Regency House Of Alexandria
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 5131 Masonic Drive, Alexandria, Louisiana 71301
- CMS Provider Number
- 195637
- Inspections on file
- 19
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Regency House Of Alexandria during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not receive their prescribed PRN Hydrocodone-Acetaminophen due to the medication not being available. An LPN borrowed the same medication from another resident and administered it, contrary to facility policy and professional standards. The incident was observed by staff and family, and confirmed by the DON and RN Supervisor.
A resident with chronic pain and opioid dependence was left without prescribed Hydrocodone-Acetaminophen due to failures in medication ordering and communication among nursing staff. In response, an LPN administered Tylenol without a physician order and later borrowed pain medication from another resident, violating medication protocols. The resident's family raised concerns about pain management, and the resident was transferred to the hospital for pain control.
Two residents experienced injuries of unknown origin that were not reported to the state agency within the required two-hour timeframe. One resident had a suspected femoral fracture, and another had a fall resulting in a scalp laceration. The facility's policy on reporting such injuries was not followed, and the Administrator's misunderstanding of reportable incidents contributed to the delay.
A resident with a history of Alzheimer's and Osteoarthritis experienced a failure in pain management when a CNA did not report the resident's complaint of leg pain to the nurse, despite being trained to do so. The resident's care plan required CNAs to report any pain complaints, but the CNA did not comply, as the resident requested not to inform the nurse. The CNA later acknowledged the oversight, and the CNA Supervisor confirmed the expectation to report all pain complaints.
An LPN failed to administer and accurately document medications for a resident, administering only 14 out of 18 scheduled pills. The LPN did not administer certain medications due to claimed unavailability and forgot others, yet documented them as given. Investigation revealed that some medications were available on the cart, and the DON confirmed they should have been administered per physician's orders.
A facility failed to provide pharmaceutical services by not ensuring the timely acquisition and administration of Sacubitril-Valsartan for a resident with congestive heart failure. The medication was not available during a scheduled administration, and although it was documented as given, it was confirmed by an LPN that it was not administered. The medication was not found on the cart or in storage, and an order was not released due to insurance denial, leading to the resident running out of the medication.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.76%. An LPN administered only 14 out of 18 prescribed pills to a resident, missing Bactrim DS, Sacubitril-Valsartan, Sodium Bicarbonate, and Cyanocobalamin. The LPN documented these as administered despite admitting to not giving them due to unavailability and oversight. The DON confirmed the discrepancies, noting that the medications should not have been documented as given if not administered.
The facility failed to implement Enhanced Barrier Precautions for a resident with wounds and another with a PICC line, as staff did not wear appropriate PPE during care. Additionally, the facility did not test its water system for Legionella, as required by its infection control program.
A resident with a history of hemiplegia and irritable bowel syndrome requested an incontinent wipe from a CNA, which was refused. The CNA cited inappropriate behavior by the resident as the reason for refusal, despite the resident's frequent requests due to feeling unclean. The incident was reported by the resident's niece and confirmed by the resident's private sitter, highlighting a deficiency in respecting the resident's rights to dignity and self-determination.
A resident with intact cognition and multiple health conditions was found to be wearing the same pair of jeans for a week due to the facility's failure to return his other pants from the laundry. The resident's closet contained minimal clothing, and staff were unaware of the issue. The facility's administrator acknowledged the oversight, noting the absence of a Social Service Director may have contributed to the situation.
A resident with moderate cognitive impairment experienced an unwitnessed fall, and the facility failed to promptly notify the physician and responsible party. The LPN on duty assessed the resident but did not follow protocol to inform the necessary parties immediately, leading to a delay in notification until the following day. The facility's procedures for handling falls were not adhered to, as confirmed by the DON.
A facility failed to ensure proper wound care for a resident with a stage 3 sacral pressure sore. A CNA applied Zinc Oxide cream, a task reserved for nurses, contrary to the resident's care plan and physician's orders. The resident's care plan required specific wound management, but the cream was improperly left in the room and applied by unqualified staff, as confirmed by the DON.
A facility failed to adhere to professional standards for respiratory care by not changing a resident's oxygen tubing as per the prescribed schedule. The resident, who required continuous oxygen therapy due to respiratory failure and other conditions, had tubing dated over a week old, contrary to the facility's policy and physician's orders. An LPN confirmed the oversight during an interview.
A resident with moderate cognitive impairment and multiple medical conditions was found with a tube of Zinc Oxide ointment and a bottle of Nystatin powder left unattended on their bedside dresser. These medications were not currently prescribed, and staff confirmed they should have been secured in the medication cart. The resident did not have a physician's order to keep medications at the bedside, nor an assessment for self-administration.
The facility failed to properly dispose of garbage and refuse, as observed with a blue dumpster outside the kitchen surrounded by dirty gloves and debris. The Dietary Manager confirmed the findings, and the Maintenance Director stated the trash was left by sanitation employees. The Administrator confirmed the Maintenance Director's responsibility for maintaining cleanliness around the dumpster.
The facility failed to use proper signage for two residents on Transmission-Based Precautions due to COVID-19. Observations showed signage for Enhanced Barrier Precautions instead, confirmed by the RN Infection Preventionist. Both residents required isolation and substantial assistance with daily activities.
A facility failed to implement a care plan for monitoring the side effects and effectiveness of an anticoagulant medication for a resident with multiple diagnoses, including chronic atrial fibrillation and end-stage renal disease. Despite the care plan's directives, no monitoring was in place, as confirmed by interviews with staff.
The facility failed to follow physician's orders for weekly PT/INR tests and did not notify the physician of an abnormal PT/INR result for a resident on Coumadin. The resident had a history of gastrointestinal hemorrhage, chronic atrial fibrillation, and end-stage renal disease, making the monitoring of PT/INR levels critical.
Failure to Administer Ordered Controlled Medication and Improper Borrowing of Medication
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that controlled medications ordered for a resident were administered as prescribed. Specifically, the resident had a physician's order for Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for pain. However, due to the facility not having the resident's pain medication available, an LPN borrowed the same medication from another resident and administered it to the resident in need. This action was acknowledged by the LPN, who stated she knew it was not appropriate, and was confirmed by the Director of Nursing and RN Supervisor. The resident involved had multiple diagnoses, including COPD, Type II Diabetes Mellitus with neuropathy, severe dementia with agitation, opioid dependence, and anxiety disorder. The resident was cognitively intact and required some assistance with activities of daily living. The lack of medication availability was noted by staff over several days, and the improper administration of another resident's medication was observed and reported by staff and family members. The facility's policy required strict adherence to medication administration standards, including verifying the right resident and medication, which was not followed in this instance.
Failure to Ensure Timely Acquisition and Proper Administration of Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the timely acquisition and dispensing of a controlled medication, Hydrocodone-Acetaminophen, for a resident with multiple diagnoses including chronic pain conditions and opioid dependence. The resident was admitted with a prescription for Hydrocodone-Acetaminophen to be given as needed for pain, but the medication supply was depleted on 12/03/2025. The process for reordering the medication was not properly followed, as the empty medication card was left on the Assistant Director of Nursing's desk without direct communication, and the responsible staff did not ensure the order was placed or received. During the period when the resident was without his prescribed pain medication, staff attempted to manage his pain by administering Tylenol, for which there was no physician order, and later by borrowing Hydrocodone-Acetaminophen from another resident, which is a violation of medication administration protocols. Multiple staff interviews confirmed that the breakdown in communication and lack of clear responsibility for medication ordering led to the resident being without his PRN pain medication for several days. The resident's family became aware of the situation and expressed concern about neglect related to pain management. The resident ultimately required transfer to the hospital for pain management at the family's request. Documentation and interviews revealed that the facility's procedures for controlled substance administration and accountability were not followed, resulting in the resident not having access to his prescribed pain medication when needed. The failure to ensure the availability of the medication and the inappropriate borrowing of another resident's medication were directly observed and confirmed by staff and administrative personnel.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents within the required two-hour timeframe as mandated by state law. Resident #1, who had a history of Alzheimer's disease and osteoarthritis, was found to have a suspected minimally displaced femoral peri arthroplasty fracture after complaining of knee pain. Despite receiving the x-ray results confirming the fracture, the facility did not report the injury within the required timeframe. The Administrator acknowledged the oversight, stating that the report should have been submitted immediately upon reviewing the x-ray results. Resident #2, who had diagnoses including protein calorie malnutrition and a history of falls, experienced an unwitnessed fall resulting in a laceration to the scalp and a subsequent emergency room visit. The RN on duty reported the incident to the Administrator shortly after it occurred, but the Administrator did not consider the fall a reportable injury at the time. It was only after the injury was revealed to be a fracture that the Administrator recognized it as a reportable incident. The facility's policy on reporting suspicious injuries of unknown origin was not followed in these cases, leading to a delay in notifying the state agency. The policy requires that all instances of serious bodily injury, such as fractures or head injuries, be reported within two hours. The Administrator's misunderstanding of what constitutes a reportable injury contributed to the failure to comply with state reporting requirements.
Failure to Report Resident's Pain Complaint
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, specifically in the area of pain management. The resident, who has a history of Alzheimer's Disease, Fibromyalgia, Osteoarthritis, and other conditions, was noted to have moderate cognitive impairment and required assistance with daily activities. The care plan included an intervention for Certified Nursing Assistants (CNAs) to monitor, record, and report any complaints of pain to the nurse. However, during an incident, a CNA did not report the resident's complaint of leg pain to the nurse, as the resident requested not to inform the nurse. The CNA, despite being trained to report any signs of pain regardless of the resident's request, failed to notify the nurse about the resident's pain complaint. This was confirmed during an interview with the CNA, who acknowledged the oversight. The CNA Supervisor also confirmed that the expectation was for all pain complaints to be reported to the nurse, even if the resident advised otherwise. This failure to report the pain complaint was a deviation from the established care plan and facility policy on pain management.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring medications were administered and accurately documented for a resident during medication administration. An LPN administered 14 pills to a resident, while the Medication Administration Record (MAR) indicated that 18 pills were scheduled to be administered. The LPN confirmed that she did not administer Bactrim DS, Sacubitril-Valsartan, or Sodium Bicarbonate due to their unavailability and forgot to administer Cyanocobalamin. Despite this, she documented the medications as administered, intending to correct the documentation later. Further investigation revealed that the Bactrim DS and Sodium Bicarbonate were available on the medication cart, contradicting the LPN's claim of unavailability. The Director of Nursing confirmed that these medications, along with Cyanocobalamin, should have been administered according to the physician's orders. Additionally, there was a discrepancy in the documentation of Bactrim DS administration, as the blister pack indicated fewer pills were removed than documented in the MAR.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition, receipt, and administration of Sacubitril-Valsartan, a non-controlled medication prescribed for congestive heart failure. During a medication administration observation, it was noted that the medication was not available and was not administered to the resident, despite being documented as given. The Licensed Practical Nurse (LPN) involved confirmed that the medication was not administered because it was unavailable and admitted to documenting it as administered by mistake. Further investigation revealed that the medication was not present on the medication cart, in the resident's cubby, or in the Pixus. The facility's records showed that the last supply of the medication was received on January 20, 2025, and the resident would have run out by February 3, 2025. An order for the medication was created on January 30, 2025, but was not released due to an insurance denial. The facility's Director of Nursing (DON) and other staff confirmed the medication was not available and that there was no follow-up to address the missing medication, despite it being documented as administered by nursing staff.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 11.76% during a survey. Specifically, the facility did not administer all prescribed medications to a resident as per the physician's orders. During a medication administration observation, an LPN administered only 14 out of the 18 prescribed pills to a resident. The missing medications included Bactrim DS, Sacubitril-Valsartan, Sodium Bicarbonate, and Cyanocobalamin. The LPN admitted to not administering these medications due to unavailability and oversight, yet documented them as administered. Further investigation revealed that the Bactrim DS and Sodium Bicarbonate were available on the medication cart, contradicting the LPN's claim of unavailability. The Sacubitril-Valsartan was not found on the cart or in storage, and the resident had reportedly run out of this medication days prior, despite it being documented as administered. The DON confirmed the discrepancies and acknowledged that the medications should not have been documented as given if they were not administered. This series of actions and inactions led to the facility's failure to adhere to its medication administration policy and maintain an acceptable medication error rate.
Infection Control Deficiencies in EBP and Water Testing
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer and a diabetic ulcer, as required by their policy. Despite the resident's condition necessitating EBP, there was no order for these precautions, and no signage or personal protective equipment (PPE) was available in or outside the resident's room. The resident's wife was not educated on infection control precautions, and staff did not wear appropriate PPE during toileting care, as observed by surveyors. Another resident, who had a PICC line and required EBP for high-contact care activities, did not receive proper care as staff failed to wear gowns during incontinent care. Although the resident's room had a red dot indicating the need for EBP, staff did not comply with the PPE requirements. Interviews with staff confirmed that they were aware of the EBP requirements but failed to adhere to them during care. Additionally, the facility did not maintain an infection prevention and control program as it failed to test the water system for Legionella. The facility's water management program required measures to minimize the risk of Legionella, but there was no documented evidence of testing since September 2024. The administrator confirmed that the facility had not conducted the necessary testing, which is a critical component of their infection control program.
Failure to Honor Resident's Request for Incontinent Wipe
Penalty
Summary
The facility failed to honor a resident's right to request an incontinent wipe, which is a violation of the resident's rights to dignity and self-determination. The incident involved a resident with a history of hemiplegia, major depressive disorder, anxiety disorder, and irritable bowel syndrome, who was dependent on assistance for toileting hygiene. The resident, who had a BIMS score indicating intact or mildly impaired cognition, requested an incontinent wipe from a CNA, which was refused. The CNA stated that the resident had already been cleaned and did not provide the wipe, citing inappropriate behavior by the resident with the wipe as the reason. The incident was reported by the resident's niece to the facility administrator, who confirmed the refusal of the request. The resident's private sitter corroborated the account, stating that the CNA told the sitter to provide the wipe if desired. The refusal to provide the wipe was confirmed by the CNA during an interview, acknowledging that the resident often requested wipes because she did not feel clean. This failure to provide the requested wipe was identified as a deficiency in treating the resident with respect and dignity, as required by federal and state law.
Resident Lacks Adequate Clothing Due to Facility Oversight
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #205, was treated with respect and dignity by not providing adequate clothing. Resident #205, who was admitted with diagnoses including Major Depressive Disorder, Type 2 Diabetes Mellitus, Acute Respiratory Failure, and Unspecified Protein Calorie Malnutrition, had a BIMS score of 15, indicating intact cognition. The resident required assistance with dressing and had been wearing the same pair of jeans for a week, as his other pair of pants, provided by the facility, had not been returned from the laundry. The resident expressed feeling bad about not having clothes and had informed two employees about the missing joggers but received no response. Observations and interviews revealed that the resident's closet contained only a pack of white t-shirts, socks, underwear, and a coat, with no other clothing items. The LPN providing care for the resident was unaware of the situation, and the Acting Social Service Director was also not informed about the resident's lack of clothing. The facility's administrator acknowledged purchasing some basic clothing items for the resident but confirmed that the facility should have assisted further in obtaining appropriate outerwear. The absence of a Social Service Director at the time may have contributed to the oversight.
Failure to Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician and responsible party after a change in a resident's condition, specifically following an unwitnessed fall. Resident #49, who was admitted with diagnoses including vascular dementia and moderate cognitive impairment, experienced a fall on 02/08/2025. The fall was reported to S10 Medical Records LPN by S8 CNA, who found the resident sitting upright on the floor with his back against his wheelchair. Although S10 Medical Records LPN conducted a head-to-toe assessment and documented the incident in the progress notes, she did not notify the physician or the resident's responsible party immediately as required. The delay in notification was confirmed during interviews with the staff, including S10 Medical Records LPN, who admitted to not notifying the necessary parties due to being overwhelmed with other tasks. The Director of Nursing (S2 DON) confirmed that the facility's protocol requires immediate notification of the physician and responsible party following a fall, which was not adhered to in this case. The notification was eventually made by another LPN the following day, and the incident report was back-dated, indicating a lapse in the facility's adherence to its own procedures for handling resident falls.
Improper Wound Care by CNA
Penalty
Summary
The facility failed to ensure that services provided to Resident #206 were delivered by individuals with the appropriate skills and qualifications, as outlined in the resident's plan of care. Specifically, S6 CNA applied Zinc Oxide cream to Resident #206's stage 3 sacral pressure sore, which was against the facility's protocol that only nurses are allowed to perform wound care. Resident #206, who was cognitively intact and required various levels of assistance for daily activities, had a care plan that included specific interventions for a stage 3 pressure ulcer. The physician's orders required cleansing the ulcer and applying Zinc Oxide, but this task was improperly performed by a CNA instead of a nurse. Observations and interviews revealed that the Zinc Oxide cream was left in Resident #206's room, and S6 CNA confirmed applying it during toileting care. The Director of Nursing (S2 DON) acknowledged that CNAs are not permitted to apply Zinc to wounds and confirmed that the cream should not have been left in the resident's room. Further observation of Resident #206's care showed a reddened, uncovered stage 3 pressure ulcer, indicating a lack of proper wound management as per the care plan and physician's orders.
Failure to Adhere to Oxygen Equipment Change Schedule
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident, identified as Resident #156, who required continuous oxygen therapy. The facility's policy mandated that oxygen tubing and mask/cannula be changed weekly and as needed if soiled or contaminated. However, observations revealed that Resident #156's oxygen tubing, dated 01/29/2025, had not been changed as per the physician's orders, which specified a change every Wednesday night shift and as needed. This oversight was confirmed during an interview with an LPN, who acknowledged that the tubing should have been changed but was not. Resident #156 was admitted with diagnoses including acute and chronic respiratory failure, chronic systolic heart failure, depression, anxiety disorder, and dependence on enabling machines and devices. The resident's medical record indicated intact cognition with a BIMS score of 14 and a requirement for continuous oxygen administration at 3 liters per minute. Despite these needs, the facility did not adhere to the prescribed schedule for changing the oxygen equipment, leading to a deficiency in the standard of care provided to the resident.
Medications Left Unsecured at Resident's Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by medications being left at the bedside of a resident. During an observation, a tube of Zinc Oxide ointment and a bottle of Nystatin powder were found unattended on the bedside dresser of a resident with moderate cognitive impairment and multiple medical conditions, including a stage 4 pressure ulcer and bipolar disorder. These medications were not prescribed for current use, as the orders for Zinc Oxide had been discontinued months prior, and the Nystatin powder order had been completed weeks before the observation. Interviews with facility staff confirmed that the medications should not have been left at the bedside and should have been secured in the medication cart when not in use. The resident did not have a physician's order to keep medications at the bedside, nor was there an assessment to determine if the resident was safe to self-administer medications. The Director of Nursing acknowledged that the medications should have been disposed of properly and confirmed that the resident does not self-administer medications.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed and confirmed by staff. During an inspection, a blue dumpster located outside the facility's kitchen was found surrounded by dirty gloves and debris, including old cardboard boxes. This observation was confirmed by the Dietary Manager at the time. The Maintenance Director indicated that the trash was left by sanitation employees, and the Administrator confirmed that the Maintenance Director was responsible for ensuring the area around the dumpster was kept clean.
Inadequate Signage for Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of proper signage for residents on Transmission-Based Precautions. Two residents, identified as Resident #2 and #R1, were placed in isolation due to positive COVID-19 tests. However, observations revealed that the signage on their doors indicated Enhanced Barrier Precautions instead of the appropriate Transmission-Based Precautions. This discrepancy was confirmed by the RN Infection Preventionist during the survey. Resident #2 was admitted with diagnoses including COVID-19, a disorder involving the immune mechanism, atherosclerotic heart disease, and an acquired absence of the right leg below the knee. The resident required varying levels of assistance with daily activities. Similarly, #R1 was admitted with diagnoses including COVID-19, rhabdomyolysis, cerebral infarction, unspecified dementia, and unspecified atrial fibrillation, and also required substantial assistance with daily activities. Despite their isolation status due to COVID-19, the incorrect signage was observed multiple times on their doors, indicating a failure in the facility's communication and implementation of appropriate infection control measures.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medication. Resident #3, who had diagnoses including gastrointestinal hemorrhage, anal fissure, chronic atrial fibrillation, end-stage renal disease, and dependence on renal dialysis, was admitted with a care plan that required monitoring for side effects and effectiveness of Warfarin therapy every shift. However, a review of Resident #3's medical record revealed no such monitoring was in place, despite the care plan's directives. Interviews with S2 RN and S1 DON confirmed that no monitoring had been implemented to assess for possible side effects and effectiveness of Resident #3's anticoagulant therapy. This lack of monitoring was a direct violation of the resident's care plan, which specified the need for such assessments to be conducted every shift. The deficiency was identified during a review of the resident's significant change MDS, which indicated intact cognition and various dependencies for daily activities.
Failure to Follow Physician's Orders for Lab Tests and Notify Physician of Abnormal Results
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of practice for Resident #3. Specifically, the facility did not follow physician's orders for obtaining labs for a medication that required a drug level. Resident #3 had orders for a weekly PT/INR test due to being on Coumadin for Atrial Fibrillation. However, the PT/INR test was not conducted weekly as ordered, with a gap from 02/01/2024 to 02/20/2024. Additionally, an abnormal PT/INR result was obtained on 12/06/2024, but there was no documentation that the Medical Director was notified when the attending physician did not immediately respond to the abnormal result. Interviews with the nursing staff confirmed that Resident #3's weekly PT/INR tests were not consistently obtained and that there was a failure to follow up with the physician regarding the abnormal test result. The Director of Nursing also confirmed that the orders for the weekly PT/INR were not followed and that there was no follow-up with the physician for the abnormal test result. Resident #3 had a history of gastrointestinal hemorrhage, chronic atrial fibrillation, and end-stage renal disease, making the monitoring of PT/INR levels critical for their care.
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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