Camelot Leisure Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Ferriday, Louisiana.
- Location
- 6818 Highway 84 West, Ferriday, Louisiana 71334
- CMS Provider Number
- 195516
- Inspections on file
- 24
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Camelot Leisure Living during CMS and state inspections, most recent first.
A facility failed to document multiple ordered meds, treatments, and monitoring tasks in the EMAR/ETAR for several residents, and also failed to obtain a scheduled PT/INR for one resident. The missing documentation involved wound care, PEG site care, contracture management, oxygen, insulin, diet, pain and symptom monitoring, and other ordered nursing tasks; the ADON and DON confirmed the omissions and stated that if it was not documented, it did not happen.
Failure to Complete and Post Daily Nursing Census: The facility did not ensure the Daily Nursing Census form was completed and posted each day. Surveyors observed an outdated form posted near the front desk with no current daily entry, and review of prior forms showed multiple missing dates. Interviews revealed the RN, ADON, and DON each believed another staff member was responsible for weekday completion, and the DON confirmed the forms were not completed daily as required.
Pureed Meal Recipes Not Followed: The Dietary Manager prepared pureed bread, vegetables, and pork loin for 7 residents without using the facility’s recipe binder or measuring ingredients. She blended unmeasured amounts of bread, milk, vegetables, broth, and thickener until the consistency looked right, despite written recipes specifying exact amounts for each pureed item.
Failure to provide grooming and facial hair removal for two residents with impaired cognition and ADL dependence. One resident with anxiety, depression, and psychosis was observed with more than 10 chin hairs and said she wanted them shaved; another resident with CHF, muscle wasting, and depressive disorder was observed with a moderate amount of facial and chin hair, and her RP said she wanted her chin shaved. A CNA stated she had never shaved a female, and the CNA supervisor and DON confirmed both residents should have been shaved but had not.
Failure to notify the Ombudsman of a resident discharge: A resident with COPD, chronic systolic CHF, and chronic atrial fibrillation had an unplanned discharge home, but the facility did not report the discharge to the Louisiana Ombudsman Program. The ADON stated the resident had been admitted for therapy and later the family decided to discharge the resident suddenly, while the SSD confirmed she only reported hospitalizations and did not report the discharge.
A resident with diagnoses including depression, schizophrenia, and bipolar disorder did not have a completed PASRR Level II after new mental health diagnoses were added. The record showed an older Medicaid certification form stating a Level II decision was not required, and an LPN confirmed that no new PASRR had been completed even though it should have been.
Improper Storage of Nebulizer Equipment: A resident with asthma, prior respiratory failure, and oxygen use had a nebulizer ordered multiple times daily, but the mask was observed face down on the bedside dresser without a labeled storage bag when not in use. An RN confirmed the mask should be stored in a plastic bag, and the DON stated nebulizer masks should be cleaned and returned to a labeled bag rather than left on the dresser.
Medication administration errors exceeded the allowed rate when an LPN gave one resident the wrong dose of Doxazosin and omitted another resident’s scheduled Metformin dose during observed med pass. The MARs showed the correct ordered doses, and the ADON stated nurses were expected to follow the MAR when administering medications.
A resident with intact cognition and multiple diagnoses, including severe persistent asthma, had an unopened nebulizer medication left unsecured on the bedside dresser instead of being stored in the locked med cart when not in use. In addition, an unsecure chained mobile narcotic box containing liquid lorazepam was observed inside the med refrigerator, and the DON confirmed it should not have been there.
An LPN failed to follow infection control practices during wound care for a resident with pneumonia, dehisced surgical wounds, and chronic burn wounds. While treating multiple wound sites, the LPN did not perform hand hygiene or change gloves between care of the right posterior knee and the right anterior thigh, and later confirmed this should have been done.
A resident with multiple medical conditions, including ileostomy status and dementia, experienced repeated issues with a leaking ileostomy bag and inadequate care, as reported by the responsible party to the DON on several occasions. Despite these complaints, the facility did not initiate a formal grievance, document an investigation, or provide a resolution, contrary to its grievance policy. Staff confirmed that concerns were communicated to nursing leadership but not processed as grievances.
A resident with significant cognitive and physical impairments, including dysphagia and altered consciousness, did not have their required feeding assistance needs reflected in their care plan. Staff confirmed the omission after a family member reported a meal tray was left unattended in the resident's room, and review of records showed the care plan lacked documentation of the necessary feeding support.
A resident with an ileostomy did not receive timely and appropriate care as required by facility policy and professional standards. The resident was found with feces on her skin due to a leaking appliance, and staff delayed changing the ileostomy bag despite repeated notifications and complaints from the responsible party. Communication lapses among nursing staff contributed to the delay in care.
The facility failed to maintain a sanitary kitchen, leading to potential foodborne illness risks for all residents. Staff used inappropriate chemicals for dishwashing, and food items were improperly labeled and stored. The walk-in freezer had excessive frost, and the kitchen was unclean. Staff did not wear proper hair restraints or practice effective hand hygiene. Temperature logs were missing, indicating inadequate monitoring of food safety.
The facility failed to effectively manage its dietary department, leading to improper dishwashing practices and inadequate staff training. A dietary staff member used bleach for dishwashing, and others lacked training on food preparation and safety standards. The absence of a dietary manager and insufficient oversight by the administrator contributed to these deficiencies.
The facility failed to adhere to professional standards for respiratory care for three residents. One resident's nebulizer mask was left uncovered, another received oxygen therapy without a required humidifier, and a third had unlabeled and improperly stored oxygen equipment. Staff confirmed these lapses, which were against facility policy.
The facility failed to properly label and store medications, including an unlabeled insulin vial and expired ophthalmic solutions. The emergency kit's tag number did not match the log, and narcotic records showed discrepancies in counts and documentation. Additionally, a discontinued Lorazepam was not removed from the cart as required by policy.
The facility failed to provide sufficient support personnel for food and nutrition services, resulting in consistently late meal service. Observations and interviews revealed that lunch was often served significantly past the scheduled times, affecting residents, including one with Type 2 Diabetes Mellitus and another with Protein Calorie Malnutrition.
The facility failed to ensure pureed foods were prepared according to standardized recipes, affecting 11 residents on pureed diets. Observations showed dietary staff did not measure ingredients or follow recipes, preparing meals by sight without proper training. The acting dietary manager confirmed that recipes should be followed, highlighting a deficiency in meal preparation.
The facility failed to maintain an effective infection prevention and control program. Staff did not decontaminate blood pressure cuffs between residents and neglected hand hygiene. Enhanced Barrier Precautions were not used for a resident on dialysis, and oxygen tubing was improperly stored on the floor. These actions were confirmed by staff interviews and observations.
The facility failed to treat two residents with dignity. A resident was not served his meal on time, despite being seated with others who were already eating. Another resident, who requires assistance with personal hygiene, was not shaved despite her requests, leaving her with unwanted facial hair. These actions contradict the facility's policy on resident dignity and grooming preferences.
A resident with a history of heart failure and other conditions experienced a syncope episode, becoming unresponsive. Despite this significant change, the charge nurse did not notify the physician, believing the resident was at baseline. The facility's policy to notify the physician of such changes was not followed.
The facility failed to secure and maintain the confidentiality of medical records when a computer screen displaying resident information was left open and unattended on a medication cart. An LPN confirmed the screen should have been closed, and further interviews with the ADONs corroborated that such screens should not be visible when staff is not present.
A facility failed to complete a Discharge MDS assessment for a resident upon discharge. The ADON, responsible for MDS assessments, confirmed the oversight and later submitted the assessment, but it was completed late, more than 14 days after the ARD.
A facility failed to complete a significant change MDS assessment within the required timeframe for a resident admitted to hospice. The resident, with diagnoses including Parkinson's Disease and Depression, was admitted to hospice services, marking a significant change in condition. However, the MDS assessment was not completed within 14 days, as confirmed by the ADON.
A resident with contractures and impaired mobility developed a wound due to the facility's failure to revise the care plan to include pressure-relieving devices. Despite being at risk for pressure injuries, the care plan lacked interventions like a hand roll, leading to a skin tear from the contracted hand. Observations confirmed the absence of preventative measures, and the wound was attributed to the fingernail pressing into the palm.
A resident with moderate cognitive impairment and mobility issues fell in the facility's parking lot due to a known hazard of cracked and uneven concrete. The resident, who required assistance for walking, was being taken to a doctor's appointment when the incident occurred, resulting in knee injuries and a hospital evaluation. The hazard had been previously reported, but remained unaddressed until after the incident.
The facility did not post the required daily nurse staffing information, including the resident census and actual hours worked by RNs, LPNs, and CNAs. Observations showed that the posted forms only listed the total number of scheduled staff, lacking details on staffing hours. The DON confirmed that while the facility tracked this information, it was not displayed as required.
The facility failed to properly dispose of garbage, affecting all 64 residents. Observations revealed open dumpster lids and doors, with one lid broken, and litter scattered around the area. The Maintenance Supervisor confirmed the issues, and the Administrator was unaware of the broken lid.
A facility failed to report a sexual abuse allegation involving a cognitively intact resident to the State Survey Agency within the required timeframe. Additionally, a resident with severe cognitive impairment and multiple diagnoses was found with fractures of unknown origin, which were not reported as required. The facility's administrator confirmed these reporting failures.
A facility failed to investigate an allegation of sexual abuse involving a resident with intact cognition and a history of mental health issues. Despite a complaint made by the resident's family to law enforcement, the facility did not conduct an investigation, contrary to its policy requiring prompt reporting and thorough investigation of such allegations.
A resident with intact cognition and multiple diagnoses fell from a wheelchair, resulting in a nosebleed and hospital transfer. The facility failed to update the care plan with fall interventions, as confirmed by the DON.
Missing EMAR/ETAR Documentation and Missed PT/INR
Penalty
Summary
The facility failed to provide services that met professional standards of quality by not documenting multiple ordered medications and treatments in the EMAR and ETAR for several residents, and by not obtaining a scheduled PT/INR for one resident. The report states that the facility failed to obtain PT/INR for Resident #2 and failed to document medications and/or treatments on the EMAR and ETAR for Resident #1, Resident #6, Resident #8, Resident #37, and Resident #59. Resident #37 had diagnoses including Type 2 Diabetes Mellitus with diabetic neuropathy, MRSA, mild protein-calorie malnutrition, GERD, dysphagia, COPD, chronic hypertension, diverticulitis, constipation, and atherosclerotic heart disease. Physician orders included daily wound care to the right lower extremity dermatitis, but the 03/2026 TAR showed no documentation of treatment on multiple days. During interview, the ADON confirmed Resident #37 did not receive treatment on those days. Resident #2 had diagnoses including COPD, ataxia, muscle weakness, secondary hypertension, UTI, atrial fibrillation, generalized anxiety disorder, and depression. The physician orders included monthly PT/INR, but the lab record showed no PT/INR drawn on the ordered date, and the ADON confirmed it should have been obtained. Resident #1 had multiple wound care orders for dehisced surgical and burn wounds, yet the TAR showed no documentation of treatment on multiple days, and the ADON confirmed the LPN had not documented those treatments. Resident #6, Resident #8, and Resident #59 also had multiple medication, treatment, monitoring, and care orders listed in their EMAR/ETARs with no documented evidence of administration or completion on the specified dates, and the DON confirmed the nurses did not document the care appropriately but should have.
Failure to Complete and Post Daily Nursing Census
Penalty
Summary
The facility failed to ensure that the Daily Nursing Census form was completed and posted each day. On 03/16/2026 at 9:10 a.m., surveyors observed a clipboard near the front desk with a Daily Nursing Census form dated 03/15/2026, and no completed form for 03/16/2026 was present. On 03/17/2026 at 9:00 a.m., the same form was still posted with a date of 03/15/2026, and no current form for 03/17/2026 was observed. Review of prior Daily Nurse Census forms from 02/14/2026 through 03/17/2026 showed multiple missing dates, including several dates in February and March when the form was not completed. During interviews, S10 RN stated she completed the Daily Nurse Census form on weekends she worked, while the RN on duty completed it on alternate weekends. S10 RN stated the S1 DON was responsible for completing the form during weekdays. S2 ADON stated the S1 DON was responsible for weekday completion and was unaware why the forms were not completed consistently. S1 DON stated she believed S2 ADON completed the forms and was unaware she needed to complete them during the week. In record review with the surveyor present, S1 DON confirmed the Daily Nurse Census forms were not completed daily as required and stated she had not completed them daily since being hired in 10/2025.
Pureed Meal Recipes Not Followed
Penalty
Summary
The facility failed to meet the nutritional needs of residents in accordance with established national guidelines by not following its pureed food recipes when preparing meals for 7 residents receiving pureed diets. During observation, the Dietary Manager chopped 7 slices of bread in a blender, added an unmeasured amount of whole milk, blended the mixture, then added 3 more torn slices of bread and blended again before scooping the pureed bread into serving bowls. After washing and sanitizing the blender bowl, she placed 10 spoons of unmeasured cooked vegetables into the blender, blended them to a smooth consistency, and then added an unmeasured amount of thickener before serving the vegetables. The closed pureed recipe menu binder was observed on a shelf away from the food prep area, and the Dietary Manager stated she had recipes available but did not use them. She said she did not measure ingredients and instead poured and blended until the consistency looked right. She also stated she had already pureed the baked pork loin by adding an unmeasured amount of broth and then enough thickener to achieve the right consistency. Review of the facility recipes showed specific measured ingredients were required for pureed bread, pureed Capri vegetable blend, and pureed baked pork loin, and the Dietary Manager confirmed she did not use the recipes to prepare the lunch meal.
Failure to Provide Grooming and Facial Hair Removal
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity by not ensuring they were free of facial hair. The deficiency was identified during observations, interviews, and record review for Resident #3 and Resident #38, both of whom had care needs related to personal hygiene and required assistance with grooming. The facility policy stated that residents who are unable to carry out activities of daily living independently will receive services necessary to maintain grooming, personal hygiene, and oral care. Resident #3 had diagnoses including anxiety disorders, depression, and unspecified psychosis, and her quarterly MDS showed a BIMS score of 07 indicating severely impaired cognition. Her care plan identified an ADL self-care performance deficit related to confusion and included 1 person assist with personal hygiene. During observation, she was noted to be unshaven with more than 10 facial and chin hairs, and she stated she wanted the hair on her chin shaved. Resident #38 had diagnoses including chronic diastolic CHF, muscle wasting and atrophy of both upper arms, and depressive disorder, with an MDS showing severely impaired cognition and a need for substantial/maximal assistance with personal hygiene. Her care plan also identified an ADL self-care performance deficit related to confusion and dementia with 1 person assist for personal hygiene. She was observed to be unshaven with a moderate amount of facial and chin hair, and her responsible party stated she would like her chin shaved. A CNA stated she had never shaved a female, and the CNA supervisor and DON confirmed both residents should have been shaved but had not.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman in writing of a resident transfer/discharge for 1 resident reviewed for transfer/discharge. Review of the facility policy titled, Nursing Home Discharge Policy: Ombudsman Notification, dated 01/16/2026, stated the facility would notify the Long-Term Care Ombudsman Program of discharges in accordance with federal and state regulations. Review of the Emergency Transfer Log form for 01/2026-03/2026 showed that Resident #68's discharge was not reported to the Louisiana Ombudsman Program. Resident #68 was admitted on 01/13/2026 and discharged on 02/20/2026. The resident had diagnoses of COPD, chronic systolic CHF, and chronic atrial fibrillation. The discharge summary documented an unplanned discharge home. In interview, the ADON stated the resident had been admitted for therapy services and later decided to stay longer, but the family then decided to discharge the resident suddenly. The SSD stated she was responsible for notifying the Louisiana Ombudsman Program of hospitalizations and was only aware of reporting hospitalizations, not planned or unplanned discharges, and confirmed she did not report Resident #68's unplanned discharge.
Missing PASRR Level II Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with identified mental health diagnoses had a completed PASRR Level II form as required. Resident #11 was admitted with diagnoses including Other Depressive Episodes, Major Depressive Disorder, Chronic Atrial Fibrillation, Other Schizophrenia, and Other Bipolar Disorder. The medical record showed no Level II PASRR screening after the new diagnoses of Other Schizophrenia and Other Bipolar Disorder were documented on 04/19/2023. The resident’s Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification form stated that a Level II decision was not required and was signed and dated 01/28/2021. During interview, an LPN stated that the resident had a new diagnosis of Schizophrenia and Bipolar Disorder and no new PASRR had been completed, but it should have been.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards by not ensuring that a resident’s nebulizer equipment was stored properly when not in use. Resident #8 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, depression, anxiety disorder, type 2 diabetes mellitus without complications, acute respiratory failure with hypercapnia, and severe persistent asthma with acute exacerbation. The resident’s quarterly MDS indicated a BIMS score of 15, showing intact cognition, and the resident received oxygen therapy and required staff assistance with toileting hygiene, dressing, personal hygiene, and bathing. The resident had a physician order for ipratropium-albuterol nebulizer solution four times daily for severe persistent asthma with acute exacerbation. During observation, the resident was lying in bed awake with the nebulizer mask placed face down directly on the bedside dresser cabinet, and no storage bag was present for the nebulizer mask and tubing when not in use. An RN confirmed that the resident used the nebulizer daily multiple times for shortness of breath and anxiety attacks and stated the mask should be stored in a plastic bag and labeled when not in use. The DON stated that nurses were expected to properly store and label all nebulizer masks when not in use and that the mask should be cleaned and placed back into the labeled plastic storage bag rather than left on the dresser cabinet.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during observed medication administration. During 27 observed medication opportunities involving 3 residents, surveyors identified 2 medication errors, resulting in a 7.41% medication error rate. The facility policy titled "Administering Medications" required staff to check the medication label against the MAR, re-check the dose, and prepare the correct dose of medication. During observation, Resident #12 was given Doxazosin Mesylate 2 mg by mouth by an LPN, even though the current MAR ordered Doxazosin Mesylate 4 mg by mouth two times a day. During another observation, Resident #50’s Metformin Hydrochloride 500 mg tablet ordered by mouth once daily was omitted during morning medication administration. The LPN confirmed both the incorrect administration to Resident #12 and the omission of Metformin for Resident #50, and the ADON stated the expectation was for nurses to follow the MAR when administering medications.
Unsecured bedside medication and improper narcotic storage
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when a tube of unopened Ipratropium-Albuterol nebulizer solution was observed on a resident’s bedside dresser cabinet, unattended and unsecure. The resident had an admission date of 07/16/2025 and diagnoses including hemiplegia and hemiparesis following cerebral infarction, depression, anxiety disorder, type 2 diabetes mellitus without complications, acute respiratory failure with hypercapnia, and severe persistent asthma with exacerbation. The resident’s quarterly MDS showed a BIMS score of 15, indicating intact cognition, and the resident was dependent on staff for toileting hygiene, dressing, personal hygiene, and showering/bathing. The resident’s physician orders included Ipratropium-Albuterol nebulizer solution four times daily for severe persistent asthma with exacerbation. The medication storage deficiency also involved the medication refrigerator in the medication room, where an unsecure chained, mobile, locked box containing an unopened box of liquid Lorazepam was observed. The DON confirmed that the medication room had a locked, mobile narcotic box inside the medication refrigerator, but stated it should not have been there. The facility policy stated that drugs shall be stored in a safe, secure, and orderly manner and assigned to an individual cubicle, drawer, or other holding area to prevent mixing medications of several residents.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Infection control measures were not followed during wound care for a resident with pneumonia, dehisced surgical wounds, chronic burn wounds, neuralgia, and neuritis. The resident had physician orders for wound care to a superficial dehisced surgical wound on the chest wall and chronic burn wounds to the right anterior hip, right anterior thigh, and right posterior knee, each requiring cleansing, application of Triple Antibiotic Ointment, and coverage with bordered gauze every other day and as needed if soiled or dislodged. During observation of an LPN performing wound care, hand hygiene was not performed and gloves were not changed between care of the right posterior knee and the right anterior thigh. After completing wound care to the right posterior knee, the LPN began wound care to the right anterior thigh without removing the soiled gloves, performing hand hygiene, or re-gloving between the two sites. In interview, the LPN confirmed that hand hygiene was not performed and gloves were not changed between the two wound care sites and stated that this should have been done.
Failure to Promptly Address and Resolve Grievance Regarding Ileostomy Care
Penalty
Summary
The facility failed to ensure prompt resolution of a grievance related to improper ileostomy care for one resident. The resident, who had diagnoses including Type 2 Diabetes Mellitus, moderate protein-calorie malnutrition, gastrostomy and ileostomy status, and dementia, required partial to moderate assistance with activities of daily living. The resident's care plan included specific interventions for ileostomy care, such as scheduled appliance changes. The resident's responsible party reported to the DON on multiple occasions that the resident's ileostomy bag was leaking, resulting in feces on the resident and towels being used to catch the leakage. Despite these complaints, the responsible party stated that the issue persisted and was not resolved as assured by the DON. Review of facility records showed that no formal grievance was initiated for this resident, and the grievance log did not contain any entries related to the reported concerns. Documentation from the facility's Hand in Hand Program indicated that concerns about the timeliness of colostomy bag changes were noted and that nursing leadership was notified, but there was no follow-up or resolution documented. Interviews with staff confirmed that complaints from the responsible party were communicated to nursing leadership but were not processed as formal grievances, and no investigation or resolution was documented as required by facility policy.
Failure to Develop Person-Centered Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop a person-centered care plan addressing feeding assistance for one resident. According to facility policy, a comprehensive care plan with measurable objectives and timetables should be developed and implemented for each resident, including support for activities of daily living such as dining. Review of the resident's medical record showed diagnoses including dysphagia, senile degeneration of the brain, anorexia, moderate protein calorie malnutrition, and sequelae of intracerebral hemorrhage. The resident was rarely or never understood, had an altered level of consciousness, and required moderate assistance with eating, as well as being dependent for personal hygiene, mobility, and transfers. A grievance filed by the resident's family member reported that a lunch tray was left on the bedside table and had tumbled onto the resident's bed, with no aide present in the room. Investigation confirmed the tray was left in the room over the resident. Review of the resident's care plan revealed it did not reflect the required level of feeding assistance. During interviews, staff confirmed that the resident required staff assistance to be fed and acknowledged that this need was not included in the care plan, despite it being necessary.
Failure to Provide Timely Ileostomy Care
Penalty
Summary
A deficiency occurred when a resident requiring ileostomy care did not receive services consistent with professional standards of practice. The facility's policy required ileostomy appliance changes every Tuesday and Thursday, and as needed for dislodgement, with documentation of care provided. The resident, who had diagnoses including Type 2 Diabetes Mellitus, moderate protein-calorie malnutrition, gastrostomy and ileostomy status, and dementia, was dependent on staff for personal hygiene and toileting. The care plan and medication administration record specified frequent attention to the ileostomy, including burping or emptying the appliance up to six times daily as needed. Despite these requirements, the resident was observed with loose feces on her skin due to leakage from the ileostomy bag, and a towel had been placed around the appliance to catch the feces. The resident's responsible party reported multiple complaints to the DON about the resident being left with feces on her and waiting long periods for ileostomy care. On the day of observation, a CNA reported the need for an appliance change to the treatment nurse, who indicated a delay. The treatment nurse did not provide care, and the LPN who eventually changed the appliance did so several hours later, after being informed late. Interviews confirmed a lack of timely communication and response among staff, resulting in the resident not receiving prompt and appropriate ileostomy care.
Deficient Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which led to the potential for foodborne illnesses affecting all 64 residents. Observations revealed that staff did not use approved chemicals or sanitizers during dishwashing, as evidenced by S3 Dietary using a Clorox/Bleach solution to clean a blender used for meal preparation. This practice was contrary to the facility's policy, which required the use of a three-compartment sink for cleaning and sanitizing utensils and dishes. Additionally, food items in refrigerators and pantries were not labeled or dated, and expired foods were available for use. The facility's walk-in freezer was found to be in poor condition, with excessive frost build-up preventing the door from closing properly. This resulted in food items being covered with frost and stored directly on the floor, contrary to professional standards for food storage. The kitchen was also observed to be unclean, with grease stains, food particles, and dust accumulation on various surfaces, including the floors, shelving, and equipment. Staff were not wearing appropriate hair restraints, and there was a lack of effective hand hygiene and glove usage during food preparation activities. Temperature monitoring was inadequate, with missing logs for both food and refrigerator temperatures on multiple dates. This failure to monitor and document temperatures could compromise food safety. Interviews with staff confirmed these deficiencies, with some staff unaware of the requirement to wear beard nets or practice proper hand hygiene. The facility's Registered Dietitian also expressed concerns about the use of bleach for dishwashing and the persistent frost build-up in the walk-in freezer, indicating ongoing issues with compliance to food safety standards.
Removal Plan
- The administrator called the dietary consultant to in-service and train the dietary staff to ensure regulatory compliance.
- The administrator removed all bleach from dietary, and the facility.
- The administrator verbally in-serviced dietary staff present that bleach is not used to sanitize equipment, pots & pans, and cutlery.
- The 3 compartment sink was explained and how to check the proper level of sanitizer.
- The administrator called the dietary consultant to in-service and train dietary staff on sanitary conditions in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance.
- The administrator called off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer.
- All dietary staff have been in-serviced.
- Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at in-services for all dietary staff.
- The kitchen will be audited randomly to ensure there is no bleach in the kitchen, the audits will be done to monitor the kitchen that no bleach is present.
- This monitoring will be included in the current QAPI being done in the kitchen and reported in the QA meeting.
- The Administrator and Maintenance Supervisor will complete the random audits and audits.
- Any dietary staff not following policies and procedures given in-services will be given written warnings up to and including termination.
Deficient Dietary Practices Due to Lack of Training
Penalty
Summary
The facility failed to administer its resources effectively, impacting the dietary department's adherence to professional standards for food services. This deficiency was observed when a dietary staff member used a Clorox/Bleach solution for dishwashing a blender used in pureed meal preparation, which was not in compliance with proper sanitation practices. The staff member admitted to using this method regularly to save time, indicating a lack of proper training and oversight. Further observations revealed that the dietary staff lacked proper training and competency checks. One staff member was seen preparing pureed meals by free-pouring an unmeasured amount of powdered thickener, admitting that she had not been taught otherwise. Another staff member was observed without a beard net, stating he was unaware of the requirement and had not received any training since his hire. Interviews with staff revealed a lack of guidance and support from the administration, with some staff members feeling uncomfortable seeking help due to perceived inattention from supervisors. The facility's documentation showed no records of training or competency evaluations for dietary staff, including the administrator and maintenance supervisor who were overseeing the kitchen in the absence of a dietary manager. The administrator acknowledged the absence of a dietary manager since July 2024 and admitted to being responsible for the kitchen's daily operations, yet there was no evidence of effective management or training being provided to the dietary staff.
Removal Plan
- The training of new dietary staff will be done on hire, and continuing education will be provided at monthly in-services for all dietary staff to improve the knowledge, and basic skills of the dietary staff to ensure regulatory compliance.
- The training and continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant.
- The administrator verbally in-serviced dietary staff present not to use bleach to sanitize equipment and instructed staff how to use the 3 compartment sink and check for the proper amount of sanitizer.
- The administrator called the dietary consultant to in-service and train dietary staff on sanitation in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance.
- The administrator called off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer.
- All dietary staff have been in-serviced.
- Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff.
- The training of each new hire in dietary will be monitored using a check list to orient them to the kitchen and dietary policies and procedures, and all dietary staff will receive monthly in-servicing training.
- The administrator will monitor the training of new dietary staff and the monthly in-services, both will be ongoing.
- The dietary consultant will monitor the administrator to ensure new hire training and monthly in-servicing is taking place during their monthly visit.
- This monitoring will be included in the current QAPI being done in the kitchen and reported in the QA meeting.
Deficiency in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents, as observed during a survey. For one resident with Chronic Obstructive Pulmonary Disease (COPD) and other conditions, a nebulizer mask was found uncovered on top of the refrigerator, contrary to the facility's policy that requires such equipment to be stored properly in a zip lock bag when not in use. The resident confirmed the use of the nebulizer mask for breathing treatments, and an LPN acknowledged that the mask should not have been left uncovered. Another resident, who had diagnoses including dementia and acute respiratory failure, was observed receiving oxygen therapy without a humidifier bottle attached, despite having orders for continuous oxygen at 3 liters per minute, which requires humidification according to the facility's policy. The oxygen tubing was also undated, and the resident confirmed wearing oxygen at all times. An LPN was unsure if the resident required humidified oxygen, and the Director of Nursing (DON) later confirmed that the resident should have had a humidifier bottle attached. A third resident with severe persistent asthma and other conditions was found with oxygen tubing on the floor and a nebulizer mask placed directly on a dresser, both unlabeled and unbagged. An LPN confirmed that the equipment should have been stored and labeled correctly. The DON reiterated that the facility's policy requires weekly changes and proper labeling and storage of oxygen and nebulizer equipment, which was not adhered to in these cases.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as evidenced by several deficiencies. An opened vial of Lantus insulin was found in the medication refrigerator without a label indicating the date it was opened, contrary to the facility's policy that requires insulin vials to be labeled and discarded 28 days after opening. Additionally, the emergency medication kit's tag number did not match the log, and the log lacked documentation of medication strength, quantity, and physician's name. A loose, unidentified pill was also found in a medication cart, which should not have been there. Further deficiencies were noted in the handling of expired medications. Several ophthalmic solutions were found in a medication cart with open dates exceeding the 28-day discard period, and one bottle lacked an open date entirely. The facility's policy requires medications to be labeled with open dates and discarded appropriately, which was not followed. Additionally, discrepancies were found in the narcotic records, with incorrect counts and missing documentation of administered doses. For instance, the narcotic record for a resident showed two different records with a total of 26 tablets, while only 13 were present. The facility also failed to manage discontinued medications properly. A blister pack of Lorazepam, which had been discontinued for a resident, was still present in the medication cart. The facility's policy requires discontinued controlled substances to be removed and returned to the pharmacy, which was not done. The Director of Nursing confirmed that the discontinued medication should have been removed but was not, indicating a lapse in following the facility's procedures for handling controlled substances.
Late Meal Service Due to Insufficient Support Personnel
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition services, resulting in meals being served late. Observations on multiple occasions revealed that lunch service began significantly past the posted meal times, with one instance showing a delay of 1 hour and 5 minutes. Interviews with residents and staff confirmed that late meal service was a regular occurrence, with lunch often served between 1:00 p.m. and 1:30 p.m., despite the scheduled time being 11:30 a.m. for the dining room and 12:00 p.m. for hall trays. Resident #32, who has intact cognition and multiple health conditions including Type 2 Diabetes Mellitus and Heart Failure, reported that lunch was consistently served late. Similarly, Resident #26, who suffers from Protein Calorie Malnutrition and is on a mechanically altered diet, experienced delays in receiving meals, with lunch sometimes served as late as 2:00 p.m. Observations confirmed that Resident #26's lunch tray was delivered at 1:04 p.m., further illustrating the facility's failure to adhere to scheduled meal times.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods that conserved nutritional value for 11 residents who were ordered and served pureed diets. Observations revealed that the dietary staff did not follow standardized recipes when preparing pureed meals. Specifically, the dietary staff member, identified as S3 Dietary [NAME], was observed preparing pureed rice, spinach, and beef patties without measuring ingredients or referring to the approved recipes. The staff member admitted to preparing the meals by sight and confirmed that she had not been trained to refer to recipes when preparing meals. The facility's policy required the use of standardized recipes to ensure the nutritional value of meals, but this was not adhered to during the preparation of pureed foods. The acting dietary manager, S4 Maintenance Supervisor, confirmed that dietary cooks were expected to follow recipes when preparing meals. The failure to follow standardized recipes and the lack of training for dietary staff contributed to the deficiency in meal preparation for residents on pureed diets.
Infection Control and Equipment Decontamination Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Staff did not decontaminate reusable medical equipment, such as blood pressure cuffs, between resident uses. Observations revealed that an LPN used a wrist and arm blood pressure cuff on multiple residents without decontaminating them between uses. Additionally, the same LPN did not wash hands or use hand sanitizer before or after direct contact with residents. Interviews with the LPN and Assistant Directors of Nursing confirmed these practices were not in compliance with the facility's policies. Enhanced Barrier Precautions (EBP) were not utilized for a resident undergoing dialysis, despite physician orders indicating the need for such precautions. Observations over two days showed no EBP signage or equipment outside the resident's room. An interview with the Assistant Director of Nursing confirmed that EBP should have been in place for residents receiving dialysis, but they were not maintained. Another deficiency involved improper storage of oxygen equipment. A resident's oxygen tubing was observed directly on the floor, contrary to the facility's policy requiring tubing to be stored in labeled bags. An LPN confirmed the improper storage, and the Director of Nursing acknowledged that all oxygen tubing should be labeled and stored correctly when not in use.
Failure to Uphold Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, impacting two residents. Resident #32 was not served his meal at the same time as other residents seated at his table. Despite being seated in the dining room since 11:50 a.m., Resident #32 did not receive his lunch tray until 12:14 p.m., after repeated requests from the CNA and intervention by the ADON. This delay in service was confirmed by the ADON, who acknowledged that all residents seated together should be served simultaneously. Resident #19, who has intact cognition and requires assistance with personal hygiene, was observed with long facial hair on her chin and neck, which she expressed a desire to have shaved. Despite her requests, staff did not shave her, citing fear of cutting her. This was confirmed by an LPN who acknowledged the need for shaving but had not addressed it. These incidents demonstrate a failure to uphold the residents' dignity and personal grooming preferences as outlined in the facility's policy.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to consult with a resident's physician following a significant change in the resident's physical status. The incident involved a resident with a medical history that included heart failure, coronary angioplasty implant and graft, essential hypertension, type 2 diabetes mellitus, and dementia. On the day of the incident, the resident experienced a syncope episode, becoming unresponsive after twitching. Despite the change in condition, the charge nurse decided not to notify the physician, believing the resident was at his baseline and did not require hospital evaluation. Interviews with staff revealed that the charge nurse and LPN were aware of the resident's unresponsiveness but did not contact the physician. The charge nurse performed a sternal rub, which elicited a response from the resident, and concluded that the resident did not need further medical evaluation. The Director of Nursing was not informed of the incident, and the physician could not recall being notified. The facility's policy requires notifying the physician of significant changes in a resident's condition, which was not followed in this case.
Failure to Secure and Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the security and confidentiality of medical records, as observed on 02/19/2025. A computer screen on Cart A in Hall A was left open and visible, displaying resident information, without any staff present. This was confirmed by a surveyor who remained with the cart until a staff member, identified as S7LPN, returned. During an interview, S7LPN acknowledged that the computer screen should have been closed when she was away from the medication cart. Further interviews with S6ADON and S5ADON confirmed that computer screens with resident information should not be visible when staff is not present, as per the facility's policy on electronic medical records dated 12/23/2024.
Failure to Timely Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) assessment for a resident upon their discharge. The resident was admitted and later discharged, but a review of their MDS record showed no Discharge MDS assessment was completed. During an interview, the Assistant Director of Nursing (ADON) confirmed that she was responsible for completing MDS assessments and acknowledged that she did not complete the Discharge MDS assessment for the resident at the time of discharge, although it was required. Later, the ADON submitted the Discharge MDS assessment, but it was completed late, more than 14 days after the Assessment Reference Date (ARD).
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 calendar days after determining there was a significant change in a resident's status. Resident #7, who was admitted to the facility with diagnoses including Parkinson's Disease, Unspecified Psychosis, and Depression, was admitted to hospice services on 02/03/2025. Despite this significant change in condition, there was no evidence that a significant change MDS had been completed or was in progress following the resident's admission to hospice. An interview with the Assistant Director of Nursing (ADON) confirmed that the significant change MDS had not been completed for Resident #7, although it should have been done within the required timeframe.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to revise the care plan interventions to prevent the development of a wound for Resident #43, who was at risk for impaired skin integrity due to contractures and impaired mobility. Despite being identified as at risk for pressure injuries, Resident #43's care plan did not include the use of a hand roll or other pressure-relieving device for the contracted right hand. Observations revealed a contracted right hand without a hand roll, and subsequent examinations showed a purple discoloration and an open wound with reddish-pink drainage on the palm where the 5th digit pressed into it. The facility's staff confirmed that Resident #43 was not care-planned for a hand roll, and attempts to use one in the past were unsuccessful due to the tight clenching of the hand. The deficiency was further highlighted by the lack of documentation of current skin impairment in Resident #43's progress notes, despite the presence of a wound. The wound was attributed to a skin tear caused by the fingernail pressing into the palm due to the contracted hand. A physician's order was eventually made to address the wound, but the initial failure to implement appropriate preventative measures in the care plan led to the development of the wound. The facility's policy required ongoing assessments and revisions of care plans as residents' conditions changed, which was not adequately followed in this case.
Resident Falls Due to Unrepaired Parking Lot Hazard
Penalty
Summary
The facility failed to maintain a safe environment for its residents, resulting in an accident involving a resident with moderate cognitive impairment and mobility issues. The resident, who had a history of chronic systolic heart failure, pain, cognitive communication deficit, lack of coordination, and muscle weakness, was being assisted to a scheduled doctor's appointment. Despite requiring supervision and assistance for walking, the resident was ambulating with a walker in the facility's parking lot when they encountered a cracked and uneven concrete surface filled with rainwater. This hazard caused the resident to fall, resulting in redness and pain in the knees, necessitating a hospital evaluation. Interviews and observations revealed that the cracked concrete in the parking lot had been a known issue, with previous incidents reported. The Director of Nursing confirmed the unsafe condition of the parking lot, and the Maintenance Supervisor acknowledged that all employees were responsible for ensuring the safety of the parking lot. Despite these acknowledgments, the hazard remained unaddressed until after the incident, highlighting a lapse in the facility's duty to provide a hazard-free environment for its residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the resident census and the total number and actual hours worked by RNs, LPNs, and CNAs responsible for resident care per shift. Observations on two consecutive days revealed that the Daily Nursing Census forms posted near the nurse's station did not include the required information on daily staffing hours. Instead, the forms only listed the total number of nurses and CNAs scheduled for each shift. An interview with the Director of Nursing (DON) confirmed that while the facility maintained records of the required and provided daily nursing hours, this information was not posted as required.
Improper Garbage Disposal and Maintenance Issues
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which had the potential to affect all 64 residents. During an observation of the facility's dumpster area, it was found that both dumpsters had their top lids and side doors open. One of the dumpsters had a broken lid that could not close properly. Additionally, there was litter, including used gloves, paper products, and metal pieces from a mechanical lift, scattered around the dumpster area. The Maintenance Supervisor confirmed these findings and acknowledged that the dumpster lids and doors should remain closed and the area should be kept clean. The Administrator was unaware of the broken lid and confirmed that dumpsters should remain closed when not in use.
Failure to Report Abuse and Injury in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Survey Agency within the required timeframe. A resident with intact cognition was admitted with various diagnoses, including anxiety and depression. A deputy from the sheriff's office visited the facility to inquire about the resident, revealing that the family had made a complaint regarding sexual abuse. The facility's administrator confirmed that the allegation was not reported as required, despite being informed by the sheriff's department about the complaint. Additionally, the facility did not report a fracture of unknown origin for another resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease and osteoporosis. The resident required extensive assistance with mobility and was found with bruising and edema on the left foot. X-rays revealed fractures in the tibia and fibula, and the resident was transferred to the hospital. The facility's administrator confirmed that this incident was not reported to the State Survey Agency, as required by regulations.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident. The facility's policy mandates that all reports of abuse, neglect, exploitation, and other related incidents must be promptly reported to relevant agencies and thoroughly investigated by facility management. However, in this case, there was no evidence of an investigation into the alleged sexual abuse of a resident, despite a complaint being made by the resident's family to the sheriff's office. The resident involved had a medical history that included pain, anxiety disorder, depression, bipolar disorder, and was receiving aftercare following surgery. The resident's cognitive function was intact, as indicated by a BIMS score of 13. Despite the family’s complaint and the involvement of law enforcement, the facility did not initiate an investigation into the allegation, which was confirmed by the facility's administrator during an interview.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to develop a comprehensive care plan with appropriate interventions following a fall incident involving a resident. The resident, who was admitted with diagnoses including pain, anxiety disorder, depression, bipolar disorder, and was receiving surgical aftercare, had a BIMS score indicating intact cognition. The resident required limited assistance with bed mobility and eating, and extensive assistance with transfers and toilet use. On a specific date, the resident fell face first out of a wheelchair in the dayroom, resulting in a nosebleed and subsequent hospital transfer. Despite this incident, the resident's care plan lacked any interventions for the fall, which was confirmed by the Director of Nursing during an interview.
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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