Bayou Vista Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bunkie, Louisiana.
- Location
- 323 Evergreen Hwy, Bunkie, Louisiana 71322
- CMS Provider Number
- 195603
- Inspections on file
- 22
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bayou Vista Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility did not submit complete and accurate direct care staffing data to CMS for an entire quarter, including missing RN hours and documentation of 24-hour licensed nursing coverage, as confirmed by the administrator responsible for PBJ submissions.
The facility did not inform residents of potential financial liability by failing to document estimated costs for non-covered services on required ABN forms. Staff responsible for presenting and completing these forms confirmed that the cost estimate section was left blank for several residents, contrary to facility policy.
A resident with a PEG tube and complex medical needs did not have their tube feeding and flush intake documented each shift as required by the care plan. Both an LPN and the DON confirmed that this documentation was not completed on multiple occasions, despite clear care plan directives.
Two residents did not receive respiratory care in accordance with professional standards. One resident's suction equipment was not labeled or dated as required, and another resident received oxygen at a higher flow rate than ordered by the physician. These deficiencies were confirmed through observations and staff interviews.
A CNA in a LTC facility verbally and mentally abused two residents, one with severe cognitive impairment and another with moderate impairment. The CNA taunted one resident by threatening to withhold a drink and dismissed the other's request for assistance with back pain. The incident was witnessed by the ADON and confirmed by video footage, leading to the CNA's termination.
A resident at high risk for falls was injured due to the facility's failure to ensure fall prevention measures were in place and functioning. The resident's fall mat was not in place, the call light was out of reach, and the bed alarm was not working properly due to a weak battery. A housekeeper moved the fall mat and did not return it, assuming a CNA would do so. The LPN checked the equipment earlier than documented, and there was no system for checking bed alarm batteries. The CNA was terminated for not replacing the fall mat.
The facility failed to submit accurate payroll information for direct care staffing, resulting in a one-star staffing rating, low weekend staffing, no RN coverage for 8 consecutive hours per day, and no licensed nursing coverage 24 hours/day. The Administrator and MDS Nurse did not check the final file validation report after 24 hours, leading to the rejection of the files due to an invalid file extension.
The facility failed to change enteral feeding tubing and supplies every 24 hours as required, as observed in a resident receiving Jevity 1.5 at 40ml per hour. The feeding setup had been in use for over 24 hours, contrary to the facility's policy and manufacturer guidelines, as confirmed by the S3 MDS Nurse.
Failure to Submit Required Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2025 revealed that the facility did not submit RN hours for any day during the 92-day quarter and failed to document licensed nursing coverage for 24 hours each day throughout the same period. These omissions resulted in triggers for a One Star Staffing Rating, excessively low weekend staffing, no RN hours, and lack of 24-hour licensed nursing coverage. During an interview, the administrator responsible for PBJ submissions confirmed that the required staffing information was not accurately submitted for the quarter.
Failure to Provide Estimated Costs on ABN Forms
Penalty
Summary
The facility failed to inform residents of the charges for services for which they may be responsible, specifically in cases where Advanced Beneficiary Notices of Non-Coverage (ABN) were issued. Record review showed that for three sampled residents who received ABNs, the section of the ABN form (CMS-10055) requiring an estimated cost per day, item, or service for continuing daily skilled nursing care was left blank. This omission was identified during a review of the facility's ABN policy, which requires a good faith effort to provide a reasonable cost estimate or to indicate if no estimate is available. Interviews with facility staff confirmed the deficiency. The administrator was unaware of why the estimated cost section was not completed, and the accounts manager, who was responsible for presenting and documenting the ABN forms, acknowledged that she failed to document the estimated costs on the forms. The accounts manager confirmed that the estimated cost should have been included on the ABN forms for the affected residents but was not.
Failure to Document Tube Feeding and Flush Intake as Care-Planned
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident with multiple complex medical conditions, including dysphagia following cerebral infarction, dementia, protein-calorie malnutrition, and a PEG tube for nutrition. The resident was care-planned to receive Jevity 1.2 cal at 50mL/hr with a 25mL/hr flush, and the care plan required monitoring and documentation of intake and output every shift. Despite these documented interventions, review of the resident's records revealed that intake of tube feeding and flushes was not documented each shift on multiple dates. Interviews with both an LPN and the Director of Nursing confirmed that the intake of tube feeding and flushes had not been documented as required by the care plan. The lack of documentation was observed on several specific dates, indicating a failure to follow the established care plan for monitoring and recording the resident's nutritional and fluid intake as ordered by the physician and outlined in the care plan.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident with a history of shortness of breath, acute respiratory failure, dysphagia, cerebral infarction, and dementia, surveyors observed that suction equipment, including a canister, tubing, and Yankauer suction tip, was available at the bedside but was not labeled or dated as required by facility policy. This lack of labeling was confirmed over two consecutive days, and staff interviews verified that the equipment should have been labeled with the date it was opened and changed every seven days. For another resident with diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and schizoaffective disorder, the oxygen concentrator was observed to be set at 3.5 liters per minute, despite a physician's order for 2 liters per minute via nasal cannula. Multiple observations over two days confirmed the oxygen was consistently set above the ordered rate. Staff later verified the discrepancy between the physician's order and the actual oxygen flow rate being administered.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect two residents from mental and verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a CNA speaking to two residents in a rude and aggressive manner. One resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was spoken to in a way that made her cry. The CNA taunted her by threatening to withhold a diet coke if she moved a pillow. The other resident, who had moderately impaired cognition, was also spoken to rudely, which upset him. The incident was captured on video footage, showing the CNA interacting with the residents in a dining area. The CNA was observed repositioning a pillow for one resident and using it as leverage to deny her a drink. The CNA also dismissed the second resident's complaint of back pain and request to go to bed, stating he would have to wait for someone else. This behavior was witnessed by the Assistant Director of Nursing (ADON), who intervened after hearing the second resident's protest. The facility's Administrator reviewed the video footage and confirmed the CNA's aggressive and antagonizing behavior towards the residents. The CNA's actions were deemed abusive, as they involved taunting and depriving the residents of care in a manner that was not respectful or considerate of their needs and conditions.
Failure to Ensure Fall Prevention Measures Resulted in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident's fall prevention measures were in place and functioning properly, leading to an accident. A resident, who was at high risk for falls due to conditions such as hemiplegia, dementia, and anxiety disorder, was found on the floor with injuries including a subdural hematoma, a left eye laceration, and skin tears. At the time of the fall, the resident's fall mat was not in place, the call light was not within reach, and the bed alarm was not functioning properly due to a weak battery. The incident occurred when a housekeeper moved the fall mat to clean the room and did not return it to its proper place. The housekeeper assumed that a CNA would replace the mat, but this did not happen. Additionally, the LPN responsible for the resident had checked the bed alarm, call light, and fall mat earlier in the day and noted them as being in place and functioning, but the bed alarm's battery was weak, making it ineffective at the time of the fall. Interviews with staff revealed that there was a lack of clear responsibility for ensuring the fall prevention equipment was in place and functioning. The LPN admitted to checking the equipment earlier than documented, and the DON confirmed that there was no prior system for checking bed alarm batteries. The CNA involved was terminated for failing to replace the fall mat, which was a violation of the facility's policy.
Failure to Submit Accurate Payroll Information for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit payroll information for direct care staffing as required. The review of the facility's PBJ (Payroll Based Journal) staffing Data Report for FY Quarter 1 2024 revealed several triggers, including a one-star staffing rating, low weekend staffing, no RN coverage for 8 consecutive hours per day, and no licensed nursing coverage 24 hours/day. The facility's CMS Payroll Based Journal submission report indicated that the submission had been received but needed to be checked for errors within 24 hours. However, the final file validation report showed that the number of files processed was 4, the number of files accepted was 0, and the number of files rejected was 4 due to an invalid file extension (.xml). The facility did not correct and resubmit the files as required. An interview with the Administrator revealed that both he and the MDS Nurse were responsible for submitting the PBJ information. The Administrator confirmed that neither he nor the MDS Nurse checked the final file validation report after 24 hours to ensure the facility staffing information had been submitted and accepted as required. This oversight led to the failure in submitting accurate and complete payroll information for direct care staffing, resulting in the identified deficiencies.
Failure to Change Enteral Feeding Supplies as Per Guidelines
Penalty
Summary
The facility failed to ensure that enteral feeding tubing and supplies were changed at least every 24 hours in accordance with manufacturer guidelines. This deficiency was observed in the case of a resident who was receiving tube feeding of Jevity 1.5 at 40ml per hour. The resident's tube feeding bag and flush bag were labeled with a date and time indicating they had been in use for over 24 hours, contrary to the facility's policy and manufacturer guidelines. During an observation, the resident was noted to be receiving tube feeding with bags labeled from the previous day. The S3 MDS Nurse confirmed that the tube feeding setup had been hanging longer than 24 hours and acknowledged that it should have been changed. The resident's clinical record included diagnoses such as Hemiplegia, Hemiparesis, Dementia, Dysphagia, and Chronic Obstructive Pulmonary Disease, highlighting the need for strict adherence to enteral feeding protocols to prevent complications.
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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