Chateau Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenner, Louisiana.
- Location
- 716 Village Road, Kenner, Louisiana 70065
- CMS Provider Number
- 195184
- Inspections on file
- 43
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Chateau Living Center during CMS and state inspections, most recent first.
Two residents received incorrect dosages of psychotropic medications during observed med passes, resulting in a medication error rate above 5%. One resident with dementia and other conditions was ordered Risperidone 0.25 mg daily, but an LPN administered 0.5 mg instead, despite the eMAR reflecting the reduced dose. Another resident with a history of cerebral infarction and depression was ordered Fluoxetine HCl 50 mg daily (2.5 tablets of 20 mg), but an LPN administered only 40 mg. Multiple staff, including the LPNs, corporate nurse, DON, assistant administrator, and administrator, confirmed that the medications were not given as ordered.
A resident’s right to privacy during perineal care was not maintained when two CNAs provided care without closing the privacy curtain or room door, leaving the resident’s buttocks exposed to a roommate and to another resident who entered the room. Facility policy required that the door and privacy curtain be closed during perineal care, and both a CNA and the DON later confirmed that the door and/or curtain should have been closed.
A resident with urinary incontinence was left in soiled clothing for over 40 minutes after staff were made aware of her need for assistance. Despite the resident's repeated requests and visible distress, both an LPN and a CNA Supervisor failed to provide timely incontinence care, which was only given after a CNA intervened. Facility policy required residents to be changed within 15 to 20 minutes after an incontinence episode, but this standard was not met.
A resident with a history of chronic pain and a previous fall was unable to receive prescribed Hydrocodone-Acetaminophen for pain relief because the medication was not reordered in time and was unavailable when requested. Staff confirmed the medication was out of stock and not administered as ordered.
A resident with a urinary catheter was observed with her drainage bag visible while using a wheelchair, despite having previously requested a privacy cover. An LPN and the Assistant Director of Nursing both confirmed awareness of the request and the need for a privacy cover, but the resident had not received one, resulting in a failure to maintain the resident's dignity and privacy.
Surveyors found that two medication carts contained insulin pens that were either expired or lacked an opened date, making it impossible to determine if they were safe for use. An LPN confirmed the expired status of one pen, while another LPN acknowledged that an unlabeled pen should have been discarded.
A medication cup with two unidentified pills was found on a resident's bedside table after the resident declined to take her sleeping pills when offered by a nurse. Facility policy prohibits leaving medications unattended with residents, and the ADON confirmed this practice was not followed.
Several residents reported that their meals were consistently served cold, and surveyors observed that food trays were transported on top of insulated carts rather than inside them. Temperature checks confirmed that food items were served below acceptable hot food standards, and both staff and surveyors found the food to be cold.
Two residents were left without a working call bell in their bathroom and bathing area for several days, requiring them to wait for staff rounds to receive assistance. Staff were aware of the malfunction but did not notify the administrator, resulting in a prolonged lack of access to the call system.
The facility failed to ensure a clean and odor-free environment, with strong urine odors in two halls and trash on a resident's floor. A resident's room contained debris, and their wedge pillow was damaged. The administrator acknowledged these issues.
A resident with multiple stage 3 pressure injuries did not receive proper wound care when a CNA removed dressings and failed to notify the nurse, leaving wounds exposed. Additionally, a heel protector was incorrectly applied to the right heel instead of the left, as ordered. The resident's medical conditions increased the risk of pressure ulcer development, highlighting the importance of following care protocols.
A resident with peripheral vascular disease did not receive necessary toenail care in a timely manner. Despite the resident's request for toenail care upon admission, observations showed the toenails were long, thick, and curled. Interviews with the ADON and an LPN confirmed the need for trimming, but the resident was not scheduled for a podiatry appointment, and there was no evidence of a prior podiatry consult.
The facility failed to ensure CNAs demonstrated competencies in hand hygiene, EBP, and proper showering, and an LPN demonstrated competency in applying a heel protector. Two residents were affected: one with stage three pressure injuries and an indwelling urinary catheter, where CNAs did not adhere to EBP, and another requiring substantial assistance, where a CNA failed to wash the resident's buttocks and did not perform hand hygiene during incontinence care.
A long-term care facility failed to maintain an effective infection prevention and control program for two residents. One resident, with multiple medical conditions, did not receive proper Enhanced Barrier Precautions (EBP) as CNAs failed to wear gowns, perform hand hygiene, or change gloves during care. Another resident received incontinence care without proper hand hygiene or glove changes. The facility's Administrator and DON confirmed these lapses in infection control protocols.
A resident with moderate cognitive impairment and incontinence issues did not receive adequate personal hygiene care during a bathing session. The CNA failed to wash the resident's buttocks, leaving them uncleaned. The CNA acknowledged the oversight, and the facility administrator confirmed that the resident's buttocks should have been washed.
A resident with a WanderGuard transmitter exited a facility through an unalarmed door, resulting in a head injury. Staff used a secondary reset code to disable door alarms, contrary to policy, compromising resident safety. The deficiency led to Immediate Jeopardy due to the risk of harm to residents at risk for elopement.
A CNA failed to recognize a resident at risk for elopement, despite facility policy requiring staff to be trained on elopement prevention. The CNA, assigned to a room with two at-risk residents, only identified one as at risk. The Director of Nursing confirmed that staff should use binders at nursing stations to identify such residents, but the CNA was unaware of this resource.
A facility failed to ensure privacy for a resident during PEG tube care. An LPN performed the procedure without closing the door, leaving the resident's abdomen exposed and visible from the hallway. The resident had a diagnosis of mild intellectual disability. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that the door should have been closed to maintain privacy.
A facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) during PEG tube care for a resident. Despite a policy requiring gown use for high-contact activities, an LPN was observed performing PEG tube care without a gown. The resident had a gastrostomy and physician orders for EBP, which mandated gown and glove use. Interviews confirmed the lapse in protocol adherence.
The facility failed to ensure a safe environment as water leaked from Shower Room A into the hallway due to an uneven floor. Observations confirmed the presence of water pooling in the hallway, and staff interviews verified the issue. The Administrator was aware of the incident.
The facility failed to complete required Braden skin assessments for a resident upon re-admission and inaccurately documented another resident's pressure ulcer status. Additionally, the facility did not implement necessary pressure ulcer prevention and treatment interventions for a resident, as staff failed to turn the resident every two hours and use heel protectors as per the care plan.
A facility failed to accurately revise a care plan for a resident's skin condition. The resident had a care plan for impaired skin integrity, but it was inaccurately updated to reflect a stage III pressure ulcer later than documented in nursing notes. This discrepancy was confirmed by a corporate nurse.
A facility failed to properly store discontinued and expired medications, as a blister packet of Norco 5-325 mg tablets was found in a medication cart despite being discontinued and expired. Staff, including an LPN, ADON, DON, and the Administrator, confirmed the oversight, acknowledging that the medication should have been removed according to facility policy.
Two residents with moderately impaired cognition were found with medications on their bedside tables without being assessed or care planned for self-administration, as required by the facility's policy. Interviews with staff confirmed the lack of assessment and care planning for these residents.
A resident's wheelchair was found in poor condition, with a blackish-brownish substance on the brake levers, a missing right arm pad, and a torn left arm pad with exposed foam. Facility staff confirmed the issues, and the DON indicated the need for replacement.
A resident admitted for rehabilitation and receiving IV medications through a PICC line reported that the site was not cleaned or bandage changed during their stay. Facility records lacked documentation of PICC site care, and staff interviews confirmed the absence of documentation and inability to recall if care was provided.
A facility failed to accurately complete a Level I PASARR for a resident with Major Depressive Disorder and Bipolar Disorder. The resident's mental illnesses were not documented, and a Level II PASARR referral was not initiated, despite the resident's diagnoses and history of mental health treatment. Interviews revealed staff were unaware of the need for a Level II referral, and the administrator confirmed the oversight.
The facility did not maintain food on the steam table at the required temperature of at least 135°F. During an observation, various foods were held on the steam table for lunch, and the temperature of pureed sweet potatoes was found to be 130°F. Interviews with staff confirmed that the steam table should maintain food at a temperature no lower than 135°F.
A facility failed to transmit a resident's discharge assessment data within the required timeframe, resulting in a deficiency. The assessment was completed and signed by the DON, but an error in the MDS caused a delay in transmission. The MDS Nurse indicated that the error in entering the Unit Certification or Licensure Designation led to the late submission.
A facility failed to ensure a resident's MDS assessment accurately reflected their skin condition. The resident had a stage III pressure ulcer documented in nursing notes, but the MDS inaccurately indicated no unhealed pressure ulcers. This discrepancy was confirmed by a corporate nurse.
Medication Error Rate Exceeded Due to Incorrect Dosages Administered
Penalty
Summary
The facility failed to maintain a medication error rate below 5% when nursing staff administered incorrect dosages of prescribed medications to two residents during observed medication passes. Facility policy on Medication Administration and Storage required staff to check medication directions against the electronic medication administration record (eMAR), ensure medications on the cart were current, and verify that drugs matched the eMAR. For one resident with Alzheimer's disease, vascular dementia, generalized anxiety disorder, and hemiplegia, the physician’s order dated 03/06/2026 specified Risperidone 0.25 mg by mouth once daily. However, review of the March 2026 eMAR showed that from 03/01/2026 through 03/05/2026 the resident received Risperidone 0.5 mg daily, and the 0.5 mg dose was discontinued on 03/05/2026 with a new order for 0.25 mg starting 03/06/2026. On 03/31/2026, observation revealed an LPN administered a 0.5 mg Risperidone tablet instead of the ordered 0.25 mg dose, and the LPN later confirmed she had given the higher dose contrary to the physician’s order. For another resident with diagnoses including unspecified sequelae of cerebral infarction and adjustment disorder with depressed mood, a physician’s order dated 03/03/2026 directed administration of Fluoxetine HCl 50 mg daily, specified as 2.5 tablets of 20 mg each by mouth once a day. During an observed medication pass on 03/31/2026, an LPN administered a single 40 mg Fluoxetine HCl tablet instead of the ordered 50 mg dose. Subsequent interviews with the LPN, the corporate nurse, the DON, the assistant administrator, and the administrator confirmed that 40 mg was given when 50 mg was ordered, and that the Risperidone dose for the first resident was also administered at 0.5 mg instead of the ordered 0.25 mg. These observed and confirmed discrepancies between the medications administered and the physician orders constituted medication errors contributing to a medication error rate greater than 5%.
Failure to Maintain Resident Privacy During Perineal Care
Penalty
Summary
The facility failed to maintain a resident’s privacy during perineal care, contrary to its Perineal Care Policy and Procedure dated 11/17/2015, which required that the resident’s door and privacy curtain be closed during such care. On 02/09/2026 at 12:28 PM, two CNAs (S2CNA and S3CNA) provided perineal care to Resident #1 without closing the privacy curtain, resulting in the resident’s buttocks being exposed to the roommate. During the same episode of care, a random resident walked into the room, and Resident #1’s buttocks remained exposed because the door and privacy curtain were not closed. In a subsequent interview at 2:10 PM, S2CNA acknowledged that she did not close the door or privacy curtain while performing perineal care and stated that she should have done so. In a separate interview at 2:12 PM, the Director of Nursing (S1) indicated that both CNAs should have closed the resident’s door and/or privacy curtain while performing the perineal care.
Delay in Providing Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely assistance with activities of daily living (ADL) for a resident who required help with toileting and hygiene due to urinary incontinence. The resident, who had diagnoses including overactive bladder and unspecified urinary incontinence, was observed crying in her wheelchair in the hallway after experiencing an episode of incontinence. Despite informing staff members, including an LPN and a CNA Supervisor, of her situation and visibly displaying distress, the resident did not receive prompt incontinence care. The LPN stated she would find a CNA to assist, and the CNA Supervisor acknowledged the resident's statement about being wet but did not provide immediate help, instead only showing the resident where her clothes were located. The resident continued to seek assistance, wheeling herself through the hallway and expressing her need for clean clothes and incontinence care. It was not until approximately 42 minutes after the initial observation that a CNA provided the necessary care. Interviews with staff confirmed that facility policy required residents to be changed within 15 to 20 minutes after a known episode of incontinence. The delay in providing care was contrary to this policy, and staff acknowledged the expectation for timely assistance following incontinence episodes.
Failure to Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's prescribed pain medication, Hydrocodone-Acetaminophen 10-325 mg, was available for administration as ordered by the physician. Review of the medication records showed that the resident had zero tablets available after receiving the last dose on 08/29/2025 at 8:43 PM. The resident reported experiencing pain related to a previous fall and chronic pain during the night and morning following the last available dose, and stated that she requested her pain medication but was informed by nursing staff that it was not available because it had not been reordered. Staff interviews confirmed that the medication was not available when requested, and the LPN on duty was unable to administer the prescribed pain medication due to the lack of supply. The Staff Development/Charge Nurse/Infection Preventionist acknowledged that medications with active orders should be available for administration, and the Director of Nursing indicated that medications should be ordered from the pharmacy before running out. The deficiency was identified for one of three residents reviewed for medication administration.
Failure to Provide Privacy Cover for Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed ambulating in her wheelchair with her catheter drainage bag attached under the seat, and the contents of the bag, including yellow urine, were visible. The resident called out to an LPN and requested a privacy cover for her catheter drainage bag, stating that she had made the same request the previous week but had not received one. The LPN acknowledged the prior request and confirmed that the resident should have a privacy cover. The Assistant Director of Nursing also confirmed that the resident should have a privacy cover for her catheter drainage bag. These observations and interviews demonstrate that the facility failed to provide the requested privacy cover, compromising the resident's dignity and right to privacy.
Expired and Unlabeled Insulin Pens Found on Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use on two medication carts. During observation, an insulin pen prescribed for one resident was found in a medication cart with an opened date that indicated it was expired, as it had been opened more than 28 days prior. The LPN present confirmed that the insulin pen was expired and still available for use. Additionally, another insulin pen for a different resident was found in a separate medication cart without any label indicating the date it was opened. The LPN interviewed stated that without the opened date, it was not possible to determine if the medication was expired, and acknowledged that the pen should have been discarded. These findings were based on direct observation, staff interviews, and review of relevant medication storage guidelines.
Medications Left Unattended at Bedside
Penalty
Summary
A deficiency was identified when a medication cup containing two unidentified white, round pills was observed on a resident's bedside table. The resident stated that these were her sleeping pills, which had been given to her by a nurse the previous night, but she chose not to take them and left them on the table. Facility policy specifies that nurses should not leave residents with medications in a medication cup. The Assistant Director of Nursing confirmed that medications should not have been left unattended at the resident's bedside.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified that the facility failed to serve food at an acceptable temperature to residents. Multiple residents reported that their food was consistently cold when served, both in their rooms and in common areas. Observations confirmed that food trays were placed on top of insulated tray carts rather than inside them during transport, which compromised the ability of the carts to maintain food temperature. On two separate occasions, surveyors collected trays that had been transported in this manner and found the food to be lukewarm or at room temperature. Temperature checks conducted by the dietary technician and surveyor revealed that food items such as pork, lima beans, and cabbage were served at temperatures ranging from 78 to 91 degrees Fahrenheit, which is below the standard for hot food service. Both the surveyor and the dietary technician confirmed through sampling that the food was cold. Interviews with staff and residents consistently indicated awareness of the issue, with staff acknowledging that the food temperatures were not acceptable.
Nonfunctional Call Bell System Leaves Residents Without Means to Request Assistance
Penalty
Summary
A deficiency was identified when it was observed that the call bell system in the bathroom and bathing area for two residents was not functional. The call light above their room door remained illuminated, indicating a malfunction. Staff interviews confirmed that the call bell had been broken since a specific date and that the issue persisted over the weekend. Both residents reported that they were unable to use the call bell to request assistance and had to wait for staff to enter their room during routine rounds. Further interviews revealed that staff were aware of the malfunction but did not notify the facility administrator. The administrator confirmed that he was not informed about the broken call bell and could not provide evidence to dispute the deficiency. The lack of a working call system left the residents without a means to call for help in their bathroom and bathing areas for several days.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations. On March 11, 2025, strong unpleasant odors of urine were detected throughout Hall A, and a combination of trash and urine odors were present in Hall B. Additionally, a resident's room was found to have debris, including a container, napkins, mints, two plastic bags, and chipped paint on the floor near the bed. Furthermore, the resident's wedge pillow, used for repositioning, was damaged with pieces of foam missing. In an interview conducted on March 13, 2025, the facility's administrator acknowledged the presence of trash on the resident's floor and confirmed that such conditions were unacceptable.
Failure in Wound Care and Heel Protector Application
Penalty
Summary
The facility failed to ensure proper wound care and prevention of pressure ulcers for a resident with multiple stage 3 pressure injuries. A Certified Nursing Assistant (CNA) removed the resident's wound dressings during incontinence care but did not notify the nurse, leaving the wounds exposed. The resident's electronic medical record indicated orders for specific wound care, including cleansing and dressing changes every hour as needed for soilage and dislodgement. However, the CNA's failure to communicate the removal of dressings resulted in the resident's wounds being left uncovered and exposed to potential contamination. Additionally, the facility did not ensure the correct application of a heel protector as ordered by the physician. The resident was observed without a heel protector on the left heel, as required, and instead had it incorrectly placed on the right heel. This oversight was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the error. The resident's medical history included conditions such as morbid obesity, muscle weakness, and reduced mobility, which increased the risk of pressure ulcer development, making adherence to care protocols critical.
Failure to Provide Toenail Care for Resident with Peripheral Vascular Disease
Penalty
Summary
The facility failed to ensure that a resident diagnosed with peripheral vascular disease received appropriate foot care, specifically toenail trimming. The resident was admitted with a condition that required careful management of blood flow to the limbs. An observation revealed that the resident's left great toe toenail was unusually long, thick, and curled backward. The resident had requested toenail care upon admission, but interviews with the Assistant Director of Nursing (ADON) and an LPN confirmed that the resident's toenails were long and thick and needed trimming. The ADON admitted that the resident was not scheduled for a podiatry appointment or consult. There was no documented evidence that the resident had seen a podiatrist prior to the survey entrance date.
Deficiencies in CNA and LPN Competencies
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) demonstrated competencies in hand hygiene, use of Enhanced Barrier Precautions (EBP), and proper showering techniques, as well as a Licensed Practical Nurse (LPN) demonstrating competency in applying a heel protector. This deficiency was observed in two residents. For Resident #1, who had multiple medical conditions including stage three pressure injuries and an indwelling urinary catheter, CNAs did not adhere to EBP by failing to wear gowns and perform hand hygiene before and after providing incontinence care. Additionally, the LPN incorrectly applied a heel protector to the wrong heel, contrary to the physician's orders. For Resident #2, who required substantial assistance with activities of daily living due to moderately impaired cognition, a CNA failed to wash the resident's buttocks during a shower. Furthermore, another CNA did not perform hand hygiene before and after providing incontinence care, and did not change gloves after removing a soiled brief. These actions were contrary to the facility's protocols and the expectations for maintaining hygiene and infection control.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents, leading to deficiencies in care. Resident #1, who had multiple medical conditions including stage three pressure injuries and an indwelling urinary catheter, required Enhanced Barrier Precautions (EBP) to prevent the spread of Multi Drug Resistant Organisms (MDRO). However, observations revealed that Certified Nursing Assistants (CNAs) did not adhere to these precautions. They failed to wear gowns, perform hand hygiene, or change gloves while providing incontinence care, and they improperly handled Resident #1's BIPAP/CPAP mask, which was left uncovered in an open drawer. Resident #2, who had moderate cognitive impairment and was incontinent of bladder and bowel, also received inadequate care. A CNA was observed performing incontinence care without performing hand hygiene before or after the procedure, and without changing gloves. This lack of adherence to infection control protocols was confirmed by the CNA during an interview. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed that the CNAs did not follow the facility's policies and procedures for infection control. The Administrator and DON acknowledged that staff should have performed hand hygiene and worn gowns when required, particularly for residents on EBP. The improper storage of medical equipment and failure to follow hygiene protocols contributed to the facility's deficiency in maintaining an effective infection prevention and control program.
Deficiency in Personal Hygiene Care for a Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident with moderate cognitive impairment and incontinence issues. The resident, who required substantial assistance with bathing and personal hygiene, was observed during a bathing session where the Certified Nursing Assistant (CNA) did not wash the resident's buttocks. The CNA transferred the resident to a shower chair, rinsed the front of the resident's body, and encouraged the resident to wash his own genital area. However, the CNA did not ensure that the resident's buttocks were washed, leaving them dry and uncleaned. During an interview, the CNA acknowledged that the resident's buttocks had not been washed. The facility administrator also confirmed that the resident's buttocks should have been washed during the bathing process. This oversight in personal hygiene care was identified during a survey, highlighting a deficiency in the facility's provision of activities of daily living (ADL) care for the resident.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, leading to an Immediate Jeopardy situation. A resident, who was ordered a WanderGuard transmitter due to being at risk for elopement, managed to exit the facility through an unalarmed door. The resident was found 0.4 miles away with a head injury, which resulted in a right temporal bone fracture and a right subdural hematoma. This incident highlighted the facility's failure to maintain effective elopement prevention measures. Further investigation revealed that staff members were using a secondary reset code to disable door alarms, allowing residents with WanderGuard transmitters to exit the facility without triggering an alert. This practice was contrary to the facility's policy, which required that door alarms remain active unless under direct supervision. Interviews with staff confirmed that multiple employees were using this code, which bypassed the WanderGuard system's security features, compromising resident safety. The facility's policy required staff to be trained on preventing and responding to elopement, including understanding risk factors and interventions. However, the use of the secondary reset code by unauthorized staff members indicated a lack of adherence to these protocols. The deficiency had the potential to cause more than minimal harm to residents identified as being at risk for elopement, as evidenced by the incident involving the resident who sustained serious injuries after eloping.
CNA Lacks Competency in Elopement Risk Procedure
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S7CNA, was competent in the procedure for managing residents at risk for elopement. The facility's policy, effective since July 31, 2019, mandates that all staff be trained on preventing elopement, including understanding risk factors and interventions. However, during an interview, S7CNA denied receiving training on residents at risk for elopement since December 23, 2024, despite having signed an in-service acknowledgment on December 26, 2024. S7CNA was unaware that Resident #R4, in her assigned room, was at risk for elopement, although the facility's Elopement Binder, located at the nursing station, listed both Resident #R4 and Resident #R7 as requiring WanderGuard transmitters due to their elopement risk. The Director of Nursing (DON), identified as S2DON, confirmed that nursing staff should be knowledgeable about which residents are at risk for elopement and that the facility's process involves checking binders at the nursing stations for this information. S2DON acknowledged that S7CNA should have been aware of the elopement binder as a resource. The deficiency was identified during a review of the facility's CNA staffing schedule and census, which showed that S7CNA was assigned to the room where both at-risk residents resided, yet she failed to recognize Resident #R4 as an elopement risk.
Failure to Ensure Privacy During PEG Tube Care
Penalty
Summary
The facility failed to ensure privacy for a resident during Percutaneous Endoscopic Gastrostomy (PEG) tube feeding care. The facility's policy required staff to pull a privacy screen and drape the resident during such care. However, an LPN entered the resident's room and performed PEG tube care without closing the door, leaving the resident's abdomen exposed and visible from the hallway. This incident involved a resident with a diagnosis of mild intellectual disability. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that the door should have been closed to maintain the resident's privacy.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to ensure that staff adhered to the Enhanced Barrier Precautions (EBP) policy during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The facility's policy, dated April 1, 2024, required staff to wear a gown when performing high-contact activities, such as feeding device care, for residents with indwelling medical devices. Despite this policy, an LPN was observed performing PEG tube care for a resident without wearing a gown, which included air bolus placement check, residual check, and free water flush. The resident involved had a diagnosis of age-related cognitive decline, moderate protein-calorie malnutrition, and a gastrostomy. The resident's physician orders from August 2024 specified the use of EBP, requiring staff to wear a gown and gloves during high-contact care activities. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that a gown should have been worn during the PEG tube care for the resident on EBP, indicating a lapse in following the established infection prevention and control protocols.
Water Leakage from Shower Room A into Hallway
Penalty
Summary
The facility failed to maintain a safe and clean environment as evidenced by water leaking from Shower Room A into the hallway. Observations on August 27, 2024, at various times revealed a pool of water present in the hallway outside Shower Room A's doorway. Interviews with staff, including the Staff Developer, Maintenance personnel, and the Assistant Director of Nursing, confirmed the presence of water in the hallway and identified the cause as an uneven floor in Shower Room A. The uneven floor allowed water to pool in low areas and drain into the hallway. The Administrator acknowledged awareness of the incident.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its policy of completing a Braden skin risk assessment upon re-admission for a resident who had multiple hospital stays. Despite the policy requiring assessments upon re-admission, the assessments were not completed on two separate occasions. This oversight was confirmed by both the Assistant Director of Nursing and the Corporate Nurse, who acknowledged that the assessments should have been conducted. Additionally, the facility did not accurately document the status of a resident's pressure ulcer. The resident had a stage III pressure ulcer to the sacral area, but the wound was inconsistently documented as an irritation/excoriation in the Wound Assessment Reports. This inconsistency in documentation was acknowledged by the Corporate Nurse, who confirmed that the wound should have been documented as a new pressure ulcer when its status changed. Furthermore, the facility failed to implement pressure ulcer prevention and treatment interventions for another resident. Despite the care plan indicating the need to turn the resident every two hours and use heel protectors, observations revealed that these interventions were not consistently carried out. Staff interviews confirmed the lack of adherence to the care plan, with staff unaware of the need for heel protectors and failing to turn the resident as required.
Inaccurate Care Plan Revision for Pressure Ulcer
Penalty
Summary
The facility failed to accurately revise a care plan addressing a resident's skin condition. Resident #62 had a care plan developed for impaired skin integrity due to irritation/excoriation in the sacral area on 06/16/2024. However, the care plan was inaccurately revised on 07/15/2024 to indicate a stage III pressure ulcer, despite nursing notes from 07/02/2024 already documenting the presence of a stage III pressure ulcer with slough in the same area. This discrepancy was confirmed by S2Corporate Nurse, who acknowledged that the care plan did not accurately reflect the resident's skin condition.
Expired and Discontinued Medication Found in Use
Penalty
Summary
The facility failed to ensure that discontinued and expired medications were properly stored and not available for resident use. During an observation of medication carts, it was found that a blister packet of Norco 5-325 mg tablets, which had been discontinued for a resident, was still present in Med Cart a. The medication had expired on 06/06/2024, yet five tablets remained available for use. This was in violation of the facility's policy on the disposal and destruction of medications, which requires that discontinued controlled medications be removed from the medication cart and stored securely until destroyed. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, confirmed the presence of the expired and discontinued Norco tablets in Med Cart a. Each staff member acknowledged that the medication should not have been available for use and should have been removed following the discontinuation order. The oversight was identified as a failure to adhere to the facility's established procedures for handling discontinued and expired medications.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for self-administration of medications, as required by their policy. Resident #122, with a Brief Interview for Mental Status score indicating moderately impaired cognition, was observed with a bottle of Nystatin Topical Powder on the bedside table. There was no documented evidence that Resident #122 was assessed or care planned for self-administration of medication. Interviews with the LPN, ADON, and DON confirmed that Resident #122 was not assessed for self-administration and should not have had medications at the bedside. Similarly, Resident #189, also with a moderately impaired cognition score, was observed with multiple bottles of Nystatin Topical Powder and a tube of Ammonium Lactate 12% lotion on the bedside table. The facility did not have documented evidence of an assessment or care plan for Resident #189 to self-administer medication. Interviews with the LPN, ADON, and DON confirmed that Resident #189 was not assessed for self-administration and should not have had medications at the bedside.
Deficiency in Wheelchair Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain a resident's wheelchair in good repair and sanitary condition, impacting one of the three residents reviewed for environmental conditions. Observations over three consecutive days revealed that the resident's wheelchair had a blackish-brownish substance covering both brake levers, a missing right arm pad, and a torn left arm pad with exposed foam. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the poor condition of the wheelchair, with the Director indicating that the wheelchair should be replaced.
Failure to Document and Provide PICC Site Care
Penalty
Summary
The facility failed to provide proper site care for a peripherally inserted central catheter (PICC) for a resident receiving intravenous medications. The resident, admitted for rehabilitation following knee surgery, reported that the PICC site was not cleaned or the bandage changed during their stay from early April to early May 2024. Record reviews revealed no documented evidence of PICC site care during this period. Interviews with the Director of Nursing and treatment nurses confirmed the absence of documentation and inability to recall if the care was performed. The administrator also acknowledged the lack of documentation for the PICC site care during the resident's stay.
Failure to Complete Accurate PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with Major Depressive Disorder and Bipolar Disorder. The resident, who was admitted with these diagnoses, was taking antidepressants daily and had a history of mental health treatment. Despite these indicators, the Level I PASARR documentation did not reflect the resident's mental illnesses, and it was neither signed nor dated by a physician. Furthermore, the facility did not initiate a referral for a Level II PASARR evaluation, which is required for residents with such diagnoses. Interviews with facility staff revealed a lack of awareness and follow-through regarding the PASARR process. The social services staff member admitted uncertainty about whether a Level II PASARR was completed and acknowledged that a referral should have been made based on the resident's mental health diagnoses and assessments. The facility administrator confirmed the inaccuracies in the Level I PASARR and the omission of a necessary Level II referral, highlighting a significant oversight in the facility's compliance with PASARR requirements.
Failure to Maintain Proper Food Temperature
Penalty
Summary
The facility failed to maintain food on the steam table at the required temperature of at least 135 degrees Fahrenheit, as per the Centers for Medicare and Medicaid Services guidelines. During an observation, it was noted that various foods, including hamburger, rice, mashed potatoes, and pureed meat, were being held on the steam table for lunch. The temperature of the pureed sweet potatoes was checked by a cook and found to be 130 degrees Fahrenheit, which is below the required temperature. Interviews with the cook and the dietary supervisor confirmed that the steam table should maintain food at a temperature no lower than 135 degrees Fahrenheit. The administrator also acknowledged that the food temperature should be at least 135 degrees Fahrenheit.
Late Transmission of Resident Assessment Data
Penalty
Summary
The facility failed to transmit a resident's assessment data within the required timeframe, resulting in a deficiency. Specifically, the discharge assessment for Resident #105 was completed on February 21, 2024, but was not transmitted by the required date of March 6, 2024, as mandated by the Centers for Medicare and Medicaid Services (CMS). The assessment was signed by the Director of Nursing on February 23, 2024. However, a review conducted on July 23, 2024, revealed that the assessment had not been transmitted within the 14-day window. The facility's Final Validation Report on July 24, 2024, confirmed that the Minimum Data Set (MDS) for Resident #105 was accepted with an error message indicating late submission. During an interview on July 24, 2024, the MDS Nurse explained that an error in entering the Unit Certification or Licensure Designation in Section A0410 of the MDS caused the delay in transmission. This error led to the discharge MDS being submitted late, beyond the required deadline.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's skin condition. Specifically, Resident #62 had a stage III pressure ulcer with slough to the sacral area as documented in the wound assessment nursing notes dated 07/02/2024. However, the MDS with an Assessment Reference Date (ARD) of 07/07/2024 inaccurately indicated that Resident #62 had no unhealed pressure ulcers. This discrepancy was confirmed during an interview with the S2Corporate Nurse, who acknowledged that the MDS did not accurately reflect the resident's skin condition at the time of the assessment.
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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