Cornerstone At The Ranch
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Louisiana.
- Location
- 103 West Martial Ave, Lafayette, Louisiana 70506
- CMS Provider Number
- 195565
- Inspections on file
- 29
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cornerstone At The Ranch during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Two residents receiving psychotropic medications did not have their gradual dose reduction (GDR) forms reviewed by a physician as required. One resident with dementia and multiple psychiatric diagnoses had GDR forms for several medications left unaddressed, while another resident on hospice with psychiatric and neurological conditions also had GDR forms for multiple medications that were not reviewed. The administrator confirmed the lack of physician documentation for these GDRs.
Staff did not consistently follow care plans and physician orders for several residents, including failures to document edema severity and fluid intake, apply prescribed medical devices, record vital signs every shift, and update care plans and orders for code status and hospice admission. These deficiencies were confirmed through record reviews, observations, and staff interviews.
The facility did not adequately monitor or audit several open QAPI projects, including those related to GDRs, weekly body audits, and expired medications. Required monitoring and observations were not consistently performed, and the DON confirmed that these deficiencies were not addressed prior to the survey, potentially affecting all residents.
A resident with a documented DNR status on both the admission record and a signed LaPOST form was incorrectly listed as 'Full Code' in the facility's Care Profile Report. The DON confirmed this inconsistency and acknowledged that the Care Profile Report was not updated to match the resident's advance directives.
A resident's MDS assessment was inaccurately coded as a discharge to a short-term general hospital, despite documentation and staff interviews confirming the resident left AMA to her own home and was not transferred to a hospital. Facility records and staff statements verified the error in the MDS coding.
Surveyors observed that expired medications, including Sodium Chloride Tablets, Acetaminophen suppositories, Bisacodyl suppositories, Ferrous Sulfate Elixir, and Vitamin D-3, were not discarded as required and remained stored in two medication rooms. The ADON confirmed these expired drugs should have been removed, but they were still present, contrary to facility policy.
Surveyors observed that garbage and refuse, including used gloves and a garbage bag, were left on the ground and around an open dumpster in the dietary disposal area. The area was not maintained in a sanitary condition as required by facility policy, and staff confirmed that the dumpster should have been kept closed and the area clean.
Surveyors identified unclean kitchen flooring, rodent droppings in a storage area, and improperly labeled and stored food items in a refrigerator used for resident supplements. Additionally, a deep fryer and the floor beneath it were found with significant debris and residue. The dietary manager and kitchen staff confirmed these sanitation lapses during the inspection.
An electrical outlet in the kitchen was found protruding from the wall with a visible hole, and was not properly sealed or secured. This was confirmed by the Assistant Administrator and was not in accordance with facility policy for maintaining a clean and orderly environment. The issue had the potential to affect all residents in the facility.
A resident with multiple health issues experienced frequent diarrhea, but the facility failed to notify the physician as required by policy. Despite the CNA reporting the issue to the LPN, the physician was not informed, and the Nurse Practitioner confirmed the lack of notification. Documentation existed of the episodes, but no action was taken to inform the physician.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including Dementia and HIV. The bowel and bladder charting for the resident showed incorrect documentation of size and consistency, marked with 'Y' instead of the designated letters. Interviews confirmed that CNAs did not document accurately, potentially affecting the entire census of 71 residents.
The facility failed to accurately document edema and behaviors for two residents. One resident had discrepancies in edema and behavior records, despite orders to monitor these conditions. Another resident's edema was inconsistently documented in the MAR and daily assessments, despite receiving a diuretic. These inaccuracies were confirmed by staff and observed during interviews.
The facility failed to maintain a clean and homelike environment for two residents, as their shared room had walls stained with tan, light brown, dark brown, and rust-colored marks. The Housekeeping Supervisor acknowledged the responsibility to clean the walls, which had not been fulfilled.
A resident activated her call light for assistance, but the facility failed to respond promptly. Despite the call light being visible on the hallway sign and electronic board, the LPN on duty did not attend to the resident, instead making overhead announcements for a CNA to respond. The resident, who required assistance for transfers and hygiene, was left waiting, highlighting a deficiency in staffing and response protocol.
A resident with multiple diagnoses and high risk for skin injury experienced inadequate wound care management due to the nursing staff's failure to complete weekly skin assessments, accurately document wound staging, update clinical records, and notify medical staff of wound deterioration. The initial wound assessment was delayed, and subsequent assessments were inconsistent, leading to a deficiency identified by surveyors.
A treatment nurse in an LTC facility failed to follow proper hand hygiene protocols during wound care for a resident with a deep tissue injury. The nurse changed gloves multiple times without sanitizing hands, contrary to the facility's policy. This deficiency was confirmed by both the nurse and the DON/Infection Preventionist.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies. A resident with severe depression had no care plan addressing their condition. Another resident's catheter was not cleaned as ordered, and a diabetic resident lacked a glucose sensor, contrary to their care plan. Communication needs for a resident with dysarthria and feeding assistance for a resident with dementia were also not addressed.
A resident with a suprapubic catheter was observed in the dining room with an uncovered catheter drainage bag, contrary to the facility's dignity policy. The resident, who requires assistance with ADLs due to medical conditions, had approximately 300 cc's of urine visible to others. The DON confirmed the absence of a covering, highlighting a failure to maintain the resident's dignity.
The facility failed to ensure the cleanliness of wheelchairs for two residents, leading to a deficiency in providing a safe, clean, and comfortable environment. Despite a policy requiring regular cleaning, both residents reported their wheelchairs had never been cleaned, and observations confirmed the presence of dust. A CNA acknowledged the oversight, indicating a lapse in adherence to the facility's cleaning schedule.
A facility failed to include pain management in a baseline care plan for a resident admitted with a fracture and other conditions. Despite having a physician's order for Oxycodone, the baseline care plan did not address pain, and the MDS Coordinator confirmed the absence of a pain assessment.
The facility failed to provide proper respiratory care for two residents by not labeling or storing oxygen equipment correctly and administering oxygen without a physician's order. One resident had unlabeled oxygen tubing and a humidifier bottle, while another had oxygen administered without an order and improperly stored oxygen tanks in their room.
A resident with a fractured humerus experienced severe pain and did not receive prescribed Oxycodone due to a lapse in communication and procedure. Despite the resident's complaints and an LPN's attempt to address the issue, the ADON was not informed, and the physician was not contacted for a new prescription, leaving the resident without pain relief for several days.
The facility failed to provide timely responses to call lights for two residents, one with quadriplegia and intact cognition, and another with severe cognitive impairment. Despite digital alerts and announcements, staff did not respond promptly, with one LPN admitting to not answering a call light and a CNA failing to inform a colleague about covering during a break. The Regional Corporate Nurse confirmed staffing issues.
A resident with conditions including End Stage Renal Failure and Heart Failure did not receive prescribed PRN medications for itching, despite having a red rash and reporting the issue to nursing staff. An LPN confirmed the resident's condition but failed to administer the medications, acknowledging the oversight.
The facility failed to remove expired medications from medication room A. During an inspection, a bottle of Vitamin B Complex with Vitamin C and a bottle of Ferrous Gluconate 240 mg were found with expiration dates of May 2024. An LPN confirmed the medications were expired.
A resident with intact cognition had their food preferences disregarded, as mashed potatoes and rice, both listed as dislikes, were served on their meal trays. The Dietary Manager confirmed the error, highlighting a failure to adhere to documented preferences.
A resident with multiple diagnoses, including Anemia and Rheumatoid Arthritis, had incomplete medical records due to a lack of nursing documentation over a month. Despite receiving an antibiotic order, there were no documented signs or symptoms leading to the order, nor was there an ongoing assessment of the resident's swollen right lower extremity. Interviews with an LPN and the DON confirmed the absence of necessary documentation.
A facility failed to maintain an updated hospice care plan for a resident, resulting in an outdated plan on file that did not reflect the resident's current DNR status. The DON was unaware of the missing updated care plan, highlighting a lapse in the facility's process for ensuring current hospice documentation.
The facility failed to maintain functioning call systems for three residents, including one with Parkinson's Disease and another with severe cognitive impairment. Observations revealed that call bells did not alert staff due to battery issues, and maintenance staff did not routinely check the systems, leading to unaddressed calls for assistance.
A facility failed to maintain a safe and sanitary environment for a resident, as evidenced by a window in disrepair. Observations revealed two large cracks on the window pane, covered with tape, indicating inadequate repair. Staff confirmed the window's poor condition, which did not meet the facility's policy for a clean and orderly environment.
The facility failed to ensure a dementia resident received appropriate treatment and services by not revising the care plan to address continued wandering, staff not reporting incidents, and not providing adequate supervision despite complaints. The resident, diagnosed with dementia, frequently wandered into other residents' rooms, causing distress, and interventions were not effectively implemented or reported.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Ensure Physician Review of Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not having gradual dose reduction (GDR) forms reviewed by a physician for two residents. For one resident with diagnoses including dementia, depression, anxiety, restlessness, and agitation, the annual Minimum Data Set (MDS) indicated the use of antipsychotic, antianxiety, and antidepressant medications. Although the MDS documented that a GDR was clinically contraindicated, the facility's GDR binder showed that multiple GDR forms for medications such as Haldol, Klonopin, Remeron, and Zoloft were not addressed by the physician. Another resident, who was on hospice and had diagnoses including depression, unspecified psychosis, anxiety, and senile degeneration of the brain, was also taking antipsychotic, antianxiety, and antidepressant medications. The quarterly MDS for this resident did not document that a GDR was clinically contraindicated. The facility's GDR binder revealed that GDR forms for medications including Seroquel, Celexa, and Lorazepam were not reviewed by the physician. The administrator confirmed that there was no documented evidence that the GDRs for these residents were addressed by the physician as required.
Failure to Follow Care Plans and Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans and physician orders were consistently followed for multiple residents, resulting in several deficiencies. For two residents with orders to monitor and document the severity of edema every shift, staff did not record the required information in the medical record. Additionally, for one of these residents, fluid intake was not documented with every meal as ordered, with staff interviews confirming the lack of documentation and a misunderstanding of responsibility between nurses and CNAs. Another resident with severe cognitive impairment had a physician's order and care plan directive to wear a swath and sling on the left arm when not icing or elevating it. Observations over multiple days showed the resident was not wearing the swath and sling, and a hospice CNA reported never having seen or applied the device. Nursing staff confirmed the order was active and should have been followed. Further deficiencies included the failure to complete and document vital signs every shift for a resident with hemiplegia, hypertension, and dementia, despite a standing physician order. Additionally, a resident admitted to hospice services with a documented DNR status did not have corresponding physician orders or care plan updates reflecting code status or hospice admission. The DON confirmed these omissions in both the physician orders and care plan documentation.
Failure to Monitor and Audit QAPI Projects
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not adequately monitoring open QAPI projects to determine if corrections or revisions were necessary. During a review and interview with the Director of Nursing (DON), it was found that several nursing Quality Assurance (QA) projects had been initiated, but ongoing monitoring and audits were not consistently performed as required. For example, a QA project for Gradual Dose Reductions (GDRs) was opened with the intent to meet with the pharmacy consultant monthly and as needed, but no monitoring or audits were conducted. The DON confirmed that she had not been monitoring or auditing the GDRs project. Another QA project for weekly body audits was also not properly monitored. Although a schedule for daily body audits was placed at each nurses' station and staff were in-serviced, monitoring that began in early June ceased by mid-July due to the absence of the treatment nurse. Similarly, a QA project for expired medications required weekly random observations, but after initial monitoring in June, no further observations were conducted through the end of July. The DON acknowledged awareness of these deficiencies and confirmed that adequate monitoring of the QA projects had not been conducted prior to the survey. These failures had the potential to affect all 73 residents in the facility.
Failure to Accurately Reflect Advance Directives in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record accurately reflected their advance directives. Record review showed that the resident was admitted with a diagnosis including normal pressure hydrocephalus and had a documented Do Not Resuscitate (DNR) status on both the admission record and a signed Louisiana Physician Orders For Scope of Treatment (LaPOST) form. However, the facility's Care Profile Report listed the resident as 'Full Code,' which conflicted with the DNR status documented elsewhere in the record. During an interview, the Director of Nursing confirmed the inconsistency and acknowledged that the Care Profile Report should have been updated to reflect the correct DNR status but was not.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's discharge status. Record review showed that the resident was admitted and later discharged from the facility, with the MDS coded as a discharge to a short-term general hospital. However, review of emergency transfer logs did not show the resident being sent to a hospital, and progress notes indicated the resident left the facility against medical advice (AMA) to go home. Interviews with the Social Services Director, Administrator, and Director of Nursing confirmed that the resident left AMA to her own home and was not transferred to a hospital, and that the MDS was incorrectly coded.
Expired Medications Not Discarded in Medication Rooms
Penalty
Summary
Surveyors found that the facility failed to store drugs and biologicals in accordance with accepted professional principles by not discarding expired medications in two medication rooms. During observations with the Assistant Director of Nursing, expired medications including Sodium Chloride Tablets, Acetaminophen suppositories, and Bisacodyl suppositories were found in Med Room A, while expired Ferrous Sulfate Elixir and Vitamin D-3 were found in Med Room B/C. The Assistant Director of Nursing confirmed that these medications were expired and should have been discarded, but they remained in the medication rooms in violation of the facility's own policy requiring the destruction of discontinued, outdated, or deteriorated drugs or biologicals.
Improper Disposal of Garbage and Refuse in Dietary Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in the dietary garbage disposal area, as observed during a survey. On one occasion, used gloves and other trash items were found on the ground immediately outside the building and along the walkway leading to the garbage dumpster. Two gloves were seen near a large yellow bucket, and three more used gloves were observed in front of the open dumpster. Additionally, a white garbage bag containing refuse was found outside and to the left of the dumpster. The facility's policy requires that waste be properly contained and dumpsters kept closed, with the surrounding area maintained in a sanitary condition. The Dietary Manager confirmed that the dumpster should be kept closed and the area clean at all times. The Administrator stated that the kitchen staff was responsible for maintaining the cleanliness of the area and that the dumpster was not supposed to be left in that condition.
Failure to Maintain Sanitary Kitchen Conditions and Proper Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and did not store food in accordance with professional standards. Observations included unclean flooring, rodent droppings in a kitchen storage area, and opened and unlabeled food items in a refrigerator designated for resident supplements. Specifically, a storage area contained a non-functioning steam table with an open section on the floor, where rodent droppings and traps were found. The refrigerator in this area held three bags of lettuce, two of which were unlabeled and unopened, and one that was opened and undated. The dietary manager confirmed these items were not properly labeled or dated. Further inspection revealed a deep fryer with a thick layer of debris and food residue on both sides, as well as a dark, thick layer of residue on the flooring underneath. The state department Sanitarian's notices from both routine and complaint visits documented violations, including the presence of rodents, unclean floors, and non-food contact surfaces not being cleaned frequently enough. Kitchen staff confirmed that the Sanitarian instructed them to clean the area due to rodent droppings, and the dietary manager acknowledged that the fryer and surrounding floor had not been cleaned as required.
Unsecured Electrical Outlet in Kitchen
Penalty
Summary
Facility staff failed to ensure that an electrical outlet in the kitchen was properly sealed and secured into the wall. During an observation, the outlet box was found protruding from the wall with a visible square hole where it should have been affixed. This condition was confirmed by the Assistant Administrator during an interview, who acknowledged that the outlet was not properly installed. The facility's policy requires a clean, sanitary, and orderly environment, but this standard was not met in this instance. This deficiency had the potential to affect all 79 residents residing in the facility, as the unsafe condition was located in a common area used for food preparation.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition for one of the residents sampled. The facility's policy requires prompt notification of the resident, their attending physician, and representative of changes in the resident's medical or mental condition. However, this policy was not followed for a resident who experienced frequent diarrhea during their stay. The resident, who had diagnoses including Dementia, HIV, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein-Calorie Malnutrition, was admitted to the facility and later discharged without the physician being informed of the diarrhea episodes. Interviews conducted with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care reported the diarrhea episodes to the nurse on duty. Despite this, the Licensed Practical Nurse (LPN) who was aware of the situation did not notify the physician. The Nurse Practitioner confirmed that they had not been informed of the resident's condition. A Corporate Registered Nurse, acting as the Director of Nursing, verified that there was documentation of the diarrhea episodes in the resident's medical record but no evidence of physician notification, which was required by the facility's policy.
Inaccurate Bowel Charting Documentation
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of the three sampled residents. Specifically, the deficiency was identified in the documentation of bowel charting for a resident who was admitted with diagnoses including Dementia, HIV, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein-Calorie Malnutrition. The resident's bowel and bladder charting for October 2024 showed inaccuracies in the documentation of size and consistency, where entries were incorrectly marked with the letter 'Y' instead of the designated letters 'S', 'M', or 'L' for size, and 'S', 'H', or 'W' for consistency. Interviews and record reviews with the Assistant Director of Nursing (S5ADON) and the Administrator (S6ADM) confirmed that the Certified Nursing Assistants (CNAs) did not document the bowel charting accurately. The key provided for documentation was not used correctly, leading to incorrect entries. This failure in documentation had the potential to affect the entire census of 71 residents, as it compromised the communication between the interdisciplinary team regarding the resident's condition and response to care.
Inaccurate Documentation of Edema and Behaviors
Penalty
Summary
The facility failed to maintain accurate medical records for two of the three sampled residents, leading to deficiencies in documentation. Resident #2, who had multiple diagnoses including Diabetes Mellitus Type II, Schizoaffective Disorder, and Congestive Heart Failure, had orders to monitor edema and mood/behaviors every shift. However, discrepancies were found in the documentation of her edema and behaviors. On specific dates in August and September 2024, the MAR indicated no edema was present, contradicting other medical notes that documented the presence of edema. Additionally, despite exhibiting behaviors such as yelling and attempting to throw objects, the MAR inaccurately recorded no behaviors observed on a particular day. Similarly, Resident #3, with diagnoses including Chronic Diastolic Heart Failure and Chronic Kidney Disease, was to have edema monitored before administering a daily diuretic. The MAR documented the presence of edema on several dates in September 2024, yet the daily skilled nursing assessments for those same dates indicated no edema. This inconsistency was confirmed by S3LPN, who acknowledged the inaccuracies in the documentation. Observations on September 24, 2024, confirmed the presence of edema, further highlighting the documentation errors.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents in a shared room. Observations revealed that the walls in the room were stained with tan, light brown, dark brown, and rust-colored marks in a drip-like pattern. These stains were located on the lower portion of the wall to the left of the bathroom door, the wall to the left of one resident's bed, and the front wall of the room. The Housekeeping Supervisor acknowledged that the walls should have been cleaned and confirmed that it was a housekeeping responsibility to maintain cleanliness in the residents' rooms.
Failure to Respond Promptly to Resident's Call Light
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary competencies and skills to ensure resident safety and maintain the highest practicable well-being of each resident. This deficiency was observed when a resident activated her call light at 8:42 a.m., but did not receive assistance until much later. The resident, who required assistance for transfers, walking, grooming, and hygiene, was left waiting despite the call light being activated and visible on both the hallway sign and the electronic board in the nurse's station. The LPN on duty, upon noticing the activated call light at 8:50 a.m., made an overhead announcement for assistance but did not personally attend to the resident. Instead, she waited for a CNA to respond, making a second announcement at 9:00 a.m. The Director of Nursing later stated that the facility's protocol does not include waiting for another staff member to respond after an overhead announcement. This incident highlights a failure in the facility's staffing and response protocol, as the resident's call for assistance was not promptly addressed, leaving her unattended for an extended period.
Deficiency in Wound Care Management Due to Inadequate Nursing Competencies
Penalty
Summary
The facility failed to ensure that the nursing staff demonstrated the necessary competencies and skills to provide safe and effective care for a resident, leading to a deficiency in wound care management. The deficiency involved a failure to complete weekly skin assessments, accurately document the staging of a resident's wound, update the clinical record with the correct wound status, obtain physician orders to continue or discontinue wound care, and notify the physician or Nurse Practitioner of a deteriorating wound. These failures were identified during a review of the facility's policies and the resident's electronic health record (EHR). The resident in question was admitted with multiple diagnoses, including hemiplegia, dysphagia, aphasia, and lack of coordination, and was considered high risk for skin injury. Despite this, the initial wound assessment was not completed when the wound was first identified, and subsequent weekly assessments were not conducted until several months later. The nursing staff inaccurately documented the wound's status and failed to notify the medical team of changes in the wound's condition, including its deterioration to a Stage 3 pressure injury. Interviews with the nursing staff revealed a lack of understanding of what constituted a high-risk resident and inconsistencies in the documentation and notification processes. The Director of Nursing and the responsible nurse confirmed the discrepancies in the wound assessments and acknowledged the failure to notify the medical team promptly. This lack of proper wound care management and communication contributed to the deficiency identified by the surveyors.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections during wound care for a resident. The incident involved a treatment nurse who did not adhere to the facility's hand hygiene policy while providing wound care to a resident with a deep tissue injury on the left ischium. The nurse was observed changing gloves multiple times without performing hand hygiene in between, which is a violation of the facility's hand hygiene policy that requires hand sanitization after removing gloves and before handling clean or soiled dressings. The resident involved had a medical history that included hemiplegia, dysphagia, aphasia, and lack of coordination, and was receiving daily wound care treatment as per physician's orders. During the wound care procedure, the nurse failed to sanitize her hands after removing gloves and before applying a clean dressing, which was confirmed by both the nurse and the Director of Nursing/Infection Preventionist during interviews. This oversight in infection control practices was identified as a deficiency by the surveyors.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to multiple deficiencies. Resident #38, diagnosed with Major Depressive Disorder with Severe Psychotic Symptoms, did not have this condition addressed in their care plan, despite being on antidepressant medication. This oversight was confirmed by the Minimum Data Set Coordinators during a review of the resident's electronic clinical record. Resident #58, who had a suprapubic catheter due to neuromuscular dysfunction of the bladder, was supposed to have the catheter tubing cleaned every shift. However, observations revealed dried, brown sediment on the tubing, indicating that the cleaning was not performed as ordered. This was confirmed by an LPN who acknowledged the unclean state of the catheter tubing. Resident #70, with Type 2 Diabetes Mellitus, was supposed to have a glucose sensor for monitoring blood sugar levels. However, the resident reported not having the sensor since admission, and blood sugars were being checked via finger sticks, which was not documented in the care plan. Additionally, Resident #50's communication difficulties due to severe dysarthria were not addressed in the care plan, and Resident #62, who required assistance with eating, did not have this need documented in their care plan, despite observations and family reports confirming the necessity for assistance.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to uphold a resident's dignity by not providing a covering for a urinary catheter bag. This deficiency was identified during an observation on 07/08/2024, when Resident #70 was seen sitting in a wheelchair in the dining room with an uncovered catheter drainage bag containing approximately 300 cc's of yellow urine, visible to other residents. The facility's policy on dignity, last updated on 06/26/2023, explicitly prohibits demeaning practices and requires staff to assist residents in keeping urinary catheter bags covered. Resident #70 was admitted with diagnoses including acute kidney failure, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive and reflex uropathy. The resident's care plan indicated a need for assistance with activities of daily living due to a left femur fracture and muscle weakness, and noted the presence of a suprapubic catheter related to his medical conditions. The Director of Nursing confirmed the lack of a covering for the catheter bag during the observation.
Failure to Maintain Wheelchair Cleanliness
Penalty
Summary
The facility failed to maintain the cleanliness of wheelchairs for two residents, leading to a deficiency in providing a safe, clean, comfortable, and homelike environment. Resident #30, who has intact cognition and uses a wheelchair, was observed on multiple occasions with a wheelchair that had a layer of dust on the metal parts. Despite being scheduled for cleaning twice a week, there was no documentation of when Resident #30's wheelchair was last cleaned. The resident confirmed that her wheelchair had never been cleaned, and this was corroborated by a CNA who acknowledged the wheelchair's dirty condition. Similarly, Resident #35, who also uses a wheelchair and has a BIMS score indicating some cognitive impairment, was found with a thick layer of dust on his wheelchair. The facility's cleaning schedule indicated that his wheelchair should be cleaned twice a week, but again, there was no documentation of the last cleaning. Resident #35 also stated that his wheelchair had never been cleaned, and the CNA confirmed the observation. These findings highlight the facility's failure to adhere to its own wheelchair cleaning policy, resulting in unclean conditions for the residents.
Failure to Address Pain in Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan addressing pain management for a resident within 48 hours of admission. The resident, who was admitted with diagnoses including hyperlipidemia, diabetes, hypertension, and a fracture of the upper end of the right humerus, had a physician's order for Oxycodone 10 mg to be taken orally every 4 hours as needed for pain. However, a review of the resident's baseline care plan, dated June 26, 2024, showed no evidence that pain was addressed. During an interview on July 10, 2024, the Minimum Data Set Coordinator confirmed that there was no documentation of a pain assessment being initiated for the resident, and pain was not included in the baseline care plan.
Improper Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. Resident #36, who has diagnoses including End Stage Renal Failure and Obstructive Sleep Apnea, had an unlabeled oxygen tubing and humidifier bottle, which were not stored properly. The tubing was observed open to air and wrapped around the oxygen concentrator. A Licensed Practical Nurse confirmed these items should have been labeled and stored in a bag. Resident #66, with diagnoses including Heart Failure and Chronic Kidney Disease, was found to have an unlabeled oxygen tubing and humidifier bottle, with the tubing hanging exposed from the oxygen concentrator. Additionally, there was no physician order for oxygen use for this resident, despite observations of oxygen being administered. Three oxygen tanks were also improperly stored in the resident's room. Both the LPN and the Director of Nursing confirmed the absence of a physician order for oxygen, which should have been obtained.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was experiencing significant pain due to a fracture in the upper end of the right humerus. The resident, who had been admitted with diagnoses including hyperlipidemia, diabetes, hypertension, and a fractured right humerus, reported severe pain and had been requesting pain medication for two days without receiving any. The resident's electronic clinical record showed a physician's order for Oxycodone 10 mg to be administered every four hours as needed for pain. However, the Medication Administration Record indicated that the last dose was given five days prior, and there was no documentation of pain medication being administered on the days the resident reported high pain levels. Interviews with facility staff revealed a breakdown in communication and procedure. An LPN acknowledged the resident's complaints of pain and confirmed that the facility had run out of Oxycodone, requiring a new prescription from the physician. Despite informing the Assistant Director of Nursing (ADON) about the need for a new prescription, the LPN did not receive a response, and the physician was not notified. The ADON confirmed that she was responsible for contacting the physician for new prescriptions but was not informed of the situation, resulting in the resident not receiving pain management for several days.
Delayed Response to Call Lights Due to Staffing Issues
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, as evidenced by delayed responses to call lights for two residents. Resident #58, who was admitted with multiple diagnoses including quadriplegia and had an intact cognitive status, experienced a delay in response to his call light. The surveyor observed dried sediment on the resident's catheter tubing and pressed the call button, which was not answered for ten minutes. The surveyor found an LPN at the nursing station who admitted to not responding to the call light promptly. Resident #61, with severe cognitive impairment, also experienced significant delays in call light response. The resident's responsible party reported that it often took 30 to 45 minutes for staff to respond, particularly on weekends. During the survey, the call light was activated, and despite digital alerts and overhead announcements, staff did not respond promptly. A CNA admitted to not checking the alerts and another CNA failed to inform her colleague about covering her residents during her break. The Regional Corporate Nurse confirmed the facility had staffing issues.
Failure to Administer PRN Medications for Itching
Penalty
Summary
The facility failed to ensure that nursing staff provided appropriate care to meet the needs of a resident, specifically in administering PRN medications for itching. Resident #36, who was admitted with conditions including End Stage Renal Failure, Unspecified Diastolic Heart Failure, and Obstructive Sleep Apnea, had a physician's order for Hydrocortisone cream and Benadryl to be used as needed for itching. Despite these orders, a review of the Medication Administration Record for June and July 2024 showed that the resident did not receive any of the prescribed medications for itching. Observations and interviews revealed that the resident had a red rash on his thighs, lower legs, and abdomen, which he had been scratching until it bled. The resident reported the itching to a nurse on 07/07/2024, but no medication was administered. An LPN confirmed the presence of the rash and acknowledged that she had not administered the PRN medications, despite being aware of the resident's condition and having left a message for hospice regarding the issue.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to ensure that expired medications were not stored in medication room A. During an inspection conducted on July 10, 2024, at 3:40 pm, a bottle of Vitamin B Complex with Vitamin C and a bottle of Ferrous Gluconate 240 mg were found on the shelf with expiration dates of May 2024. An LPN was present during the observation and confirmed that both bottles of medication were expired.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to honor and accommodate the food preferences of a resident, which was identified during an observation and interview process. The resident, who had an intact cognitive status as indicated by a BIMS score of 15, had specific dislikes listed on their Dietary Meal Ticket, including mashed potatoes and rice. Despite this, both items were found on the resident's meal trays during a meal service. The Dietary Manager confirmed that these items should not have been present on the resident's meal trays, indicating a failure to adhere to the resident's documented food preferences.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to maintain complete medical records for a resident, identified as #43, who was admitted with diagnoses including Anemia, Idiopathic Peripheral Autonomic Neuropathy, and Rheumatoid Arthritis. A review of the resident's electronic clinical record revealed a lack of nursing documentation between April 12, 2024, and May 14, 2024. During this period, a new order for the antibiotic Cephalexin was issued, but there was no documentation of the signs and symptoms that led to this order. Furthermore, there was no ongoing assessment documented for the resident's right lower extremity, which was later noted to have redness and swelling. Interviews conducted with the LPN and the Director of Nursing confirmed the absence of documentation regarding the resident's condition and the effectiveness of the antibiotic treatment. The LPN acknowledged that the resident's right lower leg was swollen and that the family had brought this to their attention, leading to an order to send the resident to the hospital to rule out Deep Vein Thrombosis (DVT). The Director of Nursing stated that nurses are expected to document signs, symptoms, and ongoing assessments, which was not done in this case.
Failure to Maintain Updated Hospice Care Plan
Penalty
Summary
The facility failed to ensure that the updated hospice plan of care was on file and available for a resident receiving hospice services. Specifically, the facility's policy required a designated staff member to obtain the most recent hospice plan of care for each resident. However, for one resident, the hospice care plan on file was outdated, dated 01/09/2024, and did not reflect the resident's current code status. The resident's electronic health record indicated a diagnosis of senile degeneration of the brain, and the hospice care plan in the binder stated the resident chose resuscitation if their heart or lungs stopped. A phone interview with the resident's hospice nurse revealed that the resident's code status had changed to Do Not Resuscitate (DNR) and was signed by the physician on 03/26/2024. This updated information was not reflected in the hospice care plan on file at the facility. The Director of Nursing (DON) was unaware that the updated hospice care plan with the resident's new code status was not obtained or on file, indicating a lapse in the facility's process for maintaining current hospice care plans.
Deficiency in Call System Functionality
Penalty
Summary
The facility failed to ensure that the call systems were functioning properly for three residents, leading to deficiencies in resident care. Resident #31, who has Parkinson's Disease and Atrial Fibrillation, was observed with a non-functioning call bell system. Despite pressing the call bell, no alert was displayed on the hall screen, and the CNA confirmed the malfunction. Maintenance staff admitted that they did not routinely check the call bells or their batteries, contributing to the issue. Resident #5, with Schizoaffective Disorder and severe cognitive impairment, demonstrated the use of his call light, but no staff responded within a reasonable time frame. Maintenance personnel later confirmed that the call light required new batteries. Similarly, Resident #66, with Chronic Kidney Disease and Morbid Obesity, experienced a similar issue where the call light was pressed, but no staff responded. Maintenance confirmed the call light was not functioning due to battery issues, and staff were unaware of the resident's call for assistance.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as evidenced by the condition of an exterior window in disrepair for one resident. During an observation on July 8, 2024, two large cracks, each approximately three feet in length, were noted on the left pane of the resident's exterior window. The cracks were covered with seven thick, black pieces of tape, indicating a temporary and inadequate repair. An interview and further observation on July 9, 2024, with staff member S7AIT confirmed the window's poor condition, acknowledging that it should not have been left in such a state. The facility's policy titled 'Quality of Life- Homelike Environment,' updated on March 12, 2024, emphasizes the importance of maintaining a clean, sanitary, and orderly environment to reflect a personalized, homelike setting. However, the condition of the window in the resident's room did not align with these policy standards, highlighting a deficiency in the facility's maintenance and environmental management practices.
Failure to Address Dementia Resident's Wandering Behavior
Penalty
Summary
The facility failed to ensure a dementia resident received appropriate treatment and services to maintain his highest practicable level of well-being. Specifically, the facility did not revise the comprehensive care plan to address the resident's continued wandering, staff failed to report incidents of the resident wandering into other residents' rooms, and adequate supervision was not provided despite complaints. The resident, diagnosed with unspecified dementia and other cognitive impairments, was known to wander into other residents' rooms, causing distress. Interventions such as redirecting the resident and placing a picture of a truck outside his room were implemented but not included in the care plan, and staff did not consistently report these incidents to the Director of Nursing (DON). The DON confirmed that the facility was first made aware of the resident's wandering behavior in December 2023, but no effective interventions were added to the care plan. Despite further complaints and reports of the resident entering other residents' rooms, the facility did not increase supervision or follow up with the affected residents. The staff's failure to report these incidents and the lack of appropriate care plan revisions contributed to the deficiency in providing adequate care for the resident with dementia.
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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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