Willow Wood At Woldenberg Village
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 3701 Behrman Place, New Orleans, Louisiana 70114
- CMS Provider Number
- 195156
- Inspections on file
- 25
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Willow Wood At Woldenberg Village during CMS and state inspections, most recent first.
The facility did not complete required post-fall evaluations or update care plans with new interventions for two residents after multiple falls, and failed to secure a portable oxygen tank in a resident's room as per policy. Nursing staff confirmed the lack of documentation and adherence to procedures.
Two residents receiving nebulizer treatments did not have their respiratory equipment changed or stored according to facility policy. One resident's nebulizer mask was kept in a plastic bag dated over a month prior, with no documentation of weekly changes, while another resident's nebulizer mask was repeatedly left uncontained on their lap or bedside table. Staff interviews and record reviews confirmed these lapses in following established procedures for respiratory care equipment.
A resident with moderate cognitive impairment was not assessed for self-administration of medications as required by facility policy. The resident was observed with multiple medications at bedside and in the bathroom, and confirmed self-application of a topical cream. Nursing staff and administration acknowledged that no assessment had been completed and that medications should not have been left accessible.
A resident with severe cognitive impairment and a new diagnosis of schizophrenia was not referred for a required PASARR Level II evaluation. Despite the diagnosis and care planning for behavioral issues, there was no documentation that the necessary screening was completed, as confirmed by the Social Service Director.
A resident with hemiplegia and moderate cognitive impairment, identified as at risk for pressure ulcers, was left on a deflated air-loss mattress for over eight hours. Despite the resident reporting air escaping and a low air pressure warning being visible, staff did not physically check the mattress's inflation. The issue was later traced to the CPR function being activated, but the resident remained on the improperly inflated mattress for an extended period, contrary to the care plan and facility policy.
A resident with a PEG tube was not given enteral nutrition at the physician-ordered rate. The feeding pump was set at 60 mL/hr instead of the prescribed 50 mL/hr, a discrepancy confirmed by both an LPN and the ADON. Facility policy requires nurses to confirm the correct rate, but this was not done.
A CNA was observed handling a resident's food with bare hands during meal service, including picking up food from the plate and bedside table, without performing hand hygiene. Facility staff confirmed that this practice was not appropriate and did not follow professional standards for food safety.
A resident with dementia who exhibited aggressive behaviors was told by facility staff that return from a behavioral health hospital would only be allowed if the family provided a personal sitter. Multiple staff communicated this requirement to the resident's representative, who could not afford the service, resulting in the resident being taken home. This action violated facility policy and resident rights regarding personal funds and conditions of continued stay.
A resident was transferred to a behavioral health hospital without the facility providing the required written notification to the resident's representative or the State's LTC Ombudsman. Record review and interviews confirmed that neither party received written notice of the transfer, and the administrator acknowledged the omission.
The facility did not post daily nurse staffing information in a prominent and accessible location as required. Observations confirmed the absence of posted information, and both the administrator and DON stated they were unaware of the requirement, resulting in the information not being made available.
The facility failed to discard insulin pens within 28 days of opening, as required. During an observation, it was found that insulin pens for two residents were available for use despite being expired. An LPN and the DON confirmed that these pens should have been discarded and replaced with new ones.
The facility failed to maintain food safety and sanitation standards, including improper thawing of raw chicken, unsanitary conditions in the walk-in cooler, excessive ice in the freezer, and inadequate monitoring of sanitization levels in dishwashing equipment.
Failure to Complete Post-Fall Evaluations and Secure Oxygen Tanks
Penalty
Summary
The facility failed to complete required evaluations after residents sustained falls, as outlined in their own policy. Specifically, two residents who were identified as high risk for falls experienced multiple falls, but there was no documented evidence that post-fall evaluations were conducted within the required timeframe. Additionally, the care plans for these residents were not revised to include new individualized interventions following each fall, despite repeated incidents. Interviews with nursing staff confirmed the absence of documentation for both the evaluations and care plan updates after the falls occurred. Furthermore, the facility did not ensure that oxygen tanks were properly secured according to policy. Observations revealed that a portable oxygen tank was found free standing on the floor in a resident's room on two separate occasions, rather than being strapped to a cylinder stand or stored in the designated cage. Staff interviews confirmed that the oxygen tanks should have been secured as per facility policy, but this was not done.
Failure to Change and Store Nebulizer Equipment per Facility Policy
Penalty
Summary
The facility failed to adhere to its own policy regarding the maintenance and storage of nebulizer equipment for two residents requiring respiratory care. For one resident with physician orders for Ipratropium-Albuterol nebulizer treatments as needed for wheezing, observations revealed that the nebulizer mask was stored in a plastic bag dated over a month prior, with no documented evidence that the tubing and mouthpiece had been changed weekly as required by facility policy. Interviews with nursing staff and review of the electronic Medication Administration Record (eMAR) confirmed that there was no documentation of the equipment being changed since the date on the bag. Another resident, also with physician orders for Ipratropium-Albuterol nebulizer treatments, was observed multiple times with the nebulizer mask left uncontained, either on the resident's lap or on the bedside table, rather than being stored in a plastic bag as required. Nursing staff confirmed during interviews that the nebulizer mask should have been stored in a plastic bag when not in use, in accordance with facility policy. These deficiencies were identified through direct observation, interviews with staff, and review of medical records, which consistently showed a lack of compliance with the facility's established procedures for cleaning, changing, and storing nebulizer equipment. The failure to follow these procedures was confirmed by both the LPN Supervisor and the Infection Preventionist, who acknowledged the absence of documentation and proper storage practices for the residents' respiratory care equipment.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required by its own policy. The policy states that residents should be assessed for self-administration of medications upon admission, quarterly, annually, and with any significant change in condition. Review of the resident's record showed no documented evidence of such an assessment, despite the resident having a moderate cognitive impairment as indicated by a Brief Interview for Mental Status score of 11 on the most recent Minimum Data Set. Observations revealed that the resident had access to multiple medications at her bedside and in her bathroom, including an opened tube of Cloderm 0.1% cream, a bottle of pain relief roll-on with lidocaine hydrochloride 4%, and several tablets in medication cups. The resident confirmed self-application of the cream. Interviews with nursing staff and administration confirmed that the resident had not been assessed for self-administration and that medications should not have been left at the bedside or in the bathroom.
Failure to Complete PASARR Level II Evaluation After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident who received a new diagnosis of schizophrenia was referred for a required Preadmission Screening and Resident Review (PASARR) Level II evaluation. The resident was admitted in 2010 and was diagnosed with schizophrenia in 2018. Despite this new diagnosis, there was no documented evidence in the clinical or medical record that a Level II PASARR evaluation was completed following the diagnosis. The resident's annual assessment indicated severe cognitive impairment and an active diagnosis of schizophrenia without dementia, and a care plan was developed for behavioral alterations related to psychosis, including placement on the Memory Care Unit. During an interview, the Social Service Director confirmed that the required Level II PASARR evaluation had not been completed after the new diagnosis.
Failure to Maintain Inflated Pressure Reducing Mattress for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for skin breakdown was left on a deflated air-loss pressure reducing mattress for over eight hours. The facility's policy required the use of a specialized mattress for residents at risk of pressure ulcers, and the resident's care plan included an intervention for a pressure reduction mattress. Observations revealed that the mattress had a low air pressure warning light activated, and the bed frame was palpable when pressure was applied, indicating the mattress was not properly inflated. The resident reported hearing air escaping from the mattress and informed staff, who responded only by confirming the mattress was plugged in, without physically checking the mattress's inflation. Further investigation found that a nurse on the night shift observed the low air pressure warning and later determined that the CPR function on the mattress had been activated, causing it to deflate. The Assistant Director of Nursing confirmed that the resident remained on the deflated mattress for an extended period. The resident had a history of hemiplegia, moderate cognitive impairment, and was at risk for pressure ulcers due to incontinence, debility, and comorbidities. The failure to ensure the mattress was properly inflated and to respond appropriately to the resident's report led to the deficiency.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
A deficiency occurred when a resident with a percutaneous endoscopic gastrostomy (PEG) tube was not administered enteral nutrition as ordered by the physician. The resident's medical record indicated an order for Glucerna 1.2 Cal to be infused at 50 mL/hour over 22 hours. However, during observation, the resident's feeding pump was found set at 60 mL/hour. This discrepancy was confirmed by both an LPN and the Assistant Director of Nursing, who acknowledged that the pump should have been set to the ordered rate of 50 mL/hour. The facility's policy requires nurses to confirm the administration method and volume/rate of enteral feedings, but this was not followed in this instance.
Failure to Maintain Sanitary Food Handling During Meal Service
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to serve food in a sanitary manner to a resident during lunch service. The CNA was observed delivering a lunch tray to the resident's room, removing the insulated cover from the plate, and handling the resident's food with bare hands. Specifically, the CNA repositioned the resident's feet, picked up a chicken tender from the plate and placed it in the resident's hand, and later picked up the same chicken tender from the bedside table and returned it to the plate, all without performing hand hygiene at any point during the process. Interviews with facility staff, including a licensed practical nurse (LPN) supervisor, the infection preventionist, and the assistant director of nursing, confirmed that staff should not touch residents' food with bare hands during meal service. The CNA also acknowledged that she should not have touched the food with bare hands. These actions were not in accordance with the 2022 FDA Food Code, which requires the use of suitable utensils or gloves to prevent cross-contamination of ready-to-eat food.
Resident Required to Provide Personal Sitter as Condition of Return
Penalty
Summary
The facility failed to ensure that a resident was not required to provide a personal sitter as a condition of continued stay. According to the facility's own Resident Rights policy, non-covered special care services such as privately hired aides may only be charged to residents if requested by the resident, and the facility must not require such services as a condition of admission or continued stay. In this case, a resident with a diagnosis of unspecified dementia was admitted to the dementia unit and subsequently became verbally and physically aggressive towards staff, leading to a transfer to a behavioral health hospital under a Psychiatric Emergency Certificate. Following the transfer, multiple staff members, including the ADON, DON, and Social Worker, communicated to the resident's representative that the resident could only return to the facility if the family supplied a personal sitter to monitor behaviors. This requirement was reiterated in emails and interviews, and the behavioral health hospital was also informed of this condition. The resident's representative stated she could not afford to pay for a personal sitter, resulting in the resident being taken home instead of returning to the facility. The facility's actions directly contradicted their policy and regulatory requirements regarding resident rights and the use of personal funds for services covered by Medicare or Medicaid.
Failure to Provide Required Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to both a resident's representative and the State's Long-Term Care Ombudsman regarding the resident's transfer to a behavioral health hospital. Review of the electronic medical record and clinical documentation for the resident showed no evidence that such written notices were issued at the time of transfer. Interviews with the assigned Ombudsman and the resident's representative confirmed that neither received written notification of the transfer. The facility administrator also acknowledged that the required written notices were not provided to the resident's representative or the Ombudsman at the time of the transfer.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent and readily accessible location as required. Observations conducted in the facility's hallways and public areas revealed that the required staffing information was not displayed. Additionally, the facility was unable to provide any documented evidence that the daily nurse staffing information had been posted. During interviews, both the administrator and the director of nursing stated they were unaware of the requirement to post this information, and confirmed that it had not been done due to this lack of awareness.
Expired Insulin Pens Not Discarded
Penalty
Summary
The facility failed to ensure that insulin medications were discarded within 28 days of being opened, as required by professional principles. During an observation of medication storage, it was found that insulin pens for two residents were available for use despite being past the 28-day expiration period. Specifically, Resident #42's Insulin Aspart Pen and Resident #97's Lantus Solostar Pen were both opened beyond the acceptable timeframe and had not been discarded. Interviews with the LPN and the Director of Nursing confirmed that these insulin pens should have been discarded and replaced with new ones, as they were expired and should not have been available for use.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in several areas. Raw chicken was observed being thawed improperly in a metal container submerged in water, which was confirmed by the chef and cook as not following the correct procedure of thawing under running water. Additionally, the walk-in cooler was found to be unsanitary, with a foul odor and various unknown substances pooled on the floor and along the baseboard tiles, which the chef acknowledged needed cleaning. The walk-in freezer was also found to have a thick layer of ice accumulation on its floor, walls, shelves, ceiling, and fan, which was confirmed by the chef as inappropriate. Furthermore, the facility did not document the water temperature and sanitization levels of the 3-compartment sink and dishwasher as required. The sanitization level of the dishwasher was tested and found to be below the required chlorine concentration, which was confirmed by the chef.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
