Jena Nursing And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jena, Louisiana.
- Location
- 5877 Aimwell Road, Jena, Louisiana 71342
- CMS Provider Number
- 195399
- Inspections on file
- 41
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Jena Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with intact cognition, multiple chronic conditions, and an indwelling urinary catheter had an NP and physician order for Clindamycin 1% topical medication to be applied twice daily to a penile erosion site. Review of the TAR showed repeated missing documentation of the evening dose on numerous days within the ordered treatment period, with no recorded reasons for omission. The DON acknowledged the lack of documentation, and an LPN admitted administering the topical medication without documenting it on the TAR, contrary to facility policy requiring documentation of each administered or omitted dose.
A resident with multiple medical conditions, including acute respiratory failure, UTI, and a stage 3 pressure ulcer, experienced a new onset of elevated heart rate ranging from 130–137 bpm that persisted throughout a shift. An LPN recognized this as a change in condition and discussed possible hospital transfer with the resident and spouse, who declined, but did not notify the NP despite facility policy requiring provider notification for significant changes in vital signs. The NP later reported receiving no notification of this change, and the DON confirmed that increased heart rate constitutes a change in condition that should have been reported.
Surveyors found that the facility failed to obtain and document an updated CNA registry verification before re-hiring a CNA who had previously been terminated. Review of the CNA’s personnel file showed an original registry check from the initial hire but no verification completed at the time of re-hire, and the administrator confirmed that no such documentation existed.
The facility failed to post complete daily nurse staffing information as required. Surveyors observed that Daily Nursing Staff Posting forms for consecutive days were displayed without documenting the resident census at the start of the shift, the daily nursing hours required, or the actual nursing hours worked. An RN responsible for staff development confirmed that these required data elements were not posted for those days and acknowledged that she had routinely posted the forms without the missing information.
Two residents with physician orders and care plans for Enhanced Barrier Precautions (EBP) during wound care did not receive care in accordance with the facility’s infection control policy. During separate wound care procedures, a treatment RN failed to wear a gown and did not change gloves between cleaning the wounds and applying ointments, powder, or clean dressings. The corporate RN confirmed that EBP requires staff to wear a gown and gloves for wound care and to change gloves after cleaning and before applying clean dressings or ointments.
A resident with a history of anoxic brain damage, cardiac arrest, and venous thrombosis was started on Apixaban for deep vein thrombosis, which was identified as a significant change in condition. The facility did not complete the required Significant Change MDS Assessment within 14 days of this change, as confirmed by MDS staff.
Two residents with complex medical histories had MDS assessments that did not accurately reflect their clinical status, including falls and antipsychotic medication use, despite documentation in their records and care plans. Staff confirmed the inaccuracies in the assessments.
A resident with a history of deep vein thrombosis and on Apixaban therapy was not care planned for anticoagulant therapy, despite staff acknowledging this should have been addressed. The resident had intact cognition and multiple significant diagnoses, but the care plan did not reflect the need for anticoagulant management.
The facility did not ensure person-centered care plans were developed and implemented for several residents. One resident with quadriplegia did not have a functioning bed alarm as ordered, with repeated observations showing the alarm was disconnected and improperly placed. Another resident who smoked was not care planned for smoking, despite facility policy and completed evaluation. A third resident with complex medical and psychiatric conditions had only a generalized care plan, lacking comprehensive, individualized interventions. Staff responsible for care planning acknowledged these deficiencies.
The facility did not meet professional standards by failing to properly document and assess a resident's skin condition, neglecting to obtain monthly weights for another resident as required, and administering medication by the wrong route to a resident with a G-tube. These deficiencies involved incomplete assessments, lack of adherence to care plans, and failure to follow physician orders.
A resident with moderately impaired cognition and multiple psychiatric diagnoses was physically assaulted by another resident after refusing a request, resulting in facial lacerations and emergency room evaluation. Both individuals had no prior history of physical aggression, and the incident was confirmed through staff interviews and record review.
A resident with schizophrenia and intact cognition was prescribed Risperdal 1mg twice daily, but there was no evidence that a gradual dose reduction was attempted or that a clinical contraindication was documented. Despite a consultant pharmacist's recommendation for a dose reduction, the physician did not provide a documented response, and the medical record lacked required documentation regarding the use of the antipsychotic medication.
Three residents had MDS assessments that did not accurately reflect their up-to-date COVID-19 vaccination status, despite immunization records showing they had received the required doses. The Infection Preventionist confirmed the discrepancy between the MDS documentation and the actual vaccination records.
The facility did not ensure that residents dependent on staff for ADLs received necessary grooming and hygiene care. A resident with impaired mobility was observed with unkempt hair and unshaven facial hair, while two other residents missed multiple scheduled bed baths, resulting in foul odors and inconsistent hygiene. Staff interviews and documentation confirmed that required care was not consistently provided.
A resident with multiple health conditions and at risk for pressure ulcers was not turned or repositioned as required by her care plan. Staff interviews and observations confirmed the resident remained in the same position for several hours, and necessary interventions were missing from both electronic and paper records. The DON acknowledged these omissions, resulting in a failure to provide necessary services to maintain skin integrity.
A resident who required continuous tube feeding and water flushes did not receive enteral nutrition as ordered by the physician. The feeding pump was found turned off, with both the resident and LPN unaware of the duration. Another LPN reported turning off the feeding due to the resident's stomach pain and later restarting it, but there was no documentation of the interruption. The DON was informed of issues but could not determine the cause or length of the feeding lapse.
The facility did not complete required annual performance reviews or provide regular in-service education for two CNAs, as shown by missing or outdated documentation in their personnel records. Both the administrator and HR confirmed the absence of these evaluations during interviews.
Multiple infection control deficiencies were identified, including an LPN administering medications via PEG tube without wearing a gown as required by EBP policy, a nurse failing to perform hand hygiene during wound care and contaminating supplies, and improper storage of both unused and used resident care items directly on the floor and in shower areas. Additionally, a visibly soiled shower curtain was observed, with staff unaware of cleaning protocols.
Two residents experienced incidents involving suspected abuse or unexplained injuries that were not reported immediately to management as required. In one case, an LPN observed bruising on a resident with severe cognitive impairment but failed to notify management, and in another, an LPN delayed reporting an abuse allegation made by a resident with moderate cognitive impairment. Both staff members later acknowledged the delay in reporting.
A facility failed to ensure controlled medications were administered and documented correctly for multiple residents. An LPN signed out doses of medications at times when she had already clocked out, and there was no documentation in the eMAR. The LPN admitted to pre-pulling medications and administering them early, against physician's orders, leading to false documentation of administration times.
The facility failed to document the effectiveness of pain management for five residents, as required by policy. Residents received pain medication without prior or post-administration assessments, and doses were not recorded on the eMAR. The DON confirmed the lack of documentation, highlighting a systemic issue in pain management practices.
A resident with a history of behavioral issues physically abused another resident by hitting them after an altercation involving a wheelchair. The incident was captured on surveillance, confirming the sequence of events. Both residents were assessed with no injuries reported.
A resident with a history of chronic left hip dislocation did not receive timely care due to a missed orthopedic specialist appointment. The resident, who required substantial assistance and had impaired cognition, was in pain and immobile. The facility failed to ensure transport to the appointment, leading to a delay in necessary medical evaluation and treatment.
A resident with a history of mental health issues physically assaulted another resident in the dayroom, despite staff presence. The altercation began when the aggressive resident attempted to take another resident's food tray, leading to a verbal confrontation and subsequent physical fight. The incident resulted in a skin tear for the aggressor and a reported head injury for the other resident, indicating a failure in the facility's abuse prevention measures.
A resident with a PEG tube did not receive the prescribed nutritional and hydration support due to incorrect feeding and flush rates set by the facility staff. The resident's feeding was set at 40ml/hr instead of the prescribed 50ml/hr, and water flushes were administered at 30ml every 3 hours instead of 50ml/hr. Additionally, the feeding and flush bags were not labeled as required. Staff interviews confirmed these discrepancies, highlighting a failure to follow the registered dietitian's recommendations.
The facility failed to maintain a clean, comfortable, and homelike environment in Rooms a, b, and c, with issues including dust, trash, dead insects, stained and loose ceiling tiles, non-functional lights, and a dirty window pane obstructing the outside view.
The facility failed to meet professional standards of quality by not obtaining required labs for a resident with multiple diagnoses and not notifying a physician of a dietician's recommendations for another resident's tube feeding regimen.
The facility failed to ensure that residents who were unable to carry out ADLs received necessary grooming and personal hygiene services. Several residents were observed with long facial hair and untrimmed, dirty fingernails, despite their care plans indicating they required assistance. Interviews with residents and staff, as well as record reviews, confirmed these deficiencies.
The facility failed to maintain dignity for a female resident by not ensuring she was free of facial hair. The resident, who has multiple diagnoses and requires total assistance with all activities of daily living, was observed with 1/4 inch facial hair on her chin. An RN confirmed that the facial hair should have been shaved but was not.
The facility failed to act promptly on grievances reported by residents during a Resident Council meeting. Concerns about CNA performance were documented and given to the DON, but no follow-up or investigation was conducted.
A resident with multiple diagnoses, including Acute Respiratory Failure and Anoxic Brain Damage, was not provided with the correct tube feeding regimen as recommended by the dietician. Despite the plan of care specifying a different feeding rate and flush schedule, the resident continued to receive inadequate nutrition and hydration.
The facility failed to post daily nurse staffing information. An observation revealed that the posted information was outdated by several days, and the DON confirmed that it should have been updated daily but was not.
The facility failed to ensure that pureed foods were prepared according to standardized recipes, resulting in the use of unmeasured ingredients and methods that did not conserve nutritional value for three residents. Dietary staff admitted to not using recipes and the dietary manager confirmed the lack of adherence to the facility's policy on pureed food preparation.
The facility failed to ensure that all staff adhered to Enhanced Barrier Precautions for a resident with a tracheostomy and mechanical ventilation. A hospice CNA provided direct care without wearing the required PPE, despite signage and equipment indicating the need for such precautions. The CNA admitted to not understanding the signage, and the nurse confirmed that hospice staff were expected to follow the posted instructions.
Failure to Accurately Document Topical Antibiotic on TAR
Penalty
Summary
The facility failed to ensure medications were accurately documented on the Treatment Administration Record (TAR) in accordance with its medication administration policy. The policy required staff to document each medication as it was prepared on the MAR/TAR and to document a reason if a medication was not given as ordered. For one resident with intact cognition, admitted with diagnoses including depression, stage 4 sacral pressure ulcer, paraplegia, presence of urogenital implants, neuromuscular dysfunction of the bladder, and an indwelling urinary catheter, a nurse practitioner ordered Clindamycin 1% topical ointment to be applied to a penile erosion site twice daily for 14 days. The corresponding physician order specified Clindamycin Phosphate External Solution 1% topical, to be applied to the penile erosion site twice daily for infection over the same 14-day period. Review of the resident’s January–February 2026 TAR showed missing documentation for the 6:00 p.m. dose of the Clindamycin topical medication on multiple dates within the treatment period, with no entries indicating administration or reasons for omission. During interview, the DON confirmed there was no documentation on the identified dates and acknowledged that nurses should have documented on the TAR after administering the topical medication. In a separate interview, an LPN stated she remembered the Clindamycin 1% topical order and confirmed she did not document on the TAR after administering the ointment, despite being required to do so.
Failure to Notify NP of Resident’s Elevated Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring notification of the attending physician extender and resident representative when there is a significant change in a resident’s condition, including unstable vital signs such as pulse. The facility’s policy titled "Notification of a Change in a Resident's Status" specifies that the physician/NP and responsible party must be notified for significant changes in or unstable vital signs. Resident #5, admitted with diagnoses including acute respiratory failure, depression, urinary tract infection, a stage 3 pressure ulcer of the left buttock, and infection of the skin and subcutaneous tissue, had a Quarterly MDS indicating moderately intact cognition with a BIMs score of 8. During a morning medication pass, the LPN observed that Resident #5’s heart rate was elevated between 130–137 beats per minute and identified this as a new change in condition. The LPN reported that the elevated heart rate persisted throughout her shift. She asked the resident and the resident’s husband if they wanted to go to the hospital, and both declined. Despite recognizing that facility practice and policy require notifying the physician or NP of a change in condition even when a resident refuses transfer, the LPN did not notify the NP of the elevated heart rate. The NP later stated he expects to be notified of any change from baseline and confirmed he had not been informed of this event. The DON also confirmed that an increased heart rate is a change in condition and that the NP should have been notified, establishing that the required notification did not occur for this resident’s elevated heart rate.
Failure to Obtain CNA Registry Verification Prior to Re-Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) registry verification was obtained prior to the re-hire of one CNA. Record review showed that this CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. The personnel file contained a CNA registry verification dated 10/22/2012, corresponding to the original hire, but there was no documented evidence that a new CNA registry verification was obtained at the time of re-hire. During an interview on 03/18/2026 at 11:50 a.m., the administrator confirmed that the facility did not have documentation showing that a CNA registry verification was completed prior to re-hiring this CNA as required. This deficiency was identified for 1 of 2 CNA personnel records reviewed, specifically for the CNA who had a break in employment and was subsequently re-hired without updated registry verification documentation in the personnel record.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to properly complete and post required daily nurse staffing information. On 03/18/2026 at 8:45 a.m., surveyors observed a Daily Nursing Staff Posting form dated 03/18/2026 on a bulletin board in the middle of the facility that did not include the resident census at the start of the shift, the daily staffing hours required, or the actual hours worked. At the same time, a Daily Nursing Staff Posting form dated 03/17/2026 was also observed without the resident census, daily staffing hours required, or actual hours worked documented or updated from the previous day. In an interview on 03/18/2026 at 9:20 a.m., the Staff Development Coordinator RN confirmed that for both 03/17/2026 and 03/18/2026 the facility did not post the resident census, daily nursing hours required, or the actual nursing hours provided, and acknowledged that she had always posted the forms without this required information but should not have. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves failure to implement the facility’s infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy for high-contact resident care activities such as wound care. The facility’s policy, last reviewed on 03/01/2026, requires staff to use gown and gloves during EBP and to change gloves between cleaning and applying ointments or dressings. Resident #2, admitted on 09/03/2025 with a primary diagnosis of Acute Respiratory Failure with Hypoxia, had an order and care plan in place for EBP in relation to wound care. On 03/16/2026 at 2:25 p.m., during wound care for Resident #2, S6 TXRN did not wear a gown and did not change gloves between cleaning the wounds and applying ointments and powder, contrary to the EBP protocol. Resident #3, admitted on 07/02/2024 with a primary diagnosis of Restless Legs Syndrome, also had an order and care plan for EBP. On 03/16/2026 at 2:45 p.m., during wound care for Resident #3, S6 TXRN again failed to follow EBP protocol by not wearing a gown and not changing gloves between cleaning and redressing the wound. In an interview on 03/16/2026 at 3:15 a.m., S2 CorpRN confirmed that EBP procedures require direct care staff to wear a gown and gloves during wound care and that S6 TXRN should have worn a gown and changed gloves after cleaning a wound and before applying clean dressings or ointments, as required by facility policy.
Failure to Complete Timely Significant Change MDS Assessment After Initiation of Anticoagulant Therapy
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days after a significant change in a resident's condition. Record review showed that a resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a history of venous thrombosis and embolism. The resident was not on anticoagulant therapy at the time of a quarterly MDS assessment, but physician orders later indicated the initiation of Apixaban for a history of deep vein thrombosis. Interview with the MDS staff confirmed that the initiation of anticoagulant therapy constituted a significant change in the resident's status, and acknowledged that the required Significant Change MDS Assessment was not completed within the mandated timeframe.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with a history of seizures, traumatic brain injury, dementia with behavioral disturbance, and delirium, incident reports and electronic medical records documented unwitnessed falls and the administration of antipsychotic medication. However, multiple MDS assessments did not indicate any falls in the relevant periods, nor did they accurately record the use of antipsychotic medication, despite physician orders and medication administration records showing otherwise. Another resident with Parkinson's disease and severely impaired cognition experienced falls, including one with injury, as documented in the care plan and electronic medical record. Despite this, the resident's quarterly MDS assessment failed to accurately reflect the occurrence of these falls. Staff interviews confirmed that the MDS assessments for both residents did not accurately represent their clinical status as required.
Failure to Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident who had a history of deep vein thrombosis and was receiving anticoagulant therapy with Apixaban. The resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a personal history of venous thrombosis and embolism. Despite having intact cognition as indicated by a BIMS score of 15, the resident's care plan did not address the ongoing anticoagulant therapy. This omission was confirmed through interviews with facility staff, who acknowledged that anticoagulant therapy should have been included in the resident's care plan.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for multiple residents, resulting in unmet needs and noncompliance with physician orders and facility policies. For one resident with quadriplegia, seizures, and a PEG tube, staff did not ensure the bed alarm was properly placed, connected, or functioning as ordered. Observations over several days showed the bed alarm control box was detached and not connected, with the alarm mat misplaced in a Geri chair rather than on the bed. The resident was unable to locate her call light and reported a history of falls, while staff confirmed the bed alarm was not in use as required by the physician's order. Another resident who smoked cigarettes was not care planned for smoking, despite a completed Smoking Evaluation Tool and facility policy requiring individualized care plans for smokers. The resident's care plan did not address smoking, and the LPN responsible for care plans acknowledged this omission during review. Facility policy specifies that all smokers must have a care plan based on their evaluation, but this was not implemented for the resident in question. A third resident with multiple complex diagnoses, including schizophrenia, anxiety disorder, and chronic liver disease, had only a single, generalized care plan area focused on disease management. The care plan lacked comprehensive, person-centered interventions and did not address the resident's full range of needs, strengths, preferences, or goals. The LPN responsible for care plans confirmed that a comprehensive care plan had not been developed or implemented in a timely manner for this resident.
Failure to Meet Professional Standards in Skin Audits, Medication Administration, and Weight Monitoring
Penalty
Summary
The facility failed to ensure that care and services provided to residents met professional standards of quality in several instances. For one resident with multiple diagnoses including COPD, heart failure, and impaired mobility, the facility's policy required weekly head-to-toe skin audits with documentation of any identified skin conditions. However, a nurse failed to document observed bruising during a body audit and did not perform a complete assessment, as she did not lift the resident's shirt to check for additional injuries. This resulted in undisclosed bruising being identified only after notification from hospital staff, rather than through the facility's own assessment process. Another resident with schizophrenia and morbid obesity was not weighed monthly as required by facility policy and the resident's care plan. The resident's last recorded weight was several months prior, despite interventions in the care plan specifying monthly weights and provider notification for significant changes. The Director of Nursing confirmed that the resident had not been weighed as required. Additionally, a resident with anoxic brain damage and a tracheostomy did not receive medication as ordered by the physician. The physician's order specified that Baclofen should be administered via G-tube, but an LPN crushed the medication and administered it orally. Both the LPN and the unit manager confirmed that the medication was not given by the correct route, and the physician's order had not been updated to reflect any changes following a swallow study. This resulted in the resident not receiving medication as prescribed.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. On 05/20/2025 at 4:09 p.m., one resident was struck multiple times on the head by another resident after refusing a request for a cigarette. This assault caused lacerations to the victim's left cheek, right cheek, forehead, and chin, requiring evaluation at the emergency room. Both residents involved did not have a prior history of physical aggression toward others, as confirmed by their medical records and staff interviews. The facility's abuse prevention policy states a commitment to protecting residents from abuse, including physical abuse such as hitting. Despite this policy, the incident occurred, and the injured resident, who had moderately impaired cognition and diagnoses including depression, anxiety, mood disorder, and seizures, suffered actual harm. The aggressor had intact cognition and diagnoses of schizoaffective disorder and major depressive disorder with psychotic symptoms. The event was substantiated through interviews, medical record reviews, and the facility's own investigation report.
Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of schizophrenia, who was admitted on 11/06/2020, was found to be receiving Risperdal 1mg twice daily without evidence of a gradual dose reduction (GDR) attempt or documentation that a GDR was clinically contraindicated. The resident's most recent MDS assessment indicated intact cognition and ongoing use of antipsychotic medication, yet there was no record of a GDR being attempted. Additionally, a consultant pharmacist had recommended a GDR for Risperdal, but there was no documented response from the physician to this recommendation. The medical record lacked any documentation supporting either a GDR attempt or a clinical reason for not pursuing one.
Inaccurate MDS Documentation of COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the COVID-19 vaccination status for three out of five residents reviewed for vaccinations. For these residents, the most recent MDS assessments indicated that their COVID-19 vaccinations were not up to date. However, a review of their immunization records showed that they had received the required COVID-19 vaccine doses, with dates documented for each administration. During an interview, the Infection Preventionist confirmed that the residents should have been considered up to date with their vaccinations according to facility policy, and acknowledged that the MDS assessments did not accurately reflect this status.
Failure to Provide Required ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who were unable to perform these tasks independently, resulting in deficiencies in grooming and personal hygiene. One resident with impaired mobility due to Muscular Dystrophy, who was dependent on staff for all ADLs, was observed with unkempt hair, dried sputum, and long facial hair. Staff interviews confirmed that the resident's grooming needs, including shaving and face washing, had not been met as required by facility policy. Two additional residents, both dependent on staff for bathing and personal hygiene, did not receive daily bed baths as specified in their care plans and facility policy. Documentation and staff interviews revealed that these residents missed multiple scheduled bed baths over a period of days. Observations noted foul odors in their rooms, and one resident reported only receiving bed baths upon request, with significant gaps between baths. Review of facility records, care plans, and staff schedules confirmed that the required ADL care, including daily bed baths and grooming, was not consistently provided. Staff acknowledged the missed care and, in one instance, admitted to documenting a bed bath that was not actually performed. The deficiencies were corroborated by direct observation, resident interviews, and review of care documentation.
Failure to Provide Required Turning and Repositioning for At-Risk Resident
Penalty
Summary
Staff failed to provide necessary services to maintain optimal skin integrity for one resident who was at risk for pressure ulcers. The resident, who had multiple diagnoses including spinal stenosis, Alzheimer's disease, morbid obesity, and was always incontinent of bowel and bladder, required moderate assistance for bed mobility and was care planned to be turned and repositioned every two hours and as needed. Observations over several hours showed the resident remained in the same position in bed, and interviews with CNAs confirmed that the resident had not been turned or repositioned during their shifts. The resident also confirmed she was unable to reposition herself and was not routinely turned by staff. Further review revealed that the resident's care plan included the need for regular turning and repositioning, but this intervention was not reflected in the facility's electronic charting system or on the paper kardex. The DON confirmed these omissions and acknowledged that the required tasks were not listed as they should have been. Staff interviews corroborated that the resident was not turned or repositioned as required by her care plan, resulting in a failure to provide necessary services to prevent pressure ulcers.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on tube feeding and water flushes did not receive enteral feedings as ordered by the physician. The resident had diagnoses including acute respiratory failure, hyperlipidemia, hypothyroidism, and insomnia, and was admitted with a care plan indicating the need for tube feeding due to nothing by mouth status. Physician orders specified Glucerna 1.5 at 60ml/hr via pump and water flushes at 250ml every 4 hours. Review of the medication administration record and progress notes for the relevant dates showed no documentation that the tube feeding was held or refused. On observation, the resident's feeding pump was found turned off, and the resident was unaware of how long it had been off. The LPN on duty at the time was also unaware that the pump was off and had not been notified of any issues during shift change. Another LPN from the previous shift reported turning off the tube feeding due to the resident's complaint of stomach pain and turning it back on a few hours later, but could not recall hearing the feeding alarm during the night. The DON was notified of issues with the tube feeding but did not know why or for how long the feeding had been off, despite the resident's orders requiring continuous feeding.
Failure to Complete Annual CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete annual performance reviews and provide regular in-service education based on those reviews for two of three certified nursing assistants (CNAs) reviewed. Personnel records showed that one CNA, hired in November 2023, did not have an annual performance review completed within the past 12 months, with the last documented review dated prior to their hire date. Another CNA, hired in May 2024, also had no evidence of an annual performance review in the past 12 months. During interviews, the administrator acknowledged that annual performance reviews had been requested but not provided, and the HR representative confirmed that the personnel records lacked evidence of completed annual performance evaluations for the affected CNAs. No information about the medical history or condition of any residents was included in the report, and the deficiency was limited to the facility's failure to observe and document CNA job performance and provide related training as required.
Infection Control Lapses in Medication Administration, Wound Care, and Environmental Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff adherence to established protocols. During a medication pass for a resident with quadriplegia and a PEG tube, an LPN administered medications and flushed the tube without wearing a gown, despite the facility's Enhanced Barrier Precautions (EBP) policy requiring both gown and gloves for such procedures. The LPN acknowledged forgetting to don a gown, and the Director of Nursing confirmed this was not in compliance with policy. The resident's medical record indicated ongoing PEG tube care for administration of Baclofen and Gabapentin. Further deficiencies were observed during wound care, where a treatment nurse failed to perform hand hygiene before preparing and applying wound dressings. The nurse handled clean gauze with ungloved hands, placed it into a cup, and then sprayed it with wound cleanser, contaminating the supplies. The nurse admitted to not performing hand hygiene and using the contaminated gauze on the resident's wound, which was inconsistent with the facility's standard precautions policy. Additional observations revealed improper storage of resident care items, with unused supplies such as adult briefs, wash basins, and under-pads stored directly on the floor, and used basins and a soiled urinal left on the shower floor. A shower curtain was also found to be visibly soiled, with staff unable to state the cleaning frequency or protocol. Facility administration confirmed these storage and cleanliness issues were not in accordance with expected standards.
Failure to Immediately Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that incidents of suspected abuse and injuries of unknown origin were reported immediately to management staff for two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including COPD and heart disease, was found to have bruising on the right eye and hip area. Although an LPN observed these bruises while accompanied by the resident's responsible party, she did not notify management at the time, believing the issue had already been addressed. Management only became aware of the bruising after being informed by a marketer who visited the resident in the hospital several days later. In the second case, a resident with moderate cognitive impairment and a history of dementia and anxiety reported to a CNA that two women were trying to harm her. The CNA relayed this to an LPN, who assessed the resident but delayed reporting the allegation of abuse to the administrator, sending a text message several hours later instead of immediately. Both staff members acknowledged during interviews that they should have reported these incidents to management without delay, as required by facility policy.
Controlled Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that controlled medications were administered as ordered and documented correctly for five residents. The deficiencies were identified through a review of medical records and interviews. The facility's policy required that when administering controlled medications, authorized personnel must record the administration on the MAR/eMAR and enter specific information on the Controlled Drug Record, including the date and time of administration, amount administered, signature of the person preparing the dose, and quantity reconciled. However, discrepancies were found in the documentation of medication administration for several residents. For Resident #1, the Controlled Drug Record for Norco 10-325mg showed doses signed out by an LPN at times when the LPN had already clocked out, and there was no documentation of these doses in the eMAR. Similar issues were found for Resident #2, where doses of Norco and Ativan were signed out without proper documentation, and the LPN had clocked out before the recorded administration times. Resident #3's records also showed doses signed out without proper documentation, and the LPN had clocked out before the recorded times. Resident #4's records revealed doses signed out without documenting a time or signature, and the LPN had clocked out before the recorded administration times. Resident #R1's records showed a dose of Tramadol signed out after the LPN had clocked out. Interviews with the Director of Nursing (DON) confirmed that the LPN documented giving controlled medications at times after she had already clocked out. The LPN admitted to pre-pulling medications and administering them early, which was against the physician's orders. The DON confirmed that the LPN did not follow the facility's policies and procedures for medication administration, leading to false documentation of medication administration times.
Failure to Document Pain Management Effectiveness
Penalty
Summary
The facility failed to provide appropriate pain management for five residents by not assessing the effectiveness of pain medication after administration. The facility's policy requires documentation of the date, time, dose, route, and effectiveness of PRN medications, but this was not followed. For each resident, there was no documentation of pain assessment prior to or after administering pain medication, nor were the doses recorded on the electronic Medication Administration Record (eMAR). Resident #1, with diagnoses including heart failure and hip dislocation, received Norco for pain on multiple occasions without documented assessments of pain or effectiveness. Similarly, Resident #2, who has severe cognitive impairment and multiple diagnoses, received Norco without proper documentation or assessment. Resident #3, with chronic heart failure and osteoarthritis, also received pain medication without documented assessments, and the doses were not recorded on the eMAR. Resident #4, who is cognitively intact and has spinal stenosis, received Norco without documented pain assessments or nurse signatures. Lastly, Resident #R1, with anemia and hypertension, received Tramadol without documentation of pain assessment or effectiveness. The Director of Nursing confirmed the lack of documentation for all residents, indicating a systemic issue in pain management practices at the facility.
Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #11, who has a history of Schizoaffective Disorder, Bipolar Type, and Traumatic Brain Injury, was involved in an altercation with Resident #12, who also has Schizoaffective Disorder and a history of behavioral issues. The incident occurred when Resident #12, while propelling himself in a wheelchair, unknowingly rolled over Resident #11's foot. In response, Resident #11 pushed the wheelchair away, leading Resident #12 to stand up and hit Resident #11 in the shoulder. The altercation escalated as both residents stood up and swung their arms at each other, although no further physical contact was made. Resident #12 lost his balance and fell to the floor. Staff members, including S9 Central Supply and S8 LPN, intervened shortly after the incident. Both residents were assessed and found to have no physical injuries, and neither resident reported any pain. The facility's surveillance footage confirmed the sequence of events, showing that Resident #11 was not the aggressor. The incident was reported to the facility's administration, and it was noted that Resident #12 had a history of behavioral issues. The facility's failure to prevent this altercation highlights a deficiency in ensuring residents' safety from abuse by other residents.
Failure to Ensure Timely Specialist Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who had a history of chronic recurrent spontaneous left hip dislocation, was referred to an orthopedic specialist following a hospital admission. Despite the referral, the resident did not attend the scheduled appointment with the orthopedic specialist due to a missed ambulance transport, which was not noticed by the facility staff. The resident, who had moderately impaired cognition and was dependent on assistance for mobility and hygiene, expressed ongoing pain and immobility due to the dislocated hip. The resident's medical records indicated a need for urgent orthopedic consultation and potential surgical intervention. However, the facility's failure to ensure the resident's transport to the specialist appointment resulted in a delay in receiving necessary medical evaluation and treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. Resident #3, who has a history of mental health issues including Schizoaffective Disorder and Major Depressive Disorder, was involved in an altercation with Resident #4. Resident #3's care plan noted a risk for altered mental status and behaviors, including outbursts and aggression. Despite these known risks, Resident #3 was able to engage in a physical altercation with Resident #4 in the dayroom. Resident #4, who has Parkinson's Disease, Major Depressive Disorder, and moderate cognitive impairment, was involved in the incident when Resident #3 attempted to take another resident's food tray. Resident #4 verbally intervened, which led to Resident #3 approaching and physically assaulting Resident #4. The altercation escalated to both residents hitting each other and falling to the floor, resulting in a skin tear for Resident #3 and a reported knot on Resident #4's head. The incident was witnessed by S2 CNA, who was present in the dayroom and attempted to intervene by verbally instructing Resident #3 to stop. Despite these efforts, the altercation occurred, highlighting a failure in the facility's ability to prevent resident-to-resident abuse. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents, but this policy was not effectively implemented in this case.
Failure to Maintain Prescribed Nutritional and Hydration Status for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident with a PEG tube maintained acceptable nutritional and hydration status as per the resident's comprehensive assessment. The resident, who had multiple diagnoses including chronic kidney disease, cerebrovascular disease, and dependence on a ventilator, was observed receiving tube feeding at a rate lower than prescribed. The prescribed rate was 50ml/hr for both Glucerna 1.5 and water flush, but the actual rate was set at 40ml/hr for the feeding and 30ml every 3 hours for the water flush. Additionally, the feeding and flush bags were not labeled with the resident's name, date, and time as required by the facility's policy. Interviews with facility staff confirmed the discrepancies in the feeding and flush rates. An LPN acknowledged that the rates were not set according to the physician's orders and that the bags were not labeled as they should have been. The Director of Nursing also confirmed that staff failed to implement the recommended changes to the feeding and flush rates made by the registered dietitian. This oversight in following the prescribed nutritional and hydration regimen for the resident led to the deficiency noted in the report.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in several resident rooms. Specifically, Rooms a, b, and c were observed to have a large amount of dust, trash, and dead insects in the corners between the beds and windows. Additionally, the window pane in Room a was covered with mildew and a green and brown substance, obstructing the outside view. The ceiling tiles in Rooms a and b were loose, had exposed insulation, and were stained brown. Furthermore, the over bed wall-mounted lights in Room b were not operational over both beds. These deficiencies were confirmed during observations on two separate days and were corroborated by S10 Maintenance, who acknowledged that the rooms had not been properly cleaned and that the ceiling tiles needed to be replaced, repaired, or painted. S10 Maintenance also confirmed that the light bulbs in Room b needed replacement and that the window pane in Room a should have been cleaned to allow the resident an outside view.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of quality for Resident #43 and Resident #268. For Resident #43, who had diagnoses including Chronic Respiratory Failure, Type 2 Diabetes Mellitus, and Paroxysmal Atrial Fibrillation, the facility did not obtain the required quarterly labs in December 2023 as ordered by the physician. This was confirmed by the Director of Nursing during an interview, acknowledging that the labs should have been collected but were not present in the medical record or Echart. For Resident #268, who had diagnoses including Acute Respiratory Failure, Anoxic Brain Damage, and Tracheostomy status, the facility failed to notify the physician of the dietician's recommendations to adjust the tube feeding regimen. Despite the dietician's assessment recommending changes to the enteral feeding to meet the resident's nutritional needs, there was no documentation that the primary care physician had been informed. This was confirmed by both the Corporate RN and the primary care physician, who expressed concern over not being notified and indicated the need for immediate action to assess the resident's hydration status.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that Residents #1 and #4 were free from facial hair and failed to provide nail care to dependent residents, including Residents #11, #17, #21, #38, #48, and #62. These deficiencies were observed during various times and confirmed through interviews with the residents and staff members, as well as through record reviews of the residents' care plans and medical records. Resident #1, who has diagnoses including cerebral infarction and dementia, was observed with long facial hair despite his care plan indicating he required assistance with grooming. Resident #1 reported asking several staff members to shave him but had not been shaved. Similarly, Resident #4, who has diagnoses including diabetes and COPD, was observed with thick gray facial hair and long, dirty fingernails. Resident #4 confirmed that it had been weeks since his nails were trimmed and over a week since he had been shaved. Other residents, such as Resident #17, #21, #38, #48, and #62, were observed with long, untrimmed fingernails, some with dark substances underneath. These residents required assistance with ADLs due to various medical conditions, including dementia, hemiplegia, and schizophrenia. Interviews with the residents and staff confirmed that the necessary grooming and nail care had not been provided, despite being outlined in their care plans. The Director of Nursing (DON) also confirmed these observations during the survey.
Failure to Maintain Resident Dignity by Ensuring Removal of Facial Hair
Penalty
Summary
The facility failed to maintain dignity for a female resident by not ensuring she was free of facial hair. The facility's policy states that both male and female residents should be free of facial hair unless otherwise noted in the care plan. The resident, who has diagnoses including Unspecified Dementia, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Anxiety Disorder, and Dysphagia, requires total assistance with all activities of daily living. An observation revealed that the resident had 1/4 inch facial hair on her chin. An interview with an RN confirmed the presence of the facial hair and acknowledged that it should have been shaved but was not.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting. Specifically, during the 02/13/2024 meeting, residents raised concerns about not being able to lay down when they wanted to when agency CNAs were working, not receiving baths, and CNAs not passing out ice. The concerns were documented and given to the Director of Nursing (DON) on 02/14/2024, with a response due by 02/23/2024. However, there was no documented evidence of an investigation into these concerns, and no follow-up was provided to the Resident Council. Interviews with the Activity Director and members of the Resident Council confirmed that the DON had not provided a follow-up or spoken to the Resident Council about the documented concerns. The Activity Director, who was responsible for assisting the Resident Council with setting up meetings and keeping minutes, confirmed that the concerns were given to the DON but no action was taken. The DON also confirmed that a follow-up should have been provided but was not. This failure to address and investigate the grievances reported by the residents constitutes a deficiency in the facility's grievance handling process.
Failure to Meet Nutritional Needs for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure services were provided according to the resident's Comprehensive Plan of Care for a resident who required tube feeding. The resident, who had multiple diagnoses including Acute Respiratory Failure, Anoxic Brain Damage, and Hypertension, was observed on multiple occasions receiving Jevity 1.5 at 50ml per hour with 50ml H20 flushes every 6 hours. However, the Registered Dietician's assessment recommended a different regimen of Jevity 1.5 at 62ml per hour with 42ml/hour flush continuous every hour to meet the resident's nutritional needs. Despite the dietician's recommendations, the resident continued to receive the incorrect tube feeding settings, as confirmed by observations and an interview with the Corporate RN. This discrepancy resulted in the resident not receiving adequate nutrition and hydration as per the Comprehensive Plan of Care, highlighting a failure in the facility's adherence to the prescribed nutritional plan for the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily. On 04/02/2024 at 9:30 a.m., an observation revealed that the daily nurse staffing information posted was dated 03/29/2024. During an interview on the same day at 11:56 a.m., the Director of Nursing (DON) confirmed that the nurse staffing information should have been updated daily but was not.
Failure to Follow Standardized Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for three residents who were ordered and served pureed diets. The facility's approved recipes for pureed roast turkey and pureed turnip greens were not followed. Instead, dietary staff prepared these items without referring to the standardized recipes, resulting in the use of unmeasured ingredients and methods that did not align with the facility's policy on pureed food preparation. Specifically, one dietary staff member admitted to adding milk and bread to the turkey without measuring or using a recipe, while another staff member also failed to follow the recipe when preparing the pureed turkey and turnip greens for serving. This was confirmed through interviews and observations with the dietary manager and staff, who acknowledged the lack of adherence to the recipes and the absence of recipe references during food preparation. The deficiency was identified during a review of the facility's approved 2024 Lunch Menu and the corresponding recipes for pureed foods. The facility's policy on pureed food preparation emphasized the use of standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. However, the dietary staff did not follow these guidelines, leading to the preparation of pureed foods that did not meet the required standards. This failure was observed and confirmed by the dietary manager, who acknowledged that the staff should have referred to the recipes but did not. The dietary manager also attempted to correct the issue by printing the recipes and preparing the pureed food items herself, but still did not adhere to the recipe instructions.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain infection control practices to prevent and control the spread of an infectious communicable disease. Specifically, the facility did not ensure that all staff adhered to Enhanced Barrier Precautions for a resident who was colonized or infected with a multidrug-resistant organism (MDRO). The facility's policy required the use of gowns and gloves during high-contact resident care activities for such residents. However, an observation revealed that a hospice CNA was providing direct care to a resident with a tracheostomy and mechanical ventilation without wearing the required PPE, despite the presence of signage and equipment indicating the need for Enhanced Barrier Precautions. The hospice CNA admitted to seeing the signage but did not understand its purpose and had not read it. The CNA was informed by facility staff that the sign and equipment were placed because state surveyors were in the building. Further interviews with the respiratory therapist and the resident's nurse confirmed that the hospice CNA was not wearing the appropriate PPE and that hospice staff were expected to follow the posted instructions. The nurse was unsure if all hospice staff had been made aware of the new precautions, although they should have been informed.
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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