Heritage Manor Of Ville Platte
Inspection history, citations, penalties and survey trends for this long-term care facility in Ville Platte, Louisiana.
- Location
- 2020 W. Main Street, Ville Platte, Louisiana 70586
- CMS Provider Number
- 195507
- Inspections on file
- 25
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Heritage Manor Of Ville Platte during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to alleged verbal abuse by a CNA, which was reported by another CNA to nursing staff. Although the incident was eventually brought to the attention of administration, the required abuse report was not submitted to the State Survey Agency within the mandated two-hour window. Staff interviews confirmed that facility policy required immediate reporting, but the administrator delayed the report due to other facility demands.
A resident with severe cognitive impairment and dysphagia experienced a choking incident that led to changes in diet orders, but the MDS assessments did not accurately reflect the resident's need for a mechanically altered diet or document episodes of coughing or choking during meals, despite these events being recorded in the medical record and incident reports.
A resident with a history of CVA and dysphagia was admitted, but the baseline care plan was not developed within the required 48-hour timeframe as per facility policy. The DON confirmed the delay in creating the care plan.
A resident with Huntington's Disease and a history of repeated falls did not have their comprehensive care plan updated after a quarterly MDS assessment. The care plan continued to list an active nasal fracture diagnosis instead of reflecting the resident's current status, as confirmed by MDS staff interviews.
A resident with Huntington's Disease and cognitive deficits experienced repeated episodes of coughing and difficulty swallowing during meals, which were observed by staff and other residents. Despite these symptoms and documentation by nursing staff, a timely swallowing assessment by ST was not completed, and the resident continued on a regular diet until the diet was later downgraded without a formal evaluation.
The facility failed to follow recipes for pureed meals for residents requiring a pureed diet. Dietary staff did not measure ingredients for pureed rotisserie chicken and broccoli cauliflower blend, using unmeasured amounts of water and thickener instead. Interviews confirmed that the recipes were not followed as required, potentially affecting the nutritional adequacy of the meals.
The facility failed to maintain proper infection control during wound care for a resident and did not adhere to isolation protocols for another resident with MRSA. Staff did not consistently use appropriate PPE, and a resident on isolation was improperly housed with a roommate, contrary to physician orders and facility policy.
The facility failed to properly administer medications to two residents, leading to deficiencies in care. A resident with a UTI did not receive a prescribed dose of Zyvox, while another resident's Voltaren Gel lacked a specified dosage on the EMAR, leading to improper application. These incidents were confirmed by facility staff.
A resident with unclear speech and cognitive intactness was found without necessary communication aids in their room, hindering their ability to communicate needs effectively. Staff confirmed the absence of aids and acknowledged the resident's communication difficulties.
A facility failed to provide necessary ADL assistance to residents, resulting in untrimmed facial hair and long, dirty fingernails. A resident with severe cognitive impairment was found with facial hair that should have been removed during scheduled bath days. Another resident expressed a desire for nail care, but staff oversight led to long, dirty fingernails. A third resident, requiring substantial assistance, also had excessively long nails due to a lapse in care responsibilities.
The facility did not accurately submit staffing information to CMS for FY Quarter 3 2024, triggering excessively low weekend staffing. A review showed more nursing hours were provided than required, but an employee failed to enter agency staff data. The administrator now handles this task.
A resident with multiple disabilities was sexually abused by another resident in an LTC facility. The incident was witnessed by a housekeeper and an LPN, who intervened and reported the abuse. The abused resident was unable to consent due to cognitive impairments, while the perpetrator was cognitively intact. The facility's policy on abuse was reviewed, confirming the incident as sexual abuse.
The facility failed to follow care plans for two residents, one requiring two-person assistance for transfers and another needing proper footwear to prevent falls. Both residents were not provided the specified care, leading to unsafe conditions.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported to the State Survey Agency within the required two-hour timeframe after the allegation was made known to facility administration. According to facility policy, any suspicion or allegation of abuse must be reported immediately to the administrator, who is then responsible for notifying the appropriate authorities within two hours if the incident involves abuse. In this case, a CNA reported to nursing staff that another CNA had used foul and derogatory language toward a resident with severe cognitive impairment. The incident was initially reported to the assigned nurses at the time it occurred, but the required incident report and subsequent notification to administration were delayed. The resident involved had significant cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, schizophrenia, and major depressive disorder, rendering her unable to participate in interviews. The alleged verbal abuse occurred during a shift change, and although staff members reported the incident to the appropriate nurses, the process for completing the incident report and escalating the matter to administration was not followed promptly. The administrator and DON were not informed until two days after the incident, at which point the accused CNA was suspended pending investigation. Despite being made aware of the allegation, the administrator did not enter the required report into the SIMS system within the mandated two-hour window. The initial attempt to submit the report was delayed, and technical issues further postponed the entry, resulting in the report being filed several days after the facility became aware of the incident. Interviews with staff confirmed that the facility's policy required immediate reporting, and the administrator acknowledged that the report was not submitted within the required timeframe due to competing priorities at the facility.
Inaccurate MDS Assessment Documentation Following Choking Incident
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. A resident with a history of cerebrovascular accident and dysphagia was admitted and subsequently experienced a choking incident during a meal, which required the Heimlich maneuver and resulted in a downgrade of the resident's diet to mechanical soft, and later to pureed with nectar consistency due to aspiration pneumonia. Despite these significant changes in the resident's condition and dietary orders, the MDS assessments did not accurately document the resident's need for a mechanically altered diet or the occurrence of coughing or choking during meals. Specifically, the Discharge Return Anticipated MDS did not indicate the resident was on a mechanically altered diet, and the Medicare 5-Day End of Part A Stay MDS failed to note the resident's coughing or choking episodes, even though these events were documented in the medical record and incident reports. These omissions were confirmed by the staff member responsible for MDS completion, who acknowledged that the assessments should have reflected the resident's actual status at the time.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan should be created within 48 hours of a resident's admission. Record review showed that a resident with a history of cerebrovascular accident and dysphagia was admitted on 03/07/2025, but the baseline care plan was not completed until 03/10/2025, exceeding the required timeframe. This was confirmed by the Director of Nursing, who acknowledged that the care plan was not developed within the policy's specified period.
Failure to Revise Care Plan After Quarterly Assessment
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan following a quarterly assessment, as required by policy and regulation. Specifically, after a quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/25/2025, the care plan for a resident with Huntington's Disease, altered mental status, cognitive communication deficit, and a history of repeated falls was not updated to reflect a history of a nasal fracture. The care plan continued to list an active diagnosis of an acute non-displaced fracture at the tip of the nasal bones, which had been initiated and last revised prior to the quarterly assessment. Interviews with MDS staff confirmed that the care plan should have been revised after the quarterly MDS to accurately reflect the resident's current status, but this was not done.
Failure to Complete Swallowing Assessment for Resident with Dysphagia Symptoms
Penalty
Summary
The facility failed to provide services that met professional standards of quality by not ensuring a swallowing assessment was completed for a resident who exhibited difficulty swallowing and coughing during meals. The resident, who had diagnoses including Huntington's Disease, altered mental status, and cognitive communication deficit, was observed coughing during meals on multiple occasions. Despite nursing staff and other residents noticing the resident's difficulty swallowing, and documentation in the medical record indicating coughing and swallowing issues, there was no evidence that a swallowing evaluation was performed in a timely manner. The facility's policy required therapy screenings within 48 hours when a change in function was noted, but this was not followed. Speech therapy (ST) notes did not document any swallowing evaluation or address the resident's coughing or choking episodes, even after nursing staff reported the issues. The speech therapist did not assess the resident's swallowing because the resident had already received the scheduled therapy visits for the week, despite the therapy director confirming that additional visits could be provided if needed. The resident's diet was eventually downgraded to mechanical soft after further observation of swallowing difficulties, but a formal swallowing evaluation was still not completed at that time.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that menus were followed to meet the nutritional needs of residents requiring a pureed diet. Specifically, the facility did not adhere to the recipe for pureed meals for six residents on a pureed diet. The facility's policy required that food items be measured and prepared according to specified recipes. However, during an observation, it was noted that the dietary staff did not measure the ingredients for pureed rotisserie chicken and pureed broccoli cauliflower blend as per the recipe. Instead, the staff added unmeasured amounts of water and food thickener, deviating from the prescribed preparation method. Interviews with the Dietary Manager and the Director of Nursing confirmed that the dietary staff did not follow the recipes as required. The Dietary Manager acknowledged that water was used in preparing pureed foods, but confirmed that the staff member should have followed the recipe. The Director of Nursing also confirmed that the dietary staff should have adhered to the recipe for preparing the pureed meals. This failure to follow the recipe could potentially impact the nutritional adequacy of the meals provided to residents on a pureed diet.
Infection Control Deficiencies in Wound Care and Isolation Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies during wound care for Resident #5 and improper isolation for Resident #7. For Resident #5, the treatment nurse and assisting staff did not adhere to proper infection control practices during wound care. Observations revealed that the treatment nurse initially entered the room without a gown and later handled wound care supplies and equipment without maintaining sterility. The nurse used hand sanitizer after removing gloves but did not ensure that the new gloves remained uncontaminated. Additionally, scissors used during the procedure were not kept sterile, as they were placed on uncovered surfaces and handled without proper sanitation. Resident #7 was not properly isolated as per the physician's orders and facility policy. Despite being on contact and droplet precautions due to MRSA, Resident #7 was observed to have a roommate, which contradicted the isolation requirements. The facility's policy indicated that a resident on such precautions should not have a roommate if they are capable of self-care. However, the Director of Nursing allowed the resident to have a roommate, and staff did not consistently use N95 masks as required. The roommate was allowed to move freely in and out of the room without following isolation protocols, potentially compromising infection control measures. Interviews with staff, including the treatment nurse, registered nurse, CNA, LPN, and DON, confirmed the lapses in infection control practices. The staff acknowledged the inappropriate methods used during wound care and the failure to adhere to isolation orders for Resident #7. The facility's failure to follow established infection control procedures and physician orders contributed to the deficiencies observed during the survey.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications properly for two residents, leading to deficiencies in meeting professional standards of quality. Resident #7, who had diagnoses including pneumonia, MRSA, and a UTI, was prescribed Zyvox Oral Tablet 600 mg to be taken twice daily for a UTI. However, the resident did not receive the evening dose on October 21, 2024, as confirmed by the Assistant Director of Nursing/ Infection Preventionist (S3ADON/IP) during an interview. This oversight indicates a lapse in following the prescribed medication regimen. Resident #19, admitted with conditions such as osteoarthritis and pain, was prescribed Voltaren Arthritis Pain External Gel 1% to be applied topically twice daily. The electronic medication administration record (EMAR) lacked a specific dosage for the Voltaren Gel, and the Licensed Practical Nurse (S16 LPN) confirmed that she did not measure the gel when applying it, as there was no dosage specified on the medical orders or EMAR. This was corroborated by a Corporate Registered Nurse (S7 Corporate RN), who confirmed that a dosage should have been specified. These incidents highlight the facility's failure to adhere to medication administration protocols, resulting in deficiencies in care for the residents involved.
Failure to Provide Communication Aids for Resident
Penalty
Summary
The facility failed to provide necessary communication aids for a resident with a communication deficit, as observed during a survey. The resident, who was admitted with diagnoses including dysphagia and hypertensive heart disease with heart failure, was found to have unclear speech and was dependent on staff for various activities of daily living. Despite being cognitively intact, the resident had difficulty communicating needs due to unclear speech, and there was no communication aid or board available in the resident's room to assist with communication. Interviews and observations confirmed that the resident struggled to communicate needs effectively, and staff, including an LPN, acknowledged the difficulty in understanding the resident's needs. The LPN confirmed the absence of any communication aids in the resident's room and noted that the resident would benefit from a communication board, as the resident was unable to write down wants or needs. This lack of communication support was a deficiency in the care provided to the resident.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADLs) to residents who were unable to perform these tasks independently. Resident #16, who had severe cognitive impairment and was dependent on staff for personal hygiene, was observed with noticeable facial hair that should have been removed during scheduled bath days. Interviews with staff confirmed that the facial hair was not removed due to oversight, despite no reports of the resident refusing care. Resident #24, also with severe cognitive impairment and dependent on staff for personal hygiene, was observed with long fingernails and a thick brown substance under the nailbed. The resident expressed a desire for his nails to be cleaned and cut, but this was not done. Staff interviews confirmed the oversight, and it was noted that the resident's nails should have been maintained during ADL care. Resident #80, who required substantial assistance for personal hygiene, was found with excessively long and thick fingernails. The resident expressed a desire for nail trimming, but this was not performed. Staff interviews revealed that the responsibility for nail care was assigned to a treatment nurse, who acknowledged the oversight and confirmed that the nails had not been trimmed as required.
Failure to Accurately Submit Staffing Information to CMS
Penalty
Summary
The facility failed to accurately submit mandatory direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year Quarter 3 2024, covering the period from April 1 to June 30. A review of the Payroll Based Journal (PBJ) Staffing Report for this period revealed that the facility triggered for excessively low weekend staffing. However, a review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated October 30, 2024, indicated that the facility provided more hours than required for nursing coverage during the triggered dates. An interview with the facility's administrator on October 30, 2024, revealed that an employee failed to enter staffing information for agency staff working in the facility. This task is now performed by the administrator, as the responsible staff member no longer works at the facility.
Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The facility failed to protect a resident from sexual abuse and psychosocial harm by another resident. The incident occurred when a housekeeper observed a resident removing his hand from beneath another resident's covers near her bottom. The housekeeper immediately informed an LPN, who then witnessed the resident pulling back the covers and sliding his hand into the other resident's brief. The LPN intervened and removed the resident from the room. The resident who was abused had multiple diagnoses, including cerebral palsy, dysphagia, aphasia, quadriplegia, and unspecified intellectual disabilities. She was dependent on staff for all activities of daily living and unable to communicate her needs or wants. The incident was witnessed by staff, and it was determined that the resident could not consent to the inappropriate touch due to her cognitive impairments. The resident who committed the abuse had a history of cerebral infarction and other physical impairments but was cognitively intact with a BIMS score of 13. The facility's policy on abuse was reviewed, and it was found that the incident constituted sexual abuse as it involved nonconsensual sexual contact. The facility had substantiated the occurrence of sexual abuse, and the incident was reported to the appropriate authorities.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For one resident, who required substantial/maximal assistance for transfers, the facility did not ensure that the resident was transferred by two-person assistance as specified in the care plan. The resident, who had severe cognitive impairment and multiple physical ailments including Parkinson's Disease and a recent fracture, was transferred by a single CNA without assistance, leading to an injury. The CNA admitted to not following the posted transfer instructions and instead relied on the resident's verbal indication that he could stand up, which was against the facility's policy. For another resident, who was at high risk of falls, the facility failed to ensure that the resident wore proper footwear as specified in the care plan. The resident, who had severe cognitive impairment and a history of falls, was observed wearing socks without grips instead of proper footwear. This was confirmed by an LPN during an interview. Both deficiencies highlight a failure to adhere to the care plans designed to ensure the safety and well-being of the residents. The facility's policies and procedures for transfers and fall prevention were not followed, leading to unsafe conditions for the residents involved.
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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