care plan documented, as of 10/22/2025, that fall mats were to be placed on each side of the bed when the resident was in bed. However, observations on 03/09/2026 at 8:27 a.m. and again at 2:20 p.m. showed the resident in bed or in the room without fall mats in place on either side of the bed. During interview at 2:20 p.m., a CNA confirmed that the resident’s room did not have fall mats in place. At 3:05 p.m., the ADON acknowledged that the care plan included the intervention of a fall mat, and a subsequent observation at 3:10 p.m. with the ADON again confirmed that no fall mats were present in the resident’s room despite the care plan requirement. This deficiency centers on the discrepancy between the documented fall-prevention intervention in the resident’s care plan and the lack of implementation of that intervention as evidenced by multiple observations and staff confirmations on the same day.
Failure to Maintain Non-Skid Flooring for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s room environment free from accident hazards by not ensuring the floor surface provided adequate non-skid traction. The facility’s own Falls and Fall Risk, Managing policy identified environmental factors such as wet floors as contributors to fall risk and required staff to identify interventions based on resident-specific risks. Resident #3, admitted with a displaced mid-cervical fracture of the left femur (subsequent encounter) and unspecified dementia, had a BIMS score of 10 indicating moderately impaired cognition and required partial staff assistance for transfers and ambulation. The resident’s care plan documented a history of falls related to impaired balance and gait, with an intervention for frequent observation and supervised placement when out of bed. The medical record showed multiple falls over several dates, and a fall risk assessment identified the resident as high risk for falls. Surveyor observations on multiple occasions found Resident #3’s room floor to be dry but shiny, slippery, and with little traction along the entry, walkway, and around the bed and recliner. A CNA, housekeeping staff, an LPN, the ADON, the Administrator, and the Housekeeping Supervisor each observed or acknowledged that the floor in this resident’s room was slippery, shiny, and posed a fall risk. The housekeeping staff reported mopping the floor with the facility’s standard floor cleaning solution, and the Administrator stated that the floors had never been waxed and were cleaned with house cleaner, while acknowledging the condition of the floor as a fall hazard. The resident reported that at times the floor felt slippery and at other times felt like glue, causing shoes to stick. Despite the resident’s high fall risk, history of falls in the room and bathroom, and multiple staff acknowledgments of the slippery condition, the floor surface remained in a state that did not provide adequate traction, resulting in an environmental accident hazard for this resident.
Failure to Address Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to ensure a resident's environment was as free of accident hazards as possible by not evaluating the resident's fall risk and implementing necessary interventions. The resident, who had multiple diagnoses including coronary artery disease, hypertension, and major depressive disorder, was admitted without a fall risk assessment being conducted. A fall risk assessment was eventually performed on 02/10/2025, revealing a high risk for falls with a score of 23, but this was after the resident had already experienced multiple unwitnessed falls on 02/01/2025, 02/05/2025, 02/09/2025, and 02/10/2025. The resident's Baseline Care Plan, initiated on 01/31/2025, identified safety concerns such as fall risk but did not include any specific interventions to address this risk. Interviews with the Director of Nursing, Assistant Director of Nursing, and the Administrator confirmed that a fall risk assessment should have been conducted upon admission and that interventions should have been included in the care plan to mitigate the resident's fall risk. The lack of these assessments and interventions contributed to the deficiency identified by the surveyors.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that two residents received medications in accordance with physician's orders and within the established liberalized medication time blocks. For one resident, multiple medications were administered outside the designated time frame of 7:00 a.m. to 10:30 a.m., with administration times recorded between 10:45 a.m. and 10:55 a.m. These medications included folic acid, vitamin C, ferrous sulfate, and several others, all of which were scheduled for earlier administration. The failure to adhere to the prescribed schedule was documented in the Medication Administration Record (MAR). Another resident's medications, which were ordered to be administered at 7:00 a.m., were not given until 11:17 a.m. The medications included Lexapro, Bupropion, Hydralazine, and others. During an interview, an LPN acknowledged that there was no set time for medication administration and admitted to not administering the morning medications on time. This indicates a deviation from both the physician's orders and the facility's policy on liberalized medication administration times.
Failure to Implement Fall Prevention Measures for a High-Risk Resident
Penalty
Summary
The facility failed to ensure that the environment for one of the sampled residents, identified as Resident #3, was as free from accident hazards as possible. Specifically, the facility did not have the required fall mats in place as ordered by the physician to prevent injuries. Observations on two separate occasions revealed that only one fall mat was positioned on the right side of the resident's bed, whereas the physician's orders dated 08/31/2024 specified that two fall mats should be applied, one on each side of the bed, when the resident is in bed. This discrepancy was confirmed during an interview with a Certified Nurse Assistant (CNA), who acknowledged that there should have been two fall mats in place. Resident #3 has a medical history that includes Alzheimer's disease, impaired balance, impaired mobility, muscle weakness, essential hypertension, and an unspecified extrapyramidal and movement disorder. The resident's fall risk assessment indicated a high risk for falls, with a total score of 18, and a history of three or more falls. The Minimum Data Set (MDS) assessment showed severe cognitive impairment with a BIMS score of 3, and the resident requires one-person physical assistance with bed mobility, transfers, eating, and toilet use. The care plan for Resident #3 included monitoring and interventions to reduce the potential for self-injury from falls, with approaches that involve supervision and verbal reminders to control risk factors.
Failure to Ensure Proper Use and Documentation for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for two residents, leading to a deficiency in compliance with safety protocols. Resident #1, diagnosed with Parkinson's disease, dementia, schizoaffective disorder, and other conditions, was found with bed rails raised without a physician's order, risk assessment for entrapment, or informed consent. Observations over two days confirmed the continuous use of bed rails without the necessary documentation or assessments. Similarly, Resident #2, with diagnoses including spondylosis, dementia, and muscle weakness, was also observed with bed rails raised without the required physician's order, risk assessment, or informed consent. Interviews with the facility's administrator confirmed the lack of proper assessments and documentation for both residents, acknowledging the oversight in following the necessary procedures for bed rail use.
Improper Use of Physical Restraint Without Consent
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints that were not required to treat medical symptoms. The resident, who was diagnosed with severe unspecified dementia with mood and behavioral disturbances and muscle weakness, was observed using a self-releasing seatbelt while seated in a high-back wheelchair. The facility's policy requires that any physical restraint must be easily removable by the resident in the same manner it was applied by staff, and consent must be obtained. However, the resident was unable to remove the seatbelt on command due to cognitive impairments, and no written consent for the use of the seatbelt was obtained. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's ability to remove the seatbelt. An LPN was unsure if the resident could remove the seatbelt and observed that the resident did not understand the request to do so. The Director of Nursing acknowledged the absence of written consent and documentation for the seatbelt's use, and the Administrator admitted that consent was not obtained because the seatbelt was not perceived as a restraint. This oversight led to the improper use of a restraint without the necessary consent and documentation, contrary to the facility's policy.
Failure to Provide Pain Management After Resident Fall
Penalty
Summary
The facility failed to ensure pain management was provided to a resident who required such services after a fall/injury. Specifically, the facility did not complete an initial pain assessment for the resident following the incident. The resident was found on the floor with multiple injuries, including a knot on the back of the head, cuts on the thumb and knee, and a skin tear on the leg. Despite these injuries, there was no documentation of a pain assessment in the initial ID notes, the Incident Report, or the Neurological Evaluation Flow Sheet. The resident was later diagnosed with a displaced fracture of the left femoral neck, which caused significant pain upon manipulation of the left lower extremity, as noted by the Nurse Practitioner the following day. Interviews with the Director of Nursing and an LPN confirmed that a pain assessment should have been completed but was not. The Director of Nursing acknowledged the absence of a pain assessment in the facility's computer system and the Incident Report. The LPN explained that standard procedure involves documenting a head-to-toe assessment and asking residents to rate their pain level, or observing their response if they are unable to communicate. However, the review of the ID notes confirmed that no such assessment was documented for this resident after the fall.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed using the CMS-specified Resident Assessment Instrument after experiencing a significant change in condition. Resident #82 was hospitalized following a cerebral infarction and a right femoral head fracture. The resident's diagnosis included hemiplegia following a cerebral infarction affecting the left non-dominant side and a right femoral head fracture. On the date of the incident, the resident was found lying supine on the floor with no movement in her right lower extremity and tremors on the left side of her body. The resident was assessed by a nurse and assisted into her wheelchair by three staff members before being transferred to the emergency room for evaluation. Hospital records confirmed the diagnosis of an acute ischemic left MCA stroke, cytotoxic cerebral edema, and a displaced right femoral head fracture. Despite the significant change in Resident #82's condition, a review of the Minimum Data Set (MDS) for the dates following the incident revealed that a significant change assessment was not completed. During interviews, the Medicare Case Manager confirmed that she did not complete the required significant change MDS, and the Administrator verified that such an assessment should have been completed. This oversight indicates a failure to follow CMS guidelines for assessing residents after a significant change in their condition.
Failure to Transmit Resident Assessments Timely
Penalty
Summary
The facility failed to ensure that resident assessments were transmitted to the State within the required 7-day timeframe for 10 residents out of a total of 35 sampled residents. The review of the Minimum Data Set (MDS) assessments for these residents revealed multiple instances where assessments were either not completed, not submitted, or not accepted within the required timeframe. For example, Resident #3 had an Other State Assessment MDS completed on 02/15/2024 but was only submitted and accepted on 03/21/2024. Similarly, Resident #41 had a Quarterly MDS that was not completed, not submitted, and not accepted. These delays and failures in submission were consistent across all 10 residents reviewed. During an interview on 04/11/2024, the Medicare Case Manager acknowledged that the MDS assessments for the 10 residents had not been completed and transmitted to CMS within the required timeframe. This acknowledgment confirms the facility's failure to adhere to the regulatory requirements for timely submission of resident assessments, which is crucial for maintaining accurate and up-to-date resident care records. The deficiencies were identified through a combination of record reviews and interviews, highlighting a systemic issue in the facility's assessment and submission processes.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions, potentially affecting 12 residents who received trays from the main kitchen. Observations revealed several deficiencies: meat with a frostbitten appearance inside an unlabeled plastic bag in the freezer, opened and unlabeled jars of jalapenos, tartar sauce, pepperoncini, and lime juice in the walk-in refrigerator, and a stand mixer with yellow and white food residue. Additionally, grease and food residue were noted on the outside of both fryers, the floor between the stove and fryers, and the pipes and wall behind the fryer and stove. The walk-in refrigerator also had food and debris on the floor. Interviews with kitchen staff confirmed these observations. The cook acknowledged that the meat should have been removed before going bad and that opened, unlabeled items should have been labeled with an opened date. The chef confirmed that the kitchen and equipment should be cleaned daily by the morning and evening staff, and that the meat and opened items should have been properly managed. These lapses in following the facility's Basic Standards-Food Services-Health Care Policy led to the identified deficiencies.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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