River Oaks Nursing & Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baker, Louisiana.
- Location
- 3612 Baker Blvd, Baker, Louisiana 70714
- CMS Provider Number
- 195561
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at River Oaks Nursing & Rehabilitation Center Llc during CMS and state inspections, most recent first.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents with psychiatric and cognitive conditions engaged in a verbal altercation that escalated when one struck the other in the face with a chair, causing multiple facial fractures. Staff were present and intervened, but the incident resulted in significant injury before separation and assessment occurred. There were no prior documented physical altercations or behavioral changes between the residents.
The facility did not ensure that two residents with mental health diagnoses were properly referred for PASRR Level II evaluation. One resident's updated diagnosis of schizophrenia was not reflected in the most recent PASRR documentation, and another resident's delusional disorder was not captured on the Level I screening form, resulting in missed referrals for required services.
Surveyors found that raw chicken was stored above ready-to-eat desserts in the freezer, expired milk was present in the refrigerator, and multiple opened food items were not properly sealed. Staff confirmed these practices did not follow facility food safety policies, potentially affecting all residents served from the kitchen.
Two residents engaged in a physical altercation in the dining room, exchanging blows before being separated by a CNA. Despite staff witnessing or being informed of the incident and recognizing it as physical abuse, there was no documentation in the nurse's notes or care plans, and the event was not reported to administration or the DON as required by facility policy.
Two residents were involved in a physical altercation in the dining room, which was witnessed by a CNA and later mentioned to an LPN. Despite staff recognizing the incident as physical abuse, there was no documentation in the clinical records or care plans, and the event was not reported to the administrator or State Agency as required by policy. Interviews confirmed that the incident was not escalated or documented, resulting in a failure to meet mandated reporting guidelines.
A resident with serious mental health diagnoses and an approved Level II PASRR was not accurately coded in the MDS assessment, as the PASRR section was marked 'No' and the serious mental illness section was left blank, despite documentation supporting a 'Yes' response.
Two incidents of resident-to-resident abuse occurred in an LTC facility. In one case, a severely cognitively impaired resident was pushed by another, resulting in a laceration requiring sutures. In another case, a cognitively intact resident was observed hitting a cognitively impaired resident, though no injuries were reported. The facility failed to protect residents from abuse by others.
A staff member at an LTC facility took and kept an unauthorized photograph of a resident, violating the resident's privacy and confidentiality rights. The resident, who had cognitive impairments, had not consented to any photographs. Facility administrators confirmed the breach after reviewing the photograph and related text messages.
The facility failed to store medications securely, leaving a resident's eye drops at their bedside and not affixing a Controlled Substance Emergency Kit containing Schedule III-IV medications. Staff confirmed the medications should have been secured, and the kit was not stored in compliance with regulations.
The facility failed to maintain dignity during meal assistance for two residents with dementia. CNAs were observed standing over and sitting on the residents' beds while feeding them, contrary to the facility's policy requiring staff to sit in a chair. Interviews confirmed the breach of procedure.
A resident reported being verbally abused by a CNA, an incident witnessed by the resident's roommate. The LPN and Administrator were informed, but the Administrator failed to report the allegation to the state survey agency as required by the facility's policy. The DON confirmed that such behavior is considered abuse.
A facility failed to accurately assess a resident's discharge status. The resident was documented as being discharged to a short-term hospital, but physician orders and nurses' notes indicated a discharge to a group home. Staff confirmed the MDS was incorrectly coded.
A resident with moderate cognitive impairment expressed a desire to transfer to a facility closer to his home, but the facility failed to update the discharge plan to reflect his wishes. Despite the resident being his own responsible party and communicating his desire to staff, no action was taken to facilitate the transfer. The Social Services Director admitted to not initiating transfer documents, resulting in a deficiency in the discharge planning process.
Two residents in the facility did not receive drinks consistent with their preferences and needs. One resident, who is cognitively intact, reported that his water cups were not filled regularly, while another severely cognitively impaired resident had an empty cup out of reach and stated that CNAs did not offer or provide ice and water. Staff interviews confirmed that CNAs failed to adhere to the facility's policy of passing ice and water every shift and as requested.
A resident with depressive disorders and dementia was prescribed Sertraline, but the facility failed to obtain or document physician orders for monitoring behaviors and side effects. Staff interviews confirmed the absence of necessary orders and tasks for monitoring the psychotropic medication, highlighting a deficiency in maintaining accurate medical records.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual physical harm. Two residents, both with psychiatric and cognitive diagnoses, were sharing a room. One resident, who was cognitively intact, became verbally aggressive with his roommate, who had moderate cognitive impairment. This verbal altercation escalated, and the cognitively impaired resident struck the other in the face with a chair, causing significant facial injuries including orbital and nasal fractures. Prior to this incident, there were no documented physical altercations or behavioral changes between the two residents, and both had a history of verbal arguments but no prior physical aggression. On the day of the incident, staff were present in the hallway and initially intervened to de-escalate a verbal argument between the two residents. After the initial intervention, the residents separated briefly, but the argument resumed. As staff approached to intervene again, the cognitively impaired resident picked up a chair and struck the other resident, also hitting the intervening LPN in the arm. Immediate staff intervention followed, and the residents were separated. The injured resident sustained a skin tear, bruising, and later was found to have multiple facial fractures. The resident initially refused emergency care but was eventually sent to the hospital for evaluation and treatment after imaging revealed the extent of the injuries. The injured resident was assessed multiple times following the incident and consistently denied pain, emotional distress, or fear, and continued to participate in daily activities. Staff interviews confirmed that there were no prior indications or behavioral changes that would have predicted the escalation to physical violence. The incident was witnessed by staff, and immediate action was taken to separate and supervise both residents. The facility's failure to prevent this altercation resulted in significant physical harm to the resident.
Failure to Refer Residents for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that residents with identified mental health diagnoses were properly referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. For one resident, the clinical record showed a diagnosis of Undifferentiated Schizophrenia with an onset date after the most recent PASRR Form 142 on file, which did not reflect the updated diagnosis. The staff member responsible for submitting resident review forms confirmed that a new review should have been submitted but was not. For another resident, the clinical record indicated diagnoses of Post-Traumatic Stress Disorder (PTSD) and Delusional Disorder upon admission. The staff member acknowledged that the Level I screening form failed to capture the Delusional Disorder diagnosis, which is considered a Tier 2 diagnosis and should have triggered a Level II review.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed that raw chicken products were stored above ready-to-eat desserts such as Boston cream pies and Philadelphia cheesecakes in the freezer, contrary to the facility's own food storage policy, which requires cooked foods to be stored above raw poultry. Additionally, an expired 1 1/2 gallon container of 2% reduced fat milk was found in the refrigerator, and several opened food items, including cheese slices, ham, and bacon, were not properly sealed. Interviews with facility staff confirmed that these practices did not align with established food safety and sanitation policies. The Dietary Manager acknowledged that desserts should not be stored under raw chicken and that expired milk should be discarded. The Administrator also confirmed that items in the kitchen should be stored in a clean and safe manner. These deficiencies had the potential to affect all 130 residents served from the kitchen.
Failure to Protect Residents from Physical Abuse and Lack of Incident Reporting
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an altercation between two residents in the dining room. One resident, with intact cognition, reported being struck in the face by another resident after grabbing the back of the other resident's wheelchair. The altercation escalated, with both residents exchanging blows, and a CNA intervened to separate them. Both residents confirmed the incident during interviews, and a CNA and LPN also acknowledged witnessing or being informed of the physical altercation. However, there was no documentation of the incident in either resident's nurse's notes or care plans. Staff interviews revealed that the incident was not reported to facility administration or the Director of Nursing, despite staff recognizing the event as physical abuse. The facility's abuse prevention manual defines physical abuse to include hitting and slapping, and both the DON and administrator confirmed that such incidents should be reported immediately. The lack of documentation and failure to report the altercation constituted a deficiency in protecting residents from abuse.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that an incident involving physical abuse between two residents was reported to the facility administrator and the State Agency as required by mandated reporting guidelines. According to the facility's Abuse-Neglect Prevention Manual, any evidence or suspicion of abuse must be reported immediately to the administrator or designee, who is then responsible for notifying the appropriate authorities. However, a review of facility-reported incidents over a one-month period revealed that no such incident involving the two residents was reported. Both residents involved in the altercation described a physical fight in the dining room, with one resident stating he was hit in the face and retaliated, and the other confirming the altercation and that staff were present. Interviews with staff confirmed that the altercation occurred, was witnessed, and was recognized as physical abuse, but there was no documentation in the residents' nurse's notes or care plans regarding the incident. Further interviews revealed that a CNA witnessed the altercation, intervened, and reported it to a nurse, but could not recall the specific date or the nurse's identity. An LPN also recalled being told about the incident by one of the residents but did not document or escalate the report. The Director of Nursing and the Administrator both confirmed that no staff reported the incident to them, despite acknowledging that such an event constitutes physical abuse and should have been reported immediately. The lack of internal reporting and absence of documentation resulted in the failure to notify the appropriate authorities as required by facility policy and state guidelines.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not properly coding the Preadmission Screening and Resident Review (PASRR) information. Specifically, a resident admitted with diagnoses including Recurrent Depressive Disorders, Bipolar Disorder, and Post-Traumatic Stress Disorder had an approved Level II PASRR for a temporary period, as documented on the state's Form 142. However, review of the resident's Annual MDS assessment showed that Section A1500 (PASRR) was incorrectly coded as 'No' and Section A1510 (Serious Mental Illness) was left blank. Both the MDS coordinator and the Director of Nursing confirmed that the MDS should have indicated a 'Yes' response for PASRR, based on the resident's documentation.
Resident-to-Resident Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in two incidents of resident-to-resident abuse. In the first incident, a severely cognitively impaired resident was pushed by another severely cognitively impaired resident, causing the former to fall and sustain a laceration above the left eyebrow. This incident occurred when the resident wandered into the other resident's room, leading to an altercation. The injured resident was sent to the emergency room where they received nine sutures for the laceration. In the second incident, a cognitively intact resident was observed hitting a cognitively impaired resident. This altercation was witnessed by a CNA who intervened and separated the residents. The cognitively impaired resident did not sustain any injuries from the incident. The aggressive resident was placed on one-to-one supervision and later transferred to a behavioral hospital for evaluation. Both incidents highlight the facility's failure to ensure the safety and protection of residents from abuse by other residents. The facility's policies on abuse and neglect were not effectively implemented, leading to these occurrences of physical harm and distress among residents.
Unauthorized Photograph Breaches Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records. This deficiency was identified when a staff member, S5A, took and kept an unauthorized photograph of a resident in their room. The resident, who was admitted with diagnoses including Alzheimer's Disease, Dementia, and other cognitive impairments, had a consent form on file that explicitly did not authorize photographs for any purpose. Despite this, S5A saved a photograph of the resident on their phone, which was later reviewed and confirmed by facility administrators and nursing staff. The incident was confirmed through interviews and a review of text messages containing the unauthorized photograph. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the action violated the resident's right to privacy and confidentiality, as outlined in the facility's policy on Resident's Rights. The deficiency had the potential to affect all residents in the facility, as it demonstrated a breach in the protection of resident privacy and confidentiality.
Improper Storage of Medications and Controlled Substances
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles. Specifically, medications were not kept in locked compartments accessible only to authorized personnel. During an observation, it was found that a resident had two bottles of eye drops left at their bedside, which were supposed to be securely stored. The resident confirmed that the nurse had left the medications there the previous night. Both the LPN and the Assistant Director of Nursing (ADON) acknowledged that medications should not have been left at the resident's bedside. Additionally, the facility did not properly store Schedule III-IV medications in a permanently affixed compartment or a single unit package drug distribution system. An observation revealed that the Controlled Substance Emergency Kit, containing Schedule III-IV medications, was not permanently affixed and could be easily removed from the medication storage room. Interviews with the Director of Nursing (DON) and ADON confirmed that the kit was not secured as required, and they were unaware of the necessity for it to be stored in a permanently affixed compartment.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were assisted with meals in a dignified manner, which is a violation of their right to a dignified existence and self-determination. Specifically, two residents, identified as #43 and #120, were observed being fed by CNAs who did not adhere to the facility's policy of sitting in a chair while assisting residents with meals. Instead, the CNAs were observed standing over the residents and sitting on their beds during meal assistance. Resident #43, who has diagnoses of Senile Degeneration of Brain and Dementia, was fed by a CNA who initially stood next to the bed and then sat on the bed to continue feeding. Similarly, Resident #120, diagnosed with Dementia, was fed by a CNA who also stood and then sat on the bed. Interviews with the CNAs and the Director of Nursing confirmed that the proper procedure was not followed, as staff should sit in a chair to feed residents, ensuring a respectful and dignified interaction.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, identified as Resident #33, to the State Survey Agency within the required timeframe. According to the facility's policy, any evidence of abuse must be reported immediately to the Administrator or designee, who then notifies the corporate office and appropriate state officials. However, in this case, the allegation was not reported as required. Resident #33, who was cognitively intact with a BIMS score of 15, reported that a CNA yelled and cursed at him. This incident was witnessed by the resident's roommate and reported to an LPN and the Administrator. Despite being informed of the incident, the Administrator confirmed that the allegation was not reported to the state survey agency. The Director of Nursing acknowledged that any staff yelling or cursing at residents would be considered abuse. The failure to report the incident promptly as per the facility's policy and state guidelines constitutes a deficiency in the facility's handling of abuse allegations.
Inaccurate Discharge Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's discharge status. A review of the clinical record for a resident revealed that she was admitted to the facility and later discharged. The Discharge Minimum Data Set (MDS) indicated that the discharge was planned and that the resident was discharged to a short-term general hospital. However, physician orders and nurses' notes indicated that the resident was actually discharged to a group home. Interviews with facility staff confirmed that the MDS was incorrectly coded, as the resident was discharged to a group home, not a hospital.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals. The policy of the facility requires that discharge planning involves the resident, family, interdisciplinary staff, and other resources as needed. However, the facility did not update the discharge plan to reflect the resident's wishes. The resident, who had moderate cognitive impairment with a BIMS score of 12, expressed a desire to transfer to a facility closer to his home. Despite being his own responsible party, the resident's care plan did not reflect his wishes, and the facility's staff did not take action to facilitate his transfer. Interviews with the resident and staff revealed that the resident had communicated his desire to transfer to a facility closer to his family multiple times. The Social Services Director acknowledged that the resident had expressed this wish but had not initiated any transfer documents because the resident was newly admitted. This lack of action and communication among staff members resulted in the resident's discharge wishes not being addressed, leading to a deficiency in the facility's discharge planning process.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to provide drinks consistent with resident preferences and needs, specifically for two residents. Resident #10, who is cognitively intact with a BIMS score of 14, reported that his water cups were not filled regularly, stating he was lucky to get his cup filled once a day. Observations confirmed that his cups were empty on multiple occasions, and he expressed that staff had not filled his cup with water and ice for two weeks. Similarly, Resident #112, who is severely cognitively impaired with a BIMS score of 3, also had an empty cup out of reach and reported that CNAs did not offer or provide ice and water, leading him to stop asking for it. Interviews with staff, including CNAs and the LPN, revealed that the facility's policy required CNAs to pass ice and water to residents every shift and as requested. However, the CNAs admitted to not providing ice and water to the two residents during the week of the survey. The Director of Nursing confirmed that CNAs should pass ice and water once to twice a shift and as requested by residents, indicating a failure in adherence to the facility's hydration management policy.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for a resident diagnosed with Major Depressive Disorder, Other Specified Depressive Episodes, and Severe Vascular Dementia with Other Behavioral Disturbance. The resident was prescribed Sertraline, a psychotropic medication, but the facility did not obtain or document physician orders for monitoring behaviors and side effects associated with this medication. This oversight was identified during a review of the resident's clinical records, which showed no orders or documentation for such monitoring from June 2024 to August 2024. Interviews with facility staff, including two LPNs and the Director of Nursing, confirmed the absence of necessary physician orders and monitoring tasks for the resident's psychotropic medication. The staff acknowledged that there should have been orders and tasks in place to monitor the resident for behaviors and side effects related to the antidepressant medication. This deficiency was noted for one resident out of a sample of 28 reviewed during the survey.
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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