Colonial Manor Nursing & Rehabilitation Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Rayville, Louisiana.
- Location
- 307 Foster Street, Rayville, Louisiana 71269
- CMS Provider Number
- 195394
- Inspections on file
- 20
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Colonial Manor Nursing & Rehabilitation Home during CMS and state inspections, most recent first.
Surveyors found that kitchen equipment was not maintained in safe and clean condition, including a refrigerator with three torn door seals, a broken toaster, another toaster missing a crumb catcher, and two toasters stored full of bread crumbs. Multiple full-size and half pans were covered in a black hardened substance, two ovens were coated with hardened black residue with one containing several silver pieces of material, and a microwave had dark splattered material on its top and sides. The dietary manager and the administrator both acknowledged that kitchen equipment should be in good repair and clean.
A resident with multiple comorbidities, moderate cognitive impairment, and dependence on staff for ADLs was found to have a large bruise on the right shoulder/armpit area, with no clear cause identified and while receiving Eliquis. Nursing staff documented the bruise, noted the recent use of a sling lift and the resident’s history of easy bruising, and verbally educated CNAs on positioning techniques. The DON and Administrator were aware of the injury and treated it as an injury of unknown origin, but they did not report it to the State Agency within the required 24-hour timeframe, contrary to the facility’s incident/accident and abuse reporting policies.
A resident with multiple comorbidities, moderate cognitive impairment, total dependence for transfers, and on Eliquis was observed with a large bruise on the right shoulder/armpit and could not state how it occurred. Documentation showed the bruise had been present for some time, was first reported by a hospice CNA, and measured 7 cm by 3 cm. Staff referenced recent use of a sling lift and noted the resident bruised easily, but the DON and Administrator acknowledged that no full investigation or incident report was completed for this injury of unknown origin, contrary to facility policies requiring investigation and documentation of such incidents and potential abuse indicators.
A resident with hemiplegia, diabetes, hypertension, late syphilis, and unspecified dementia with behavioral symptoms had a PRN order for Oxazepam 15 mg at night for insomnia written without a discontinue date. Pharmacy consultant review noted that PRN psychotropic medications must be limited to 14 days, with prescriber evaluation, documented rationale, and a specific duration if extended. The physician did not specify a duration for this PRN psychotropic order, and the DON confirmed the absence of a defined time limit, resulting in noncompliance with requirements to prevent unnecessary psychotropic use and chemical restraint.
A resident with a history of falls and other medical conditions fell in the facility, but the physician and family were not notified as required by the facility's fall prevention program. Staff confirmed the resident was assessed and found to have no injuries, but the necessary notifications were not made, as verified by the facility's administrator and DON.
A resident with a history of falls and cognitive impairment was found on the floor by staff, but the LPN did not document a post-fall assessment or complete an incident report as required by the facility's fall prevention policy. Despite the resident showing no immediate signs of injury or pain, the necessary documentation and reporting were not conducted, leading to a deficiency in care.
A resident with cognitive impairments was found with socks on her hands to prevent self-scratching, which she could not remove herself, classifying them as restraints. The facility lacked documentation of a pre-restraint assessment, consent, and monitoring, violating their restraint-free policy.
A facility failed to implement a comprehensive care plan for a resident on anticoagulants. The resident, who was taking Eliquis, was observed with bruising on her hands, which was not documented by nursing staff as required. The care plan included monitoring for bruising, but the MAR entries incorrectly indicated no bruising. The ADON confirmed the oversight.
The facility failed to ensure water temperatures in resident rooms were below 120 degrees, with temperatures ranging from 127.0 to 127.8 degrees confirmed by the Maintenance Supervisor and Assistant Administrator.
A resident with a history of pressure ulcers and at moderate risk was observed multiple times without prescribed heel protectors, despite having a physician's order for them to be worn at all times. Interviews with staff revealed a lack of adherence to the care plan, with an LPN unsure of the resident's compliance and a CNA admitting to not placing the protectors on the resident.
A facility failed to implement its infection control policy for enhanced barrier precautions for a resident with a Foley catheter. There was no signage on the resident's door, and no PPE supplies were available nearby, despite the policy requiring these measures. The Assistant DON confirmed the oversight.
A resident in a long-term care facility, who was cognitively impaired and had multiple medical conditions, was verbally and physically abused by a CNA. The abuse was captured on video, showing the CNA using derogatory language and physically mishandling the resident, causing distress and harm. The incident was reported by the resident's family member, and the facility confirmed the abuse, acknowledging the severe psychosocial harm caused to the resident.
A resident with severe cognitive impairment and mobility issues was denied assistance to the restroom by a CNA, who instructed the resident to use their brief instead. This incident was confirmed by video footage and acknowledged by the facility's administrator as inappropriate.
A resident with severe cognitive impairment was verbally and physically abused by a CNA, as captured on video by the resident's family. The facility's Administrator failed to report the incident to the State Survey Agency within the required timeframe, submitting the report more than 24 hours after being informed of the abuse, which violated state regulations.
Failure to Maintain Kitchen Equipment in Safe and Clean Condition
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain kitchen equipment in safe operating condition and in a clean state. During an initial kitchen tour, they observed three torn door seals on three individual refrigerator doors on one refrigerator, one broken toaster, and another toaster missing a crumb catcher. Two of the three toasters were stored while full of bread crumbs. In addition, four full-size pans and four half pans were covered in a black hardened substance, two ovens were covered with a hardened black substance, one oven contained four silver pieces of material approximately the size of a golf ball, and a microwave had a dark splattered substance on its top and sides. In interviews, the Dietary Manager confirmed that kitchen equipment should be working and clean, and the Administrator confirmed that the equipment in the kitchen should be in good repair and clean.
Failure to Report Injury of Unknown Origin Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency within the required 24-hour timeframe. Facility policies on incidents/accidents and on abuse, neglect, and exploitation require that injuries of unknown origin be treated as reportable events, with written procedures for identifying, investigating, and reporting such occurrences. The abuse policy specifies that all alleged violations, including injuries of unknown origin, must be reported to the Administrator and appropriate state agencies within specified timeframes, including not later than 24 hours if the events do not involve abuse or serious bodily injury. Resident #55, who had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast, was identified as having a large bruise on the right shoulder/armpit area. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and documented dependence on staff for all ADLs, including substantial/maximal assistance with rolling in bed and dependence for transfers. On observation, the resident was unable to state how the bruise occurred, and a CNA reported that the bruise had been present for several weeks without a known cause. The resident was also receiving Eliquis 2.5 mg twice daily. Nursing documentation dated 12/04/2025 showed that the treatment nurse was notified by a hospice CNA of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and could not recall how the bruise was acquired, and the treatment nurse noted that a sling lift had been used earlier in the week and that CNAs were verbally educated on proper lift techniques and positioning. The DON later documented that the lift used did not go under the arms and that the resident had a history of easy bruising and skin tears, and acknowledged that CNAs sometimes assisted the resident by placing a hand under her arm for repositioning. During interviews, the LPN and DON confirmed awareness of the bruise and that it had been reported internally to the DON and Administrator, but the DON and Administrator both confirmed that the injury of unknown origin was not reported to the State Agency as required by facility policy and state law.
Failure to Investigate Injury of Unknown Origin to Resident’s Shoulder/Armpit
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin in accordance with its own incident/accident and abuse policies. The facility’s policies required staff to report, investigate, and document incidents and accidents, including injuries of unknown origin, and to conduct an immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation. These policies also required identification and interviewing of all involved persons and complete documentation of the investigation. Despite these written requirements, the facility did not complete a full investigation when a large bruise of unknown origin was identified on a resident’s right shoulder/armpit area. The resident involved had diagnoses including chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and a history of malignant neoplasm of the right breast. A quarterly MDS showed moderate cognitive impairment (BIMS score of 8), dependence on staff for all ADLs, substantial/maximal assistance needed for rolling in bed, and total dependence for transfers. The resident was also receiving Eliquis 2.5 mg twice daily. During surveyor observation, the resident was seen sitting up in bed with a large bruise on the right shoulder/armpit and was unable to state how the bruise occurred. Record review showed that on a prior date, a hospice CNA had notified the treatment nurse of a new large bruise under the resident’s right armpit, measuring 7 cm by 3 cm with a light purple tint. The resident denied pain and did not recall how the bruise was acquired. Staff notes referenced use of a sling lift earlier in the week and staff education on proper lift and positioning techniques, and the DON documented that the lift used did not go under the arms and that the resident was an easy bruiser. However, the DON later acknowledged being unsure whether an incident report and investigation were completed, and both the DON and the Administrator confirmed that a full investigation into this injury of unknown origin was not conducted, despite the facility’s policies requiring such an investigation.
Failure to Time-Limit PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from chemical restraints and to limit PRN psychotropic medications to 14 days as required. Record review for Resident #2, who was re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, diabetes, late syphilis, and unspecified dementia with behavioral symptoms, showed a physician’s order dated 10/03/2024 for Oxazepam 15 mg PO PRN every 24 hours at night for insomnia without a discontinue date. The Pharmaceutical Consultant Report dated 10/13/2025 documented that PRN psychotropic medications must be limited to 14 days, with the prescriber required to evaluate the resident before extending the order, document the rationale for any extension, and indicate a specific duration. The report further showed that the physician did not indicate a specific duration for this PRN Oxazepam order, and during interview the DON confirmed that the physician had not specified a duration for the psychotropic PRN order. This failure to include a time-limited duration and required evaluation for the PRN psychotropic medication order for Resident #2 resulted in noncompliance with requirements intended to prevent unnecessary psychotropic use and chemical restraint.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to notify the physician and family after a resident's fall, as required by their fall prevention program. The program mandates that when a resident experiences a fall, the facility must assess the resident, complete an incident report, notify the physician and family, and document all assessments and actions. However, after a resident fell on 02/16/2025, the facility did not fulfill these requirements. Interviews with staff, including CNAs and an LPN, confirmed that although the resident was assessed and found to have no injuries or complaints of pain, the physician and family were not notified of the incident. The resident involved had a medical history that included depression, anxiety, dementia, repeated falls, and a non-displaced fracture of the right clavicle. Despite the resident's fall, there was no documented evidence in the medical record of any notifications made to the family or physician. The facility's administrator and director of nursing confirmed that the LPN should have contacted the physician and family regarding the fall, indicating a lapse in following the established protocol for fall incidents.
Failure to Document Post-Fall Assessment and Incident Report
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as outlined in their fall prevention program policy. Specifically, the nursing staff did not document a post-fall assessment or complete an incident report for a resident who experienced a fall. The facility's policy requires that when a resident falls, an assessment must be conducted, an incident report completed, and the physician and family notified. However, these steps were not followed for the resident in question. The resident involved had a history of depression, anxiety, dementia, repeated falls, and a non-displaced fracture of the right clavicle. On the evening of the incident, the resident was found on the floor by staff, but the LPN who assessed the resident did not document any injuries or pain and failed to complete the necessary incident report or post-fall assessment. Subsequent interviews with staff confirmed these omissions, and the facility's investigation revealed that the required documentation and reporting were not completed as per the facility's policy.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. The resident, who was admitted with diagnoses including cognitive communication deficit, Alzheimer's disease, and generalized anxiety disorder, was observed with socks on her hands. This was done to prevent her from scratching herself, as she was at high risk for skin tears. However, the resident was unable to remove the socks on her own, which classifies them as a physical restraint. The facility's policy mandates that restraints should only be used when medically necessary and with proper documentation, including a pre-restraint assessment and consent. In this case, there was no documented evidence of a pre-restraint assessment, restraint consent, or monitoring for the use of the socks as restraints. Interviews with facility staff confirmed the use of socks as restraints and the lack of necessary documentation and monitoring, indicating a failure to adhere to the facility's restraint-free environment policy.
Failure to Document Bruising in Anticoagulant Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who was on anticoagulant medication. During an observation, the resident was found to have bruising on the back of both hands, which she attributed to taking a blood thinner. The medical record confirmed that the resident was prescribed Eliquis, a blood-thinning medication, at a dosage of 2.5 mg twice daily. The care plan included an intervention to monitor for bruising, and the Medication Administration Record (MAR) required nursing staff to check for bruising each shift. However, the December MAR entries consistently indicated that the resident had no bruising, despite the observed bruising. An interview with the Assistant Director of Nursing confirmed the presence of bruising and the failure of the nursing staff to document it on the MAR.
Excessive Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that the water temperature in resident rooms was below 120 degrees, as required. During an inspection on December 16, 2024, the water temperatures in the rooms of four residents were found to be excessively high, ranging from 127.0 to 127.8 degrees. This was confirmed by the S2Maintenance Supervisor, who acknowledged that the temperatures exceeded the safe limit. The S1Assistant Administrator also confirmed that the water temperatures should not exceed 120 degrees, indicating a lapse in maintaining the required safety standards for resident rooms.
Failure to Provide Ordered Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. The resident, who had a history of a stage 3 pressure ulcer on the left heel and was at moderate risk for pressure ulcers, was observed multiple times without the prescribed heel protectors. Despite having a physician's order for heel protectors to be worn at all times, the resident was seen without them on several occasions, both in the Geri chair and in bed, even after being placed on isolation due to a positive COVID test. Interviews with facility staff revealed a lack of adherence to the care plan. The LPN confirmed the resident's high risk for pressure ulcers and the order for heel protectors, but was unsure if they were being used. A CNA admitted to not placing the heel protectors on the resident, and the Assistant Director of Nursing confirmed that the resident should have had them on as ordered. This indicates a breakdown in communication and responsibility among staff regarding the implementation of the resident's care plan to prevent pressure ulcers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program to prevent the transmission of communicable diseases and infections by not implementing its policy for enhanced barrier precautions for a resident with a Foley catheter. During an observation, it was noted that there was no signage regarding Enhanced Barrier Precautions on the resident's door, and no personal protective equipment (PPE) supplies were located nearby. The facility's policy, dated 11/01/2024, specified that catheters were a qualifying condition for enhanced barrier precautions, requiring clear signage and the availability of gowns and gloves outside the resident's room. An interview with the Assistant Director of Nursing confirmed the facility's failure to implement the policy by not placing the necessary signage and PPE near the resident's room.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively impaired and had multiple medical conditions, including dementia, anxiety, and chronic heart failure. The abuse occurred when the CNA was observed on video surveillance being verbally and physically abusive while providing care to the resident. The resident's family member reviewed the footage and reported the incident to the facility administrators. The video footage revealed that the CNA used derogatory language and physically mishandled the resident. The CNA was seen pushing the resident's wheelchair and making threatening remarks. The resident, who was unable to walk and used a wheelchair, was verbally abused and physically forced into bed, resulting in the resident hitting her head against the wall. The CNA's actions were observed to cause distress to the resident, who responded with upset language. The facility's investigation confirmed the abuse, and the administrators acknowledged that a reasonable person would have been very upset by the treatment the resident received. The incident was reported to have caused severe psychosocial harm to the resident, including feelings of dehumanization and humiliation. The facility's policies on abuse, neglect, and exploitation were reviewed, and it was determined that the CNA's actions violated these policies.
Failure to Assist Resident with Restroom Needs
Penalty
Summary
The facility failed to uphold the resident's right to dignity and self-determination by not assisting a resident with severe cognitive impairment to the restroom upon request. The resident, who was admitted with multiple diagnoses including dementia, chronic heart failure, and mobility issues, required limited physical assistance for daily activities such as bed mobility, transfers, eating, and toilet use. Despite these needs, a Certified Nursing Assistant (CNA) refused to assist the resident to the bathroom, instructing them to use their brief instead. This incident was corroborated by video footage reviewed by the resident's family member and the surveyor, which showed the CNA telling the resident to use their brief or hold it. The facility's administrator confirmed that the CNA's actions were inappropriate and that the resident should have been assisted to the restroom as requested.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal and physical abuse involving a resident to the State Survey Agency within the required timeframe. The incident was reported to the Administrator by the resident's family member, who provided video evidence of the abuse. The video footage showed a Certified Nursing Assistant (CNA) making rude comments and handling the resident roughly during care. Despite being informed of the incident, the Administrator did not report it to the State Survey Agency within the mandated two-hour window. The resident involved in the incident was admitted with multiple diagnoses, including severe cognitive impairment, dementia, and other physical and mental health conditions. The resident required assistance with daily activities and was using a manual wheelchair for mobility. The video evidence captured the CNA verbally abusing the resident and physically forcing the resident into bed, resulting in the resident hitting their head against a wall. The Administrator confirmed the abuse occurred but delayed reporting the incident to the State Survey Agency. The report was submitted more than 24 hours after the incident was discovered, violating the facility's policy and state regulations that require immediate reporting of abuse allegations. This delay in reporting represents a significant deficiency in the facility's adherence to abuse reporting protocols.
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.
Trusted data from CMS and state health departments
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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