Bayou Chateau Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Simmesport, Louisiana.
- Location
- 16232 Hwy. 1, Simmesport, Louisiana 71369
- CMS Provider Number
- 195546
- Inspections on file
- 22
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Bayou Chateau Nursing Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple neurologic and nutritional diagnoses had a PEG feeding tube and was placed on Enhanced Barrier Precautions (EBP), as indicated by signage on the room door and the facility’s infection control policy requiring gown use for high-contact care involving indwelling devices. During observed medication administration, an LPN provided medications and tube feeding via the PEG tube without donning a gown. In interviews, the LPN acknowledged the resident was on EBP and confirmed a gown was not worn, and the DON and ADON stated that a gown was required for direct contact under EBP and confirmed it should have been used during this care but was not.
A treatment nurse did not follow required hand hygiene and glove change protocols during wound care for a resident with severe cognitive impairment and multiple medical conditions. The nurse failed to remove gloves and perform hand hygiene at key steps, as outlined in facility policy, during a pressure ulcer dressing change. This was confirmed by both the nurse and the DON during interviews.
The facility did not post daily nurse staffing information as required. Observations showed that the form for daily nursing hours was not updated for several days. An RN was unsure who was responsible for posting the information over the weekend, and the DON confirmed that the required updates had not been made.
A facility failed to ensure a resident's call bell was within reach, as required by their policy. Despite staff indicating the resident could use the call bell, observations showed it was on the floor, inaccessible. The resident, with conditions like Microcephaly and Muscle Wasting, required staff assistance for daily activities, emphasizing the need for accessible call systems.
A resident with moderate cognitive impairment and multiple medical conditions did not receive necessary nail care, despite expressing a desire for it. The resident's care plan required assistance with ADLs, including personal hygiene. An LPN confirmed the need for nail cutting, noting that the treatment nurse or nurses could perform this task for diabetic residents.
The facility did not follow the menu for residents on a pureed diet, omitting seasoned greens, cornbread, and fruit crisp from the lunch meal. This was confirmed by the dietary manager, resulting in a failure to meet the nutritional needs of the residents.
The facility failed to properly store and label food items, with issues such as exposed cheese, improperly defrosting meat, and undated frozen fish. Additionally, dented cans and unsealed noodles were found in dry storage. Cooked food was not maintained at the required temperature, with pureed sausage served below 135°F. The Dietary Manager acknowledged these deficiencies.
A resident with severe cognitive impairment and a history of falls did not have the prescribed bright tape applied to her bathroom door frame as part of her care plan. The DON acknowledged the oversight, noting the tape had been ordered but not yet received, and confirmed no alternative fall prevention measures were in place.
Failure to Follow Enhanced Barrier Precautions for Resident With PEG Tube
Penalty
Summary
Surveyors identified a failure to follow the facility’s own infection prevention and control policy regarding Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The facility’s policy, dated 04/15/2025, required implementation of EBP, including use of gowns for high-contact resident care activities such as device use with feeding tubes, for residents with indwelling medical devices even if they were not known to be infected or colonized with multidrug-resistant organisms. The policy also stated that all staff were to receive training on EBP upon hire and at least annually and were expected to comply with all designated precautions. The resident involved was admitted on 09/04/2025 and had diagnoses including anoxic brain damage, dysphagia following cerebral infarction, gastrostomy, moderate protein-calorie malnutrition, personal history of sudden cardiac arrest, and aphasia following other cerebrovascular disease. The quarterly MDS showed the resident had severe cognitive impairment and was dependent for multiple ADLs, including hygiene and bathing. The resident had a PEG feeding tube and a care plan addressing PEG tube feedings. An EBP sign was posted on the resident’s room door. During observation of medication administration, an LPN administered medications and tube feeding through the PEG tube without donning a gown. In a subsequent interview, the LPN acknowledged the resident was on EBP due to the PEG tube and confirmed she did not wear a gown, and the DON and ADON stated that a gown should be worn for direct contact with residents on EBP and confirmed a gown should have been worn during this care but was not.
Failure to Perform Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a treatment nurse failed to follow proper hand hygiene protocols during the care of a pressure ulcer for a resident. The facility's policy required hand hygiene and glove changes at specific steps during wound care, including after removing the old dressing, after cleaning the wound, and before applying a new dressing. However, during an observed dressing change for a resident with multiple complex medical conditions, the nurse did not remove gloves or perform hand hygiene at any of these required points. The resident involved had severe cognitive impairment and was totally dependent on staff for all activities of daily living. The resident's medical history included adult failure to thrive, long-term antibiotic use, anxiety disorder, functional quadriplegia, encephalopathy, MRSA infection, multiple contractures, and cognitive communication deficits. The nurse confirmed during an interview that she did not perform hand hygiene or change gloves as required during the wound care procedure. The DON also confirmed that the nurse had previously completed a skills checkoff on hand hygiene but failed to follow protocol during this incident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, which is a requirement. Observations on August 5, 2024, at 6:03 a.m. revealed that the form for daily nursing hours, dated from August 1, 2024, to August 12, 2024, was posted on a bulletin board near the nurse's station. However, the daily staffing hours for August 2, 2024, through August 5, 2024, were not posted. An interview with an RN indicated uncertainty about who was responsible for posting the daily nursing hours over the weekend, although it was acknowledged that they should be posted daily. Further observation on the same day at 7:45 a.m. confirmed that the form had not been updated to include the required information. An interview with the Director of Nursing (DON) at 12:35 p.m. revealed that she was responsible for updating and posting the facility's daily nursing hours. The DON confirmed that the daily nursing hours for the specified dates had not been updated or posted.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of needs, specifically regarding the placement of a call bell. The facility's policy on call light accessibility requires that the call system be accessible to residents while in their bed or other sleeping accommodations. However, observations on multiple occasions revealed that the call light for a resident with diagnoses including Microcephaly, Cognitive Communication Deficit, and Muscle Wasting and Atrophy, was on the floor next to the left-hand side of the bed, out of reach. Interviews with staff indicated that the resident was able to use the call bell if needed, yet the call bell was not accessible during the observations. The resident's medical record indicated a need for staff assistance with various activities of daily living, highlighting the importance of having the call bell within reach.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately performed for a resident, specifically in providing nail care. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Heart Failure, and Major Depressive Disorder, had a BIMS score indicating moderate cognitive impairment and required supervision or assistance with personal hygiene. The resident's care plan noted the need for assistance with all ADLs due to general weakness and impaired cognition, with interventions such as verbal cues and task breakdowns. Observations revealed that the resident had long fingernails and expressed a desire to have them cut, indicating that the resident did not refuse nail care. An LPN confirmed the need for nail cutting and stated that the treatment nurse or nurses could perform this task for diabetic residents.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to meet the nutritional needs of residents on a pureed diet by not following the established menu. During the lunch meal on August 5, 2024, for residents on a pureed diet, the menu included sliced ham, red beans and rice, seasoned greens, cornbread, and fruit crisp. However, observations revealed that seasoned greens, cornbread, and fruit crisp were not served to residents #15, #19, and #22. The dietary assistant prepared trays without these items, and the trays were subsequently served to the residents by CNAs. An interview with the dietary manager confirmed that the menu called for these items, which were missing from the serving line. This oversight resulted in the facility not adhering to the menu designed to ensure nutritional adequacy for the residents on a pureed diet.
Food Storage and Temperature Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, preparation, and labeling of food items in accordance with professional standards for food service safety. During an observation of the kitchen, a block of cheese was found partially wrapped and exposed to air, resulting in discoloration. A tube of ground meat was improperly defrosting on a wire rack, dripping blood-tinged liquid onto the shelf and floor. Additionally, a bag of frozen fish lacked an expiration or use-by date. In the dry storage area, dented cans of syrup and pineapple sauce were found on the shelf, and an open bag of fettuccini noodles was not stored in a sealed bag. The Dietary Manager acknowledged these issues during the observation. Furthermore, the facility did not maintain cooked food at the required temperature. During breakfast service, pureed sausage was observed on a steam table in a non-heated area, with a temperature reading of 125 degrees Fahrenheit, below the required 135 degrees. The Dietary Manager confirmed that the sausage was not at the appropriate holding temperature, indicating a failure to adhere to food safety standards.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident with severe cognitive impairment, as indicated by a BIMS score of 7. The resident, who had diagnoses including unspecified dementia, aphasia, dizziness, and anxiety disorders, experienced a fall in her room while attempting to ambulate to the bathroom. The care plan, reviewed on 08/02/2024, included an intervention to add bright tape to the bathroom door frame to prevent further falls. However, an observation on 06/06/2024 revealed that the bright tape had not been applied to the door frame. The Director of Nursing (DON) acknowledged the absence of the tape, stating it had been ordered but not yet arrived, and confirmed that no other fall prevention measures had been implemented for the resident.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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