Claiborne Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 1536 Claiborne Ave., Shreveport, Louisiana 71103
- CMS Provider Number
- 195316
- Inspections on file
- 34
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Claiborne Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and a documented high risk for wandering, who wore a wander guard and ambulated independently, eloped from the facility by following visitors out the front entrance while staff were unaware. Policy assigned responsibility to the charge nurse to know resident locations and required all personnel to report attempts to leave, yet no staff noticed or reported the resident’s departure after last seeing him at dinner. Video showed the resident exiting behind visitors, attempting to re-enter, then walking off toward another wing and out of view; he was later found by police walking on a nearby interstate and returned to the facility, stating he was trying to go home.
A resident with intact cognition and multiple chronic conditions, including an above-knee amputation, DM with neuropathy, PVD, HTN, schizophrenia, and CHF, reported that a CNA complained about back pain while providing incontinent care and then questioned, in front of the resident, whether the resident had to be assisted back into a wheelchair after requesting to get up. An LPN and another CNA confirmed hearing the CNA state there would be no "up and down" that night and complain that getting the resident in and out of bed was hard on her back, directing comments to the LPN in the resident’s presence. The DON later confirmed that the CNA’s communication in front of the resident was unprofessional and not respectful, failing to support the resident’s dignity.
A resident with a history of UTI had chronic, asymptomatic UTI noted in the record and was treated with levofloxacin for a wound infection, which was also expected to cover the UTI. The DON confirmed the resident had a UTI and was treated, and the corporate nurse verified that no care plan had been completed for the resident's UTI needs.
Failure to post and retain daily nurse staffing data. Observations showed the staffing data was not posted, and the Interim Administrator confirmed it should have been posted daily. The Interim Administrator also could not locate the staffing postings going back to 08/27/2025, despite the requirement to retain them for at least 18 months.
A resident with severe cognitive impairment and no functional impairment to the upper or lower extremities was observed in bed with the call light on the floor and out of reach on more than one occasion. Staff confirmed the call light should have been within the resident’s reach, and the roommate reported calling for help when the resident yelled out.
Outside dumpster lids were left completely open, despite the facility policy requiring dumpsters to be kept closed and free of surrounding litter. During observation, both lids were open to the backside of the dumpster, and the Dietary Manager verified the condition.
A resident with multiple mental health diagnoses was subjected to verbal abuse by a CNA during a dispute over a dinner tray. The situation escalated into a loud, profane argument in the dining area and hallway, witnessed by an LPN who intervened. The incident was confirmed through statements from those involved and was found to violate the facility's abuse prohibition policy.
A resident with multiple psychiatric diagnoses and intact cognition experienced a verbal abuse incident that was reported verbally to the administrator by an LPN, but no incident report or required documentation was completed as per facility policy.
A facility failed to implement a comprehensive care plan for a resident, lacking orders for a knee immobilizer and non-weight bearing status, despite the resident's leg fractures. Additionally, the facility did not reorder the diuretic Bumex in a timely manner, resulting in missed doses. Observations and interviews confirmed these deficiencies, highlighting lapses in care planning and medication management.
A resident was found with medication left at their bedside without proper authorization for self-administration. The resident, who had intact cognition, was unsure of the medication's purpose. The facility lacked necessary physician orders and evaluations for self-administration, as confirmed by the DON and Corporate Nurse.
A facility failed to document a resident's DNR order in their medical records, despite the resident's LaPOST form indicating a DNR status. The resident, with severe cognitive impairment and multiple medical conditions, had no DNR order in their EHR or physician orders. Staff interviews confirmed the oversight, acknowledging the absence of the DNR order in the records.
The facility failed to monitor two residents on critical medications. A resident on Eliquis for atrial fibrillation was not monitored for bleeding signs, and another on Bumex for heart failure was not monitored for edema. Interviews confirmed the lack of required monitoring.
The facility's kitchen failed to maintain sanitary conditions, affecting 70 residents. Observations showed improper storage of ground beef, utensils, and food items, risking cross-contamination. The back-up freezer lacked a thermometer, and several food items were undated. The Dietary Manager acknowledged these deficiencies, highlighting a failure to adhere to professional standards for food safety.
The facility failed to maintain essential kitchen equipment, resulting in water pooling from the dishwasher and refrigerator, and improper temperature maintenance in a freezer. The Dietary Manager and Service Technician acknowledged the issues, but repairs were not made. The Administrator attributed the problems to staff training issues.
A resident with multiple medical conditions requiring substantial assistance with personal hygiene was found to have long, untrimmed fingernails and toenails. Despite the resident's requests and the care plan indicating the need for nail care, staff attempted to trim the nails while the resident was at dialysis, resulting in the nails remaining untrimmed. The DON and a Corporate Nurse acknowledged the deficiency.
The facility failed to document new hire and/or annual competency demonstrations for CNAs, affecting 2 out of 5 personnel files reviewed. Interviews confirmed the lack of documentation and acknowledged that skill competencies had not been completed prior to providing patient care, potentially affecting all 72 residents.
The facility's QAA committee meetings did not include the required six staff members, as the Medical Director was absent from the last two meetings. The Administrator was unaware of the requirement for the Medical Director's attendance, and the DON confirmed the Medical Director's irregular attendance.
A resident with multiple medical conditions and bilateral above-knee amputations fell while being transported inappropriately by van instead of by ambulance, leading to increased anxiety and a new diagnosis of anxiety disorder. The incident occurred due to a failure in communication and verification of the resident's transportation needs by facility staff.
The facility failed to develop and implement a comprehensive care plan for a resident with anxiety and specific transportation needs. Despite medical orders and documented requirements, the care plan did not address the resident's anxiety management or the need for ambulance transport to dialysis appointments.
Failure to Supervise High-Risk Wanderer Resulting in Elopement to Highway
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent elopement for a resident who was a known elopement risk. The resident had diagnoses including memory deficit, dementia with behavioral disturbance, major depressive disorder, mild neurocognitive disorder with behavioral disturbance, and gastric reflux disease. A Quarterly Wander Data Collection assessment showed a score of 22, indicating high risk for wandering, with documentation that the resident verbally expressed a desire to go home and that the resident’s wandering placed him at significant risk of reaching a potentially dangerous place outside the facility. The resident’s MDS documented daily use of a wander guard bracelet and independent ambulation, and the comprehensive care plan identified the resident as an elopement risk/wanderer with an intervention for a wander bracelet on the right ankle, to be checked each shift. On the day of the incident, the resident was last seen by staff in the dining room around the dinner hour, sitting at a table and eating. Multiple CNAs and the LPN assigned to the resident reported that they saw the resident at dinner and were not aware that he had left the building until he was returned by police. The facility’s policy stated that the unit charge nurse is responsible for knowing the location of residents and that all personnel must report any resident attempting to leave or suspected of being missing to the charge nurse as soon as practical. Despite this, no staff member identified or reported the resident’s departure from the facility in real time, and no one noticed that the resident was missing until law enforcement brought him back. Video footage from the facility’s outside cameras showed that at 5:31 p.m. three visitors exited through the front entrance door, and the resident followed directly behind them. One of the visitors held the door open, allowing the resident to walk out. The visitors then left, and the resident remained at the entrance before attempting to re-open the locked door at 5:33 p.m., then walking away toward the east wing and out of camera view. The resident’s wander guard bracelet remained in place and was later confirmed to be functioning, yet staff did not detect his exit or absence. The resident was ultimately found by a local police officer walking on an interstate highway approximately 0.9 miles from the facility and was returned to the facility at about 6:45 p.m., awake, alert, oriented with confused conversation, and stating he was trying to go home. This sequence of events demonstrates that the facility did not ensure adequate supervision and monitoring of a high-risk wanderer to prevent elopement.
Undignified Staff Communication During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was treated with respect and dignity in accordance with the facility’s Resident Rights policy. The policy, revised in 04/2017, states that residents shall be treated as individuals in a manner that supports their dignity. Resident #6 was admitted on 06/17/2025 with diagnoses including acquired absence of the left leg above the knee, diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, essential hypertension, schizophrenia, and chronic combined systolic and diastolic congestive heart failure. A Significant Change MDS dated 02/24/2026 documented a BIMS score of 15, indicating intact cognition. During an interview, the resident reported that on the previous day a CNA complained of her back while providing incontinent care and, after completing the care, questioned whether she had to get the resident back up when the resident requested to return to her wheelchair. Multiple staff interviews corroborated that the CNA’s communication in front of the resident was not respectful. An LPN reported hearing the resident ask to be assisted back into her wheelchair and hearing the CNA respond that there was not going to be any “up and down tonight,” delivered with an attitude. In a phone interview, the CNA acknowledged that after changing the resident, she asked the LPN if the resident could stay in bed because getting the resident in and out of bed was a lot on her back, and when the LPN instructed her to get the resident up, she told the LPN it was on her back and not the LPN’s back. Another CNA reported hearing the CNA ask the LPN if she had to get the resident up while care was being provided. The DON stated that the facility’s investigation concluded the CNA’s communication in front of the resident was unprofessional and not respectful, failing to support the resident’s dignity as required by policy.
Incomplete Care Plan for UTI History
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of urinary tract infections. The resident was admitted with a diagnosis of personal history of UTI, and a nurse practitioner progress note documented chronic, asymptomatic UTI, continued Estrace cream intravaginally three times per week, cranberry-vitamin C-inulin UTI-Stat twice daily, and encouragement of hydration and routine hygiene measures. The same note also stated the resident was receiving levofloxacin for a wound infection and that it should cover the UTI as well. During interview, the DON reported the resident had a UTI and was treated, and the corporate nurse verified that a care plan had not been completed for the resident's urinary tract infections.
Failure to Post and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure nurse staffing data information was posted daily and retained for a minimum of 18 months. Observations on 03/16/2026 at 1:15 p.m. and 03/17/2026 at 1:00 p.m. did not reveal any nurse staffing data information posted. During an interview on 03/17/2026 at 1:09 p.m., the Interim Administrator stated the daily nurse staffing data information was not posted and should be. During a later interview on 03/17/2026 at 2:00 p.m., the Interim Administrator reported she was unable to locate the daily staffing data postings since 08/27/2025 and that the postings should have been retained for at least 18 months.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to accommodate the needs of 1 resident by not keeping the resident’s call light within reach. Resident #29 had a BIMS score of 00, indicating severe cognitive impairment, and did not have any functional impairment to the upper or lower extremities. During an observation, the resident was lying in bed with the dresser positioned at the foot of the bed, and the call light was found on the floor behind the dresser. On a later observation, the resident was again lying in bed and the call light was found on the floor between the foot of the bed and the dresser. Staff interviews confirmed the call light was out of reach and should have been kept within the resident’s reach. The resident’s roommate reported that he called for assistance when the resident yelled out for help.
Outside Dumpster Lids Left Open
Penalty
Summary
The facility failed to ensure the outside dumpster lids were closed. Review of the Food-Related Garbage and Refuse Disposal policy, revised 03/05/2026, stated that outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During observation on 03/16/2026 at 8:14 a.m., both dumpster lids were completely open to the backside of the dumpster. During interview on 03/16/2026 at 8:15 a.m., the Dietary Manager verified that both dumpster lids were completely open to the backside of the dumpster.
Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a staff member, specifically a CNA, engaged in verbal abuse toward a resident. The incident began when the resident initially declined a dinner tray but later changed her mind and requested it. The CNA did not immediately respond, leading the resident to feel ignored. As the resident attempted to leave the dining area, a verbal altercation ensued between her and the CNA, with both parties raising their voices and using profane language. The exchange was witnessed by an LPN, who intervened to de-escalate the situation. The resident involved had a history of mental health diagnoses, including Post-Traumatic Stress Disorder, Schizoaffective disorder-Bipolar type, Anxiety disorder, and Major Depressive disorder. At the time of the incident, the resident was assessed as cognitively intact. The altercation took place in the dining area and extended to the hallway, where the CNA continued to yell at the resident, using derogatory language. The LPN present reported overhearing the shouting and observed both the resident and the CNA exchanging profanities. Following the incident, the administrator was notified by the LPN and DON. Statements were collected from the resident, the CNA, and the LPN, all of which confirmed the occurrence of a loud and profane verbal exchange. The resident later reported feeling embarrassed by the incident but denied any ongoing concerns and stated she felt safe at the facility. The deficiency was substantiated based on these accounts and the facility's policy prohibiting verbal abuse.
Failure to Report and Document Verbal Abuse Incident
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the reporting and documentation of incidents for one resident who experienced a verbal abuse incident. According to the facility's policy, an incident report must be completed by the person reporting the incident or the supervisor on the shift when the incident occurred, and specific documentation must be entered into the resident's medical record. However, for a resident with diagnoses including Post-Traumatic Stress Disorder, Schizoaffective disorder-Bipolar type, Anxiety disorder, and Major Depressive disorder, there was no documentation in the progress notes or incident reporting system regarding a verbal abuse incident that occurred. The resident was cognitively intact at the time, as indicated by a Brief Interview for Mental Status score of 15. Interviews confirmed that an LPN notified the facility administrator about the verbal abuse incident, but no incident report was completed as required by policy. The administrator acknowledged that the incident report should have been completed but was not. This failure to follow established procedures resulted in the lack of required documentation and reporting for the incident involving the resident.
Failure to Implement Comprehensive Care Plan and Timely Medication Reordering
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #265, to meet their medical and nursing needs. Specifically, the facility did not have a physician's order or a care plan in place for the resident's left knee immobilizer and non-weight bearing status, despite the resident having a history of fractures in the left leg. Observations confirmed the resident was wearing a knee immobilizer, and interviews with the resident and the Director of Nursing (DON) verified the absence of necessary orders and care planning for this condition. Additionally, the facility did not ensure the timely reordering of a diuretic medication, Bumex, for the resident, resulting in missed doses. The resident's medication administration record showed that Bumex was not administered as scheduled, and interviews revealed that the medication had not been reordered in accordance with the facility's policy, leading to a lapse in therapy. The Licensed Practical Nurse (LPN) confirmed that the medication should have been ordered but was not, contributing to the deficiency in care provided to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident. During an observation, two medicine cups containing various pills were found on the bedside table within reach of the resident. The resident reported that a staff member had left the medications there, and he was unsure of what the pills were or their purpose. This practice was confirmed as inappropriate by the Director of Nursing and the Corporate Nurse present during the observation. The resident's medical record did not contain any physician's orders or evaluations authorizing self-administration of medications. Despite the resident having intact cognition, as indicated by a BIMS score of 15, there was no documented assessment or approval for the resident to manage their own medications. The Corporate Nurse acknowledged the absence of necessary evaluations and orders for self-administration, confirming the deficiency in medication administration practices.
Failure to Document DNR Order in Resident's Medical Records
Penalty
Summary
The facility failed to ensure that a resident's medical records accurately reflected their wishes regarding advance directives, specifically a Do Not Resuscitate (DNR) order. The resident, who had severe cognitive impairment and multiple medical conditions including metabolic encephalopathy and dementia, had a LaPOST form indicating a DNR status. However, this status was not reflected in the resident's electronic health record (EHR) profile header or in the current physician orders, which should have included the DNR order as per the facility's policy. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of the DNR order in the resident's medical records. The staff acknowledged that the DNR order should have been documented in the resident's records to align with the resident's LaPOST form and the facility's policy on advance directives. This oversight indicates a failure in the facility's process to ensure that residents' code statuses are accurately documented and accessible in their medical records.
Failure to Monitor Residents on Critical Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, specifically for two residents who were not properly monitored while receiving critical medications. Resident #5, who was admitted with diagnoses including cerebral infarction and paroxysmal atrial fibrillation, was prescribed Eliquis, an anticoagulant. Despite a physician's order to monitor for signs of bleeding, such as discolored urine and black tarry stools, the January Medication Administration Record (MAR) showed no evidence of such monitoring. Interviews with the LPN and Corporate Nurse confirmed that the required monitoring was not conducted throughout January. Similarly, Resident #29, admitted with chronic systolic heart failure and edema, was prescribed Bumex, a diuretic, to manage heart failure. The comprehensive care plan required monitoring for edema, yet the January MAR indicated that no monitoring occurred from January 4th to 21st. Interviews with the LPN and Corporate Nurse confirmed the absence of monitoring during this period, despite the resident's known condition of edema in the lower extremities.
Sanitary Deficiencies in Kitchen Food Storage and Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, which had the potential to affect the 70 residents receiving food trays. Observations revealed several deficiencies: ground beef was improperly stored on the top shelf of a freezer, sitting on an opened box of frozen fish and directly above an open box of cookie dough and bags of frozen vegetables, risking cross-contamination. Utensils were not stored correctly, with a flour scoop left on top of a box above the flour bin and a sugar scoop left inside its container. Food serving plates and cover lids were stored in an upright position, which is not in accordance with professional standards. Additionally, the upright back-up freezer lacked a thermometer, which is essential for monitoring proper food storage temperatures. Several food items were found undated, including a half-gallon of Pimento cheese spread, a gallon of Ranch dressing, a gallon of sweet and sour sauce, and a 32-ounce jar of lemon juice. Open and undated items included a 5-pound block of sliced cheese with exposed slices, a sandwich-size Ziploc bag of cherry pie filling, a gallon bag of uncooked fried squash, an opened gallon of coleslaw dressing, and a box containing a 5-gallon open/unsecured bag of powdered food thickener. The Dietary Manager acknowledged these deficiencies during an interview, recognizing the failure to adhere to professional standards for food service safety and sanitary conditions.
Failure to Maintain Safe Kitchen Equipment Conditions
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, leading to potential health and safety risks. During an observation, water was found standing approximately 1/2 inch deep and 3 feet wide at the kitchen entry door, originating from the dishwasher and extending to the steam table. Additionally, water was pooling under refrigerator #1, extending into the dry food storeroom. The external temperature of freezer #1 was -5 degrees Fahrenheit, while the internal temperature was 38 degrees Fahrenheit, indicating a failure to maintain a safe temperature range for frozen foods. Interviews revealed that the Dietary Manager was aware of the maintenance issues with the refrigerator, freezer, and dishwasher but had not addressed them. The Service Technician also acknowledged the need for repairs in the kitchen. The Administrator recognized the maintenance issues but attributed them to a training issue with the staff.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for a resident who was unable to perform self-care due to medical conditions. The resident, who had diagnoses including end-stage renal disease, type 2 diabetes mellitus, and paraplegia, required substantial assistance with personal hygiene and nail care. Despite these needs being documented in the care plan, the resident's fingernails and toenails were observed to be long and untrimmed. The resident reported that staff attempted to trim her nails while she was at dialysis, resulting in the nails never being trimmed. The Director of Nursing and a Corporate Nurse acknowledged the oversight during an observation and interview, confirming that the nails should have been trimmed.
Lack of Documented CNA Competency Checks
Penalty
Summary
The facility failed to ensure that all certified nursing assistant (CNA) staff had documented new hire and/or annual competency demonstrations for all skills related to their expected roles. This deficiency was identified in 2 out of 5 personnel files reviewed, specifically for employees hired on 08/07/2024 and 12/06/2023. There was no documented evidence of any competencies being completed upon hire for these CNAs. Interviews with the Human Resources representative and the Administrator confirmed the lack of documentation and acknowledged that skill competencies had not been completed prior to the CNAs providing patient care. The Corporate Nurse also confirmed that competency checks had not been conducted upon hire for these employees, which should have been done. This oversight had the potential to affect all 72 residents residing in the facility.
QAA Committee Meetings Lacked Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee meetings included the required six staff members for the last two quarterly meetings. Specifically, the sign-in sheets for the meetings held on June 12, 2024, and October 30, 2024, did not show the attendance of the Medical Director or a representative. During an interview, the Administrator acknowledged the absence of the Medical Director and admitted to being unaware of the requirement for the Medical Director's attendance. Additionally, the Director of Nursing reported that the Medical Director does not regularly attend the QAA meetings.
Failure to Ensure Safe Transportation for Resident
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards during transport, resulting in a fall for one resident who required transportation to appointments. The incident occurred when a van driver attempted to load the resident, who was supposed to be transported by ambulance on a stretcher, onto the facility van via a wheelchair. The resident's wheelchair tilted backwards after being loaded onto the van lift, causing the resident to fall and hit his head on the driver's foot. This incident led to increased anxiety for the resident, who had previously experienced a similar fall from the facility van lift. The resident's medical record revealed that he had multiple diagnoses, including end-stage renal disease, dependence on renal dialysis, and bilateral above-knee amputations. The resident was assessed as having moderately impaired cognition and required total assistance for transfers. Despite these needs, the facility staff failed to verify the appropriate mode of transportation with the resident's nurse. The van driver, who was in training, and other staff members involved did not confirm the transportation method, leading to the resident being transported inappropriately. Interviews with various staff members, including the social services director, assistant administrator, and nurses, confirmed that the resident was supposed to be transported by ambulance. However, due to a misunderstanding and lack of proper communication, the resident was transported by van, resulting in the fall. The facility's investigation determined that the resident's wheelchair was top-heavy due to his bilateral amputations, causing it to flip over backwards on the van lift. The incident highlighted a failure in communication and adherence to the resident's transportation requirements, leading to actual harm for the resident.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses, including anxiety and the need for specific transportation arrangements. The resident's medical records indicated a diagnosis of anxiety and a prescription for Klonopin to be administered before dialysis to manage this condition. However, the resident's comprehensive care plan did not include a problem and approach for the anxiety diagnosis or the administration of the antianxiety medication. Additionally, the care plan did not address the resident's required mode of transportation by ambulance to appointments and dialysis, despite a physician's order and a Certification of Ambulance Transportation form specifying the need for ambulance transport due to the resident's mobility limitations and medical conditions, including bilateral leg amputations and dependence on renal dialysis. The deficiency was further highlighted during interviews with facility staff. The Assistant Administrator acknowledged that the lack of written documentation regarding the resident's transportation needs could have led staff to mistakenly believe it was acceptable to transport the resident by facility van instead of an ambulance. The Medical Director confirmed that the resident experienced anxiety before dialysis and that Klonopin was prescribed to alleviate this anxiety. Despite these orders and the resident's documented needs, the facility did not incorporate these critical aspects into the resident's care plan, resulting in a failure to provide appropriate and comprehensive care.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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