Avalon Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 4385 Old Sterlington Road, Monroe, Louisiana 71203
- CMS Provider Number
- 195492
- Inspections on file
- 29
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avalon Place during CMS and state inspections, most recent first.
Two residents had inaccurate MDS assessments: one was incorrectly marked as a non-smoker despite documentation and care planning for smoking, and another was documented as not having a colostomy when their care plan included interventions for colostomy care. These inaccuracies were confirmed by facility leadership.
Nursing staff did not properly assess or document care for two residents, including failing to record the rationale for a foot x-ray for one resident and not completing an assessment when another resident reported abdominal pain before hospital transfer. Leadership confirmed the lack of required documentation and assessment by nursing staff.
The facility did not notify the physician or resident representatives when two residents experienced significant changes in condition or were transferred to the hospital. In both cases, documentation confirming required notifications was missing, as verified by staff interviews and record reviews.
A resident with a colostomy did not receive or have documented colostomy care as ordered and per facility policy over several days. Required checks of the stoma site and colostomy bag changes were not documented, and the resident was later hospitalized with complications at the ostomy site, including abnormal bowel color and questionable gangrene.
A resident with dementia and other conditions was involved in an incident where she hit her head on a table. The LPN attempted to notify the resident's physician but was unable to due to outdated contact information, resulting in a failure to communicate the incident. The Interim DON confirmed the LPN should have notified the physician, indicating a deficiency in the notification process.
The facility failed to provide adequate pressure ulcer care for two residents. A resident with moderate cognitive impairment was found with an open pressure ulcer on her heel, without a pressure-relieving device in place, despite previous complaints of pain. Another resident with severe cognitive impairment and a Stage II pressure ulcer on the hip was observed sitting in a geri chair without a pressure-relieving device, risking further skin breakdown.
The facility failed to document and assess incidents involving assistive devices for two residents with severe cognitive impairments. One resident slid under a lap tray and fell, while another broke a lap tray and slid to the floor, resulting in a skin tear. Neither incident was documented in an Incident/Accident Report, nor were the residents assessed for the appropriateness of the assistive devices.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease by not monitoring fluid intake as per physician orders. Despite a 1000 cc fluid restriction, staff interviews revealed that no fluid intake log was maintained, and the ADON confirmed the lack of documentation.
The facility failed to assess the risk of entrapment from bed rails for four residents before installation, despite policy requirements. Observations revealed residents with cognitive impairments and mobility issues had bed rails raised without documented assessments. Interviews confirmed the lack of assessments.
The facility experienced a medication error rate of 10.71%, exceeding the acceptable threshold of 5%. An LPN administered incorrect dosages of Furosemide and Gabapentin to a resident, and another resident received an incorrect dosage of Fludrocortisone. These errors were confirmed by the ADON during an interview.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling medical devices, as required by their policy. Observations showed that these residents did not have EBP signage on their doors, despite having conditions that necessitated such precautions. Interviews confirmed the oversight in communicating and implementing the EBP policy.
The facility failed to notify the appropriate parties of changes in resident conditions. A resident with severe cognitive impairment experienced a fall, but the family was not informed by the LPN. In another case, a resident with moderate cognitive impairment was found with multiple bruises, but the nursing administration was not notified as required by policy.
The facility failed to ensure residents were free from physical restraints used for convenience, as three residents were observed with lap trays without proper documentation or physician orders. Despite severe cognitive impairments, these residents were not monitored for the release of restraints as required by policy, and staff confirmed these deficiencies.
A facility failed to notify a resident and their representative of hospital transfers and did not inform the Ombudsman. The resident was transferred twice without proper notification, as confirmed by the Ombudsman and facility records.
The facility failed to complete quarterly MDS assessments for two residents as required by CMS. One resident's last assessment was in late June, and the other in early June, with no subsequent assessments documented within the required three-month period. The ADON confirmed the oversight.
A facility failed to ensure accurate MDS documentation for a resident's discharge status. The MDS indicated a discharge to the hospital, but nurse's notes and staff interviews confirmed the resident was discharged to home, revealing a documentation inaccuracy.
A facility failed to document the required assessment of a resident's urine character every shift, as outlined in the care plan for a resident with an indwelling urinary catheter. Despite the resident's cognitive intactness and need for substantial assistance, the necessary documentation was absent, which was confirmed by the Assistant Director of Nursing.
A facility failed to maintain a resident's personal hygiene by not keeping their fingernails trimmed. The resident, with severe cognitive impairment and dependent on staff for daily living activities, had long and untrimmed nails despite a care plan for daily nail cleaning. Observations confirmed the deficiency, and the Activity Director addressed the issue after being notified.
A resident with severe cognitive impairment and hand contractures was observed without necessary hand rolls, which are crucial for maintaining range of motion. The LPN was unaware of this oversight, and the resident's care plan lacked documentation addressing the hand contractures, indicating a failure in providing appropriate care.
A facility failed to monitor edema in a resident who was prescribed Lasix, a diuretic, for edema management. The resident had multiple diagnoses, including depression, hypotension, and edema, and required assistance with daily activities. Despite a care plan that included monitoring for hypertension/hypotension and administering medications as ordered, there was no documentation of edema checks. This deficiency was confirmed by the ADON.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of three sampled residents. For one resident with multiple diagnoses including heart disease, dementia, and chronic obstructive pulmonary disease, the MDS assessment inaccurately documented the resident as a non-smoker. However, record reviews and staff interviews confirmed that the resident was identified as a smoker upon admission, had a smoking assessment completed, and had a care plan in place addressing smoking safety, with cigarettes and lighter kept at the nurse's station. Both the administrator and assistant directors of nursing confirmed the omission on the MDS assessment. For another resident with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease, the MDS assessment inaccurately indicated the absence of an ostomy and dependence with toileting hygiene. In contrast, the resident's care plan documented a colostomy and included interventions for colostomy care and monitoring for skin breakdown. The director of nursing confirmed that the MDS assessment was inaccurate regarding the resident's colostomy status.
Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the assessment and documentation of care for two residents. For one resident with a history of cerebral infarction, biliary cirrhosis, heart failure, diabetes, and gout, there was no documented assessment or rationale in the medical record to support the completion of a left foot x-ray. Both the Director of Nursing and the Administrator confirmed that there was no evidence of an assessment or explanation for the x-ray performed. For another resident with diagnoses including Parkinson's Disease, COPD, hypertension, GERD, pain, and edema, nursing staff did not complete or record an assessment when the resident complained of abdominal pain prior to being transferred to a hospital. Interviews revealed that the LPN involved did not recall the resident's code status and believed the decision to transfer was made by hospice staff. Hospital records later showed the resident was diagnosed with a perforated sigmoid colon requiring surgery. The Director of Nursing confirmed there was no documentation to support that a competent assessment was performed by the LPN.
Failure to Notify Physician and Representative of Resident Status Changes and Transfers
Penalty
Summary
The facility failed to notify the physician and/or the resident's representative when there was a significant change in the resident's condition or when a transfer to the hospital occurred. For one resident with multiple chronic conditions, including diabetes, chronic kidney disease, atrial fibrillation, gout, and hypertension, there was no documented evidence that the physician or the resident's representative was notified when the resident was transferred to the emergency room. This was confirmed through record review and staff interview, which verified the absence of documentation regarding the required notifications at the time of transfer. In another case, a resident with diagnoses including Parkinson's disease, COPD, hypertension, GERD, pain, and edema experienced a significant change in condition that led to a hospital transfer and subsequent surgery for a perforated sigmoid colon. The responsible party had voiced concerns about the resident's status, and hospice staff were notified, but there was no documentation that the physician was informed of the change in condition prior to the transfer. Staff interviews confirmed the lack of physician notification and documentation regarding the resident's status change.
Failure to Provide and Document Colostomy Care per Orders and Policy
Penalty
Summary
The facility failed to provide colostomy care in accordance with physician orders, professional standards, and the resident's comprehensive plan of care for one resident. The facility's policy required documentation of colostomy care, including the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, how the resident tolerated the procedure, and notification of the supervisor for refusals or abnormal findings. For the resident in question, who had multiple diagnoses including Parkinson's Disease and a colostomy, the care plan and physician orders specified that the stoma site should be checked every shift for swelling and redness, and the colostomy bag changed as needed every shift. However, a review of the medical record, medication administration record (MAR), and nursing notes revealed no documentation that colostomy care was performed or that the stoma site was checked from June 28 to July 7. During this period, the resident was later transferred to the emergency department, where hospital records noted abnormal bowel color at the ostomy site and questionable gangrene, requiring surgical consultation. The facility's Director of Nursing confirmed the absence of documentation for the required colostomy care during the specified timeframe.
Failure to Notify Physician of Resident Incident
Penalty
Summary
The facility failed to ensure proper notification of a change in a resident's condition, as evidenced by the lack of communication with the resident's physician following an incident. A resident with diagnoses including unspecified dementia, depression, and hypothyroidism was involved in an incident where she hit her head on a table in the day room. The Incident/Accident Reporting Form indicated that the resident was assessed for injuries, and a knot was found on the left side of her head. However, the report inaccurately documented the object as a chair instead of a table. The LPN attempted to notify the resident's physician but was unable to do so because the contact information in the system was outdated, and the phone number was disconnected. Despite efforts to find the correct number, the LPN was unsuccessful, resulting in the physician not being notified of the incident. The Interim Director of Nursing confirmed that the LPN should have notified the physician about the incident, highlighting a deficiency in the facility's notification process.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for two residents. Resident #6, who had a history of pressure ulcers and moderate cognitive impairment, was observed with her feet pressed against the footboard of her bed, complaining of pain. A CNA discovered an open area with drainage on her left heel, indicating a pressure ulcer. Despite previous complaints of foot pain, the LPN had not assessed the resident's feet, and no pressure-relieving device was in place to prevent further skin breakdown. Resident #52, with severe cognitive impairment and dependent on staff for daily living activities, was observed sitting in a geri chair without a pressure-relieving device. The resident had a Stage II facility-acquired pressure ulcer on the right hip. The absence of a pressure-relieving device in the geri chair was confirmed by the ADON, indicating a failure to prevent further skin breakdown.
Failure to Document and Assess Incidents Involving Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate use of assistive devices for two residents, leading to incidents that were not properly documented or assessed. Resident #70, who has severe cognitive impairment and multiple medical conditions, was observed using a geri chair with a lap tray. Despite documented behaviors indicating distress and attempts to remove the lap tray, no Incident/Accident Report was completed when the resident slid under the tray and fell to the floor. Additionally, there was no assessment conducted to determine if the lap tray was an appropriate assistive device for this resident. Similarly, Resident #25, also with severe cognitive impairment and dependent on staff for daily activities, experienced an incident where he broke his lap tray and slid to the floor, resulting in a skin tear. This incident was not documented in an Incident/Accident Report, and the resident's care plan was not updated to reflect the fall. These oversights indicate a failure in the facility's processes for monitoring and documenting incidents involving assistive devices, potentially compromising resident safety.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease, hypertensive heart disease, and unspecified psychosis. The resident was admitted with physician orders for dialysis on Monday, Wednesday, and Friday, along with a 1000 cc fluid restriction. However, there was no documentation in the medical record indicating that the resident's fluid intake was being monitored. Interviews with staff, including a Certified Nurse Aid (CNA) and the Assistant Director of Nursing (ADON), confirmed that the staff were not documenting the resident's fluid intake to ensure compliance with the fluid restriction.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation for four out of five residents reviewed. The facility's policy requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails. However, there was no documented evidence of such assessments for residents #5, #12, #17, and #38. Resident #17, with intact cognition and requiring assistance with activities of daily living, was observed with bed rails raised on both sides of the bed. Despite the facility's policy, there was no documented assessment for the risk of entrapment. Similarly, resident #38, who had moderate cognitive impairment and a history of falling, was observed with bed rails raised, but no assessment for entrapment risk was documented. Resident #12, with moderate cognitive impairment and a history of repeated falls, was observed with bed rails in a locked position, yet there was no documented assessment for entrapment risk. Resident #5, with severe cognitive impairment and requiring substantial assistance, also had bed rails raised without a documented assessment for entrapment risk. Interviews with the Assistant Director of Nursing confirmed the lack of documented assessments for these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.71% error rate during a medication administration observation. Three medication errors were identified out of 28 opportunities. For one resident, the LPN administered incorrect dosages of Furosemide and Gabapentin, providing 20 mg of Furosemide instead of the prescribed 40 mg, and 100 mg of Gabapentin instead of the prescribed 300 mg. Another resident received only one tablet of Fludrocortisone 0.1 mg instead of the prescribed two tablets, totaling 0.2 mg. These errors were confirmed by the Assistant Director of Nursing during an interview, acknowledging the discrepancies in medication administration as observed during the morning medication pass.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy and procedures for three residents who required such precautions due to their medical conditions. The EBP policy, dated April 1, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. This policy applies to residents with indwelling medical devices or those colonized with targeted multidrug-resistant organisms. However, observations revealed that residents with indwelling catheters and dialysis access did not have the required EBP signage posted on their doors, indicating a lapse in communication and implementation of the policy. Resident #18, who had a urinary catheter, did not have an EBP sign posted on her door, despite physician orders for EBP during high-contact care activities. Similarly, Resident #28, who had a dialysis access, also lacked the necessary signage. Resident #35, with an indwelling catheter, was observed multiple times without the EBP sign on his door. Interviews with the Assistant Director of Nursing confirmed these oversights, acknowledging that the facility failed to communicate the need for EBP as per their policy.
Failure to Notify of Changes in Resident Conditions
Penalty
Summary
The facility failed to ensure proper notification of changes in resident conditions, as evidenced by two separate incidents involving residents. In the first case, a resident with severe cognitive impairment, as indicated by a BIMS score of 5, experienced a fall. Despite the facility's policy requiring prompt notification of the resident's representative, the attending physician, and the resident themselves, the family of the resident was not informed of the fall by the LPN responsible. This oversight was confirmed through interviews with the LPN and the Assistant Director of Nursing. In the second incident, another resident with moderately impaired cognitive skills, as indicated by a BIMS score of 9, was found to have multiple bruises on her body. The staff failed to notify the nursing administration upon discovering these injuries, which were of unknown origin. The bruises were observed during an inspection by the Assistant Directors of Nursing, who confirmed they were unaware of the injuries prior to the inspection. The facility's policy mandates that staff notify the administration of any injuries of unknown origin, which was not adhered to in this case.
Failure to Monitor and Document Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, three residents were observed using lap trays as restraints without proper documentation or physician orders. The facility's policy requires that restraints only be used with a physician's order and informed consent, and that residents be monitored and the restraints released regularly. However, the facility did not adhere to these requirements for the residents in question. Resident #70, who has severe cognitive impairment and requires assistance with activities of daily living, was observed multiple times sitting in a geri chair with a lap tray. Despite the use of the lap tray being documented as a physical restraint for trunk control, there was no physician's order for its use, nor was there documentation of monitoring the release of the lap tray every two hours as required. The Assistant Director of Nursing confirmed these deficiencies during an interview. Similarly, Resident #52, who also has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed with a lap tray in place without documentation of monitoring for its release. The resident's hands were contracted, indicating an inability to remove the tray independently. Resident #25, with severe cognitive impairment and multiple diagnoses, was also observed with a lap tray without a physician's order or documentation of monitoring. Interviews with staff confirmed these lapses in compliance with the facility's restraint policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to a resident and the resident's representative regarding the transfer or discharge to a hospital, as well as the reasons for the move, in writing. Additionally, the facility did not send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman. This deficiency was identified for a resident who was transferred to the hospital on two separate occasions. A review of the Emergency Transfer Logs for June and July 2024 revealed that there was no documented evidence of the Ombudsman being notified of the resident's transfers on the specified dates. During a telephone interview, the local Ombudsman confirmed that she had not been notified of these transfers. The facility administrators were informed of these findings.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to conduct quarterly assessments for two residents, as required by the Centers for Medicare and Medicaid Services (CMS). Resident #25 was admitted on an unspecified date, and their last documented Quarterly Minimum Data Set (MDS) Assessment had an Assessment Reference Date (ARD) of 06/25/2024. However, there was no subsequent Quarterly MDS Assessment recorded for this resident. Similarly, Resident #27, also admitted on an unspecified date, had their last Quarterly MDS Assessment with an ARD of 06/04/2024, but no further assessment was documented within the required three-month period. An interview with the Assistant Director of Nursing (ADON) confirmed that the Quarterly MDS Assessments for both residents were not completed within the mandated timeframe. This oversight indicates a failure to adhere to the regulatory requirement of updating each resident's assessment at least once every three months.
Inaccurate MDS Documentation of Resident Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for one of the residents selected for closed record reviews. Specifically, the discharge MDS assessment for a resident indicated that the resident was discharged to the hospital, while a review of the nurse's notes and interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed that the resident was actually discharged to home. This discrepancy highlights an inaccuracy in the documentation of the resident's discharge status.
Failure to Document Urine Assessment for Resident with Catheter
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with an indwelling urinary catheter. The care plan required documentation of the character of the resident's urine, including color, clarity, and odor, every shift. However, a review of the resident's medical records, including the Medication Administration Record (MAR) for September and October 2024, revealed no documented evidence of staff assessing these aspects of the resident's urine as required. The resident, who was cognitively intact and required substantial assistance with activities of daily living, had diagnoses including urinary retention and chronic urinary tract infection. Despite the care plan's directive to assess the urine's character every shift, observations confirmed the presence of the indwelling catheter, but the necessary documentation was missing. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the failure to document the required assessments.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the facility did not keep the resident's fingernails trimmed. The resident, who was admitted with diagnoses including dementia, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect, had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene. Despite a care plan that included daily nail cleaning, there was no documented evidence of nail care being provided during the 30-day look-back period. Observations on October 14, 2024, revealed the resident sitting in a geri chair with long and untrimmed fingernails. Later that day, the Activity Director trimmed the resident's fingernails after being notified of their condition. The Activity Director confirmed that the resident's nails needed trimming. The facility's failure to document and provide regular nail care for the resident was noted during the survey, and the Corporate Administrator and Administrator were informed of these findings.
Failure to Provide Hand Rolls for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically in addressing hand contractures. Resident #52, who was admitted with diagnoses including dementia, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect, was observed without hand rolls in place, which are necessary to prevent further decrease in range of motion. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene. Despite these needs, there was no documented evidence in the plan of care to address the resident's hand contractures. During an observation, it was noted that the resident was sitting in a geri chair with both hands contracted and closed, without any hand rolls present. When notified, the LPN was unaware of the absence of hand rolls and confirmed that they were supposed to be in place at all times. This oversight indicates a failure in the facility's responsibility to ensure that the resident received the necessary treatment and services to maintain or improve range of motion, as there was no plan of care addressing this specific need.
Failure to Monitor Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring edema for a resident who was prescribed a diuretic. The medical record review for the resident revealed an admission with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness, and anemia. The resident's annual Minimum Data Set (MDS) assessment indicated intact cognition for daily decision-making, and the resident required assistance with activities of daily living. The care plan noted a potential for hypertension/hypotension related to medication use, with interventions to monitor blood pressure, administer medications as ordered, and obtain labs and diagnostic tests as ordered. However, despite a physician's order for Lasix, a diuretic, to be administered every other day for edema, there was no documented evidence of edema checks being performed. This was confirmed in an interview with the Assistant Director of Nursing.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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