Desoto Retirement & Rehab Ctr, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansfield, Louisiana.
- Location
- 635 Schley Street, Mansfield, Louisiana 71052
- CMS Provider Number
- 195556
- Inspections on file
- 17
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Desoto Retirement & Rehab Ctr, Llc during CMS and state inspections, most recent first.
A CNA verbally abused a resident with multiple medical conditions by using loud, profane, and derogatory language while assisting with mobility. The incident was captured on video by the resident's family and later confirmed through investigation. Although the resident did not report feeling abused, the CNA's conduct met the facility's definition of verbal abuse, and the facility failed to protect the resident's right to be free from such treatment.
A resident was subjected to verbal abuse by a CNA, as evidenced by a video provided by the resident's sister. Although the incident was promptly brought to the attention of facility leadership and an investigation was initiated, the required report to the state agency was not submitted within the mandated two-hour window, resulting in noncompliance with reporting requirements.
The facility failed to accurately document the use of bedrails in the MDS assessments for three residents, despite physician orders indicating their necessity for bed mobility assistance. This discrepancy was confirmed by the MDS coordinator, highlighting a deficiency in the facility's assessment process.
The facility failed to develop comprehensive care plans for two residents, omitting critical interventions for conditions such as diabetes, hypertension, and impaired mobility. This oversight was acknowledged by the MDS coordinator, indicating a lack of individualized care planning.
The facility failed to provide necessary nail care for two residents, leading to deficiencies in personal hygiene. One resident with multiple health issues had untrimmed fingernails with a brown substance, while another resident with a history of fractures and muscle weakness had long toenails. Both residents expressed dissatisfaction with their nail care, and staff confirmed the need for trimming, indicating a lapse in the facility's nail care policy.
A resident with a contracted right hand did not receive care according to physician orders, as the palm protector was not used, and the resident's fingernails were long and discolored. The resident sometimes refused the palm protector, but these refusals were not documented, and the care plan was not updated to reflect the resident's condition. An LPN was unable to locate the palm protector and acknowledged the need for care plan updates.
The facility failed to ensure proper use and maintenance of bed rails for two residents, lacking safety assessments and informed consent. One resident with multiple health issues had bilateral bed rails without a care plan or consent, while another with a fracture and muscle weakness had quarter side rails without a risk assessment or consent. The DON confirmed these deficiencies.
The facility failed to ensure proper medication administration and storage for two residents. An LPN documented administering insulin before it was given, and another LPN stored an inhaler in a resident's room without an order for self-administration. The DON confirmed these actions were against protocol.
The facility failed to provide current pharmaceutical services by having expired medications on two medication carts. Observations revealed that Vitamin D 25 mcg with a best used by date of January 2025 was available on both carts. LPNs confirmed the medications were expired, and the DON reported that carts should be checked monthly to discard expired medications.
A facility failed to follow infection control practices during incontinence care for a resident with cognitive and physical impairments. A CNA placed soiled items on the resident's overbed table and floor, and did not change gloves before touching surfaces, risking cross-contamination. Additionally, a water cooler was improperly stored in a resident's room instead of the hallway, as confirmed by the DON.
A facility failed to transmit a completed resident's assessment within the required 7-day period. The resident, admitted with conditions such as hypertensive heart disease and obesity, had an MDS assessment marked as in progress. The MDS coordinator acknowledged the assessment was completed but not transmitted as required.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple complex diagnoses, including malnutrition, anxiety, schizophrenia, dementia, and gastrostomy status. The MDS coordinator confirmed the oversight during an interview.
A resident with COPD was found to have an unclean oxygen concentrator filter, contrary to the facility's guidelines requiring weekly cleaning. Observations showed the resident using continuous oxygen with a filter containing fluffy gray particles. Interviews with an LPN and the DON confirmed the oversight.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbal abuse toward a resident who had multiple complex medical conditions, including cerebral infarction, stroke, peripheral vascular disease, diabetes, heart disease, COPD, kidney failure, and dementia with behavioral disturbances. The resident was cognitively intact, required partial to moderate assistance with mobility and transfers, and had documented impairments in range of motion. The incident took place when the CNA entered the resident's room and used loud, profane, and derogatory language, instructing the resident to get up off the floor and onto the bed in a manner that was both forceful and inappropriate. The CNA's statements included explicit language and commands, and the interaction was captured on video by the resident's family, who had installed a camera in the room. The CNA admitted to making inappropriate comments out of frustration, acknowledging that her language and behavior were not suitable while caring for the resident. The video evidence confirmed that the CNA used profane language and spoke loudly and disparagingly in the presence of the resident. Although the resident did not report feeling disrespected or abused during subsequent interviews, the CNA's conduct met the facility's definition of verbal abuse, which includes the use of oral or gestured communication that is disparaging or derogatory, regardless of the resident's perception or response. The incident was initially discovered by the resident's family, who shared the video with facility administration. The investigation revealed that the CNA had been allowed to return to work after an initial suspension, and the full extent of the incident was not immediately recognized by all facility leadership. The Director of Nursing (DON) and former administrator did not view the complete video until later, and the investigation was not thoroughly conducted at first. The deficiency was cited based on the failure to protect the resident's right to be free from verbal abuse by a staff member.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to comply with required reporting procedures for suspected abuse, specifically in the case of a resident who was subjected to verbal abuse by a CNA. According to the facility's policy, allegations of abuse must be reported to the state survey agency and other authorities within two hours of the allegation being made. In this incident, the resident's sister provided video evidence of the CNA using derogatory and profane language toward the resident. The incident was brought to the attention of the facility's former administrator and DON, who acknowledged the unprofessional conduct and initiated an investigation, including suspending the CNA. Despite being made aware of the allegation on the same day it was reported by the resident's sister, the facility did not enter the required report into the Self-Reported Incident Management System (SIMS) until several days later, well beyond the mandated two-hour timeframe. The DON confirmed that the report should have been submitted promptly on the day the allegation was made, but it was not entered until a week later. This delay constituted a failure to meet state law and facility policy requirements for timely reporting of abuse allegations.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents during the observation period. Specifically, the MDS assessments for these residents did not accurately document the use of bedrails, which were ordered by physicians to assist with bed mobility. Resident #5, who had severe mental cognition impairment and required extensive assistance for bed mobility, had physician orders for side rails, but the MDS did not indicate their use. Similarly, Resident #21, with moderate cognitive impairment and dependence on assistance for toileting and hygiene, had orders for bedrails, yet the MDS failed to reflect this. Resident #50, with moderate cognitive impairment and requiring assistance for bed mobility and transfers, also had orders for enablers to aid in bed mobility, but the MDS did not document their use. During an interview, the MDS coordinator confirmed that the MDS assessments for these residents did not include the use of bedrails as indicated in the physician orders. This discrepancy highlights a failure in accurately coding the MDS, which is crucial for ensuring that residents' needs and care requirements are properly documented and addressed. The oversight in accurately reflecting the use of bedrails in the MDS assessments for these residents represents a deficiency in the facility's assessment process.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #28's care plan did not include necessary interventions for several conditions, including oxygen therapy, type 2 diabetes mellitus, hypertension, activities of daily living self-care deficit, impaired mobility due to amputation, anticoagulant therapy, unsafe smoking habits, and diuretic use. This oversight was acknowledged by S4 MDS during an interview, indicating a lack of comprehensive planning for the resident's complex medical needs. Similarly, Resident #118's care plan was incomplete, failing to address critical issues such as nutrition, hypertension, insomnia, and anemia. The absence of these elements in the care plan was also confirmed by S4 MDS, highlighting a significant gap in the facility's approach to individualized care planning. These deficiencies suggest a systemic issue in the facility's ability to create and implement effective care plans tailored to the specific needs of its residents.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care services to two residents, leading to deficiencies in personal hygiene and grooming. Resident #43, who has a history of cerebrovascular disease, heart failure, epilepsy, chronic atrial fibrillation, and end-stage renal disease, was found to have untrimmed fingernails with a brown substance underneath. This resident, with moderately impaired cognition, required assistance with activities of daily living, including grooming. Despite the resident's expressed desire to have their nails trimmed, the facility did not ensure this care was provided, as confirmed by the Director of Nursing. Similarly, Resident #63, who has a history of a wedge compression fracture, lack of coordination, and generalized muscle weakness, was observed with long toenails that had grown over the nail bed. This resident, with intact cognition, also expressed dissatisfaction with the length of their toenails. The facility's failure to provide timely nail care was confirmed by an LPN, who acknowledged the need for the resident's toenails to be trimmed. These observations indicate a lapse in adhering to the facility's nail care policy, which outlines regular nail maintenance as part of the residents' care plans.
Failure to Follow Physician Orders for Palm Protector
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a contracted right hand, as per physician orders and professional standards of practice. The resident, who has diagnoses including end-stage renal disease, hypertensive heart disease, and major depressive disorder, was ordered to use a palm protector on the right hand to prevent complications such as skin breakdown. However, observations revealed that the palm protector was not in use, and the resident's hand was tightly closed with long, discolored fingernails that had grown over the nail bed, potentially leading to skin integrity issues. Interviews and record reviews indicated that the resident sometimes refused the palm protector, but there was no documentation of these refusals or attempts to apply the protector. The resident's care plan and MDS did not accurately reflect the resident's limitations in range of motion or refusals of care. Additionally, the LPN was unable to locate the palm protector and acknowledged the need for updated care planning based on the resident's refusals and the condition of the resident's fingernails, which could contribute to skin breakdown.
Failure to Ensure Proper Use and Consent for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for two residents, leading to deficiencies in safety assessments and informed consent. Resident #43, who has a history of cerebrovascular disease, heart failure, epilepsy, chronic atrial fibrillation, and end-stage renal disease, was observed with bilateral bed rails without a documented care plan addressing bed rail use or a signed consent for their installation. Despite having moderately impaired cognition and requiring two-person assistance for bed mobility, there was no evidence of a risk assessment for entrapment or a discussion of risks and benefits with the resident or their representative. Similarly, Resident #63, with a history of a wedge compression fracture, lack of coordination, and generalized muscle weakness, was observed with quarter side rails raised on both sides of the bed. Although this resident had intact cognition and required assistance with bed mobility, the facility failed to document a care plan specific to the use of quarter side rails and did not obtain a signed consent. Additionally, there was no assessment conducted for the risk of entrapment prior to the installation of the bed rails. The Director of Nurses confirmed these deficiencies during an interview.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for two residents, leading to deficiencies in nursing services. For Resident #24, an LPN administered Sucralfate but prematurely documented the administration of Humalog, which was not given at the time of documentation. The LPN acknowledged that the Humalog was due later and had not been administered, despite the resident's blood sugar being 310 earlier, indicating a need for the medication closer to meal time. The Director of Nursing confirmed that medications should not be documented in the electronic medication administration record until they are actually administered. For Resident #26, an LPN was observed without the resident's prescribed Fluticasone-Salmeterol Inhaler on the medication cart, finding it instead in the resident's room. The LPN confirmed that the inhaler should have been stored on the medication cart, as the resident did not have an order for self-administration. The Director of Nursing reiterated that the medication should not have been kept in the resident's room, highlighting a failure in proper medication storage and administration procedures.
Expired Medications Found on Facility's Medication Carts
Penalty
Summary
The facility failed to provide current pharmaceutical services to meet the needs of each resident by having expired medications available for use on two medication carts. During an observation of Medication Cart 1 for Hall 1, it was found that Vitamin D 25 mcg had a best used by date of January 2025, which was confirmed by an LPN to be expired and should not have been available. Similarly, an observation of the Medication Cart for Hall 2 revealed the same expired Vitamin D 25 mcg, which was also confirmed by another LPN. The Director of Nursing reported that medication carts should have been checked at the end of each month to discard expired medications, indicating a lapse in the facility's medication management process.
Infection Control Lapses in Incontinence Care and Equipment Storage
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident with moderately impaired cognition and physical limitations due to macular degeneration and hemiplegia. During an observation, a CNA was seen retrieving towels and a draw pad from a linen cart and placing them on the resident's overbed table along with personal items. The CNA used wet towels to perform perineal care and placed the used towels back on the overbed table. The CNA also placed a used incontinence brief on the floor and reused towels to clean the resident's buttocks and rectal area. After completing the care, the CNA disposed of the soiled items on the floor and touched various surfaces, including the bed remote and door knob, without changing gloves, leading to potential cross-contamination. Additionally, the facility failed to store patient equipment properly, as observed with a water cooler containing ice for resident drinking being stored in an occupied resident's room on a secured unit. A CNA confirmed the storage location and reported no alternative storage space on the unit. The Director of Nursing acknowledged that the water cooler should be stored in the hallway rather than in a resident's room, indicating a lapse in maintaining a sanitary environment for residents.
Failure to Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to transmit a completed resident's assessment within the required 7-day period for one resident out of 31 sampled. The resident, who was admitted with diagnoses including hypertensive heart disease without heart failure, obesity, anemia, and insomnia, had an MDS assessment marked as in progress. During an interview, the MDS coordinator acknowledged that the assessment was completed but had not been transmitted as required.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident. The resident was admitted with multiple diagnoses, including unspecified protein-calorie malnutrition, generalized anxiety disorder, undifferentiated schizophrenia, unspecified dementia with agitation, anorexia, other specified extrapyramidal and movement disorders, major depressive disorder, impulsive disorder, and gastrostomy status. A review of the resident's medical records revealed that a baseline care plan was not completed upon admission. During an interview, the MDS coordinator acknowledged that the baseline care plan was not developed as required.
Failure to Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD). The deficiency was identified when the oxygen concentrator filter for the resident was observed to have a moderate amount of fluffy gray particles, indicating it had not been cleaned as required. The facility's Respiratory Equipment - Infection Control Guidelines specify that housekeeping is responsible for cleaning oxygen concentrator filters weekly, which was not adhered to in this case. The resident, who was admitted with a diagnosis of COPD, had a physician's order for oxygen at 2 liters per nasal cannula as needed for shortness of breath or when oxygen saturation was below 90%. Observations on multiple occasions revealed the resident wearing continuous oxygen, with the concentrator filter remaining uncleaned. Interviews with the LPN and the Director of Nursing confirmed the oversight, acknowledging that the filter was dirty and should have been cleaned according to the facility's guidelines.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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