Kinder Retirement And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kinder, Louisiana.
- Location
- 13938 Hwy 165, Kinder, Louisiana 70648
- CMS Provider Number
- 195493
- Inspections on file
- 21
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Kinder Retirement And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure that PRN psychotropic medication orders were limited to 14 days or that appropriate physician documentation was provided for continued use. Several residents received ongoing PRN psychotropic medications without required reassessment or rationale, and one resident was given a psychotropic drug for staff convenience to manage combative behavior. Staff interviews revealed a lack of awareness of the 14-day reassessment requirement.
A resident with chronic pain and a physician order for PRN Norco repeatedly reported pain to nursing staff over several weeks, but did not receive pain assessments or the prescribed medication. Nursing staff acknowledged the complaints but did not follow through with assessment or administration, and the DON confirmed that expected procedures were not followed.
The facility failed to maintain accurate controlled drug counts for two residents, with discrepancies found in the medication log books compared to the actual count. An LPN confirmed the mismatches, and it was revealed that the required shift change medication count was not conducted, nor were the medications documented properly, leading to the deficiency.
The facility failed to properly store medications, with loose pills found in all three medication carts and discontinued controlled medications not removed from one cart. An RN and LPN confirmed the presence of loose pills, and the DON acknowledged that discontinued medications should have been removed promptly.
A facility failed to ensure licensed nurses had the appropriate competencies, resulting in errors in narcotic medication orders and administration. This included missing drug strength in orders, incorrect entries into electronic records, and inconsistencies between narcotic sign-out logs and MARs. Interviews with the DON and an LPN confirmed these issues, with the LPN admitting to administering medication despite dosing inconsistencies.
A resident with multiple medical conditions was transferred to the hospital for hypoxia evaluation, but the facility failed to document notifying the responsible party. The resident, who was cognitively intact, informed the responsible party of the transfer from the hospital. The facility's policy required such notification and documentation, which was confirmed missing by the DON and the LPN involved.
The facility did not meet residents' nutritional needs by serving incorrect portion sizes, as observed when the Dietary Manager used smaller scoops than required for mustard greens and red beans with sausage. This affected 51 residents receiving regular diets, as the staff did not follow the menu's serving sizes.
The facility did not ensure pureed foods were prepared according to the approved recipe, affecting seven residents on pureed diets. A dietary aide was observed preparing meals without measuring ingredients or using a recipe, and the dietary manager confirmed the lack of training in recipe adherence.
A facility failed to accurately complete the MDS for a resident with End Stage Renal Disease, omitting dialysis treatment from the record. Despite physician orders for regular dialysis, the MDS did not reflect this treatment. The error was confirmed by the MDS Coordinator during a review.
Failure to Limit and Justify PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that residents with orders for psychotropic medications were not subjected to chemical restraints and that PRN (as needed) psychotropic medication orders were limited to 14 days, as required. Multiple residents had PRN psychotropic medication orders that either lacked an end date or extended beyond the 14-day limit without documented physician rationale or evaluation. For example, several residents had ongoing PRN orders for medications such as morphine, hydrocodone-acetaminophen, oxycodone, alprazolam, tramadol, and lorazepam, with no evidence of physician documentation justifying the continuation of these orders past 14 days. Additionally, one resident was prescribed Buspirone three times daily specifically for being combative with staff and excessive pacing, with staff confirming the medication was used for combativeness. This indicates the medication may have been used for staff convenience or discipline, rather than for a medically necessary indication, which constitutes a chemical restraint. Interviews with facility staff, including the DON and LPN, revealed a lack of awareness regarding the regulatory requirement to reassess PRN psychotropic medications after 14 days and to document the rationale for continued use. The facility's own policy stated that PRN orders for psychotropic drugs are limited to 14 days unless the physician documents the rationale for extension, but this was not followed in practice for the residents reviewed.
Failure to Provide Timely Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of chronic pain conditions, including chronic obstructive pulmonary disease, below-knee amputation, muscle spasm, and neuropathy. Despite having a physician order for PRN Norco for pain and a care plan outlining pain management interventions, the resident repeatedly reported pain to nursing staff over a period of several weeks. Documentation showed multiple pain complaints, but there was no evidence of pain assessments or administration of the ordered pain medication during this time. The last recorded administration of Norco and pain assessment occurred several weeks prior to the resident's ongoing complaints. Interviews revealed that nursing staff were aware of the resident's pain complaints but did not perform pain assessments or administer the prescribed PRN pain medication. The resident expressed frustration, stating he had stopped reporting pain because staff did not respond to his requests, despite knowing he had an active order for pain medication. The DON confirmed that staff failed to follow expected procedures for pain assessment, documentation, and medication administration in response to the resident's reports of pain.
Discrepancies in Controlled Drug Count for Two Residents
Penalty
Summary
The facility failed to maintain an accurate account of controlled drugs for two residents, leading to discrepancies in the medication count. During an observation of the locked controlled medication drawer and log book on Medication Cart B, it was found that Resident #5's Clonazepam 1mg tablet blister package had 55 tablets remaining, while the log book documented 56 tablets. Similarly, Resident #6's Lorazepam 0.5 mg tablet blister package had 15 tablets remaining, but the log book recorded 16 tablets. These discrepancies were confirmed by S3 LPN, who acknowledged that the recorded numbers did not match the actual count. The deficiency was further compounded by the failure to conduct a controlled medication count at shift change, as required by the facility's policy. An interview with S1 DON revealed that S3 LPN did not perform the necessary count with the off-going and oncoming nurses at the beginning and end of their shifts. Additionally, the controlled substances were not documented electronically and on paper in the log book when administered to the residents, as per the facility's policy. This lack of adherence to established procedures contributed to the inaccuracies in the controlled drug count for the residents involved.
Improper Medication Storage and Handling
Penalty
Summary
The facility failed to ensure proper storage of medications in all three medication carts, as observed during a survey. Loose pills were found in each cart, with Medication Cart C containing two unidentified loose pills, Medication Cart B containing four loose pills with varying shapes and markings, and Medication Cart A containing two loose pills, one of which was identified by its markings. These observations were confirmed by the respective nursing staff accompanying the surveyor, who acknowledged that loose pills should not be present in the medication carts. Additionally, the facility did not remove discontinued controlled medications from Medication Cart B. Specifically, Resident #4's Tramadol and Resident #7's Lyrica, both of which had been discontinued, were still present in the cart. The Tramadol bottle contained 83 pills and was wrapped in the resident's medication log, while the Lyrica blister package had 3 pills remaining. The LPN confirmed that these medications were no longer in use and should have been removed and disposed of properly. The Director of Nursing also confirmed that medication carts should be clean and free of loose pills, and that discontinued medications should be removed within the same shift they were discontinued.
Medication Order Errors and Inconsistencies in Narcotic Administration
Penalty
Summary
The facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing services that assured resident safety and well-being. This was evidenced by multiple errors in the transcription and administration of narcotic medication orders. Specifically, there were failures to include the strength of the drug in transcribed verbal narcotic medication orders, incorrect entries of written narcotic orders into the electronic medical record, and inconsistencies between the dosing information on the narcotic sign-out log and the Medication Administration Record (MAR). Additionally, not all narcotic medication doses signed out on the Narcotic Medication Record were documented as given on the MAR for one of the sampled residents. The deficiencies were highlighted through a review of physician orders and interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN). The DON confirmed the inability to locate an order changing the dose of Morphine Sulfate and acknowledged that the information was entered incorrectly when the facility transitioned to a new electronic health record system. The LPN admitted to signing out and administering Morphine despite inconsistencies in the dosing information and confirmed that the orders she wrote did not include the necessary dose/concentration details. The facility's policy on medication orders was not followed, leading to these discrepancies and errors in medication administration.
Failure to Document Responsible Party Notification for Hospital Transfer
Penalty
Summary
The facility failed to document the notification of a responsible party regarding the transfer of a resident to the hospital. The resident, who was cognitively intact with a BIMS score of 13, had multiple medical conditions including Peripheral Vascular Disease, End Stage Renal Disease, and Chronic Obstructive Pulmonary Disease, among others. The resident required extensive assistance with daily activities and had been experiencing shortness of breath. The care plan included interventions for hypoxia, and the resident was on continuous oxygen therapy. Despite these measures, the resident was transferred to the hospital for evaluation and treatment of hypoxia. The deficiency was identified when the resident's responsible party reported not being notified of the hospital transfer, learning of it only through a call from the resident. The facility's policy required notification of the resident's family or representative in such situations, and documentation of this notification in the medical record. However, the nurse responsible for the resident on the day of the transfer admitted to not documenting the notification, and the Director of Nursing confirmed the absence of such documentation in the medical record.
Failure to Adhere to Menu Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of its residents by not adhering to the established portion sizes as outlined in their approved menu. The facility's policy on menu planning requires that all menu items have standardized recipes with ingredient listings to ensure the appropriate number of portions. However, during an observation, it was noted that the Dietary Manager served mustard greens and red beans with sausage in incorrect portion sizes, using a 3 oz. scoop for mustard greens instead of the required 4 oz., and a 4 oz. scoop for red beans and sausage instead of the required 6 oz. The Dietary Manager confirmed that the residents were served incorrect portion sizes and acknowledged that the staff did not follow the serving sizes posted on the menu. The manager admitted that the scoops and ladles should have been checked prior to meal service to ensure compliance with the menu requirements, but this was not done. This oversight affected 51 residents who received regular diets prepared by the facility kitchen, leading to a failure in meeting their nutritional needs as per national guidelines.
Failure to Follow Recipe for Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to the approved recipe, which is necessary to conserve nutritional value for seven residents on pureed diets. During an observation, a dietary aide was seen preparing a pureed meal without measuring the ingredients or referring to a recipe. The aide blended mustard greens, red beans/sausage, and rice without using the specified amounts and added an unmeasured amount of thickener to adjust the consistency. The dietary manager confirmed that the aide did not use the recipe and admitted that staff had not been trained to follow recipes when preparing meals.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including End Stage Renal Disease and dependence on renal dialysis, was not correctly coded for dialysis treatment in the MDS. The Quarterly MDS, with an Assessment Reference Date of 06/03/2024, did not reflect the resident's ongoing dialysis treatment, despite physician orders indicating dialysis was scheduled every Monday and Friday. This discrepancy was confirmed during an interview and record review with the Minimum Data Set Coordinator, who acknowledged the inaccuracy in the MDS coding.
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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