Waldon Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenner, Louisiana.
- Location
- 2401 Idaho Street, Kenner, Louisiana 70062
- CMS Provider Number
- 195203
- Inspections on file
- 25
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Waldon Health Care Center during CMS and state inspections, most recent first.
The facility did not follow its policy for documenting witness statements during investigations of alleged sexual abuse. Verbal statements from a housekeeper, an LPN, and a CNA were not properly signed, dated, or titled, and required witness signatures were missing. The corporate administrator confirmed that statements were taken verbally but not documented according to policy.
Staff assigned to provide one-on-one supervision for a resident with a history of inappropriate sexual behaviors did not receive resident-specific behavior training or guidance on intervention strategies. Multiple staff members, including social services, porters, and a housekeeping supervisor, were unaware of the resident's behavioral issues or how to respond, and facility leadership confirmed the lack of training documentation.
A resident with chronic heart failure and sinusitis did not receive prescribed doses of Lasix and Flonase because an LPN could not locate the medications during a medication pass. The LPN reported that several medications had been ordered from the pharmacy and were awaiting delivery, and the DON confirmed the medications were not obtained in time.
The facility failed to ensure that the dietary manager completed an approved food safety program and passed the accompanying test. The dietary manager admitted to not having taken the exam for the ServSafe course, and the facility's administrator was unaware of this lack of certification. No evidence was provided to show that the dietary manager had passed the ServSafe examination.
The facility failed to meet professional standards in food storage and preparation, with issues such as water accumulation on food packaging, uncovered and expired food items, and improper storage of chemicals and staff food. The Dietary Manager and Administrator confirmed these deficiencies, indicating non-compliance with the facility's policies.
The facility failed to maintain comprehensive infection surveillance, as several residents prescribed antibiotics for infections were not documented in the facility's reports. Additionally, CNAs did not perform proper hand hygiene during incontinence care for a resident, as they did not change gloves or wash hands after removing a soiled brief. These deficiencies were confirmed by the DON and facility administrator.
A resident with severe cognitive impairment did not have their privacy maintained during incontinence care, as staff failed to close the privacy curtain while the resident's roommate was present. The resident's genitalia was exposed throughout the process, and staff later confirmed the oversight.
A resident was physically assaulted by another resident in the courtyard, resulting in a red mark and scratch near the eye. The incident was captured on video and confirmed by the aggressor's confession. The assaulted resident was sent to the hospital for evaluation, while the aggressor was sent for a behavioral health evaluation. Facility staff confirmed the incident and the substantiation of physical abuse.
A facility failed to conduct a required PASARR Level II evaluation for a resident diagnosed with Schizoaffective Disorder. The resident was readmitted and diagnosed, but no evaluation was documented. Interviews with staff confirmed the oversight.
A facility failed to develop a person-centered care plan and implement interventions for a resident requiring dialysis. The resident's care plan, generated from a template, incorrectly included monitoring of intake and output, which was not documented. Interviews with the DON and Medical Director confirmed the care plan's interventions were not followed, and there was no evidence of the required monitoring.
A resident's blister on the right lower leg was not evaluated or treated by the facility staff, leading to a deficiency in care. Despite observations over several days, the blister was not reported or assessed until it opened and began draining. Interviews revealed a lack of communication among staff, with CNAs failing to notice or report the blister to the LPN, and the Director of Nursing acknowledging the oversight.
An expired bottle of Meclizine Hydrochloride 12.5 mg caplets was found on a medication cart, despite its expiration date having passed. This was confirmed by an LPN, the DON/Infection Preventionist, and the Administrator, who all acknowledged that expired medications should not be available for resident use.
Two residents experienced medication administration errors, resulting in a 22% error rate. One resident received Sodium Bicarbonate outside the prescribed time, while another had multiple medications administered late, and a prescribed inhaler was missed. Interviews revealed confusion among LPNs regarding medication schedules.
A resident with dementia and a history of elopement risk was not monitored as per physician's orders, leading to an unreported absence from the facility. LPNs failed to conduct required checks and falsified records of medication administration and wander guard checks. The resident was later found with health complaints, highlighting a significant lapse in care and communication.
A resident with dementia and depression eloped from a facility due to inadequate supervision and failure to perform required checks. The resident exited through a window and was missing for over a day, later found with health complaints. Other residents at risk of elopement were also not properly monitored, highlighting a systemic issue in supervision and adherence to protocols.
A facility failed to effectively manage its resources, leading to deficiencies in resident supervision and staffing. An LPN did not follow a physician's order for supervisory checks on a resident at risk of elopement, resulting in the resident being missing for an extended period. Additionally, LPNs falsified documentation regarding medication administration and wander guard checks. The facility was understaffed, with insufficient licensed nurses for direct care, and nurses left shifts without notifying administration, leaving residents without assigned care.
The facility experienced significant staffing deficiencies, with insufficient licensed nursing staff to provide direct care to residents. On multiple occasions, only one LPN was present for a large number of residents, and there were frequent gaps in nursing coverage during shift transitions, leaving residents without assigned nurses for extended periods.
The facility's assessment tool was not updated annually and lacked input from CNAs, residents, and their representatives. It also failed to include necessary contract information for resident care, as confirmed by the administrator.
The facility did not ensure its Quality Assessment and Assurance Committee met quarterly as required for the QAPI program. Meetings were only documented on two occasions, with no evidence of meetings between these dates. The administrator confirmed the lack of documentation for the required meetings.
The facility failed to reconcile controlled drugs across all medication carts and did not administer medication per physician's orders for a resident. The policy required end-of-shift counts by both oncoming and off-going nurses, but records showed incomplete reconciliations. Additionally, an LPN documented administering medications at a time when surveillance footage showed they did not enter the resident's room. The DON confirmed the documentation was incorrect.
The facility did not complete a criminal background check for a CNA, as required by state law, before hiring. The CNA, hired in December 2021, provided care to residents in August 2024 without the necessary background verification. Interviews with HR and the Administrator confirmed the lack of documentation for the background check.
The facility failed to provide mandatory QAPI training to four CNAs, as revealed by a review of personnel files and interviews. Despite being hired between December 2021 and August 2024, these CNAs lacked documented evidence of receiving the required training. Interviews with the HR Director, Administrator, and DON confirmed the absence of documentation, highlighting a lapse in the facility's training and documentation processes.
A CNA at the facility did not receive the required ethics training, as evidenced by the lack of documentation in their personnel file. The HR Director and Administrator confirmed the absence of this documentation during interviews.
A resident with a wander guard bracelet was not monitored as required by physician's orders, leading to potential neglect. Surveillance footage and time sheets showed that LPNs did not perform necessary visual checks every two hours. One LPN admitted to not locating the resident during rounds and failed to report the absence. The facility's focus on finding the resident led to an oversight in suspending the involved staff.
The facility did not post daily nurse staffing information as required. Observations showed outdated postings on several occasions. Staff interviews confirmed that the ward clerk and a CNA were responsible for updating the information on weekdays and weekends, respectively. The DON acknowledged the requirement for daily postings.
The facility failed to obtain a final disposition for a fugitive charge on a CNA's criminal background check. The CNA was hired without documented evidence of the charge's final disposition, which is necessary to determine if it involved a conviction barring employment. The facility's administrator confirmed the absence of this documentation.
A resident with severe cognitive impairment and a history of falls was injured when a CNA used a rolling bedside table as a fall prevention measure. The resident was found slumped over the table and later assessed with bruising and an abrasion, which matched the table's curve. The use of the table as a fall precaution was deemed inappropriate.
A facility failed to administer pain medication to a nonverbal resident who showed signs of pain, resulting in untreated pain and a subsequent fracture requiring surgery. Despite reports from an OT and CNA, the LPN did not provide the prescribed Acetaminophen, and the resident's pain was not managed according to the care plan and facility policy.
A resident with severe cognitive impairment and a history of falls sustained a fracture of unknown origin. The facility failed to report the injury to the state survey agency within the required 2-hour timeframe, instead reporting it more than two days later. The delay was confirmed by the administrator.
Failure to Properly Document and Authenticate Witness Statements in Abuse Investigations
Penalty
Summary
The facility failed to follow its own Abuse, Neglect, and Misappropriation of Funds Policy and Procedure regarding the documentation of witness statements during investigations of alleged abuse. Specifically, in multiple instances involving allegations of sexual abuse, statements obtained verbally from staff members were not properly signed, dated, or titled as required by policy. For example, a housekeeper's statement was documented by the administrator but was not signed or dated by the housekeeper, nor was the statement titled by the administrator. Similarly, statements from an LPN and a CNA were not signed by the individuals making the statements or by any witnesses. During an interview, the corporate administrator confirmed that verbal statements were taken in the presence of other staff but that written statements and required signatures were not obtained.
Failure to Train Staff on Resident-Specific Behavioral Needs
Penalty
Summary
The facility failed to ensure that staff assigned to provide one-on-one supervision for a resident with a history of inappropriate sexual behaviors received resident-specific behavior training prior to their assignments. Four staff members, including social services, porters, and a housekeeping supervisor, were assigned to supervise a resident who had documented incidents of exposing himself and making unwanted sexual advances toward staff and peers. Despite the resident's care plan and multiple psychiatric assessments indicating ongoing hypersexual behaviors and the need for specific interventions, there was no evidence that these staff members were informed about the resident's behaviors or trained on how to intervene appropriately. Interviews with the involved staff revealed that they were unaware of the specific reasons for the one-on-one supervision or how to respond to the resident's behaviors. Documentation review confirmed the absence of any training records related to the resident's behavioral needs or general training on caring for residents with psychosocial disorders. Facility leadership acknowledged that the staff had not received the necessary training prior to being assigned to supervise the resident.
Failure to Provide Timely Medication Administration Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for one resident. The resident had diagnoses including chronic diastolic congestive heart failure and sinusitis, with physician orders for Lasix 20 mg (three tablets daily) and Flonase 50 mcg (one spray in both nostrils daily). During a medication pass observation, an LPN was unable to locate the resident's Flonase and Lasix for administration. The LPN stated that multiple medications had recently been ordered from the pharmacy and were still pending delivery. Review of the electronic Medication Administration Record confirmed that the resident did not receive the prescribed doses of Flonase and Lasix on the observed date. The DON confirmed that the medications were not obtained in a timely manner.
Dietary Manager Lacks ServSafe Certification
Penalty
Summary
The facility failed to ensure that the dietary manager, who had been employed for two years, completed an approved food safety program and passed the accompanying test. During an interview, the dietary manager admitted to not having taken the exam for the ServSafe course. Additionally, the facility's administrator was unaware that the dietary manager had not completed the examination and therefore did not possess the ServSafe certification. At the time of the survey exit, the facility could not provide evidence that the dietary manager had passed the ServSafe examination.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to adhere to professional standards in food storage and preparation, leading to several deficiencies. Observations revealed that food items were placed in areas with accumulated water, such as ice on top of boxes under the freezer's fan. Additionally, the refrigerator contained uncovered containers of fruit cocktail and expired heavy whipping cream. The dry storage area had a dented container of mandarin oranges stored among other canned goods. Staff members, including the Dietary Manager, did not have their hair fully restrained while in food preparation areas, and chemicals were improperly stored under the food preparation table. Further deficiencies included the presence of undated and unlabeled food containers in the refrigerator, as well as staff food items stored alongside residents' food. The Dietary Manager confirmed these findings and acknowledged the deficiencies. The facility's Administrator also confirmed the deficiencies, indicating a lack of compliance with the facility's food receiving and storage policy, which requires proper labeling, dating, and storage of food items to prevent contamination and ensure safety.
Infection Surveillance and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain a comprehensive facility-wide surveillance of residents' infections, as evidenced by the lack of documentation for several residents who were prescribed antibiotics for various infections. Resident #7 was prescribed Levofloxacin and Doxycycline for a right knee infection, Resident #12 was prescribed Cefepime Hydrochloride for acute osteomyelitis of the left ankle, Resident #27 was prescribed Tobradex for blepharitis of the left upper eyelid, and Resident #84 was prescribed Augmentin for cellulitis. However, the facility's Infection Surveillance Map and Infection Reports for the respective months did not include these residents' infections, indicating a failure to capture all residents' infections as part of the facility's infection surveillance program. Additionally, the facility failed to ensure that Certified Nursing Assistants (CNAs) completed proper hand hygiene during incontinence care. During an observation, CNAs S11 and S12 were seen performing incontinence care for Resident #21, who was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. The CNAs removed the resident's soiled brief, cleaned the buttock area, and placed a clean brief on the resident without changing gloves or performing hand hygiene. This was confirmed by both CNAs and the Director of Nursing/Infection Preventionist, who acknowledged that proper hand hygiene procedures were not followed. The Director of Nursing/Infection Preventionist and the facility administrator confirmed the deficiencies in both infection surveillance and hand hygiene practices. The lack of comprehensive infection surveillance and failure to adhere to hand hygiene protocols during resident care were identified as significant issues during the survey, highlighting gaps in the facility's infection prevention and control program.
Failure to Ensure Resident Privacy During Incontinence Care
Penalty
Summary
The facility failed to maintain privacy for a resident during incontinence care, as observed during a survey. Resident #21, who has severe cognitive impairment and is dependent on staff for toileting hygiene, was subjected to incontinence care without the bedside privacy curtain being closed. This occurred while Resident #21's roommate was present in the room, leading to the exposure of Resident #21's genitalia throughout the care process. Interviews with the involved staff confirmed the oversight. S11CNA admitted to not closing the privacy curtain, acknowledging that it should have been done to ensure privacy. The Director of Nursing/Infection Preventionist and the Administrator both confirmed that the CNAs should have maintained the resident's privacy by closing the curtain during incontinence care, especially with another resident present in the room.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #64 physically assaulted Resident #84 by hitting her in the face with an open hand while they were sitting outside in the courtyard. This incident was captured on video surveillance and confirmed by Resident #64's confession. The facility's policy on abuse, neglect, and misappropriation of funds emphasizes zero tolerance for any form of abuse, yet the incident occurred, resulting in physical harm to Resident #84. Following the altercation, Resident #84 reported the incident to the nurse's station and was noted to have a red mark and scratch on the left side of her eye. She was subsequently sent to the hospital for evaluation due to complaints of pain. Resident #64, who had a documented history of physical aggression, was sent for a behavioral health evaluation. Interviews with facility staff, including the administrator and social services, confirmed the occurrence of the incident and the substantiation of physical abuse.
Failure to Conduct PASARR Level II Evaluation for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of Schizoaffective Disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation, as required. Resident #63 was readmitted to the facility and subsequently diagnosed with Schizoaffective Disorder. However, there was no documented evidence that a PASARR Level II evaluation was completed following this new diagnosis. Interviews with the Admissions Coordinator and the Administrator confirmed that the evaluation was not conducted, despite the requirement to do so after the diagnosis was made.
Failure to Implement Person-Centered Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who required dialysis and did not implement the interventions as outlined in the resident's plan of care. The resident, who was admitted with diagnoses including Diabetes Mellitus, a sacral pressure ulcer, and renal insufficiency, had a care plan indicating dialysis three times per week with monitoring of intake and output. However, the care plan was generated from a template, and the intervention to monitor intake and output was mistakenly included. Furthermore, the facility did not document the monitoring of the resident's intake and output as required by the care plan. Interviews with the Director of Nursing (DON) and the Medical Director confirmed that the care plan's interventions were not followed, and there was no documented evidence of the required monitoring. The DON acknowledged the lack of documentation and confirmed that the facility did not have records showing that the resident's intake and output were monitored, as was expected by the care plan.
Failure to Evaluate and Treat Resident's Blister
Penalty
Summary
The facility failed to ensure that a resident's blister was evaluated and treated, leading to a deficiency in care. Observations over three consecutive days revealed that a resident had a blister on the right lower leg measuring approximately 3 centimeters. Despite the presence of the blister, there was no documented evidence of an evaluation or assessment being completed by the facility's staff. The blister eventually opened, and clear liquid drainage was observed, indicating a deterioration in the resident's skin condition. Interviews with facility staff, including a CNA, LPN, and the Director of Nursing, revealed a lack of communication and awareness regarding the resident's blister. The CNA assigned to the resident did not notice the blister, and the LPN was not informed of any skin changes by the CNAs. The Charge Nurse acknowledged that the blister should have been reported and evaluated, especially since it was present for several days. The Director of Nursing confirmed that the blister was not reported until after it had opened, acknowledging that it should have been noticed and assessed earlier.
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use, as evidenced by the presence of an expired bottle of Meclizine Hydrochloride 12.5 mg caplets on Medication Cart c. The expiration date on the bottle was 12/2024, yet it was still available for use during an observation on 01/15/2025. This was confirmed by an LPN who acknowledged the medication was expired and should not have been available. Further confirmation was provided by the Director of Nursing/Infection Preventionist and the Administrator, both of whom agreed that expired medications should not be stored on the medication cart and available for resident use.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by errors in medication administration for two residents. Resident #R3 was prescribed Sodium Bicarbonate to be administered three times daily at specific times, but it was observed that the medication was given outside the prescribed time frame. Similarly, Resident #R4 had multiple medications scheduled for administration at 8:00 AM, including Furosemide, Potassium Chloride, and Oxycodone-Acetaminophen, but these were administered late. Additionally, the Budesonide-Formoterol inhaler was not administered as ordered, and the Albuterol inhaler was given without assessing the resident's need for it. The report highlights that there were 27 opportunities for medication administration, with 6 errors observed, resulting in a 22% error rate. Interviews with the LPNs involved revealed confusion regarding medication schedules and a lack of adherence to the facility's policy of administering medications within one hour of the scheduled time. The Director of Nursing and the Administrator confirmed the discrepancies in medication administration for the residents involved.
Failure to Monitor Elopement Risk Resident
Penalty
Summary
The facility failed to adhere to professional standards of care by not ensuring that LPNs conducted supervisory checks every two hours for a resident identified as an elopement risk. The resident, who had a history of dementia, major depressive disorder, and alcohol abuse, was supposed to be monitored closely due to his fixation on leaving the facility. Despite physician's orders for regular checks and the presence of a wander guard bracelet, the LPNs did not perform the required visual inspections, leading to the resident's absence from the facility for an extended period. The report highlights that the LPNs involved did not follow the physician's orders for medication administration and wander guard checks. Surveillance footage and interviews revealed that the LPNs documented administering medications and checking the wander guard without actually performing these tasks. This falsification of records contributed to the resident's unmonitored absence, as the staff failed to notice or report the resident's disappearance in a timely manner. The situation escalated to an Immediate Jeopardy when the resident was found missing and later returned with health complaints, necessitating emergency medical attention. The facility's administration was not informed promptly about the resident's absence, indicating a breakdown in communication and protocol adherence among the staff. This deficiency posed a significant risk to the resident's safety and well-being, as well as to the other residents in the facility.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as an elopement risk. The resident, who had a history of dementia, major depressive disorder, and alcohol abuse, was last seen entering their room and was not visually checked by the assigned LPN during the night shift. The LPN did not complete the required census checks every two hours as ordered and failed to report the resident's absence to the facility's administration or other staff members. The resident was discovered missing the following morning, and it was determined that they had exited through their bedroom window, as evidenced by a missing window screen and a dirty windowsill. The resident was not located until the next day, at which point they were found to have nausea and epigastric pain and were transferred to the emergency room. The facility's surveillance footage confirmed that the resident did not leave their room through the door, supporting the conclusion that they exited through the window. Additionally, the facility's staff failed to adequately monitor other residents identified as elopement risks. Two other residents, both with cognitive impairments and wearing wander guards, were not consistently monitored as required. Staff members were unsure of the residents' elopement risk status and did not perform the necessary visual checks every two hours. The facility's failure to ensure proper supervision and adherence to elopement prevention protocols placed these residents at risk of harm.
Deficiencies in Resident Supervision and Staffing
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to several deficiencies. Licensed Practical Nurses (LPNs) did not follow a physician's order for supervisory checks every two hours for a resident identified as an elopement risk. This resident was not located in the facility and was missing for an extended period, resulting in an Immediate Jeopardy situation. Additionally, LPNs falsified documentation regarding medication administration and the placement of a wander guard for the same resident. The facility also lacked sufficient licensed nurses to provide direct care to residents, and there were instances where nurses left their shifts before the oncoming nurse arrived, leaving residents without assigned care. The deficiencies were highlighted through interviews with the facility's administration and nursing staff. The Administrator and Director of Nursing (DON) acknowledged the failure to conduct visual checks on the resident as per the physician's orders. The Assistant Director of Nursing (ADON) confirmed that the facility was understaffed, with only three direct care nurses assigned for a night shift to care for over 100 residents. The DON also noted that nurses were leaving their shifts without notifying administrative staff, resulting in periods where residents were left without an assigned nurse.
Staffing Deficiencies and Shift Transition Failures
Penalty
Summary
The facility failed to ensure sufficient licensed nursing staff to provide direct care to residents on multiple occasions. On specific dates, the facility's census ranged from 108 to 113 residents, yet there were instances where only one Licensed Practical Nurse (LPN) was documented as present to provide direct care. This was noted during various shifts, including times when no nurse was documented as present, leaving residents without adequate nursing care. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that the staffing levels were insufficient for the number of residents, and there were issues with nurses arriving late or leaving early. Additionally, the facility failed to ensure proper handover of care between shifts. There were multiple instances where nurses left their assigned shifts before the oncoming nurse arrived, resulting in residents being left without an assigned nurse for periods ranging from a few minutes to several hours. This occurred across various room assignments and shifts, indicating a systemic issue with shift transitions and staffing coverage. The facility's documentation, including time sheets and daily nursing assignments, revealed numerous gaps in nursing coverage. These gaps were corroborated by interviews with staff, who acknowledged the lack of proper staffing and the challenges faced in maintaining continuous nursing care. The absence of documented evidence of sufficient staffing during these periods highlights a significant deficiency in the facility's ability to meet the needs of its residents consistently.
Facility Assessment Tool Lacks Updates and Input
Penalty
Summary
The facility failed to ensure that its Facility Assessment Tool was reviewed and updated annually, as required. The last documented update was on 07/24/2023, and by 09/03/2024, the facility had not conducted a review or update. This oversight was confirmed in an interview with the administrator, who acknowledged the lapse in maintaining the assessment tool's currency. Additionally, the facility assessment did not include necessary information about contracts required for resident care, nor did it involve input from certified nursing assistants (CNAs) or residents and their representatives. The administrator confirmed that these elements were not considered in the development of the Facility Assessment Tool, indicating a lack of comprehensive involvement and documentation in the assessment process.
Failure to Meet Quarterly QAPI Meeting Requirement
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance Committee met at least quarterly as required to evaluate the activities under the Quality Assurance and Performance Improvement (QAPI) program. A review of the facility's Quality Assurance Committee sign-in sheets revealed that meetings were only documented on November 14, 2023, and June 28, 2024. There was no documented evidence of any meetings held between these dates to fulfill the quarterly meeting requirement. During an interview on September 5, 2024, the administrator confirmed that there was no documented evidence of a Quality Assurance Committee meeting occurring between November 14, 2023, and June 28, 2024. The administrator also indicated that no additional documentation could be provided to address this deficiency.
Medication Reconciliation and Administration Failures
Penalty
Summary
The facility failed to maintain a system for periodically reconciling controlled drugs across all four medication carts reviewed. The facility's policy required controlled medications to be counted at the end of each shift by both the oncoming and off-going nurses. However, the records for August 2024 showed multiple instances of incomplete reconciliation across all shifts for Medication Carts a, b, c, and d. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the required reconciliation process was not consistently followed, with some nurses leaving the facility without completing the necessary counts. Additionally, the facility failed to administer medication to a resident according to the physician's orders. The resident was prescribed Atorvastatin Calcium, Quetiapine Fumarate, and Mirtazapine Tartrate to be administered daily at bedtime. However, the electronic Medication Administration Record indicated that these medications were documented as administered at 8:23 p.m. on a specific date, despite surveillance footage showing that the LPN did not enter the resident's room at that time. The DON confirmed that the LPN should not have documented the administration of medication when it did not occur. These deficiencies highlight a lack of adherence to established protocols for medication reconciliation and administration, potentially compromising the safety and well-being of the residents. The facility's failure to ensure proper documentation and adherence to physician orders indicates a significant lapse in the standard of care expected in such settings.
Failure to Conduct Required Criminal Background Check for CNA
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA), identified as S6CNA, had a criminal background check completed as required by Louisiana Revised Statute 40:1203.2. This statute mandates that employers must request a criminal history and security check for non-licensed personnel before making an employment offer. Despite this requirement, the facility did not have any documented evidence of a criminal background check for S6CNA, who was hired on December 30, 2021. S6CNA provided care to residents in various room assignments on multiple dates in August 2024, as evidenced by the facility's time sheets and room assignments. Interviews with the Human Resources Director and the Administrator confirmed the absence of a criminal background check for S6CNA. The facility was unable to present any further information or documentation to demonstrate compliance with the required background check process for this employee.
Failure to Provide QAPI Training to CNAs
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of personnel files and interviews, which revealed that four out of five sampled CNAs did not have documented evidence of receiving the required QAPI training. The CNAs in question were hired between December 2021 and August 2024, yet their personnel files lacked any documentation to confirm that they had undergone the necessary training. Interviews with the Human Resources Director, the Administrator, and the Director of Nursing confirmed the absence of documentation for QAPI training for the CNAs mentioned. The Human Resources Director acknowledged the lack of evidence, and both the Administrator and the Director of Nursing were unable to provide any additional documentation to support that the CNAs had received the required training. This oversight indicates a failure in the facility's training and documentation processes for ensuring compliance with QAPI training requirements.
Failure to Provide Ethics Training to CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received the required ethics training. Specifically, the personnel file of one CNA, hired on December 30, 2021, lacked documented evidence of ethics training. During interviews, the Human Resources Director confirmed the absence of such documentation, and the Administrator acknowledged that no additional documentation could be provided to address this deficiency.
Failure to Implement Abuse Policy and Monitor Resident
Penalty
Summary
The facility failed to implement its abuse policy to protect residents from potential neglect, specifically concerning the care of a resident with a wander guard bracelet due to an elopement risk. The facility's policy required immediate investigation of incidents or suspected incidents of neglect, and staff were expected to intervene in situations where neglect was at risk. However, the facility did not adhere to these policies, as evidenced by the lack of proper monitoring of the resident by the assigned LPNs. The resident had physician's orders for census checks every two hours, which were not conducted as required. Surveillance footage and time sheet reports revealed that the LPNs assigned to the resident's care did not perform the necessary visual inspections during their shifts. One LPN admitted to not being able to locate the resident during her rounds and failed to report the resident's absence to the administration or other staff members. This lack of action resulted in the resident not being visually checked throughout the night, contrary to the physician's orders. The facility's administrator acknowledged the oversight in not suspending the LPNs involved, as the focus was primarily on locating the resident. The administrator also admitted to not noticing the lack of staff monitoring while reviewing surveillance footage. This oversight contributed to the failure to protect the resident from potential neglect, as the facility did not ensure compliance with its own policies and procedures regarding resident safety and monitoring.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted as required. Observations on multiple dates revealed discrepancies in the posting of the nurse staffing information. On September 1, 2024, the information was dated August 30, 2024. On September 4, 2024, the information was dated September 3, 2024, and on September 5, 2024, it was dated September 4, 2024. Interviews with staff members confirmed the responsibility for updating the nurse staffing information. The ward clerk was responsible for updating the information on weekdays, while a certified nursing assistant was responsible for posting it on weekends. The Director of Nursing confirmed that the information should be posted daily as required.
Failure to Obtain Final Disposition for CNA's Fugitive Charge
Penalty
Summary
The facility failed to obtain a final disposition for a fugitive charge that appeared on a Certified Nursing Assistant's (CNA) criminal background check. This deficiency was identified during a review of personnel records, specifically for one CNA out of five reviewed. The CNA in question was hired on 07/07/2023, and their criminal background check, dated 06/30/2023, revealed a charge from 10/17/2016 under Louisiana Code of Criminal Procedure Article 575 for being a fugitive. The facility did not have documented evidence of a final disposition for this charge, which is necessary to determine if the charge involved a conviction that would bar employment. During an interview, the facility's administrator confirmed the lack of documented evidence regarding the final disposition of the charge.
Inappropriate Use of Bedside Table Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident did not sustain an injury when staff used a rolling bedside table as a fall prevention measure. This incident involved a resident with a history of falls, severe cognitive impairment, and who was non-ambulatory, requiring moderate assistance with transfers. On the date of the incident, a Certified Nursing Assistant (CNA) placed the resident in a wheelchair and positioned a rolling bedside table in front of her to prevent her from falling forward. However, the resident was later found slumped over the table, with no immediate visible injuries or complaints of pain. Subsequent observations revealed that the resident had sustained bruising on the left side of the mouth and shoulder, along with an abrasion in the upper oral cavity. The facility's administrator noted that the bruising pattern resembled the curve of a bedside table, indicating that the table was likely the cause of the injuries. The use of the bedside table as a fall precaution was identified as inappropriate, contributing to the resident's injuries.
Failure to Administer Pain Medication to Nonverbal Resident
Penalty
Summary
The facility failed to administer pain medication to a nonverbal resident, Resident #2, who showed signs and symptoms of pain. On 04/09/2024, an Occupational Therapist (OT) reported to a Licensed Practical Nurse (LPN) that Resident #2 exhibited facial grimacing with movement of the right lower extremity, indicating pain. Despite this report, the LPN did not administer any pain medication. The resident's care plan included an intervention for staff to observe for muscle, bone, or joint pain and medicate as ordered, and there was an existing physician's order for Acetaminophen to be given as needed for pain. However, there was no documented evidence that the pain medication was administered to Resident #2 on 04/09/2024 or 04/10/2024, even though the resident continued to show signs of pain and discomfort, including pushing away a Certified Nursing Assistant (CNA) and displaying facial grimacing when touched or repositioned. This lack of intervention resulted in actual harm to Resident #2, who was later found to have a subacute fracture of the left distal femur requiring surgery, as revealed by an x-ray on 04/11/2024. The Director of Nursing (DON) confirmed that the nurse should have administered pain medication to Resident #2 following the reports of pain. Interviews with staff members, including the OT, CNA, and DON, corroborated the failure to manage Resident #2's pain appropriately. The OT reported the resident's pain to the LPN, who admitted to not administering the pain medication. The CNA also reported the resident's pain to the CNA Supervisor and the DON, who subsequently assessed the resident and discovered bruising and swelling in the left lower leg. The DON then notified the resident's doctor, leading to the x-ray and diagnosis of the fracture. The facility's policy on pain management, which includes observing for signs of pain in nonverbal residents and administering prescribed medication, was not followed, resulting in the resident's untreated pain and subsequent harm.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency within the required 2-hour timeframe. Resident #2, who had severe cognitive impairment and a history of falls, sustained a fracture of unknown origin on 04/11/2024 at 3:00 p.m. The incident was documented as bruising/swelling. However, the facility did not report the injury to the state until 04/13/2024 at 10:02 a.m., well beyond the mandated reporting period. The administrator confirmed the delay in reporting during an interview on 04/15/2024.
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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