Legacy Nursing At St. Christina
Inspection history, citations, penalties and survey trends for this long-term care facility in Pineville, Louisiana.
- Location
- 122 Hillsdale Drive, Pineville, Louisiana 71360
- CMS Provider Number
- 195613
- Inspections on file
- 40
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Legacy Nursing At St. Christina during CMS and state inspections, most recent first.
The facility failed to maintain documentation of its ongoing QAPI program as required by its own QAPI policy, which called for a facility-wide plan to monitor and improve the quality and safety of resident care and to maintain related records. When a surveyor requested QAPI information, the DON and a regional representative provided a binder that lacked QAPI documentation, and later reported they were unable to locate the actual QAPI binder that contained evidence of the ongoing program. This deficiency had the potential to affect all residents in the facility.
The facility failed to maintain and produce documentation of its QAPI program, including evidence of performance improvement activities, projects, and their frequency. During surveyor review, no records were available to show systems for reporting, investigation, tracking, trending, or monitoring of identified issues, nor any ongoing performance improvement plans. In an interview with the DON, ADM, and a regional representative, staff reported they were unable to locate the QAPI binder that contained the facility’s QAPI documentation, affecting all residents in the facility.
The facility failed to ensure residents were treated with dignity during meal service by not serving all residents at the same table at the same time and by not serving roommates who ate in their room simultaneously. In one instance, multiple residents seated together received their trays at different times while staff served other tables. In another instance, a cognitively intact resident with multiple chronic conditions, including Type 2 DM, bipolar disorder, HTN, and hyperlipidemia, reported that his roommate routinely received breakfast about an hour earlier, and observations confirmed he had not received his tray while his roommate had already been served. Staff and the dietary manager acknowledged that residents seated together or sharing a room should receive their trays at the same time, but this did not occur.
The facility failed to develop and implement comprehensive, person-centered care plans and to follow existing plans for several residents. One resident with COPD, seizures, psychiatric disorders, and moderate cognitive impairment was repeatedly observed on the floor without the fall mat required by the care plan, despite a documented history of falls. Another resident with COPD, asthma, psychiatric and movement disorders, and moderate cognitive impairment required partial to maximal assistance with multiple ADLs, yet had no ADL needs addressed in the care plan, as confirmed by the DON. A third resident with post-stroke hemiplegia and a left-hand contracture had a care plan requiring a splint/brace for several hours daily, but no splint was available or in use, and the palm showed discoloration and peeling skin; staff were unaware of the device. Additionally, a resident with anemia, hypertension, Parkinson’s disease, and respiratory symptoms had scheduled ipratropium-albuterol nebulizer treatments ordered by the physician, but there was no corresponding care plan for these treatments, which the MDS nurse acknowledged was missing.
The facility failed to meet professional standards by not assessing, documenting, or reporting multiple skin tears and a forehead abrasion for a cognitively impaired resident, despite existing care plan directives and physician treatment orders for specific wound care. Staff, including the DON, treatment nurse, RN weekend supervisor, and a CNA, acknowledged awareness of injuries such as the resident walking into a wall and prior skin tears, yet there were no incident reports or nursing documentation of these events or initial wound assessments. In addition, the facility did not administer ordered nighttime Tresiba insulin doses to another resident with type 2 DM on multiple occasions, as confirmed by MAR review and the DON, and there was no documentation of any clinical justification for withholding the medication.
Surveyors found that the facility failed to follow the prescribed puree diet menu for six residents who required puree meals. A kitchen staff member reported serving six residents on puree diets but was observed not pureeing a roll that was listed on the lunch menu. The staff member later confirmed that she had not been pureeing any bread items on the menu for an unspecified period of time for all residents on puree diets, and the dietary manager confirmed that the menu was not followed when the roll was not pureed.
A resident with multiple medical conditions, including hypertension, neuroleptic-induced parkinsonism, protein-calorie malnutrition, and generalized anxiety disorder, had a documented LaPOST-DNR order and DNR status on the face sheet, but the care plan listed the resident as Full Code and described an advance directive for Full Code. The facility’s policy required that each plan of care be consistent with the resident’s documented treatment preferences and/or advance directive. During review and interview, the DON and an LPN/MDS nurse confirmed the resident’s care plan code status was incorrect and should have reflected DNR, not Full Code.
A resident with multiple chronic conditions, moderate cognitive impairment, and a care plan requiring staff assistance with ADLs did not consistently receive scheduled bathing assistance. Review of records showed only three whirlpool baths documented in a 30-day period and a 10-day span with no documentation of a bath or refusal. The resident reported not consistently receiving scheduled baths, and both a CNA and clinical education staff confirmed that there was no bath or refusal documentation for that period, despite the expectation that scheduled baths would be provided.
A resident with anemia, Parkinson’s disease, respiratory symptoms, and a history of pneumonia had physician orders for routine Ipratropium-Albuterol nebulizer treatments. Surveyors observed the resident’s nebulizer machine on the bedside table with the mask lying on top, uncovered and undated, despite a facility policy requiring oxygen-related tubing, cannulas, and masks to be stored in a plastic bag when not in use and changed weekly and as needed. An LPN confirmed the resident received regular breathing treatments, had been treated earlier that day, and acknowledged that the nebulizer mask and tubing should have been covered and dated but were not.
A resident with paraplegia, COPD, essential hypertension, and neuromuscular bladder dysfunction had physician orders and a care plan for a NAS diet with regular texture, thin liquids, and double meat, but the lunch meal ticket omitted the double meat and the resident received only a single meat portion. The resident reported never receiving double portions, and the dietary manager confirmed double meat was part of the ordered diet but was not reflected on the ticket. In addition, RD recommendations to add Boost/Ensure BID between meals for added protein/calories and to monitor weekly weights were provided to the facility but were never transcribed into physician orders or documented in nursing notes, and the DON confirmed there was no order for the supplements.
The facility failed to maintain an effective pest control program as required by its own policy, which mandates that the building be kept free of insects and rodents through an ongoing program. During multiple observations of a resident’s room, surveyors noted numerous gnats on and around a basket of soiled clothes. A NS Adm acknowledged that the gnats were present and should not have been, and an environmental services staff member confirmed these findings. This deficiency meant the facility was not free from insects and had the potential to affect all 131 residents.
The facility did not ensure that bearded kitchen staff consistently wore required beard restraints while preparing, serving, and cleaning up food, despite these items being readily available. During a survey observation, three male dietary workers with beards were seen handling food and washing dishes without beard restraints, and the Dietary Manager acknowledged they should have been wearing them. This failure affected all residents who received meals prepared and served from the kitchen.
The facility failed to ensure its QAA committee met at least quarterly and maintained required documentation. Surveyors’ review of the Quality Assurance binder showed the last recorded QAA meeting was for the 3rd quarter of the year, with no documented meeting for the 4th quarter. During interview, the ADM reported that a 4th quarter QAA meeting had occurred and that minutes were kept in a QAPI binder, but the facility could not locate that binder and had no documentation to verify the meeting.
Several residents with complex medical needs did not receive scheduled bathing assistance as outlined in their care plans, with documentation and staff interviews confirming that required baths were missed and not properly recorded. Facility staff acknowledged that bathing was not provided routinely as required.
A facility failed to report an allegation of verbal abuse within the required timeframe after a third-party staff member witnessed a staff member curse at a resident in front of others. The administrator did not submit the required report to the Department of Health, citing the delay in notification and the resident's lack of recollection, despite facility policy mandating immediate reporting of such incidents.
A resident with impaired cognition and significant medical history was physically assaulted by a roommate after staff were made aware of escalating threats but failed to intervene or notify appropriate clinical leadership. The incident resulted in facial injuries requiring emergency treatment.
The facility did not report allegations of staff-to-resident sexual abuse and resident-to-resident physical abuse involving two residents with cognitive and physical impairments, as required by policy and regulations. The DON and Administrator were aware of the incidents but did not submit the required reports to the State Survey Agency within the mandated timeframe.
A resident with multiple chronic conditions and a history of UTIs did not receive a prescribed antibiotic in a timely manner after lab results indicated the need for treatment. Although the antibiotic was available in the emergency kit, it was not administered on the day it was ordered, and a subsequent allergy to the medication required a change in therapy. The ADON confirmed the delay in administration.
A resident with severe cognitive impairment and multiple medical conditions did not receive physician-ordered continuous overnight enteral feedings. Observation found the feeding tube disconnected and the pump off, while nursing staff interviews confirmed the feeding was missed and not refused by the resident.
A resident with multiple complex conditions and a pressure ulcer did not have wound care documentation on two days, with no record of care being provided or refused, despite physician orders and facility policy requiring such documentation. Staff confirmed the lack of required entries in the Treatment Administration Record (TAR).
A resident with multiple medical conditions and dependence on staff for ADLs did not receive scheduled bathing assistance, with only three documented baths in a 30-day period despite a care plan requiring three baths per week. Staff interviews and documentation reviews revealed inconsistencies in recording refusals and missed care, and the resident reported not receiving a bath in two weeks.
Surveyors found that the facility failed to maintain a clean and orderly environment, with observations including a resident's room containing hair and a splattered substance on the wall, broken window blinds, a large puddle of urine in another area, and a moldy ceiling tile due to an unresolved leak. Staff and a resident confirmed these unsanitary and disrepaired conditions had persisted for some time.
The facility did not perform weekly weights as ordered for three residents with significant weight loss or at risk for weight changes, and failed to obtain physician orders for wound care for a resident with active wounds. These deficiencies were confirmed by the DON and treatment nurse, and were not in accordance with facility policy or dietician recommendations.
Two residents with significant physical limitations were unable to access or use their call lights, as the devices were repeatedly observed out of reach and not adapted to their needs. Both residents, who required extensive assistance with daily living and had limited mobility, reported having to yell for help due to inaccessible call lights, a fact confirmed by staff and family. Facility policy required call lights to be within reach, but this was not consistently implemented.
A nurse failed to perform hand hygiene when changing gloves and between the treatment of multiple pressure ulcers for a resident who was fully dependent on staff and had several complex medical conditions. The nurse believed hand hygiene was only necessary between residents or if hands were visibly soiled, a misunderstanding confirmed during interviews. The DON acknowledged that proper hand hygiene should have been performed during the wound care process.
A resident with multiple medical and psychiatric conditions was not administered Amiodarone as ordered upon return from the hospital, due to the medication being overlooked during the transition. The omission was confirmed by both the nurse practitioner and DON, and the resident did not experience any reported adverse effects from the error.
A resident with severe cognitive impairment and hemiplegia did not receive ordered wound care for a skin tear on the right elbow, resulting in cellulitis. Despite a physician's order for treatment, the care was not administered on multiple occasions, and documentation was inaccurately completed. Interviews revealed that the treatment nurse was unaware of the wound, and the DON signed off on care that was not provided, leading to harm for the resident.
A resident who fell and sustained a wound to the elbow did not have their wound care order documented or entered by the facility. The DON later entered the order with a backdated start date and inaccurately initialed the TAR for wound care on two dates, despite not performing the care. The DON confirmed providing wound care on a later date but failed to document it, leading to inaccurate medical records.
The facility failed to follow care plans for two residents, missing monthly Trileptal lab tests for one resident with a seizure disorder and not providing daily wound care for another resident with a surgical wound. The lack of communication among nursing staff led to these deficiencies.
The facility failed to ensure a clean and safe environment by not maintaining the cleanliness and repair of wheelchairs for two residents. One resident's wheelchair was repeatedly observed with a soiled cushion, while another's wheelchair had cracked arm pads for about two years. Staff interviews revealed confusion over cleaning responsibilities and a lack of reporting on equipment disrepair.
A resident with a complex medical history requested a transfer to another facility after one night. The facility incorrectly encoded the discharge as unplanned and facility-initiated instead of planned and resident-initiated. Staff interviews confirmed the error in the MDS transmission report.
A resident with complex medical needs did not receive the prescribed continuous tube feeding of Glucerna 1.5 at 55 ml/hr and water at 45 ml/hr. Instead, Jevity 1.5, an incorrect formula, was found hanging and disconnected. Staff confirmed the error and the lapse in following physician's orders.
A resident with Huntington's disease and other conditions requiring assistance with meals was not provided the necessary help during dining services, despite care plan and physician's orders. Observations showed the resident struggling to eat independently, with significant food spillage, and staff interviews confirmed the lack of assistance.
A resident with multiple health conditions, requiring a two-person assist for transfers, was injured when a CNA attempted a solo transfer without a Hoyer lift. The resident hit their head, resulting in a superficial laceration. The incident was due to a lack of adherence to the care plan and poor communication among staff.
The facility failed to manage respiratory equipment properly for two residents, leading to deficiencies. A resident with respiratory conditions had an uncovered and undated nasal cannula, while another resident's nebulizer and suction equipment were similarly mishandled. LPNs confirmed the equipment should have been covered and dated, highlighting lapses in care standards.
The facility did not provide sufficient nursing staff to meet the needs and safety of residents, compromising their well-being. On a specific day, the facility's census was 110 residents, requiring 258.5 staffing hours, but only 256.5 hours were provided, resulting in a 2-hour shortfall. This deficiency was confirmed by the Interim DON.
A resident with cognitive impairments and a history of wandering was physically abused by another resident on two occasions, resulting in a laceration requiring medical attention. The facility failed to manage the aggressive behavior of the second resident, who had a history of delusions and aggression, leading to harm to the first resident.
A facility failed to report a resident-to-resident abuse incident within the required timeframe. A resident with a history of cerebral infarction and other conditions was found on the floor being kicked by another resident with a history of aggressive behavior. Despite the incident being reported to the DON by a CNA, a SIMS report was not completed, resulting in a deficiency in regulatory compliance.
A resident reported being physically and verbally abused by a CNA, but the facility failed to report the allegation to the State Survey Agency within the required 2-hour timeframe. The incident was not entered into the Statewide Incident Management System (SIMS) as mandated.
A facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse. The investigation lacked a timeline and signed statements from staff, despite the resident having intact cognition and reporting the abuse to the nurse and administrator. The administrator confirmed the incomplete documentation.
Failure to Maintain Documentation for Ongoing QAPI Program
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and maintained in an effective and comprehensive manner, as required by its own QAPI Policy and Procedure. The policy stated that the facility would develop, implement, and maintain an ongoing, facility-wide QAPI plan to monitor and evaluate the quality and safety of resident care, improve care quality, resolve identified concerns, and establish systems and processes to maintain documentation relative to the QAPI program. During the survey, the surveyor requested QAPI program information from the DON, and the binder provided by the DON and the regional representative lacked documentation for the facility’s QAPI program. In a subsequent interview with the DON, the administrator, and the regional representative, it was revealed that the facility was unable to locate its QAPI binder, which contained the documentation and evidence of its ongoing QAPI program, and the regional representative confirmed they could not provide evidence of the facility’s QAPI program due to the missing binder. This deficient practice had the potential to affect 131 residents residing in the facility. No specific residents, medical histories, or clinical conditions were described in the report beyond the total number of residents potentially affected.
Failure to Maintain and Produce QAPI Documentation and Performance Improvement Records
Penalty
Summary
The facility failed to provide documentation of an ongoing Quality Assurance and Performance Improvement (QAPI) program, including performance improvement activities and projects, during a survey. Based on record review and interviews, the facility could not produce evidence of the number or frequency of improvement projects conducted, nor any documented activities or projects addressing services under the QAPI program. Surveyors were not given documentation of systems and reports related to reporting, investigations, tracking, trending, and monitoring of identified issues, or any ongoing performance improvement plans. In an interview with the DON, the administrator, and a regional representative, it was revealed that the facility was unable to locate its QAPI binder, which contained the documentation and evidence of the facility’s QAPI program. This deficiency had the potential to affect all 131 residents residing in the facility.
Failure to Serve Roommates and Tablemates Simultaneously During Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity during meal service, including not serving residents seated at the same table simultaneously. During a dining room observation, three residents were seated together at one table, but only one resident received her meal tray while staff then proceeded to serve residents at other tables. More than 15 minutes later, the remaining residents at that table still had not received their meal trays. The weekend RN supervisor confirmed that residents seated at the same table should be served their meal trays at the same time, but this did not occur. The deficiency also includes the facility’s failure to serve meal trays at the same time to roommates who both received meals in their room. One resident, admitted with diagnoses including Type 2 diabetes without complications, bipolar disorder, hypertension, hyperlipidemia, mild cognitive impairment, and muscle weakness, had an intact cognition (BIMS score of 15) and was independent or required set-up assistance with ADLs. This resident reported that his roommate routinely received breakfast about an hour before he did, and at the time of interview he had not yet received his breakfast tray. Staff interviews revealed that two meal carts were used on the hallway, with the first cart arriving earlier and the second cart arriving after dining room residents were served. Observations confirmed that the resident still had not received his breakfast tray later that morning, while his roommate had received his tray with the first cart. The dietary manager confirmed that roommates who eat in their room should receive their trays at the same time and acknowledged this did not occur for this resident.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans and to follow existing care plans for multiple residents. For one resident with COPD, seizures, severe major depressive disorder, schizophrenia, and moderate cognitive impairment, the care plan identified a fall risk and required a fall mat on the floor next to the bed. The incident/accident log showed this resident had both witnessed and unwitnessed falls over several months. On three separate observations on the same day, the resident was found on the floor of the room in different positions, including with purple discoloration of the right arm, one shoe off, and pants around the ankles, and in each instance no fall mat was present despite the care plan requirement. The assistant administrator confirmed that the resident did not have a fall mat in the room as care planned. Another resident, admitted with COPD, asthma, schizoaffective disorder, major depressive disorder, impulse disorder, and movement disorder, had a quarterly MDS showing moderate cognitive impairment and a need for partial to maximal assistance with multiple ADLs, including bathing, dressing, transfers, personal hygiene, and footwear. Review of this resident’s care plan, initiated shortly after admission and due for review, revealed no information related to the resident’s ADL needs. During interview, the DON stated that all residents’ ADL needs should be care planned and confirmed that this resident’s ADL needs were not included in the care plan. A third resident with hemiplegia and hemiparesis following cerebral infarction, dysphagia, mood disorder, epilepsy, anxiety, PTSD, and a history of falling had a care plan indicating impaired range of motion requiring a splint/brace for the left hand, to be worn three hours a day to address difficulty with active motion and prevent contractures. Observation showed the resident in bed with a left-hand contracture and no splint/brace visible, and a brief search did not locate the device. The resident reported not having worn the splint/brace for a long time and not knowing its whereabouts, and a CNA stated she was unaware of any splint/brace for this resident. Further observation of the left hand revealed dark pink discoloration and peeling, surface-damaged skin in the palm. The DON confirmed the resident should have had a splint/brace as care planned but did not. In addition, another resident with anemia, hypertension, Parkinson’s disease, and respiratory symptoms had a physician’s order for scheduled ipratropium-albuterol nebulizer treatments, but review of the current care plan showed no care plan addressing these nebulizer treatments, which the MDS nurse confirmed should have been present.
Failure to Document Skin Injuries and Administer Ordered Insulin
Penalty
Summary
The facility failed to ensure services met professional standards of quality by not accurately assessing, documenting, and following up on multiple skin injuries for one resident. This resident was admitted with hypertension, neuroleptic-induced parkinsonism, protein-calorie malnutrition, and generalized anxiety disorder, and had a BIMS score of 3 indicating severe cognitive impairment, requiring varying levels of assistance with ADLs. The care plan directed staff to watch for changes in skin status and notify the physician of worsening wounds. On observation, the resident was seen in bed with blood on the forehead, a large bandage on the left hand, and uncovered skin tears on both arms. Physician orders dated in February directed specific cleansing, topical treatment, and dressing for multiple identified skin tears and an abrasion above the eye. However, nursing progress notes contained no initial assessment or documentation of these skin tears. The DON and treatment nurse both stated they did not know how the resident acquired the skin tears or forehead abrasion, and there were no incident reports. The weekend RN supervisor acknowledged that a CNA had reported the resident walked into a wall and had a scratch above the eyebrow, and that skin tears had occurred about two weeks earlier, but she had not completed incident reports or documented these events in the medical record, despite the DON confirming that injuries should be reported to the physician and family and documented. The facility also failed to ensure physician orders for insulin were implemented for another resident. This resident, with diagnoses including type 2 diabetes without complications, bipolar disorder, hypertension, hyperlipidemia, mild cognitive impairment, and muscle weakness, had an intact BIMS score of 15 and was independent with set-up assistance for ADLs. The physician’s order directed administration of 32 units of Tresiba subcutaneously at bedtime for type 2 diabetes. The resident reported not receiving several scheduled nighttime insulin doses. Review of the MAR for January and February showed multiple dates on which the ordered Tresiba dose was not administered. The DON confirmed that the insulin was not given on those dates and that there were no corresponding progress notes documenting any clinical reason for withholding the medication, and further confirmed the resident should have received Tresiba as ordered but did not.
Failure to Follow Puree Diet Menu for Bread Items
Penalty
Summary
The deficiency involves the facility’s failure to follow the prescribed puree diet menu for all six residents who required a puree diet. During a kitchen visit, a kitchen staff member reported that six residents were being served a puree diet. Observations showed that during a lunch meal, the kitchen staff did not puree the roll that was included on the lunch menu. In a subsequent interview, the same kitchen staff member confirmed that the roll on that day’s menu had not been pureed and further acknowledged that she had not been pureeing any bread items listed on the menu for an unspecified period of time for all six residents on puree diets. The dietary manager later confirmed that the kitchen staff did not follow the menu by failing to puree the roll, despite the expectation that it should have been pureed. These findings show that the facility did not ensure that the menu for puree diets was followed as written, specifically regarding bread items, for all residents receiving a puree diet, thereby failing to ensure the nutritional adequacy of the meal as planned for those residents.
Care Plan Code Status Inconsistent With Resident’s DNR Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s plan of care was consistent with the resident’s documented treatment preferences and advance directive. The facility’s Advance Directives Policy stated that each resident’s plan of care would align with their documented treatment preferences and/or advance directive. Review of the medical record for Resident #68, admitted on 12/23/2025 with diagnoses including hypertension, neuroleptic-induced parkinsonism, protein-calorie malnutrition, and generalized anxiety disorder, showed a physician’s order dated 01/16/2026 for LaPOST-DNR (Do Not Resuscitate), and the resident’s face sheet also indicated DNR status. However, review of the resident’s care plan with a target date of 04/11/2026 documented the resident as “Full Code” and included interventions indicating the resident had an advance directive for Full Code. During an interview, the DON and the LPN/MDS nurse confirmed that, despite the DNR physician order and DNR status on the face sheet, the resident was care planned as Full Code and acknowledged the care plan code status should have been DNR instead of Full Code. This discrepancy between the resident’s documented DNR order and the care plan coding constituted a failure to honor and accurately reflect the resident’s advance directive and treatment preferences in the care planning process, as required by facility policy.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
Surveyors identified a failure to provide necessary assistance with activities of daily living, specifically bathing, for one resident. The resident was admitted on 07/10/2025 with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Atrial Fibrillation, Paranoid Schizophrenia, Major Depressive Disorder, Heart Failure, and Lack of Coordination. A Quarterly MDS with an ARD of 01/05/2026 showed a BIMs score of 9, indicating moderate cognitive impairment, and documented that the resident required partial/moderate assistance with bathing. The resident’s care plan also indicated a need for staff assistance with ADL care, including bathing. Review of the bathing task documentation for the prior 30 days showed the resident received whirlpool baths on 02/06/2026, 02/17/2026, and 02/19/2026, but there was a 10-day gap from 02/07/2026 through 02/16/2026 with no evidence that bathing services were provided or refused. During an interview on 02/22/2026, the resident reported not consistently receiving baths as scheduled. On 02/24/2026, a CNA stated that completed baths and refusals are documented in the facility bath log and in the electronic medical record and confirmed there was no documentation of a bath or refusal for this resident during the 10-day gap. The clinical education staff member also confirmed there was no documentation in either the electronic medical record or bath log for that period and acknowledged that the resident should have received scheduled baths but did not.
Failure to Properly Store and Date Nebulizer Equipment
Penalty
Summary
Facility policy titled "Oxygen Concentrator Cleaning Policy and Procedure" directed that oxygen tubing, cannulas, and masks be stored in a plastic bag when not in use and be changed weekly and as needed. Resident #10, admitted on 01/02/2025, had diagnoses including anemia, Parkinson’s disease without dyskinesia, other specified symptoms and signs involving the circulatory and respiratory systems, and a personal history of pneumonia. Physician orders from 11/24/2025 directed that the resident receive Ipratropium-Albuterol inhalation solution via nebulizer every six hours for respiratory symptoms. On 02/22/2026 at 1:55 p.m., surveyor observation revealed a nebulizer machine on the resident’s bedside table with the nebulizer mask lying on top of the machine, uncovered and undated, contrary to the facility’s policy requiring such equipment to be covered and dated. In an interview shortly thereafter, an LPN confirmed that the resident received routine breathing treatments, that she had administered a treatment earlier that day, and that the nebulizer mask and tubing should have been covered and dated but were not. This failure to follow the facility’s oxygen equipment storage and maintenance policy for Resident #10’s nebulizer mask and tubing constituted the cited deficiency.
Failure to Follow Therapeutic Diet and RD Supplement Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with the ordered therapeutic diet and nutritional supplements. The resident, admitted with diagnoses including paraplegia, COPD, essential hypertension, and neuromuscular bladder dysfunction, had a physician’s order dated 10/25/2025 for a no added salt (NAS) diet with regular texture, thin liquids, and double meat, with paper tray setup. The resident’s care plan also specified that the diet should be served as ordered. On observation of a lunch meal on 02/23/2026, the resident’s meal ticket listed NAS, regular texture, and thin liquids but did not include the double meat order, and the tray contained only one piece of fried chicken breast. The resident stated he never receives double portions of meat, and the dietary manager confirmed that the resident’s diet included double meat and that it should have been on the meal ticket but was not. The facility also failed to implement and/or document the registered dietitian’s recommendations for oral nutritional supplements and weight monitoring. RD notes dated 12/23/2025 and 01/23/2026 recommended adding Boost/Ensure twice daily between meals to provide additional protein and calories for wound healing and weight maintenance, along with weekly weights for four weeks. The RD later confirmed she had provided these recommendations to the facility. Review of the record showed no documentation that these recommendations were transcribed into physician orders or, if not approved, documented in nursing notes. The DON confirmed that the resident did not have an order for Boost/Ensure twice daily, despite the RD’s recommendations.
Failure to Maintain Effective Pest Control Resulting in Gnat Infestation in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control environment as required by its Pest Control Policy and Procedure, which states the building shall be kept free of insects and rodents through an ongoing pest control program. During multiple observations of one resident’s room on 02/23/2026 at 7:51 a.m., 8:50 a.m., and 9:20 a.m., surveyors observed multiple gnats on a basket of soiled clothes and flying around on top of the basket. The facility’s Nursing Services Administrator acknowledged that multiple gnats were present in the resident’s room and that they should not have been there, and the Chief Environmental Services staff member later confirmed these findings. This deficient practice resulted in the facility not being free from insects as required by its own pest control policy and had the potential to affect all 131 residents residing in the facility.
Failure to Ensure Bearded Kitchen Staff Wore Required Hair Restraints
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen and to store, prepare, and serve food in accordance with professional food service safety standards when kitchen staff did not use required hair restraints. During an observation of the kitchen on 02/23/2026 at 12:15 p.m., three male kitchen workers with beards were seen preparing food, serving food, and washing dishes without wearing beard restraints. An interview at 12:17 p.m. with the Dietary Manager confirmed that beard restraints were readily available to male workers with beards and that these workers should have been wearing them but were not. This deficient practice had the potential to affect all 131 residents who received meals from the facility’s kitchen, as all residents were served food prepared and handled in this environment where beard restraints were not consistently used by bearded kitchen staff.
Failure to Maintain Quarterly QAA Committee Meeting Documentation
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly as required. Record review of the facility’s Quality Assurance binder showed the last documented QAA meeting occurred on 10/15/2025 for the 3rd quarter of 2025 (July–September). There was no documentation available to show that a QAA meeting was held for the 4th quarter of 2025. During an interview on 02/24/2026, the administrator stated that the QAA committee did meet for the 4th quarter and that the minutes were kept in the QAPI binder, but the facility was unable to locate that binder, and the administrator acknowledged having no documented evidence that the 4th quarter QAA meeting occurred. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency centers solely on the lack of documented quarterly QAA committee activity and records for the specified time period.
Failure to Provide Scheduled Bathing Assistance and Documentation
Penalty
Summary
Multiple residents with significant medical conditions, including Chronic Obstructive Pulmonary Disease, Type II Diabetes, Benign Prostatic Hyperplasia, Morbid Obesity, Cerebral Palsy, Bipolar Disorder, and Severe Intellectual Disabilities, did not receive bathing assistance as required by their care plans. Documentation revealed that residents who required moderate to total assistance with bathing received significantly fewer baths than scheduled, with some receiving only one or two baths in a 30-day period despite care plans specifying three times weekly. Interviews with staff and review of both electronic and handwritten records confirmed insufficient documentation and a lack of routine provision of bathing care. Residents expressed that they had not received baths as expected, and staff, including the DON and CNA Supervisor, acknowledged that the required care was not provided consistently. The facility's policy mandates that residents receive necessary care to maintain their highest practicable well-being, but the failure to provide scheduled bathing and to document care as required led to a deficiency in meeting residents' basic hygiene needs.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. According to the facility's policy, any alleged violation of abuse, neglect, exploitation, or mistreatment must be reported within two hours if it involves abuse or results in serious bodily injury. In this case, a staff member from a third-party company reported to the facility administrator that she had witnessed a facility staff member curse at a resident in front of others after the resident urinated on the floor. The incident was discussed with facility staff, and notes were made regarding the investigation. Despite being informed of the incident, the administrator did not report the allegation to the Department of Health, as required, because he did not believe it was warranted based on his findings, including the delay in reporting and the resident's lack of recollection of the event. The administrator confirmed that no report was made through the Statewide Incident Management System (SIMS) after becoming aware of the alleged verbal abuse. The resident involved had a medical history including Chronic Obstructive Pulmonary Disease, Type II Diabetes, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Obstructive and Reflux Uropathy.
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 the specified date, one resident with a history of cerebral infarction, hemiplegia, diabetes, and schizoaffective disorder, and with moderately impaired cognition, attempted to prevent his roommate from leaving their shared room. This interaction escalated into a physical altercation, during which the resident was struck in the face by his roommate, resulting in facial bruising and a contusion that required emergency department evaluation and treatment. Prior to the incident, multiple staff members, including CNAs, were made aware of escalating threats of physical harm from the aggressor resident, who had a history of bipolar disorder, intellectual disabilities, and severely impaired cognition. These threats were reported to an LPN and subsequently to the DON. Despite these warnings, no new interventions or orders were obtained, and the primary care provider or nurse practitioner was not notified of the threats. The administrator was also not informed of the behavioral issues or threats prior to the altercation. The facility's policy on abuse prevention and prohibition was not followed, as residents must not be subject to abuse by anyone, including other residents. The lack of timely intervention and communication among staff and leadership contributed to the failure to prevent the physical abuse, resulting in actual harm to the resident.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse incidents to the State Survey Agency as required by both facility policy and regulatory guidelines. Specifically, an allegation of staff-to-resident sexual abuse involving a resident with moderate cognitive impairment and multiple psychiatric and medical diagnoses was not reported to the Statewide Incident Management System (SIMS) within the mandated two-hour timeframe, nor was it reported at all. The Director of Nursing (DON) was notified of the allegation and informed the Administrator, who decided not to report the incident, believing it was not necessary. Additionally, an allegation of resident-to-resident physical abuse involving another resident with significant cognitive and physical impairments was also not reported to SIMS. The DON, who was responsible for reporting, did not enter the incident into the system due to lack of administrative approval. The Administrator confirmed awareness of the incident but chose not to initiate a report, stating it was not warranted. These actions resulted in the failure to comply with required abuse reporting protocols for two of four sampled residents.
Failure to Timely Administer Prescribed Antibiotic
Penalty
Summary
A deficiency occurred when the facility failed to provide a prescribed antibiotic in a timely manner to a resident with multiple complex diagnoses, including chronic osteomyelitis, cerebral infarction, hemiplegia, epilepsy, and a history of urinary tract infections. The resident was admitted with these conditions and later developed symptoms of dysuria and altered mental status, prompting a urinalysis with culture and sensitivity. The preliminary lab results were available in the facility's electronic medical record system on the same day the sample was collected. However, the order for the antibiotic Cefdinir was not entered until the following day, with a start date set for yet another day later. Despite the availability of the antibiotic in the facility's emergency kit, the resident did not receive the medication on the day it was ordered. Further complicating the situation, the resident reported an allergy to Cefdinir after the order was placed, leading to a change in the prescribed antibiotic to Macrobid. The Assistant Director of Nursing confirmed that the resident should have received the antibiotic from the emergency kit on the day it was ordered, but this did not occur. The surveyor was unable to reach the nurse responsible for entering the original order during the investigation.
Failure to Administer Ordered Enteral Feedings
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral palsy, aphasia, mild protein calorie malnutrition, gastrostomy status, dysphagia, type 2 diabetes mellitus, and bipolar disorder, did not receive enteral feedings as ordered by the physician. The resident's care plan specified the need for a PEG tube for adequate nutritional intake and required tube feedings to be administered according to physician orders. The physician's orders included continuous Glucerna 1.5 feedings via pump overnight, scheduled bolus feedings, and water flushes. On the morning of the survey, observation revealed that the resident's feeding tube was not connected, and the feeding pump was turned off, despite the presence of a full bag of Glucerna and water hanging on the pole. Interviews with nursing staff confirmed that the overnight continuous feeding had not been administered as ordered, and there was no documentation or report of the resident refusing the feeding. The DON confirmed that the resident should have received the ordered continuous feeding but did not.
Failure to Document Wound Care Administration or Refusal
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that a resident's medical record accurately reflected whether physician-ordered wound care was implemented or refused. Specifically, for one resident with multiple complex diagnoses, including chronic osteomyelitis, hemiplegia, peripheral vascular disease, and an unhealed, unstageable pressure ulcer, there was no documentation on the Treatment Administration Record (TAR) indicating that wound care was provided or refused on two consecutive days, as required by both physician orders and facility policy. Facility policy required that skin and wound care be documented upon admission, readmission, weekly, and as needed, with each dressing change or at least weekly, including the date and time of treatments. Review of the resident's care plan and physician orders confirmed the need for daily wound care to the left lateral foot. During interviews, facility staff confirmed the absence of documentation for the specified dates and acknowledged that, if care had been refused, this should have been recorded on the TAR but was not.
Failure to Provide Scheduled Bathing Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to a resident who was unable to perform these tasks independently. The resident, who had multiple complex medical conditions including chronic osteomyelitis, hemiplegia, and a documented unhealed pressure ulcer, required moderate assistance for bathing and was dependent for all transfers. According to the care plan, the resident was to receive assistance with bathing, hygiene, and grooming. However, a review of the electronic health record and facility documentation revealed that the resident received only three documented baths in the past 30 days, despite being scheduled for three baths per week. Interviews with staff and review of the facility's bath schedule and refusal binder indicated inconsistencies in documentation, with some staff stating the resident did not refuse care, while others noted refusals that were not consistently documented in the medical record. The deficiency was further substantiated by the resident's own report of not having received a bath in two weeks and expressing a desire for daily bathing. The facility's system for tracking refusals and bath schedules was found to be inadequate, as the resident was overlooked in the process and not all refusals or missed baths were properly recorded. The Director of Nursing acknowledged the lack of documentation and the failure to provide the scheduled care, confirming that the resident had not received a bath within the past two weeks as required by their care plan.
Failure to Maintain Sanitary and Orderly Facility Environment
Penalty
Summary
Surveyors observed multiple instances of inadequate housekeeping and maintenance services within the facility, resulting in unsanitary and disordered conditions. In one resident's room, the floor was found to have hair and a dark brown substance near the bed, while the wall near the bed had a moderate amount of a splattered tan and pink substance. The window blinds in the same room were broken and in disrepair. These conditions persisted over several days, as confirmed by repeated observations and interviews with the resident, who stated that the wall and blinds had been in this state for some time and expressed a desire for them to be cleaned and replaced. Additional observations included a large puddle of yellow liquid on the floor in another room, accompanied by a strong urine odor, which was confirmed by a corporate staff member to be unsanitary and in need of cleaning. In a hallway near another room, a ceiling tile was found to have a moderate amount of mold, reportedly due to a leak that had been ongoing for several weeks. Housekeeping and maintenance staff confirmed that the issue had been reported but not resolved, and the ceiling tile required replacement. These findings indicate a failure to maintain a sanitary and orderly environment for residents, staff, and the public.
Failure to Perform Ordered Weights and Obtain Wound Care Orders
Penalty
Summary
The facility failed to provide care and services that meet professional standards of quality by not performing resident weights as ordered and not obtaining physician orders for wound care. Specifically, three residents with significant weight loss or at risk for weight changes were not weighed weekly as required by facility policy and as recommended by the registered dietician. For example, one resident experienced a 5% weight loss over 30 days and was not weighed weekly after this was identified, another resident was not weighed weekly as indicated in their care plan, and a third resident with significant weight loss also missed weekly weights despite dietician recommendations. These lapses were confirmed by the Director of Nursing (DON) during interviews, who acknowledged that the required weekly weights were not performed. Additionally, the facility failed to input physician orders for wound care for a resident with active wounds. Observation revealed bandages on both forearms of the resident, but there were no active treatment orders for these wounds in the medical record. The treatment nurse and DON both confirmed that physician orders should have been in place for all active wounds, but were not obtained for this resident.
Failure to Provide Accessible Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents received reasonable accommodation for their needs and preferences regarding access to call lights. For one resident with a history of spondylolisthesis, neuromuscular dysfunction of the bladder, hemiplegia, and other conditions resulting in total dependence and limited use of fingers and arms, the call bell was repeatedly observed out of reach, placed on the bedside table away from the bed. The resident reported being unable to use the call bell unless it was placed near her fingers and stated she had to yell for help or rely on her roommate. The responsible party also confirmed that the call bell was not consistently within reach during visits. Facility staff, including the DON, confirmed through observation and interview that the resident was physically incapable of using the standard call bell. Another resident, with diagnoses including paroxysmal atrial fibrillation, respiratory failure, heart disease, malnutrition, and psychiatric disorders, was also found to have the call bell inaccessible, clipped to a light over the bed and out of reach. This resident, who required substantial assistance with activities of daily living and had moderately impaired cognition, stated he had to holler for assistance due to the call light not being accessible. Staff confirmed that the call bell was not within reach and that the resident was unable to utilize it due to physical limitations. Facility policy required that call lights be placed on the bed and within reach at all times, but this was not followed for these residents.
Failure to Perform Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a nurse failed to perform proper hand hygiene during the treatment of multiple pressure ulcers for a resident. The resident, who was totally dependent on staff for all activities of daily living and had intact cognition, was admitted with several medical conditions including spondylolisthesis, neuromuscular dysfunction of the bladder, major depressive disorder, hemiplegia, and a history of urinary tract infection. Physician orders required specific wound care for five separate pressure ulcers, including cleansing, application of medihoney and calcium alginate with silver, and covering with dry dressings. During an observed wound care session, the nurse did not perform hand hygiene with alcohol-based hand rub or handwashing when changing gloves or between the care of each of the resident's five pressure ulcers. The nurse later confirmed in an interview that she did not perform hand hygiene during the wound care and believed it was only necessary between residents or if hands were visibly soiled. The Director of Nursing confirmed that hand hygiene should have been performed when changing gloves and between the care of each wound, but it was not done in this instance.
Medication Error: Omission of Prescribed Amiodarone Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident was free from medication errors by not administering a prescribed medication as ordered upon the resident's return from hospitalization. Specifically, the resident, who had multiple diagnoses including Paroxysmal Atrial Fibrillation, heart failure, and psychiatric disorders, was discharged from the hospital with an updated medication list that included Amiodarone HCL 400mg to be taken every morning. Upon review of the resident's medical record, physician orders, and MAR for June 2025, it was found that Amiodarone was not initiated after the resident's re-entry to the facility. Interviews with the nurse practitioner and the Director of Nursing confirmed that the medication was overlooked and not administered as directed in the hospital discharge paperwork. The resident, who had moderately impaired cognition and required substantial assistance with activities of daily living, did not receive the medication as ordered, constituting a medication error. There were no reported adverse reactions related to this omission at the time of the survey.
Failure to Provide Ordered Wound Care Leads to Cellulitis
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the resident's person-centered plan of care for a resident who sustained a skin tear on the right elbow following a fall. The resident, who had severe cognitive impairment and used a manual wheelchair, did not receive the ordered wound care on multiple occasions. Despite a physician's order on 02/23/2025 to clean the wound, apply Triple Antibiotic Ointment, and cover it with a clean dry dressing, the treatment was not administered on 02/23/2025, 02/24/2025, and there was no documentation of care on 02/25/2025. This lack of care led to the development of cellulitis, requiring antibiotic treatment. Interviews with facility staff revealed discrepancies in the documentation and administration of wound care. The Director of Nursing (DON) admitted to signing off on the Treatment Administration Record (TAR) for dates when care was not provided, based on the assumption that it had been done. The Assistant Director of Nursing (ADON) confirmed that no wound care had been provided since the incident. The treatment nurse was unaware of the wound until 02/26/2025, when the resident was diagnosed with cellulitis. This series of inactions and miscommunications resulted in harm to the resident, highlighting a significant deficiency in the facility's care practices.
Inaccurate Documentation of Wound Care for a Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who sustained a fall resulting in a wound to the right elbow. On the day of the incident, a Registered Nurse (RN) notified the provider and received an order for wound care, but this order was not documented or entered into the system. The Director of Nursing (DON) later realized the oversight and entered the order with a backdated start date. Despite the order being received, the wound care was not documented as performed on the specified dates. The DON admitted to initialing the Treatment Administration Report (TAR) for wound care on two dates, even though she did not personally perform the care, because the nurse responsible had not initialed it. This resulted in inaccurate documentation in the resident's medical records. The DON confirmed that she did provide wound care on a subsequent date but failed to document it, further contributing to the inaccuracy of the resident's medical records.
Failure to Follow Care Plans for Lab Tests and Wound Care
Penalty
Summary
The facility failed to provide services according to the residents' care plans for two residents. For one resident, the facility did not follow the physician's orders for monthly Trileptal lab tests, missing results for several months. This resident had a history of Type 2 Diabetes Mellitus, Cerebellar Stroke Syndrome, and a seizure disorder, which required regular monitoring of Trileptal levels as part of their care plan. The Interim Director of Nursing confirmed that the lab tests were not conducted as required. Another resident did not receive wound care as ordered by the physician. This resident, who had a surgical wound, was supposed to have daily wound care, but the treatment was not performed on a specific day when the resident was out for an Intensive Outpatient Program. The nursing staff failed to communicate effectively, resulting in the wound care not being administered upon the resident's return. Interviews with various staff members revealed a lack of communication and coordination, leading to the oversight in wound care treatment.
Failure to Maintain Clean and Safe Equipment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for its residents, specifically concerning the cleanliness and repair of patient care equipment. Resident #52's wheelchair and cushion were observed to be soiled with a brown substance over several days, indicating a lack of proper cleaning and maintenance. Interviews with staff, including a CNA, LPN, and the Housekeeping Supervisor, revealed confusion and lack of clarity regarding responsibility for cleaning the wheelchairs. The Assistant Director of Nursing (ADON) acknowledged that it was everyone's responsibility to clean visibly soiled wheelchairs but was unsure of a scheduled cleaning day, ultimately placing the responsibility on housekeeping. Additionally, Resident #39's wheelchair was found to have cracks and tears in the arm pads, exposing the material underneath. This condition had persisted for about two years, as confirmed by the resident and a CNA who had been working since September 2024. The Maintenance staff was unaware of the disrepair, indicating a failure in reporting and addressing equipment maintenance issues. These deficiencies highlight a lack of adherence to the facility's policy on maintaining reusable medical devices, potentially compromising resident safety and comfort.
Incorrect MDS Discharge Encoding for Resident Transfer
Penalty
Summary
The facility failed to accurately encode and transmit a Discharge MDS Assessment for a resident, leading to a deficiency. The resident, who had a complex medical history including Bipolar Disorder, Sepsis, Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, and Hypertension, was admitted to the facility and requested a transfer to a sister facility after staying only one night. The resident's discharge was incorrectly recorded as an unplanned, facility-initiated discharge instead of a planned, resident-initiated discharge. Interviews with facility staff revealed that the MDS Coordinator, S18, mistakenly input the discharge data as facility-initiated. This error was confirmed by the Assistant Director of Nursing, S3, who acknowledged that the MDS transmission report was completed incorrectly. The discrepancy in the discharge coding was identified during a review of the facility's MDS transmission report, which showed the incorrect Assessment Reference Date and discharge type for the resident.
Failure to Implement Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not implementing physician's orders as prescribed for a resident receiving tube feeding. The resident, who has a complex medical history including cerebral infarction, schizoaffective disorder, and dysphagia, was supposed to receive continuous enteral feeding of Glucerna 1.5 at 55 ml/hr and water at 45 ml/hr via a PEG tube. However, observations on a specific day revealed that the resident was not receiving the prescribed continuous feeding, and instead, a bottle of Jevity 1.5, which was not the ordered formula, was found hanging and disconnected from the resident. Interviews with facility staff, including an LPN and the interim DON, confirmed that the incorrect formula was administered and that the continuous feeding had not been maintained as ordered. The LPN admitted to hanging the last bottle of the correct formula, Glucerna 1.5, on a previous evening, indicating a lapse in following the physician's orders. This deficiency was confirmed by the interim DON and the assistant DON, highlighting a failure in ensuring that the resident's nutritional needs were met according to professional standards and physician directives.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #52, during meal times, which is a violation of their Meal-Time Assistance Policy. Resident #52, who has a history of Huntington's disease, contracture of the right hand, drug-induced subacute dyskinesia, and vitamin deficiency, requires assistance with activities of daily living, including eating. The resident's care plan and physician's orders specify that they need assistance with meals and should be seated at the assist table. However, during observations on two separate days, Resident #52 was not provided with the required assistance during meals, resulting in food being dropped and the resident struggling to eat independently. On the first observation, Resident #52 was seen eating without assistance, dropping food, and struggling due to arm tremors. The CNA interviewed stated that the resident usually feeds himself and does not sit at the assistance table, contradicting the care plan. On the second observation, although seated at the designated assistance table, Resident #52 was again left to eat without help, consuming 80% of the meal but with difficulty and food spillage. The resident expressed a need for assistance, which was not provided until prompted by the surveyor. Interviews with staff confirmed that the resident should have been assisted, highlighting a failure in adhering to the facility's policy and care plan requirements.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure staff followed a resident's person-centered plan of care by not using the required two-person physical assistance during a transfer. This deficiency involved a resident with a history of hypertensive heart disease with heart failure, schizoaffective disorder, major depressive disorder, and peripheral vascular disease. The resident, who had intact cognition and required a two-person assist for bed mobility and transfers, was transferred by a single CNA without the use of a Hoyer lift, contrary to the care plan. During the transfer, the resident tensed and jerked backward, resulting in a head injury. The incident occurred when the CNA attempted to transfer the resident alone after calling for help and receiving no response. The resident hit his head on the wooden headboard, causing a superficial laceration with moderate bleeding. The facility's MD assessed the resident, determined the laceration was superficial, and ordered neuro checks. The incident highlighted a failure in communication and adherence to the care plan, leading to the resident's injury.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents, leading to deficiencies in the handling and storage of respiratory equipment. Resident #81, who has a history of Chronic Obstructive Pulmonary Disease, Asthma, and other respiratory conditions, was observed with a nasal cannula lying uncovered and undated on top of an oxygen concentrator. This observation was confirmed by an LPN, who acknowledged that the equipment should have been properly covered and dated. The resident's care plan indicated the need for oxygen during respiratory crises, yet the equipment was not maintained according to these standards. Similarly, Resident #67, who has multiple diagnoses including Cerebral Infarction and Schizoaffective Disorder, was observed multiple times with a nebulizer concentrator and respiratory suction that were uncovered and undated. Despite the resident's care plan specifying the need for respiratory therapy and monitoring for medication effectiveness, the equipment was not properly managed. An LPN confirmed that the equipment should have been covered and dated, indicating a lapse in adherence to professional standards for respiratory care within the facility.
Insufficient Nursing Staff on Specific Day
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available at all times to meet the needs and safety of residents, which compromised their rights, physical, mental, and psychosocial well-being. On 09/28/2024, the facility's census was 110 residents, and the minimum staffing hours required for that day was 258.5 hours. However, the facility only provided 256.5 nursing hours, falling short by 2 hours. This deficiency was confirmed by the S2 Interim Director of Nursing (DON) during an interview, acknowledging the shortfall in staffing hours necessary to meet the residents' needs and safety.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident on two separate occasions. On the first incident, a resident with a history of wandering and cognitive impairments entered another resident's room, leading to a physical altercation. The resident was found on the floor being kicked by the other resident, resulting in no immediate injuries reported by the Director of Nursing (DON). However, the resident was later involved in another incident where he was pushed from behind by the same resident, causing him to fall and sustain a laceration to his lip that required emergency medical attention. The resident who was abused had a complex medical history, including cerebral infarction, chronic kidney disease, schizoaffective disorder, and a history of traumatic brain injury, which contributed to his cognitive impairments and wandering behavior. His care plan noted the need for increased supervision due to his unsteady gait and history of falls. Despite these precautions, the resident was not adequately protected from the aggressive behavior of another resident, who had a history of physically and verbally aggressive behavior and was known to have delusions and refusal of care. The second resident involved in the incidents had intact cognition but displayed aggressive behaviors, including delusions and a history of pacing and wandering. The facility's failure to effectively manage and separate these residents, despite their known behavioral issues, resulted in physical harm to the first resident. The incidents highlight a deficiency in the facility's ability to ensure the safety and protection of its residents from abuse by others within the facility.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe to the State Survey Agency. The incident involved a resident with a history of cerebral infarction, chronic kidney disease, schizoaffective disorder, and other conditions, who was found on the floor being kicked by another resident. The resident who was the aggressor had a history of schizoaffective disorder, bipolar type, and displayed physically and verbally aggressive behavior. Despite the incident being reported to the Director of Nursing (DON) by a Certified Nursing Assistant (CNA), the DON did not complete a SIMS report for the incident. The incident occurred when a CNA heard a noise from the room of the resident with aggressive behavior and found the other resident on the floor being kicked. The aggressor admitted to the actions when questioned. The facility's failure to report the incident within two hours, as required for allegations involving abuse, constitutes a deficiency in adhering to regulatory requirements for reporting suspected abuse, neglect, or mistreatment.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of staff-to-resident physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Resident #1, who had a BIMS score of 13 indicating intact cognition, reported that approximately two weeks prior, a CNA hit him with a fan on his back and head, and then took him to a shower room where she hit him with a plastic hanger on various parts of his body. Resident #1 also reported verbal abuse, including being called derogatory names. He stated that he reported the incident to a nurse on duty that evening and to the facility administrator the following morning. The facility administrator confirmed that she was notified of the allegation on 02/26/2024, and that the alleged incident occurred on 02/25/2024. Despite this, the allegation was not entered into the Statewide Incident Management System (SIMS) as required. The failure to report the incident within the mandated timeframe constitutes a deficiency in the facility's adherence to its abuse prevention and prohibition policy.
Failure to Thoroughly Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that an allegation of staff-to-resident physical abuse was thoroughly investigated for one of the sampled residents. The facility's policy requires a thorough investigation, including interviews with employees, obtaining signed statements, and interviewing the resident if cognitively able. However, the investigation documentation for the resident in question lacked a timeline of the investigation and signed statements from staff. The resident, who had intact cognition, reported being physically abused by a CNA, including being hit with a fan and a plastic hanger, and subjected to derogatory language. The resident reported the incident to a nurse and the administrator the following morning. The administrator confirmed that she was notified of the allegation and conducted interviews with the resident, the resident's roommate, and the involved CNAs. However, she did not obtain written statements from the staff or the roommate. The administrator acknowledged that the investigation documentation was incomplete, lacking a timeline and signed statements, which is a violation of the facility's policy on abuse prevention and prohibition.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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