Meadowview Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minden, Louisiana.
- Location
- 400 Meadowview Drive, Minden, Louisiana 71055
- CMS Provider Number
- 195281
- Inspections on file
- 30
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Meadowview Health & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, tracheostomy, and dependence on staff for ADLs did not receive the ordered oral hygiene care every shift as outlined in the care plan. The care plan required morning and nighttime oral care, but observation revealed white debris on the resident’s lips, and staff interviews showed that CNAs and an RT had differing understandings of who was responsible for providing oral care. An LPN confirmed the resident had not received oral care the previous day, and leadership confirmed that CNAs were responsible for providing oral care each shift and that this had not occurred.
A resident with severe cognitive impairment, multiple sclerosis, hemiplegia, and a Stage 4 sacral pressure ulcer had physician orders and a care plan for sacral wound care three times weekly and as needed when soiled. During an observed treatment, a treatment nurse removed a saturated sacral dressing and completed the ordered wound care while leaving a soiled brief in place, then secured the same soiled brief on the resident afterward and replaced the bed linens. The nurse acknowledged the brief was soiled during treatment, and the DON stated the brief should have been changed before and not left on after the wound care, contrary to the facility’s pressure injury prevention policy requiring residents to be kept clean and dry.
A resident with chronic respiratory failure, lumbar osteomyelitis, complete paraplegia, a sacral pressure ulcer, and a tracheostomy had only one documented face-to-face physician visit during an extended stay, despite requirements for physician evaluation at least every 60 days. Record review showed a single visit shortly after admission with no further face-to-face physician encounters documented, and the DON confirmed that additional 60-day visits should have occurred but did not.
A resident with significant physical and mental health needs, who required substantial assistance for bathing, did not receive this care for a two-week period. Staff incorrectly documented bathing as 'not applicable' instead of providing and recording the required ADL care, as confirmed by interviews with the resident and facility staff.
A resident with multiple serious diagnoses, including heart failure and kidney failure, was prescribed Furosemide for edema. Despite care plan and physician orders requiring monitoring, staff did not document or monitor the resident's edema while the diuretic was administered. This lapse was confirmed by both an LPN and a corporate nurse during interviews.
A resident with diabetes, an open wound, and dementia was transferred to the hospital without a required head to toe skin assessment by an LPN, and a CNA failed to report a newly observed skin injury. The facility did not follow its policy for skin integrity monitoring and notification of changes in skin status.
A facility failed to prevent pressure ulcers for a resident with severe cognitive impairment and multiple medical conditions. Despite a care plan requiring repositioning every two hours, there was no documentation of these actions on specific shifts, leading to the development of a stage 2 pressure ulcer. Interviews confirmed the lack of adherence to the care plan.
A resident with severe cognitive impairment suffered a fall resulting in a right femur fracture. The facility failed to report the injury of unknown source with serious bodily injury to the state agency within the required 2-hour timeframe, as per their Abuse Prohibition Policy. The incident was reported approximately 12 hours after the injury was confirmed by x-ray.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and multiple fractures. The care plan lacked measurable objectives and timeframes, and necessary interventions, such as monitoring a cast and using a stabilizer, were not implemented. This deficiency was confirmed by the Corporate Nurse during an interview.
A facility failed to ensure residents were free from accident hazards by not completing quarterly fall risk assessments and not implementing specific interventions for a resident with severe cognitive impairment. The resident experienced a fall resulting in a femur fracture, and interviews confirmed the absence of documented interventions and adherence to the facility's Fall Prevention Program policy.
A CNA in an LTC facility failed to follow the Incident/Accident policy by moving a resident found on the floor before a nurse's assessment. The resident, with severe cognitive impairment and multiple health issues, was at risk for falls. The CNA's actions did not align with the facility's procedures, as confirmed by the DON.
The facility failed to complete a discharge assessment for a resident who was sent to the hospital due to worsened wounds and abnormal vital signs. Both the MDS RN and the Corporate Nurse confirmed that the discharge MDS was not completed as required.
The facility failed to apply splints as ordered for two residents with limited range of motion. One resident with anoxic brain damage and muscle atrophy did not have bilateral hand splints applied on multiple dates, and another resident with Parkinson's disease and muscle wasting did not have a right-hand splint applied on several dates. Observations and staff interviews confirmed these deficiencies.
The facility failed to change the enteral feeding container every 24 hours for a resident with multiple medical conditions, as required by physician's orders. Observations and staff interviews confirmed the deficiency.
The facility failed to ensure annual performance reviews for three CNAs, as their personnel records lacked evidence of such reviews. The Administrator confirmed the absence of these reviews during an interview.
The facility failed to ensure that a resident with moderate cognitive impairment and multiple medical conditions had access to a call light, as it was repeatedly found on the floor behind the bed. The resident confirmed the inability to reach the call light, and a CNA verified this observation.
The facility failed to ensure proper garbage disposal, as multiple trash bags and loose trash were found scattered around the dumpster, and the dumpster lids were not closed. The Maintenance Director confirmed the trash should be inside the dumpster and the lids should be closed.
Failure to Provide Ordered Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary oral hygiene care as outlined in the care plan. The resident was admitted with diagnoses including sequelae of cerebral infarction, acute respiratory failure with hypoxia, aphasia, tracheostomy, and gastrostomy, and had an ADL self-care performance deficit related to cardiovascular accident and respiratory failure. The care plan specified an oral care routine in the morning and at night, including brushing teeth, cleaning gums with a toothette, and rinsing the mouth. An MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for oral hygiene. On observation, the resident was noted to have a tracheostomy and lips covered with white debris, and the respiratory therapist acknowledged that oral care was needed and stated that CNAs were responsible for providing oral care and that it should have been done. An LPN reported that she cared for the resident and that the resident did not receive oral care the previous day and was unsure how often CNAs provided oral care. A CNA stated she did not provide oral care because she believed the respiratory therapist did so. The ADON confirmed that oral care was in the resident’s plan of care, that CNAs were responsible for providing oral care every shift, and that the resident should have received oral care, demonstrating that the ordered oral hygiene interventions were not carried out as required.
Failure to Maintain Clean, Dry Conditions During Sacral Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with its own pressure injury prevention policy and professional standards of practice for a resident with a Stage 4 sacral pressure ulcer. The facility’s policy required residents to be kept clean and dry and to receive appropriate incontinent care as part of pressure injury prevention and treatment. The resident had multiple significant diagnoses, including multiple sclerosis, a Stage 4 sacral pressure ulcer, altered mental status, and hemiplegia/hemiparesis, and was documented as severely cognitively impaired and dependent on staff for toileting and personal hygiene. Physician orders and the resident’s care plan directed that the sacral area be cleaned with wound cleanser, Ioplex applied, and the area covered with a super absorbent dressing three times weekly and as needed if soiled. During an observed wound care treatment, the treatment nurse removed a saturated dressing from the resident’s sacral area and performed the ordered wound care while leaving a soiled brief in place. After completing the wound care and securing the new dressing, the nurse repositioned and secured the same soiled brief on the resident and replaced the bed linens without changing the brief. The treatment nurse acknowledged during interview that the brief was soiled during the wound care treatment. The DON later stated in interview that the soiled brief should have been changed prior to starting wound care and should not have been left on the resident after the wound care was completed.
Failure to Ensure Required Face-to-Face Physician Visits Every 60 Days
Penalty
Summary
The facility failed to ensure that a resident was seen face to face by a physician at least once every 60 days as required. Record review showed that the resident was admitted on 04/11/2025 with multiple serious diagnoses, including chronic respiratory failure, osteomyelitis of the lumbar vertebra, complete paraplegia, a sacral pressure ulcer, and a tracheostomy requiring ongoing attention. From admission on 04/11/2025 through discharge on 11/22/2025, the medical record contained documentation of only one face-to-face physician visit, dated 05/06/2025, with no additional face-to-face physician visits recorded for the remainder of the stay. During an interview on 01/06/2026 at 3:18 p.m., the DON confirmed that the resident had only one face-to-face physician visit during the entire period from admission to discharge and acknowledged that a face-to-face physician visit should have occurred every 60 days after the initial visit.
Failure to Provide and Document Required Bathing Assistance
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Multiple Sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness, agitation, polyosteoarthritis, and schizoaffective disorder, did not receive required assistance with bathing. The resident was assessed as needing substantial to maximal assistance for bathing, meaning staff were expected to provide more than half the effort. Despite this, documentation for a two-week period showed no evidence that bathing was completed, with staff entering a code indicating 'not applicable' for bathing on multiple consecutive days. Interviews with the resident, CNAs, the DON, and a corporate nurse confirmed that the resident did not receive a bath during this period and that the 'not applicable' code was incorrectly used in place of proper documentation. The resident reported not receiving a bath for two weeks, and staff verified that the resident required assistance for bathing. The facility used a kiosk system for documenting care, which included an option for 'not applicable,' but this was not appropriate for the resident's needs. The failure to provide and document required ADL care for bathing led to the identified deficiency.
Failure to Monitor Edema in Resident Receiving Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for edema while the resident was receiving a diuretic. The resident, who had diagnoses including acute respiratory failure with hypoxia, pneumonia, acute kidney failure, and heart failure, was admitted with a care plan that required monitoring and documentation of any edema. Physician orders indicated the resident was to receive Furosemide 40mg twice daily for edema. However, a review of the February Medication Administration Record (MAR) showed no evidence that edema was monitored during this period. Both an LPN and a corporate nurse confirmed during interviews that the required monitoring for edema was not performed while the resident was on the diuretic.
Failure to Complete Skin Assessment and Report New Pressure Injury
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and manage pressure ulcers for one resident. Specifically, a Certified Nursing Assistant (CNA) observed a red spot and a blister on the resident's bottom while preparing the resident for transfer to the hospital but did not report this new skin issue to the licensed nurse. As a result, the required notification of a change in skin status was not made, and the incident was not documented or addressed at the time it was discovered. Additionally, a head to toe assessment was not completed by the Licensed Practical Nurse (LPN) prior to the resident's discharge to the hospital, as required by the facility's Skin Integrity Prevention and Treatment Program Policy. The resident involved had a medical history including type 2 diabetes mellitus, an unspecified open wound on the right ankle, and dementia with behavioral disturbances. The care plan for this resident included monitoring for potential skin integrity impairment and reporting abnormalities, which was not followed in this instance.
Failure to Prevent Pressure Ulcers Due to Inadequate Repositioning
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for one of the residents reviewed. The facility's policy on pressure injury prevention included interventions such as turning and repositioning residents every two hours. However, there was no documented evidence that the nursing staff adhered to this policy for a resident with severe cognitive impairment and multiple medical conditions, including a history of fractures and dementia. The resident was re-admitted to the facility without any pressure ulcers, but a stage 2 pressure ulcer was later identified on the sacrum, indicating a failure in preventive care. The resident's care plan required turning and repositioning every two hours, but records showed no documentation of these actions on specific shifts over two days. Interviews with the Wound Care Nurse and the Director of Nursing confirmed the lack of documentation for the required care. This deficiency highlights a lapse in following the care plan and maintaining proper records, which are crucial for preventing pressure ulcers in residents with significant health challenges.
Failure to Timely Report Resident Injury
Penalty
Summary
The facility failed to report an incident involving a resident's injury of unknown source with serious bodily injury within the required timeframe. The facility's Abuse Prohibition Policy mandates that such incidents be reported immediately or within 2 hours to the state agency. However, in this case, the incident was reported approximately 12 hours after the injury was identified. The resident, who had severe cognitive impairment and required assistance with daily activities, suffered a fall resulting in a right femur fracture. The incident occurred at 12:17 a.m., and the injury was confirmed by x-ray at 9:55 a.m., but the state agency was not notified until 10:16 p.m. The resident involved had a complex medical history, including severe cognitive impairment, chronic heart failure, and a history of fractures. After the fall, the resident exhibited signs of pain, prompting an x-ray that revealed the fracture. Despite the facility's policy, the administrator did not report the incident to the state agency within the required 2-hour window after being notified of the injury. This delay in reporting constitutes a deficiency in adhering to the facility's own policies and state regulations regarding the timely reporting of serious injuries.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The resident in question had a complex medical history, including severe cognitive impairment, multiple fractures, and other significant health conditions. Despite these needs, the care plan did not adequately address the necessary interventions, such as monitoring the cast on the right lower arm and using a stabilizer with an ace bandage on the right leg, ankle, and toes. The deficiency was confirmed during an interview with the Corporate Nurse, who acknowledged that the facility did not implement the specified interventions on the care plan. This oversight was identified through a review of the resident's records, which showed no documented evidence of the interventions being carried out as required. The lack of implementation of these critical interventions highlights a failure in the facility's responsibility to provide appropriate care for the resident's complex medical needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents remained as free of accident hazards as possible, specifically for one resident who was reviewed for accidents. The facility did not complete fall risk assessments quarterly as required by their Fall Prevention Program Policy. The resident, who had a severe cognitive impairment and required assistance with activities of daily living, experienced a fall resulting in a right femur fracture. The facility's records showed that a fall risk assessment was not completed quarterly, with the last assessment done in April, prior to the fall in August. Interviews with facility staff revealed that specific interventions were not implemented for residents assessed to be at risk for falls, despite the facility's policy requiring such measures. The Corporate Nurse and Administrator confirmed that the facility did not have documented evidence of interventions being implemented when the resident returned from the hospital. Additionally, the facility did not follow its own policy and procedure for the Fall Prevention Program, as evidenced by the lack of a fall risk assessment on the specified date and the absence of specific interventions for the resident at risk.
Failure to Follow Incident Policy Leads to Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide care that maximizes the well-being of residents. This deficiency was evidenced by an incident involving a Certified Nurse Aide (CNA) who did not follow the facility's Incident/Accident policy when a resident was found on the floor. The policy required that the resident should not be moved until assessed by a licensed nurse, but the CNA assisted the resident back into bed before notifying the Licensed Practical Nurse (LPN). The resident involved had a complex medical history, including severe cognitive impairment, multiple fractures, heart failure, and other serious conditions. The resident was at risk for falls, and interventions were in place to mitigate this risk. However, the CNA's actions did not align with the established procedures, as she moved the resident without a nurse's assessment, potentially compromising the resident's safety. The Director of Nursing confirmed that the CNA's actions were not in accordance with the facility's policy.
Failure to Complete Discharge Assessment
Penalty
Summary
The facility failed to ensure a discharge assessment was completed for Resident #98 after being sent to an acute hospital. Record review revealed that Resident #98 was transported to the emergency room due to worsened wounds and abnormal vital signs. However, the Minimum Data Set (MDS) for Resident #98 did not include a discharge assessment following this hospitalization. During interviews, both the MDS RN and the Corporate Nurse confirmed that a discharge MDS should have been completed but was not.
Failure to Apply Splints as Ordered
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to increase or maintain their range of motion. Specifically, the facility did not apply splints as ordered for two residents. Resident #102, who has diagnoses including anoxic brain damage and muscle atrophy, had physician orders for bilateral hand splints to be applied daily. However, the documentation revealed that the splints were not applied on multiple dates in May 2024. Observations confirmed that the resident did not have the splints on during several checks, and a corporate nurse acknowledged the failure to follow the orders. Similarly, Resident #118, who has diagnoses including Parkinson's disease and muscle wasting, had orders for a right-hand splint to be applied daily. The documentation also showed that the splint was not applied on several dates in May 2024. Observations confirmed the absence of the splint during multiple checks, and an LPN confirmed that the splint should have been on but was not. The corporate nurse reviewed the clinical record and confirmed the lack of documentation for the splint application on the specified dates.
Failure to Change Enteral Feeding Container at Appropriate Interval
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding by not changing the enteral feeding container at the appropriate interval for one resident. The resident had multiple medical diagnoses, including cerebral infarction, facial weakness from a cerebrovascular accident, dysphagia, lack of coordination, and unspecified dementia. The physician's orders specified that the enteral feeding should be administered every night shift and the container should be changed every 24 hours. However, an observation revealed that the feeding tubing and container were dated four days prior, indicating they had not been changed as required. Interviews with the LPN, Corporate Nurse, and ADON confirmed that the enteral feeding should have been changed every 24 hours but was not.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews were completed at least every 12 months for three Certified Nursing Assistants (CNAs). Specifically, the personnel records for S5CNA, S6CNA, and S7CNA did not contain evidence of annual performance reviews. S5CNA was hired on 08/09/2022, S6CNA on 02/23/2023, and S7CNA on 02/28/2023. During an interview, the Administrator confirmed the absence of these performance reviews in the personnel records for the mentioned CNAs.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs of Resident #38 by not ensuring that the call light was within reach. Resident #38, who has a history of Alzheimer's disease, hypertension, chronic atrial fibrillation, seizures, intracerebral hemorrhage, cognitive communication deficit, major depressive disorder, and unspecified psychosis, was observed on multiple occasions with the call light on the floor behind the bed, out of reach. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 09, confirmed during an interview that he could not reach the call light. A CNA also observed and confirmed that the call light was not within the resident's reach, contrary to the care plan's directive to ensure the call light is accessible and to respond promptly to the resident's needs.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure garbage was disposed of properly. During an observation on 05/13/2024 at 8:40 a.m., multiple trash bags and loose trash were found scattered around the perimeter of the dumpster outside the facility. Additionally, the lids to the dumpster were not closed. In an interview conducted at 8:41 a.m. on the same day, the Maintenance Director confirmed that the trash should not be outside of the dumpster and that the dumpster lids should be closed.
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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