West Carroll Care Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Grove, Louisiana.
- Location
- 706 Ross Street, Oak Grove, Louisiana 71263
- CMS Provider Number
- 195398
- Inspections on file
- 25
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at West Carroll Care Center, Inc during CMS and state inspections, most recent first.
A resident in an LTC facility experienced a fall that was not assessed or documented by the nursing staff, leading to a delay in treatment for a displaced femoral neck fracture. The resident, who had impaired cognitive skills and was at high risk for falls, was not properly evaluated after the incident, resulting in a delay in identifying the injury.
A facility failed to document supper meal intake percentages for a resident with severe cognitive impairment and multiple diagnoses, including dementia and diabetes. The resident was at risk for weight loss due to leaving 25% or more of food uneaten at most meals. Despite an intervention in the care plan to document food intake, there was no evidence of supper meal intake documentation for two months, as confirmed by the DON.
A facility failed to document insulin injection sites for a resident with diabetes, as evidenced by missing records in the MAR for July and August. The resident, with severe cognitive impairment and multiple health issues, required regular blood sugar monitoring and insulin administration. The DON confirmed the lack of documentation, indicating a lapse in nursing staff competency.
A CNA failed to use proper PPE while providing care to a resident on Enhanced Barrier Precautions (EBP) due to MRSA. The CNA did not wear a gown and gloves as required, and performed multiple tasks without changing gloves or washing hands, contrary to the facility's EBP policy. The Infection Control Nurse confirmed the breach in protocol.
A resident with moderate cognitive impairment and high fall risk was not properly secured in a lift chair during a whirlpool bath, resulting in a fall and severe injuries. The CNA assisting the resident failed to use the seat belt, leading to the resident's fall. Immediate medical attention was required, and the CNA was suspended during the investigation.
A resident with severe cognitive impairment and identified as an elopement risk eloped from the facility and was found 300 yards away. The resident exited through an activity room door and was returned by a staff member. The facility's policies for monitoring at-risk residents were not adequately followed, leading to the incident.
Failure to Assess and Document Resident Fall Leads to Delayed Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice when a resident experienced a fall in their room. The nursing staff did not recognize, assess, intervene, or document the resident's condition following the fall, which led to a delay in treatment. The incident involved a resident who was unable to verbally communicate effectively and had a history of behaviors such as yelling out and resisting care. The resident was at high risk for falls and required substantial assistance for daily activities. On the day of the incident, the resident fell from their bed, but the nurse on duty did not assess the resident or document the fall. The incident was not reported to the resident's physician or the director of nursing. It was only after several days that the resident was found to have a displaced femoral neck fracture, which required surgical intervention. The lack of immediate assessment and documentation resulted in a delay in identifying and treating the injury. Interviews with staff revealed that the fall was initially unreported and undocumented. The CNA who witnessed the fall did not observe any immediate injuries or complaints of pain from the resident. However, the nurse who was informed of the fall did not recall being notified or assessing the resident. This oversight and failure to follow protocol contributed to the delay in addressing the resident's injury, which was later identified through an x-ray.
Removal Plan
- Weekly body audits reviewed to determine if there were any unknown injuries or significant findings. Body audits will continue until full facility body audits are completed. Statewide Incident Management System (SIMS) report opened.
- Staff education initiated: Abuse and neglect, staff rounding requirements: CNA even hours/nurses odd hours, ensure staff using proper transfer techniques, report changes in condition, change in behavior, change in skin condition to the nurse in a timely manner and any issues identified with a resident should be assessed immediately and addressed in a timely manner.
- Investigation continues regarding resident #1's injury of unknown origin, and full facility body audits continued.
- Video footage was reviewed by S1Administrator and S2DON. The video footage supported S4 CNA's statement. S3LPN was witnessed entering the resident's room after being notified of the incident. There were no issues identified with review of the footage and routine care rounds were being provided.
- S3LPN was suspended pending investigation.
- Incidents and accidents for resident #1's hall reviewed, no injuries of unknown origin noted; no additional incidents/accidents were noted.
- QA started on reviewing nurse's notes and 24-hr report to ensure that incidents/accidents are reported, processed, and completed. QA will be done 5x a week x 8 weeks then 3x a week x 4 weeks then as needed.
- Residents that resided on resident #1's hall were assessed to identify any potential significant changes, any recent hospitalizations, or other abnormal findings and there were no concerns noted.
- Staff members who worked with resident #1 through the weekend were re-interviewed in order to gain more details regarding his care, complaints, and activity level. No signs or report of distress or pain was noted. Resident appeared to continue normal activities, including being out of bed, in day room watching television, interacting with others and meal intake was normal.
- Safety measures were assessed and found to be functioning properly. Included in these were the following: Resident #1's call light was activated, the light lit up in the hall and at the switchboard (the clerk at the desk and nurse in the room could clearly hear each other speaking). Wedge cushion was in place and properly fit the resident's wheelchair. Assist bar was properly attached to resident #1's bed and raised/lowered correctly. Functions of the bed were checked. The head and foot of the bed raised and lowered properly. The bed raised and lowered also with no issues. The mattress fit was checked and was correct. There was no physical damage noted to the exterior of the mattress (no rips, tears or sunken spots).
- Resident #1's incidents were reviewed for the last six months and all prior interventions were assessed and found to be in place.
- Staff in-service for CNAs: Reporting any incident or accidents that occur with a resident. If unsure if something is new or if you should report, always report to the nurse or supervisor. If you feel like an additional assessment may need to be done then report to a management nurse.
- Staff in-service for nurses: An incident report should be done for any of the following (bruises, skin tears, falls, unintentional change in plane, setting a resident in the floor from getting weak, sliding out of bed or wheelchair, etc). Physician, responsible party, and DON should all be made aware. Proper documentation should be done and include any new orders or treatment. If any immediate actions should be put into place, then make sure those are done (increase supervision, increase monitoring, etc.).
- Staff in-service: Abuse & Neglect, reporting any change in condition or change in status to nurse/nurses station.
- QA initiated to ensure nurse competency and return demonstration for incident/accident reporting and completion of appropriate documentation.
- Resident #1 returned to the facility with orders for non-weight bearing status and hip rehab exercises. He is a two person assist with lift transfer. Nursing assessment completed.
- As an immediate protective action, S6CNA sat near the resident's door providing additional supervision due to him having had a fall and behaviors.
Failure to Document Meal Intake for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not document the supper meal intake percentages daily for a resident who had severe cognitive impairment and required assistance with activities of daily living. The resident had multiple diagnoses, including hypertension, diabetes mellitus, and dementia, and was at risk for weight loss due to leaving 25% or more of food uneaten at most meals. Despite an intervention in the care plan to document the resident's food intake with each meal, there was no documented evidence of the supper meal intake percentage for July and August 2024. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Document Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in administering insulin injections, as evidenced by the lack of documentation of injection sites for a resident with multiple health conditions, including diabetes mellitus. The medical record review for the resident revealed an admission with several diagnoses, such as hypertension, diabetes, and severe cognitive impairment, requiring assistance with daily activities. The care plan indicated the need for regular blood sugar monitoring and insulin administration according to a sliding scale. However, the Medication Administration Record (MAR) showed no documented evidence of the sites of administration for sliding scale insulin injections 47 times in July and 6 times in August. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to document the injection sites, highlighting a lapse in the nursing staff's competency in managing the resident's diabetes care.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by a Certified Nurses Assistant (CNA) while providing care to a resident on Enhanced Barrier Precautions (EBP). The resident, who had a history of multiple health issues including MRSA in the urine, was placed on EBP to prevent the spread of multi-drug resistant organisms. Despite the presence of a sign indicating the need for PPE, the CNA did not wear a gown and gloves as required during high-contact care activities. During the observation, the CNA was seen performing incontinent care without wearing any PPE initially and later donned gloves without washing hands. The CNA proceeded to perform various tasks, including transferring the resident and providing hygiene care, without changing gloves or washing hands between tasks. This included touching the resident, handling personal items, and moving equipment, all with the same pair of gloves, which were also used to clean the resident. The CNA's actions were confirmed to be against the facility's EBP policy, which mandates the use of gloves and gowns during high-contact activities and changing PPE before caring for another resident. The Infection Control Nurse confirmed the breach in protocol, acknowledging that the CNA should have adhered to the EBP requirements, including proper hand hygiene and PPE use. Additionally, the wipes used during care were improperly handled, as they were taken into the resident's room and later placed back on the hall cart for potential use on another resident.
Resident Injury Due to Improper Use of Lift Chair
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident during a whirlpool bath. The resident, who had moderate cognitive impairment and was at high risk for falls, was not properly secured with a seat belt in a lift chair. This resulted in the resident falling from the chair to the floor, sustaining severe injuries including a fractured skull, fractured left arm, a laceration to the head, and a brain bleed. The incident occurred when a Certified Nurse Aid (CNA) assisting the resident failed to secure the seat belt on the lift chair. While the CNA was looking down to lock the lift's wheels, the resident fell from the chair. The resident was found unresponsive on the floor with shallow respirations and a slow heart rate. Immediate medical attention was provided, and the resident was taken to the emergency room for further treatment. Interviews and facility records revealed that the CNA did not follow the facility's policy, which required securing the safety belts when using the lift system. The CNA was suspended during the investigation, and it was confirmed that the failure to use the seat belt directly led to the resident's fall and subsequent injuries.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed at risk for elopement, resulting in the resident eloping from the facility. The resident, who had severe cognitive impairment and was identified as an elopement risk, was found approximately 300 yards outside the facility by a staff member. The incident occurred on 04/19/2024 at approximately 6:20 p.m., and the resident was returned to the facility at approximately 6:32 p.m. The resident's medical record indicated diagnoses including depressive disorder, macular degeneration, dementia, and hypothyroidism, and the resident had a history of expressing a desire to go home, which was noted as a risk factor for elopement. The facility's investigation revealed that the resident exited the building through an exit door by the activity room. The resident was able to ambulate independently and was observed walking in the hallways by multiple staff members. Interviews with staff confirmed that the resident frequently walked independently in the halls. The facility's camera footage showed the resident exiting the building at 6:20 p.m. on 04/19/2024. The resident was found by an employee and brought back to the facility, with no apparent injuries noted upon a body audit. The facility's policies and procedures for monitoring residents at risk for elopement were not adequately followed, as evidenced by the resident's ability to exit the building without staff intervention. The care plan for the resident included interventions such as monitoring for risk factors, encouraging participation in activities, and educating staff on the resident's potential for elopement. However, these measures were insufficient to prevent the resident from eloping, leading to the Immediate Jeopardy situation on 04/19/2024.
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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