The Bradford Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 3050 Baird Road, Shreveport, Louisiana 71118
- CMS Provider Number
- 195513
- Inspections on file
- 38
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Bradford Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
A resident with multiple chronic conditions was using bilateral hand assist rails without documented quarterly assessment for entrapment risk or informed consent, as required by facility policy. The DON confirmed that the necessary Side Rail Utilization Assessment and consent process had not been completed.
A facility failed to report an alleged abuse incident involving a resident to the State Agency, despite conducting an internal investigation. The resident, with severe cognitive impairment and other mental health conditions, was allegedly kicked and cursed at by a CNA. The facility's policy requires timely reporting of such incidents, but this was not done, resulting in a deficiency.
A resident with severe cognitive impairment and frequent bowel incontinence was not checked every two hours as required by their care plan. Video footage showed a CNA entered the resident's room at night and did not return until the next morning, which was confirmed by the facility's administrator and DON.
A resident with multiple diagnoses and a self-care performance deficit was found with long and dirty fingernails, despite having a care plan requiring assistance with personal hygiene. The resident, who was cognitively intact, had requested nail trimming a week prior, but the facility failed to provide this care. The DON confirmed the need for nail trimming.
A resident, who was cognitively intact and receiving hospice care, felt threatened and unsafe after an administrator threatened to notify APS over a payment issue. The resident expressed a desire to leave the facility due to the administrator's rude behavior, which was confirmed by multiple staff members.
A resident with severe cognitive impairment and high fall risk was found with side rails in use without a physician's order, assessment, or consent, effectively acting as a restraint. Facility staff confirmed the lack of necessary documentation and acknowledged the inappropriate use of side rails as a restraint.
The facility failed to ensure proper use and maintenance of bed rails for several residents, lacking assessments, consents, and physician orders. Residents with various medical conditions had side rails raised without necessary documentation, as confirmed by observations and interviews with the corporate nurse. This indicates a systemic issue in adhering to protocols for safe bed rail use.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. An LPN administered incorrect medications to two residents: one received the wrong inhalation medication, and another received half the prescribed dose of Metoprolol Succinate ER. Both errors were confirmed by the LPN, a Nurse Practitioner, and the DON.
The facility failed to submit accurate payroll information for direct care staffing to CMS. A review of the PBJ report indicated low weekend staffing. Interviews revealed that the corporate office handles report submissions, and late agency staffing hours can result in inaccurate staffing levels being reported, suggesting inadequate staffing.
A resident with severe cognitive impairment and multiple diagnoses was unable to reach their call light, which was placed on a bedside table. Despite requiring extensive assistance, the resident's call light was observed out of reach on multiple occasions, and a CNA confirmed it should not have been placed there.
A facility failed to investigate an incident of resident-to-staff violence, where a resident with a history of violent behavior pushed an LPN and used profanity. Despite the facility's policy requiring such incidents to be reported and investigated, the DON did not complete an incident report, and the Administrator did not review available camera footage. The incident was not reported to the Corporate Compliance Officer, as it was deemed a behavior rather than an incident, indicating non-compliance with regulatory requirements.
The facility failed to ensure that a resident with multiple diagnoses, including mobility issues, was free from accidents and hazards. The resident was repeatedly observed with their bed in a high position and the call bell out of reach, contrary to physician orders and the care plan. A Restorative Aide confirmed these deficiencies.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Obtain Informed Consent and Complete Quarterly Side Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails and did not conduct quarterly assessments for the risk of entrapment as required by its own policy. Specifically, for one resident with diagnoses including muscle wasting, chronic pain, osteoarthritis, and morbid obesity, the medical record did not contain evidence that a Side Rail Utilization Assessment had been completed quarterly. The facility's policy mandates that such assessments be performed upon admission, readmission, quarterly, or with significant changes, and that informed consent be obtained after discussing the risks and benefits with the resident or their representative. Observations confirmed that the resident was using bilateral hand assist rails during multiple surveyor visits, and interviews with the resident and the DON verified that the required assessment and consent process had not been completed as per policy. The resident, who was cognitively intact, reported using the rails for bed mobility, but documentation of the necessary assessment and consent was missing from the medical record.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the State Survey and Certification Agency. The facility's policy mandates timely reporting of suspected abuse to appropriate agencies, but this was not adhered to in the case of a resident who was allegedly kicked and cursed at by a CNA. The incident was reported internally on December 25, 2024, and an investigation was conducted, including interviews with the involved staff and witness statements. However, the facility did not notify the State Agency as required. The resident involved in the incident had a complex medical history, including severe cognitive impairment, neurocognitive disorder with Lewy Bodies, and other mental health conditions. The resident's MDS assessment indicated severely impaired cognition, which underscores the vulnerability of the resident. Despite the internal investigation and acknowledgment of the incident by the Director of Nursing, the failure to report the alleged abuse to the State Agency constitutes a deficiency in the facility's adherence to regulatory requirements.
Failure to Implement Incontinence Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and frequent bowel incontinence. The resident, who had a BIMS score of 2 indicating severely impaired cognition, was admitted with diagnoses including schizoaffective disorder bipolar type, Alzheimer's disease, history of falls, and osteoarthritis. The care plan required staff to check the resident every two hours for incontinence. However, a review of the facility's video footage revealed that a CNA entered the resident's room at 11:08 p.m. and did not return until 6:25 a.m. the following morning, indicating that the resident was not checked every two hours as required. Interviews with the facility's administrator and DON confirmed the lapse in care, acknowledging that no staff entered the resident's room during the specified time frame, thus failing to adhere to the care plan's intervention for incontinence management.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care for a resident who was unable to perform self-care due to a self-care performance deficit related to decreased vision and impaired balance. The resident, who was admitted with multiple diagnoses including muscle wasting, COPD, and anxiety, was cognitively intact with a BIMS score of 15. Despite having a care plan that required assistance with personal hygiene, the resident's fingernails were observed to be long and dirty. The resident expressed that he did not want long fingernails and had requested them to be trimmed a week prior. The Director of Nursing confirmed the observation that the resident's fingernails were dirty and needed trimming.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically in the case of one resident. The facility's Resident Rights Policy mandates that all residents be treated with kindness, respect, and dignity. However, the administrator's interaction with a resident did not adhere to this policy. The resident, who was cognitively intact and receiving oxygen therapy and hospice care, reported feeling fearful and threatened after an encounter with the administrator. The resident expressed a desire to leave the facility due to the administrator's rude behavior. The incident involved a discussion about the resident's payment process, during which the administrator threatened to notify Adult Protective Services (APS) if the resident's funds were not used to pay his bill. This threat left the resident visibly shaken and adamant about leaving the facility, as confirmed by multiple staff members. The administrator acknowledged making the statement about contacting APS if the payment was not made, which contributed to the resident's distress and feeling of unsafety.
Failure to Ensure Resident's Right to Be Free from Unnecessary Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. Specifically, the facility did not complete a side rail utilization assessment, obtain consent for the use of side rails, or secure a physician's order for the use of bedrails for Resident #360. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully and must be based on a physician's order with consent from the resident or their representative. Resident #360, who was admitted with severe cognitive impairment and a high risk for falls, was observed with bilateral upper side rails in use without the necessary assessments or orders. Despite the resident's dependency on staff for mobility and the absence of an indication for side rails for mobility assistance, the side rails were used, effectively acting as a restraint. Interviews with facility staff confirmed the lack of a physician's order, side rail assessment, and consent for the use of side rails, acknowledging that the side rails were used as a restraint.
Failure to Ensure Proper Use and Maintenance of Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for several residents, as evidenced by the lack of assessments, informed consents, and physician orders. The facility's policy requires a thorough assessment of residents for the use of side rails, obtaining informed consent, and ensuring physician orders are in place. However, for 11 out of 17 residents investigated, these steps were not followed, leading to deficiencies in compliance with the facility's guidelines and regulatory requirements. For instance, Resident #3, who has multiple diagnoses including hemiplegia and schizophrenia, had side rails raised without a documented assessment or consent. Similarly, Resident #17, diagnosed with Alzheimer's disease and a history of falls, had side rails raised without consent or documented checks for placement and functioning. These oversights were confirmed through observations and interviews with the facility's corporate nurse, who acknowledged the absence of necessary documentation and assessments. Other residents, such as Resident #23 and Resident #41, also had side rails raised without prior assessments or consents, and in some cases, without physician orders. The facility's failure to conduct quarterly assessments and obtain necessary consents and orders for the use of side rails was a recurring issue across multiple residents, indicating a systemic problem in adhering to the established protocols for the safe use of bed rails.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate during a medication pass observation. Two specific errors were identified. The first involved Resident #19, who was administered Fluticasone Propionate and Salmeterol 250mcg/50mcg by oral inhalation instead of the prescribed Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act. This discrepancy was confirmed by the LPN during an interview, who acknowledged that the medication administered did not match the physician's order. The second error involved Resident #93, who received one-half tablet of Metoprolol Succinate ER 25mg instead of the full tablet as prescribed for essential hypertension. The LPN and a Nurse Practitioner confirmed the error upon reviewing the medication card and physician's order. The Director of Nursing also verified that the medications administered to both residents did not align with the physician orders, contributing to the facility's medication error rate exceeding the acceptable threshold.
Inaccurate Payroll Submission for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. A review of the Payroll Based Journal (PBJ) report for the fiscal year 2024, 2nd quarter, revealed that excessively low weekend staffing was triggered. During interviews, the administrator and human resources personnel indicated that the corporate office is responsible for submitting the PBJ report. The administrator suggested that an agency invoice might have been missed or not available at the time of reporting. The human resources representative explained that when staffing agencies send staffing hours late, the reported staffing hours to the corporate office do not reflect the actual staffing levels, leading to an appearance of inadequate staffing.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring the call light was within reach. The resident, who was admitted with diagnoses including parkinsonism, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus, pain unspecified, restlessness and agitation, and insomnia, had a severe cognitive impairment as indicated by a BIMS score of 03. The resident required extensive assistance with bed mobility, transfer, and toilet use. On the morning of August 19, 2024, observations revealed that the resident's call light was placed on the bedside table, out of reach. During an interview, the resident confirmed the inability to reach the call light. Later, the resident was heard calling for help, and the call light was still observed to be out of reach. A CNA confirmed that the call light should not have been out of the resident's reach.
Failure to Investigate Resident-to-Staff Violence Incident
Penalty
Summary
The facility failed to comply with applicable Federal, State, and local laws, regulations, and codes by not investigating an incident involving resident-to-staff violence. The incident involved a resident who was cognitively intact and had a history of violent behavior, including bipolar disorder and anxiety disorder. On the night of the incident, the resident was observed yelling and using profanity in the hallway. When approached by an LPN, the resident pushed the LPN and slammed the door. Despite this, the facility did not complete an incident report or conduct an investigation as required by their Workplace Aggression/Violence Policy. The facility's policy mandates that all employees report any threats or violent acts, which include verbal or physical harassment and threats, to the appropriate supervisor or HR Director. However, the Director of Nursing (DON) did not consider it necessary to write an incident report after seeing the progress note in the resident's medical record. Additionally, the facility's Administrator did not review the camera recording of the incident, and the recording was no longer available. This lack of action and documentation indicates a failure to adhere to the facility's policy and ensure a safe environment for both staff and residents. Interviews with staff revealed that the incident was not reported to the facility's Corporate Compliance Officer, as it was not considered an incident but rather a behavior. The resident's behavior was notably above baseline, and the resident was later transferred to a Behavioral hospital with police assistance. The facility's failure to investigate and report the incident demonstrates non-compliance with their own policies and regulatory requirements, compromising the safety and well-being of both staff and residents.
Failure to Ensure Resident Safety and Accessibility
Penalty
Summary
The facility failed to ensure that Resident #3 was free from accidents and hazards. Resident #3, who has multiple diagnoses including muscle wasting, gait and mobility issues, anxiety disorder, and heart failure, was observed multiple times with their bed in a high position and the call bell out of reach, despite physician orders and a comprehensive care plan specifying the use of a low bed and fall mats. On several occasions, the call bell was found hanging off the side of the bed, wrapped around the assist rail, or on the floor, making it inaccessible to the resident. These observations were confirmed by a Restorative Aide who acknowledged that the bed should be lowered and the call bell should not be on the floor.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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