New Iberia Manor South
Inspection history, citations, penalties and survey trends for this long-term care facility in New Iberia, Louisiana.
- Location
- 600 Bayard St, New Iberia, Louisiana 70560
- CMS Provider Number
- 195326
- Inspections on file
- 29
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at New Iberia Manor South during CMS and state inspections, most recent first.
A resident with bipolar disorder, anxiety, dementia, and depression was receiving buspirone, olanzapine, and venlafaxine with Q-shift behavior monitoring ordered and care-planned, including documentation of specific behavior codes and medication effectiveness. Despite ongoing, frequent yelling and hollering episodes reported by night-shift and day-shift staff as longstanding and occurring both day and night, these behaviors were rarely recorded on the MAR and were instead noted mainly on informal nurse report sheets that were not part of the clinical record. The DON, administrator, and corporate nurse confirmed that required behavior monitoring was not documented in the official record, and psychiatric providers, who relied on MAR-based 24-hour reports, documented the resident’s sleep as fair without full awareness of the resident’s recurrent outbursts.
Nursing staff failed to follow professional standards by leaving medications at the bedside for three residents, including one with severe cognitive impairment and two with intact cognition, without documented assessments authorizing self-administration. LPNs confirmed the medications were not supposed to be left in resident rooms, and facility staff acknowledged the absence of required documentation.
Two residents identified as fall risks, both with histories of falls and recent joint replacement surgeries, were observed with their beds not properly positioned or locked as required by their care plans. An LPN confirmed that one bed was not locked and another was left in the highest position after staff left the room, contrary to fall prevention protocols.
A resident with end stage renal disease who required regular dialysis did not have consistent and complete communication between the facility and the dialysis provider. Multiple dialysis communication forms were missing required pre-dialysis information, such as meal provision, medication administration, and condition alerts, and several forms were unsigned or missing altogether. Facility staff confirmed these documentation lapses, which were not in line with established protocols.
Three residents reported or were observed receiving food that was unpalatable, served cold, poorly prepared, or in portions deemed too small. One resident with severe malnutrition and end stage renal disease received a burnt, hard hamburger patty that was difficult to cut, despite her dietary needs and swallowing difficulties. Staff, including a CNA, LPN, and RD, confirmed the poor quality of the meal.
Surveyors found that opened food items in the kitchen's walk-in cooler were not labeled with opening or use-by dates, the deep fryer had not been cleaned after use and contained significant debris, and a cook was observed preparing food with exposed facial hair, all in violation of facility policies for food storage, sanitation, and staff hygiene.
Residents repeatedly reported issues with food quality, including cold, uncooked meals and small portions, during council meetings over several months. Despite ongoing complaints, the concerns were not addressed, and residents stated the situation had worsened. The Activity Director confirmed the persistent nature of these unresolved grievances.
A resident reported the theft of a wallet containing cash and personal identification shortly after admission and stated that the incident was reported to administrative staff. However, there was no evidence that the grievance was investigated or that follow-up occurred, and staff could not provide documentation of any actions taken.
A resident with a midline catheter and multiple infections did not have their catheter dressing changed according to physician orders. The dressing remained unchanged past the scheduled date, as confirmed by the ADON/IP, resulting in a failure to follow prescribed infection control protocols.
A resident with heart failure and other chronic conditions experienced shortness of breath and a low O2 saturation. An LPN applied oxygen but did not document the resident's condition or notify the provider before the resident was transported to a medical appointment. Staff interviews confirmed the lack of documentation and provider notification prior to the resident's hospital transfer.
A resident was found with a suction canister containing drainage left on their dresser for several days. The resident reported the canister had not been changed, and an LPN confirmed it should have been discarded but was unsure of its duration in the room. The DON stated there was no policy for suction equipment, though the canister should have been replaced.
A resident with severe cognitive and physical impairments was found secured in a wheelchair seat belt she could not remove, used to prevent falls. Staff confirmed the resident's inability to remove the belt, and records showed no physician order, care plan intervention, or interdisciplinary assessment for its use, contrary to facility policy.
A resident with End Stage Renal Disease and Dependence on Renal Dialysis was transferred to the hospital and later returned, but the transfer was not documented in the Emergency Transfer Log or reported to the State LTC Ombudsman as required. Both the Social Service Director and Administrator confirmed the omission during interviews and record reviews.
A resident with end stage renal disease and dependence on dialysis did not have required dialysis communication forms completed and documented for two dialysis sessions. Staff confirmed that these forms, which are used to assess the resident before each dialysis transfer and communicate with the dialysis agency, were missing from the medical record as required by facility policy.
A CNA working on a PRN basis did not receive a required annual performance evaluation, as confirmed by both the CNA and a review of her personnel file. The DON stated that PRN staff were not evaluated due to not receiving raises, and the administrator was unaware that such evaluations were required for PRN staff.
A resident with multiple complex medical conditions did not receive prescribed Hydrocodone-Acetaminophen for pain due to delays in prescription processing and pharmacy delivery. Despite repeated complaints of pain and inquiries from the resident and family, staff did not administer the ordered medication or implement effective alternative pain management, and communication breakdowns prevented timely resolution.
A resident with multiple complex medical conditions did not receive ordered Hydrocodone-Acetaminophen for pain because the prescription was not sent to the pharmacy in a timely manner. Nursing staff documented the absence of the medication, offered Tylenol instead, and explained the situation to the resident and family, but the pain medication was not available when needed.
The facility failed to implement comprehensive care plans for two residents, resulting in uncompleted monitoring and wound care. A resident with multiple diagnoses did not receive daily monitoring and treatment for a hematoma and laceration as ordered. Another resident with a fracture and dementia did not receive scheduled wound care for surgical incisions. The Treatment Nurse confirmed these deficiencies, indicating a lapse in following care plans.
The facility failed to provide and document adequate care for pressure ulcers in five residents, as evidenced by missing treatment records and unverified administration of physician-ordered wound care. This included neglecting to check the functionality of a low air loss mattress for a resident, potentially compromising their health. Interviews with staff confirmed the lack of documentation and inability to verify treatment administration.
The facility did not post daily nursing staffing information in a visible area for residents and visitors. An observation found no evidence of the required posting, and a blank board was discovered in Hall B. The Corporate Nurse confirmed the board should display the census, staff numbers, and hours worked, and acknowledged it was not visible as required.
The facility did not adhere to the scheduled menus, affecting 80 residents. During lunch, the served menu differed from the planned one, lacking pureed options for residents needing them. S5Cook admitted to not checking the menu, and S8RD confirmed the kitchen staff did not use the substitution list, nor did they contact her for guidance.
The facility failed to maintain sanitary conditions in the kitchen, affecting 80 residents. Observations showed unclean kitchen equipment, improperly labeled and expired foods, and lack of temperature monitoring. An activity coordinator was also seen without a hair covering, violating facility policy.
The facility did not post the most recent survey results in an accessible location for residents, family members, and legal representatives. A binder near the main entrance contained survey results from 2018 to 2021, but lacked those from 2022 to 2024. The DON and Administrator confirmed the oversight.
The facility failed to implement comprehensive care plans for two residents. A resident with Type 2 Diabetes Mellitus did not receive prescribed insulin or a blood sugar recheck after an elevated reading. Another resident with Functional Quadriplegia lacked enabler bars on their bed, essential for mobility and care, despite being part of their care plan. These deficiencies were confirmed by the DON and an LPN.
The facility failed to follow recipes for pureed diets, affecting residents with conditions like dysphagia and hemiplegia. A cook prepared pureed potatoes without measuring ingredients or using a recipe, despite available resources. Interviews confirmed that recipes were accessible and should have been used, highlighting a lack of training or oversight in the kitchen.
The facility failed to maintain effective infection control practices, as a CNA did not remove PPE before exiting a COVID-19 positive room and did not perform hand hygiene. Additionally, a housekeeper handled a dirty mop pad without gloves and did not sanitize her hands afterward, both actions against the facility's infection control procedures.
A resident with Chronic Kidney Disease and Heart Failure was observed with an uncovered urinary catheter drainage bag, compromising their dignity. The RN Supervisor confirmed the absence of a privacy cover and was unsure of the facility's policy on covering catheter bags. Another staff member confirmed that a privacy cover should have been used.
A resident in an LTC facility was found to have a stained pillowcase, which was not changed despite the bed being made. The resident had medical conditions requiring assistance with personal care. An LPN confirmed that linens should be clean and changed, highlighting a failure to maintain a homelike environment.
The facility failed to accurately complete PASARR Level 1 screenings for two residents. One resident's screening omitted a diagnosis of Bipolar Disorder, while another's did not include Schizophrenia. The inaccuracies were confirmed by facility staff, indicating a lapse in reviewing and ensuring accurate preadmission screenings for residents with serious mental health diagnoses.
A resident with intact cognition was left with medication at their bedside by an LPN, contrary to the facility's policy requiring a physician's order and evaluation for self-administration. The RN Supervisor was unaware of this policy, and the DON confirmed the resident should not have self-administered the medication without proper authorization.
The facility failed to ensure proper reconciliation of controlled drugs during shift changes, as required by their policy. Missing signatures for narcotic reconciliations were found for several shifts, indicating that the process was not followed. This deficiency had the potential to affect the 80 residents in the facility.
The facility failed to properly store drugs and biologicals, with a multi-use vial of flu vaccine found open and unlabeled, and loose pills discovered in a medication cart. These deficiencies were confirmed by staff and had the potential to affect 80 residents.
A resident sustained injuries after unlocking their wheelchair on a van's ramp, causing it to roll backward and flip over. The van driver failed to follow proper procedure by not standing behind the resident to assist them off the ramp. The facility lacked a policy for unloading residents from the van's wheelchair ramp, and the transportation supervisor confirmed the driver should have ensured the resident's safe removal.
A resident with intact cognition experienced a breach of dignity when an LPN threatened to leave the room if the resident continued to scream during a painful wound care session. The facility's DON and Administrator acknowledged the comment was unprofessional and contrary to the facility's policy on respectful communication.
A resident with multiple diagnoses, including muscle weakness and repeated falls, was dropped by staff during a transfer, resulting in a skin tear. The facility failed to notify the physician and family immediately, with notifications occurring two days later, contrary to the facility's policy.
The facility failed to provide ordered nutritional supplements to two residents, one of whom did not receive Ensure Plus due to a lack of stock, and another who was given milk-based Ensure instead of Ensure Clear, which he could not consume.
The facility failed to document and offer a resident's nutritional supplement as ordered. An LPN signed the MAR without verifying the availability of the supplement, and the Administrator and Corporate Nurse confirmed this should not have occurred. This deficiency could potentially affect all 82 residents.
Failure to Document Behavioral Symptoms for Resident on Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to document and monitor the behaviors of a resident with multiple mental health diagnoses, as required by the care plan and physician orders. The resident was admitted with bipolar disorder, anxiety disorder, and dementia, and had physician orders for buspirone for anxiety, olanzapine for dementia, and venlafaxine for depression. The care plan and orders required behavior monitoring every shift for anti-psychotic, anti-anxiety, and anti-depression medications, using specific behavior codes and documentation of side effects and effectiveness. Review of the MARs from October 2025 to January 2026 showed only sporadic entries of behavior code “6. Noisy” on a few dates, despite standing orders for Q-shift behavior monitoring. Interviews with nursing staff revealed that the resident had frequent nighttime and daytime yelling and hollering episodes that were known and ongoing since admission. Night shift LPNs and CNAs reported that the resident regularly yelled out at night because he did not like to be alone, sometimes after bad dreams, and that this behavior occurred often. Staff described going into the room, asking the resident to stop yelling because others were sleeping, and attempting to meet his requests, but the yelling would resume. One LPN stated she had written a note in July 2025 about the behavior but otherwise the behaviors were typically recorded only on nurses’ report sheets used for shift-to-shift communication, which were not part of the clinical record. The DON, administrator, and corporate nurse confirmed that the nurses were not documenting the resident’s behaviors on the MARs as required and that the nurses’ report sheets were not official documentation. The DON stated she was unaware of the resident’s nighttime outbursts prior to a July 2025 note and that their process for new behaviors was to contact psychiatric services. Review of monthly psychiatric service notes showed the psychiatric provider documented the resident’s sleep as “fair” and relied on 24-hour nursing reports generated from MARs and progress notes. Because the resident’s frequent yelling and outbursts were not documented in the official record, these behaviors were not reflected in the reports used by the psychiatric provider, and the resident did not receive services based on accurate behavior monitoring as required by his care plan and orders.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
Nursing staff failed to ensure that medications were administered according to professional standards, resulting in medications being left at the bedside for three residents. One resident with a history of falling and intact cognition was found with a Zyrtec tablet on her bed, which she stated was given by the nurse, and she had not signed any form to self-administer her medications. Another resident with severe cognitive impairment was observed with a Vitamin D tablet left on her over bed table, and there was no documentation that she was permitted to self-administer medications. The LPN confirmed the pill matched the resident's prescribed medication and acknowledged it should not have been left in the room. A third resident, who had intact cognition and diagnoses including bipolar disorder and dysphagia, was observed keeping his Albuterol inhaler on his person and on his window seal. Nursing notes indicated that staff assisted the resident in accessing the inhaler, but there was no documented assessment authorizing the resident to self-administer this medication. Facility staff confirmed the lack of documentation for self-administration for all three residents involved.
Failure to Maintain Safe Bed Positioning for Residents at Fall Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for residents at risk for falls, as evidenced by observations and interviews involving two residents. One resident, with a history of falling, a left pubis fracture, and recent joint replacement surgery, was observed in bed with the bed not locked, despite clear indicators and care plan interventions requiring the bed to be locked and in a low position. A therapy screen had previously identified this resident as a fall risk with safety concerns, and a yellow falling star was posted outside the room to indicate this risk. The LPN confirmed during the observation that the bed was not locked as required. Another resident, also with a history of falls and recent joint replacement, was found in bed with the bed left in the highest position, contrary to the care plan intervention to keep the bed in the lowest position. The resident, identified as a fall risk by a yellow falling star, reported that staff had been present to assist with therapy but left the bed elevated and unattended. The LPN confirmed that the bed should not have been left in the highest position. These failures demonstrate that the facility did not consistently implement fall prevention interventions as outlined in their policy and residents' care plans.
Failure to Ensure Proper Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice. The resident, admitted with end stage renal disease and dependent on renal dialysis, had physician orders to receive dialysis three times a week at an external provider. Review of the facility's dialysis communication sheets revealed multiple instances where required pre-dialysis information was missing, including documentation of meal provision, medication administration, and condition alerts. Several forms were also not signed by facility staff, and on some dates, the forms were missing entirely. Interviews with the Director of Nursing and an LPN confirmed the missing information and incomplete forms. The LPN explained that the forms should include vital signs, meal status, and the resident's condition, and that the forms serve as the primary means of communication with the dialysis provider. The Director of Nursing acknowledged that the facility's protocol required these forms to be completed and signed by nursing staff, which was not consistently done for the resident in question.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature, as evidenced by observations, interviews, and record reviews involving three residents. One resident reported dissatisfaction with the preparation of food, stating that meals were served cold and portion sizes were inadequate. Another resident expressed that the food was unappetizing, lacked seasoning, the meat was tough, and portions were too small. A Certified Nursing Assistant confirmed that this resident often did not eat meals due to dislike of the food provided. A third resident, who had diagnoses including severe protein-calorie malnutrition and end stage renal disease, was observed receiving a meal that included a burnt and hard hamburger patty, which she struggled to cut. Both a Licensed Practical Nurse and a Certified Nursing Assistant attempted to cut the hamburger and stated they would not serve it to anyone due to its poor quality. The Registered Dietician also confirmed the meat was hard and dry. The resident's medical records indicated she had difficulty or pain when swallowing, and her diet required regular texture and thin consistency, further highlighting the inappropriateness of the meal served.
Failure to Maintain Food Storage, Sanitation, and Staff Hygiene Standards
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage and kitchen sanitation practices. During a kitchen tour, several opened food items in the walk-in cooler, including containers of garlic, mayonnaise, cherries, mustard, margarine, and various bags of produce and prepared foods, were found without labels indicating the date and time they were opened or their use-by dates. These findings were confirmed by the dietary aide present, who acknowledged that the items should have been labeled according to facility policy. Additionally, the deep fryer’s cooking oil collection area was observed to have a thick layer of debris and large pieces of fried food material, with staff confirming that the fryer had not been cleaned after its last use the previous week. Further observation revealed a cook in the kitchen with exposed facial hair while preparing to puree a lunch meal, in violation of the facility’s dress code policy requiring facial hair to be properly covered. The staff member confirmed that his facial hair should have been covered. These deficiencies were found despite the facility’s written policies mandating proper food labeling, storage, and employee hygiene practices.
Failure to Address Resident Group Food Complaints
Penalty
Summary
The facility failed to address and resolve grievances voiced by the resident group regarding the quality of food served. Review of monthly resident council meeting minutes from January to July 2025 documented repeated complaints that meals were cold, improperly cooked, and served in small portions. During a resident council meeting in July, multiple residents reported that the food issues had not been addressed and had worsened, with meals being served uncooked, cold, and with tough meat. The Activity Director, present at the meeting per residents' request, confirmed that these complaints had been ongoing since January and remained unresolved at the time of the survey.
Failure to Investigate and Address Resident Grievance Regarding Theft
Penalty
Summary
The facility failed to provide evidence that a resident's grievance regarding the theft of his wallet was reported and investigated. The resident stated that upon admission to the facility, his wallet containing $350, a driver's license, and a social security card was stolen, and he reported this to administrative staff. Despite this report, the resident indicated that no one followed up with him about the incident or conducted an investigation. Review of the resident's nurse notes confirmed the report of the theft, and a registered nurse recalled being informed of the incident but could not remember if it was reported further. The administrator was aware of the grievance but was unable to provide documentation showing that the grievance was addressed or investigated by the time of the survey exit conference.
Failure to Change Midline Catheter Dressing as Ordered
Penalty
Summary
The facility failed to implement a physician's order for a resident who had a midline catheter, resulting in the dressing not being changed as prescribed. The resident, who was admitted with diagnoses including urinary tract infection, ESBL resistance, and enterococcus, had a physician's order dated 07/11/2025 to change the midline dressing and apply an antimicrobial patch every Friday during the day shift. Observation on 07/21/2025 revealed that the dressing on the resident's midline catheter was still dated 07/11/2025, indicating it had not been changed as ordered. This was confirmed by the Assistant Director of Nursing/Infection Preventionist, who acknowledged that the dressing should have been changed on 07/18/2025 but was not.
Failure to Notify Provider and Document Resident's Respiratory Decline
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including heart failure, COPD, chronic kidney disease, and cirrhosis, received care and treatment in accordance with professional standards of practice. On the day in question, the resident exhibited a low oxygen saturation of 88% and was experiencing shortness of breath. The LPN on duty applied 2 liters of oxygen but did not document the resident's O2 saturation or conduct a full assessment of the resident's condition prior to the resident being transported to a scheduled doctor's appointment. Furthermore, the LPN did not notify the resident's physician or nurse practitioner about the low oxygen saturation and respiratory distress. Interviews with facility staff, including the transportation driver, MDS coordinator, and DON, confirmed that there was no documentation of the resident's clinical condition prior to transport and that the physician or nurse practitioner was not informed. The lack of documentation and failure to communicate the resident's deteriorating condition to the appropriate medical provider resulted in the resident being sent to the hospital, where he was found to be in fluid overload and continued to experience respiratory distress.
Failure to Maintain Sanitary and Homelike Environment Due to Unchanged Suction Canister
Penalty
Summary
The facility failed to provide a sanitary and homelike environment for one resident when a suction canister containing drainage was observed on the resident's dresser. The resident reported that the canister had been present for several days. When an LPN entered the room, she acknowledged the canister should have been discarded but was unsure how long it had been there. The Director of Nursing confirmed that the facility did not have a policy or procedure regarding suction equipment, but agreed the canister should have been changed out. These observations and interviews indicate that the facility did not maintain a clean and comfortable environment for the resident, as required.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, severe intellectual disabilities, and aphasia was found using a wheelchair seat belt that she was unable to remove. Observations confirmed that the seat belt was secured across her lap, and both a CNA and an LPN verified that the resident could not remove it herself. The seat belt had been in use since the resident's admission, and staff stated it was used to prevent falls. The resident's cognitive assessment indicated severely impaired decision-making abilities, and she was unable to complete a mental status interview. Record review revealed there was no physician order for the seat belt, and the resident's care plan did not address its use. The MDS assessment did not code the resident as using restraints. The facility's policy requires an interdisciplinary team assessment, consideration of less restrictive alternatives, and proper documentation before using restraints, none of which were completed in this case. The DON confirmed that the seat belt was used without assessment, care planning, or a physician order.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis, was initially admitted on 08/29/2024 and re-admitted on 04/15/2025. Nurse's notes documented that the resident was transferred to the hospital on 03/30/2025 and returned to the facility on 04/15/2025. However, a review of the Emergency Transfer Log for March and April 2025 showed that this transfer was not recorded. During interviews and record reviews with the Social Service Director and the Administrator, both confirmed that the resident's transfer to the hospital was not included in the notification list sent to the State Long Term Care Ombudsman, as required. The Social Service Director acknowledged responsibility for completing and sending the Emergency Transfer Log and confirmed the omission. The Administrator also confirmed that the Ombudsman was not notified of the facility-initiated transfer, which should have occurred.
Failure to Document and Communicate Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper assessment and ongoing communication with the contracted dialysis agency for a resident requiring dialysis services. According to the facility's agreement with the dialysis agency, healthcare staff are required to assess each patient's physical condition and determine stability prior to every transfer for outpatient hemodialysis, with this assessment and communication documented on a dialysis communication form. For one resident with end stage renal disease and dependence on renal dialysis, there was no documented evidence of completed dialysis communication forms for two specific dates following the resident's re-admission. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that the dialysis communication forms were not present in the facility's records for the identified dates. Staff acknowledged that these forms are the established method for communication between the facility and the dialysis agency, and that they should have been completed and included in the resident's electronic health record for each dialysis session.
Failure to Complete Annual Performance Review for PRN CNA
Penalty
Summary
The facility failed to complete a yearly performance review for one Certified Nurse Assistant (CNA) out of four personnel records reviewed. The CNA, who was hired on 06/06/2023, reported during an interview that she had not received a performance evaluation since starting employment. Review of her personnel file confirmed the absence of a performance evaluation. The Director of Nursing stated that the CNA, who works on a PRN (as needed) basis, had not received an evaluation because she did not receive raises. The Administrator indicated unawareness that performance evaluations were required for PRN staff.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the lack of timely administration of prescribed pain medication. The resident, who had multiple complex medical diagnoses including spastic cerebral palsy, paraplegia, recent coronary artery bypass graft, and chronic heart failure, was admitted with an order for Hydrocodone-Acetaminophen to be given every six hours as needed for pain. Despite this order, the medication was not available or administered for at least two days following admission, during which time the resident repeatedly complained of pain, including a documented pain score of 5 out of 10. Nursing staff documented that the resident and his mother inquired multiple times about the pain medication, but it was not available due to issues with the prescription and pharmacy delivery. Staff offered Tylenol as an alternative, which the resident refused, stating a need for stronger pain relief. There was confusion among staff regarding the status of the prescription, and communication with the nurse practitioner and pharmacy was delayed or ineffective. Documentation shows that staff did not escalate the issue to administrative personnel in a timely manner, and there was no evidence that alternative pain management strategies were implemented while awaiting the ordered medication. Interviews with staff confirmed that the prescription for Hydrocodone-Acetaminophen was not properly processed or delivered, and that there was a lack of clear communication and follow-up to ensure the resident's pain was managed according to the care plan and physician's orders. The facility's own pain management policy required assessment and intervention for pain, but these steps were not effectively carried out for this resident, resulting in unrelieved pain over a documented period.
Failure to Provide Ordered Pain Medication Due to Prescription Processing Delay
Penalty
Summary
The facility failed to ensure that pain medication was available for a resident who had a physician's order for Hydrocodone-Acetaminophen 5-325 mg to be given every 6 hours as needed for pain. The resident, who had multiple complex medical diagnoses including atrial septal defect, post-myocardial infarction complications, CABG, spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure, and dysarthria, was admitted with this order in place. Nursing progress notes documented that the resident and his mother inquired about the pain medication, but it was not available in the medication bins delivered by the pharmacy. Staff explained that a hard script from the nurse practitioner was needed for the pharmacy to fill the medication, and Tylenol was offered instead when the resident complained of chest pain. Further review revealed that the pharmacy did not receive the prescription for the ordered pain medication until two days after the initial order, and the medication was not available for administration when the resident reported pain. The Assistant Director of Nursing confirmed that there was no documentation showing the prescription was sent to the pharmacy on the day of admission. As a result, the resident did not receive the ordered pain medication when needed, and the facility did not meet the pharmaceutical needs of the resident as required.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, leading to deficiencies in monitoring and wound care. Resident #1, who was admitted with multiple diagnoses including cerebral infarction and end-stage renal disease, had specific physician orders to monitor a hematoma and perform wound care for a laceration daily. However, the Treatment Administration Record (TAR) showed no documentation of these actions being completed on several dates in October and November 2024. Similarly, Resident #3, admitted with conditions such as a displaced intertrochanteric fracture and dementia, had orders for wound care on surgical incisions to be performed every other day and as needed. The TAR indicated that these treatments were not documented as completed on specific dates in December 2024. The Treatment Nurse confirmed that the required monitoring and treatments for both residents were not carried out as ordered, highlighting a failure in the facility's adherence to the care plans.
Failure to Document and Administer Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent and treat pressure ulcers for five residents. The deficiencies were identified through a review of treatment administration records (TARs) and physician orders, which revealed multiple instances where wound care was not documented as administered according to the physician's orders. This lack of documentation suggests that the treatments may not have been provided as required, potentially compromising the residents' health and safety. Resident #1 had several pressure injuries, including those on the left ankle, left foot, right heel, and left ischium. The facility failed to document the administration of prescribed treatments on multiple occasions across October, November, and December 2024. Additionally, the facility did not consistently check the proper functioning of a low air loss mattress, which was part of the resident's care plan to manage pressure ulcers. Similar issues were found with Resident #2, who had pressure injuries on the left buttocks, right lower lateral leg, and right heel, with missing documentation of treatment administration in December 2024. Resident #3 also experienced a lack of documented wound care for pressure injuries on the right buttocks, sacrum, and left ankle. The facility's failure to administer and document wound care treatments extended to Residents #4 and #5, with missing documentation spanning several months. Interviews with the treatment nurse and director of nursing confirmed the absence of documentation and the inability to provide evidence that the treatments were administered as ordered.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post daily nursing staffing information in a prominent place accessible to residents and visitors. On July 22, 2024, at 3:30 p.m., an observation was conducted throughout the facility, revealing no evidence of the required posting. An interview with the Corporate Nurse confirmed that the daily census should be posted and that staff had been posting it on Hall B. However, upon inspection, a white dry-eraser board located under the TV on Hall B was found to be blank, lacking the necessary information such as the census, the number of staff, and the total number and actual hours worked. The Corporate Nurse acknowledged that the board was not visible to all residents and visitors, as it should have been.
Failure to Follow Scheduled Menus
Penalty
Summary
The facility failed to ensure that the menus were followed for residents, which had the potential to affect a census of 80 residents. During an observation of the meal service at lunch, it was noted that the residents were served a different menu than what was scheduled. The served menu included Rice Pilaf, Glazed Ham, Baked beans, Pureed Ham, Chopped Ham, Mashed Potatoes, Pork Chops with Gravy, Pureed Beans, Dinner Rolls, and Lemon Cake, while the scheduled menu was supposed to include Glazed Ham, Baked sweet potato, Braised cabbage, Cornbread, and Frosted cake. Additionally, there was no pureed dinner rolls or cornbread available for residents requiring pureed meals. An interview with S5Cook confirmed the discrepancy between the served and scheduled menu, and she admitted to not preparing and serving pureed bread for residents on pureed diets. S5Cook acknowledged that she should have checked the menu. Furthermore, S8RD, the Registered Dietician, stated that the kitchen staff should not change the menu on their own and confirmed that the substitution list was not used. S8RD also mentioned that she was available by phone for any menu concerns but did not receive any calls from the facility.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect the 80 residents consuming food from it. Observations revealed that the kitchen fryer, fryer baskets, and the floor beside the fryer were not cleaned, with oil and food residue present. The baking oven doors were also dirty with caked-on grease stains. The cook confirmed that these areas had not been cleaned as required. Additionally, refrigerated foods were not labeled or dated properly, and expired foods were not discarded, contrary to the facility's policy. Items such as pitchers of juice, mixed beans, and tomato paste lacked labels indicating content and preparation dates, while other items like mousse, fruit, butterscotch, cheese slices, and parmesan cheese were found to be expired. The facility also failed to monitor and document refrigerator, freezer, and dishwasher temperatures and chemicals, as required by their policies. No temperatures were recorded for a specific date, and the cook confirmed this oversight. Furthermore, an activity coordinator was observed in the kitchen without a hair covering, which is against the facility's policy for maintaining sanitary conditions. The cook acknowledged that all staff were aware of the requirement to wear hair restraints in the kitchen.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were posted in a location easily accessible to residents, family members, and legal representatives. During an observation on July 21, 2024, a clear plastic file holder was found mounted to the wall outside the human resources office near the main entrance. Inside the holder was a binder containing licensing surveys from 2018 to 2021, but it lacked the survey results and plans of correction for the years 2022 through 2024. In an interview conducted on July 23, 2024, the Director of Nursing and the Administrator confirmed that the survey results for the last three years were not included in the binder and acknowledged that they should have been posted in an accessible location.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered plan of care for two residents, leading to deficiencies in their care. For Resident #33, who was diagnosed with Type 2 Diabetes Mellitus, the facility did not follow the physician's orders for managing elevated blood sugar levels. On June 27, 2024, the resident's blood glucose level was recorded at 404 mg/dL, but the prescribed 12 units of Humulin R were not administered, nor was a recheck of the blood sugar conducted as required. The Director of Nursing confirmed the oversight, noting the absence of documentation for the administration of insulin or a recheck, and no record of the resident refusing treatment. For Resident #1, who had a diagnosis of Functional Quadriplegia, the facility failed to ensure the presence of enabler bars on the resident's bed, which were necessary to assist with bed mobility and turning during care. Observations on July 21 and July 22, 2024, confirmed the absence of enabler bars, despite their inclusion in the resident's care plan. An LPN verified the lack of enabler bars and acknowledged their importance for the resident's care, highlighting a failure to adhere to the care plan designed to meet the resident's needs.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that recipes were followed for residents on pureed diets, specifically in the preparation of mashed potatoes. This deficiency was identified through observations, record reviews, and interviews. Four residents, all of whom had physician orders for pureed diets due to conditions such as dysphagia and hemiplegia following cerebral infarctions, were affected. During an observation, a cook was seen preparing pureed potatoes without measuring the ingredients or following a recipe, despite recipes being available on the packaging and in a recipe book provided by the facility. The cook admitted to never having measured ingredients or used a recipe, indicating a lack of training or oversight in the kitchen. Interviews with the corporate nurse and registered dietician confirmed that recipes were available and should have been used. The dietician noted that a recipe book had been printed to accompany the menus, and she was available for consultation, yet no contact was made to address any concerns with the recipes. This oversight in food preparation compromised the dietary needs of residents requiring pureed diets.
Infection Control Deficiencies in PPE and Housekeeping Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving staff. In the first incident, a Certified Nursing Assistant (CNA) was observed exiting a COVID-19 positive resident's room without removing her personal protective equipment (PPE) inside the room. The CNA removed her isolation gown while walking down the hallway and discarded it in a room without performing hand hygiene afterward. This action was confirmed by a Registered Nurse Supervisor, who acknowledged that the CNA should have removed the PPE before leaving the isolation room and sanitized her hands after discarding the gown. In the second incident, a housekeeper was observed handling a dirty mop pad with her bare hands and failing to perform hand hygiene afterward. The housekeeper admitted to not using gloves and not sanitizing her hands after handling the soiled mop pad. This was confirmed by the Housekeeping Supervisor and the Infection Preventionist, who both stated that the housekeeper's actions were against the facility's infection control procedures.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not providing a covering for a urinary catheter bag. Resident #428, who was admitted with diagnoses including Chronic Kidney Disease and Heart Failure, was observed on July 21, 2024, with an uncovered urinary catheter drainage bag. During an interview and observation with the Registered Nurse Supervisor, it was confirmed that the catheter bag lacked a privacy cover, and the supervisor was unsure of the facility's policy regarding this matter. Further confirmation was obtained from another staff member, who acknowledged that a privacy cover should have been placed on the resident's urinary drainage bag.
Failure to Provide Clean Bed Linens
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, as evidenced by the presence of stained bed linens. The deficiency was identified during observations and interviews conducted by surveyors. A resident, who was admitted with diagnoses including cerebral infarction, muscle weakness, unspecified lack of coordination, and a need for assistance with personal care, was found to have a pillowcase with a large red and brown stain. This observation was made on two consecutive days, and the stain remained on the pillowcase despite the bed being made. An LPN confirmed the presence of the stain and acknowledged that bed linens should be clean and changed when the bed is made.
Inaccurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the PASARR Level 1 screening was completed accurately for two residents. Resident #43 was admitted with diagnoses including Bipolar Disorder, End Stage Renal Disease, and Essential Hypertension. However, her Level 1 PASARR did not indicate any serious mental health diagnoses, specifically omitting her Bipolar Disorder. The Acting Administrator confirmed the omission upon review, and the Director of Nursing acknowledged that the nursing home staff failed to review the Level 1 PASARR for accuracy, which was initially submitted by the hospital. Resident #1 was admitted with a diagnosis of Schizophrenia, but his Level 1 PASARR screening, completed at another facility, only indicated Major Depression Disorder. The Corporate Nurse confirmed that Schizophrenia was not checked on the PASARR and was unable to verify if a corrected submission was sent. These inaccuracies in the PASARR screenings for both residents highlight a failure in the facility's process to ensure accurate and complete preadmission screenings for residents with serious mental health diagnoses.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to safely meet the needs of residents, as evidenced by an incident involving a Licensed Practical Nurse (LPN) leaving medication at the bedside of a resident. The resident, who had been admitted with diagnoses including Chronic Kidney Disease and Heart Failure, had a Brief Interview for Mental Status (BIMS) score indicating intact cognition. However, the facility's policy required a physician's order and an evaluation to determine if a resident could safely self-administer medication, which the resident did not have. On the day of the incident, the LPN left a medicine cup with seven pills on the resident's over-bed table, allowing the resident to take the medication after breakfast without supervision. The RN Supervisor was unaware of the facility's policy on self-administration, and the Director of Nursing confirmed that the resident should not have been left to self-administer medication without the proper order and evaluation. The Administrator identified the LPN responsible for the medication administration, highlighting a lapse in adherence to the facility's medication administration policy.
Failure in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring proper drug record reconciliation of controlled substances during shift changes. This deficiency was identified during an annual survey, where it was found that the reconciliation process for Medicine Cart 1 (MC1) was not properly documented. The facility's policy requires that both the nurse coming on duty and the nurse going off duty perform the count together and document any discrepancies. However, during the review of the July 2024 Controlled Drugs-Count Record, it was discovered that there were missing signatures for the off-going nurse for the 7:00 a.m. - 3:00 p.m. shift on July 22, 2024, indicating that the narcotics were not reconciled as required. Further investigation revealed additional instances of missing signatures for narcotic reconciliations on other dates, including July 20 and July 21, 2024. The Director of Nursing (DON) confirmed that the nurses for these shifts should have signed the records to indicate that the narcotics were reconciled, but they had not. This failure to adhere to the facility's policy for controlled substances had the potential to affect the 80 residents residing in the facility, as it compromised the accountability and security of controlled drugs.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to properly store drugs and biologicals, as evidenced by two specific incidents. During an observation of the medication storage room, a multi-use vial of flu vaccine was found open without a labeled opening date. This was confirmed by both the LPN and the Corporate Nurse, who acknowledged that the vial should have been labeled with the date it was opened. This oversight indicates a failure to adhere to the facility's policy on medication storage, which requires all drugs and biologicals to be stored in a safe, secure, and orderly manner. Additionally, during an inspection of a medication cart, loose pills were discovered in the bottom drawers. An LPN confirmed the presence of two round white pills in the second drawer and one white round pill in the bottom drawer, acknowledging that these pills should not have been loose. This incident further highlights the facility's failure to maintain medication storage areas in a clean, safe, and sanitary manner, as required by their policy. These deficiencies had the potential to affect the 80 residents residing in the facility.
Inadequate Supervision During Van Unloading Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident while exiting the transportation van's wheelchair ramp, resulting in the resident sustaining injuries. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 15, and had diagnoses including Bipolar, Depression, and Chronic Obstructive Pulmonary Disease. On the day of the incident, the resident was positioned on the van's wheelchair ramp, and the van driver, who was responsible for assisting the resident, stood on the side of the ramp instead of behind the resident. As the ramp hit the ground, the resident unlocked his wheelchair, causing it to roll backward and flip over, leading to a head injury, shoulder contusion, neck strain, and scalp abrasion. The facility did not have a policy or procedure for unloading residents from the van's wheelchair ramp, and the van driver did not follow the proper procedure of standing behind the resident to assist them off the ramp. The van driver admitted to being caught off guard and acknowledged that she did not follow the facility's procedure. The administrator stated that the van driver was not responsible for the fall, attributing it to the resident unlocking his wheelchair. However, the transportation supervisor confirmed that the van driver should have stood behind the resident to ensure safe removal from the ramp.
Resident Dignity Compromised During Wound Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident with intact cognition who was subjected to inappropriate comments by a staff member. The resident, who had been admitted with diagnoses including post-procedural complications and anxiety, reported that during a wound care session, she was in significant pain and expressed this by hollering. In response, an LPN assisting with the care threatened to leave the room if the resident continued to scream, which was deemed unprofessional and inappropriate by the facility's Director of Nursing and Administrator. The incident was documented in a facility investigation, and the LPN involved confirmed during an interview that she had made the statement due to the resident's loud screams causing discomfort. The facility's policy on dignity, which mandates respectful communication with residents at all times, was not adhered to in this instance. The Director of Nursing acknowledged that the LPN's response was not suitable and that alternative approaches to managing the resident's pain should have been considered.
Failure to Notify Physician and Family Immediately After Resident Accident
Penalty
Summary
The facility failed to notify the physician and responsible party immediately after an accident involving a resident. On 02/17/2024, a resident with diagnoses including Acute Embolism and Thrombosis of the Left Femoral Vein, Generalized Muscle Weakness, and Repeated Falls, was dropped by staff members while being transferred from a wheelchair to a bed. The incident resulted in a skin tear to the resident's left shin. Despite the incident occurring on 02/17/2024, the resident's physician was not notified until 02/19/2024 at 10:00 a.m., and the family member was notified on 02/19/2024 at 3:00 p.m. The deficiency was identified through interviews and record reviews. The facility's policy requires immediate notification of the physician and family in the event of an incident or accident involving a resident. However, this policy was not followed in this case. The administrator confirmed that the notifications were not made immediately as required. This failure to promptly inform the physician and family member was highlighted in a complaint filed by the resident's family member and corroborated by the incident report prepared by the LPN involved.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to implement a person-centered care plan for two residents by not ensuring they received the nutritional supplements ordered by their physicians. Resident #1, who was admitted with severe protein-calorie malnutrition and other health issues, had an order for Ensure Plus before meals. However, during an observation, it was found that Ensure Plus was not stocked in the facility's refrigerators. The LPN responsible for ordering supplements confirmed that she had not ordered Ensure Plus in 2024 and was not aware of the need to do so. Resident #2, who had multiple health conditions including dysphagia and protein-calorie malnutrition, had an order for Ensure Clear in the afternoon. Despite this, the resident reported not receiving Ensure Clear since admission and was instead given milk-based Ensure, which he could not consume. The LPN responsible for ordering supplements confirmed that she had ordered Ensure Clear but switched to regular Ensure after residents reported disliking the flavors of Ensure Clear. This switch was made without ensuring the specific needs of Resident #2 were met.
Failure to Document and Offer Nutritional Supplements
Penalty
Summary
The facility failed to provide accurate documentation that a resident's nutritional supplement was offered. Specifically, for one resident, the order to encourage intake of supplements brought by family was not followed. The resident's MAR indicated that the supplements were to be offered every shift, but an LPN confirmed that she had signed off on the order without actually offering the supplement. During an observation and interview, the LPN was unaware of the supplements and could not find them in the resident's room. The LPN admitted to signing the MAR without verifying the availability or offering the supplement. Further interviews with the facility's Administrator and Corporate Nurse confirmed that the LPN should not have signed the MAR if the supplement was not available. They agreed that the LPN should have indicated the supplement was not available or offered an equal substitute from the facility. This deficiency has the potential to affect all 82 residents in the nursing home.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
