Villa Feliciana Chronic Disease
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Louisiana.
- Location
- 5002 Highway 10, Jackson, Louisiana 70748
- CMS Provider Number
- 195150
- Inspections on file
- 31
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Villa Feliciana Chronic Disease during CMS and state inspections, most recent first.
Two residents did not receive ordered weekly weights. One resident with Type 2 DM, GERD, dysphagia, and severe cognitive impairment had weekly weights ordered and included in the care plan, but the weight log did not show them. Another resident with metastatic prostate cancer had a care plan for weekly weights, but several weeks had no documented weights. The DON, RD, and LPN confirmed the orders were not followed.
Insufficient CNA Staffing on Multiple Units: The facility did not provide enough CNAs to meet resident needs on several units, with repeated shifts staffed below the number of CNAs identified as necessary. A resident on one unit reported waiting about an hour for incontinence care, while staff said residents often waited 30 minutes to 2 hours for ADL care. On another unit, a resident paced and became agitated while waiting for a shower, and staff reported missed or delayed rounding and perineal care, with security officers sometimes needed to monitor residents when staff were unavailable.
Expired medications were found available for use in medication carts. Two bottles of Latanoprost Ophthalmic Solution 0.005% were observed for two residents in one cart, and another expired bottle was observed for a third resident in a separate cart. An LPN confirmed the medications were expired and should not have been available for use, and the DON stated nurses were responsible for checking carts for expired medications.
Improper Food Storage in Kitchen: Surveyors observed an opened container of soy sauce stored in the dry storage room despite a label stating it should be refrigerated after opening, and an opened block of margarine that was unsealed and lacked an open date. The DM and RD confirmed the storage issues and that the items should have been refrigerated, sealed, labeled, and dated.
Oxygen Tubing Not Labeled With Date and Time: A resident with COPD, pleural effusion, and atrial fibrillation had O2 via nasal cannula as needed, but observations showed the oxygen tubing was not labeled with the date and time. An LPN confirmed the tubing was not labeled and should have been, and the DON stated staff were expected to label oxygen tubing with the date and time it was changed.
A resident with severe cognitive impairment and a history of wandering did not have a functioning Wanderguard alarm, as required by physician orders. The alarm failed to sound when the resident exited a door, and staff confirmed the system had not been tested recently. No elopement risk assessment was completed, and facility leadership was unaware of the malfunction.
The facility did not maintain adequate nursing staff as required by its Facility Assessment, resulting in staff being unable to complete timely rounds or provide necessary care to all residents. Multiple staff members, including CNAs and LPNs, reported unmanageable workloads and confirmed that staffing levels were below the required numbers, impacting the ability to meet residents' needs.
Several residents who were physically able to use the call bell system did not have call bells accessible or within reach while in bed. Observations and staff interviews confirmed that call bells were either missing from the wall system or placed on the floor behind beds, contrary to facility policy. All affected residents had no upper extremity impairment and should have had access to the call system.
A urine-soiled brief was found on the floor between a resident's bed and their roommate's bed and remained there for at least five hours. Multiple staff, including an LPN, DON, and the director of housekeeping, confirmed the brief's presence and agreed it was unacceptable for it to remain on the floor.
The facility failed to provide sufficient CNA staff on Unit 2B, where only one CNA was assigned per shift instead of the required two. This led to delays in care for 20 residents, many of whom required two staff members for ADL assistance due to behaviors. Observations and staff interviews confirmed that the staffing was inadequate to meet the residents' needs, resulting in wait times of 20 to 30 minutes for assistance.
The facility failed to accurately document medication administration for two residents, compromising the reliability of their MARs. A resident with multiple diagnoses, including Diabetes Mellitus-Type 2, had no documented evidence of receiving or refusing medications over several days. Another resident also had missing documentation for medication administration. Staff interviews revealed issues with accessing the electronic MAR system and the absence of current paper MARs, affecting the facility's compliance with its medication administration policy.
An RN at a facility was observed misappropriating medications intended for two residents, placing them in her personal bag instead of administering them. The residents, both severely cognitively impaired, were prescribed critical medications for various conditions, including cardiac and psychiatric disorders. The RN falsely documented that the residents refused their medications, leading to an Immediate Jeopardy situation. Despite the potential for serious harm, the residents reportedly suffered no negative outcomes.
Two residents' medications were misappropriated by a nursing supervisor, who was observed placing the medications into her personal bag. Despite immediate discovery, the incident was not reported to the state survey agency until several days later, violating the facility's policy and state regulations.
The facility failed to ensure staff used appropriate PPE for residents on Enhanced Barrier Precautions, as observed in three residents with chronic wound care needs and indwelling medical devices. Staff did not wear gowns during high-contact care activities, and there was no signage indicating the need for EBP, leading to staff being unaware of the precautions required.
A facility failed to ensure a resident was assisted with meals in a dignified manner. A CNA was observed standing over a resident while feeding him, contrary to the facility's policy of sitting at the resident's level. The resident, dependent on staff for eating due to medical conditions, was not fed at eye level, and the CNA acknowledged not sitting during the process. The DON confirmed the CNA should have been seated.
A resident with Schizoaffective Disorder - Bipolar Type did not receive recommended specialized services, including outpatient therapy and a psychiatric evaluation, due to a lack of an effective system for implementing Level II PASARR recommendations. Staff interviews revealed a breakdown in communication and responsibility, resulting in the oversight.
A resident with pressure ulcers did not receive the prescribed wound care treatment, as the wound vacuum was not applied, and a dry dressing was used instead. Despite this, the treatment was inaccurately documented as completed per physician orders. Interviews with the involved LPNs and the DON confirmed the discrepancy, highlighting a failure to meet professional standards of quality in the facility.
A resident with pressure ulcers did not receive the physician-ordered wound vacuum treatment, as staff applied a dry dressing instead. Interviews and observations confirmed the wound vacuum was not in place on multiple occasions, despite orders for continuous use. This lapse in care was acknowledged by the LPNs, wound care nurse, and DON, highlighting a failure to follow the facility's wound care policy.
The facility failed to protect residents from physical abuse in three separate incidents involving residents with different levels of cognitive impairment. In one case, a resident was pushed out of a wheelchair by another resident over a drink dispute. In another, a resident was slapped on the head by another resident in the day room. The third incident involved a resident being physically assaulted over a cigarette disagreement, resulting in visible injuries. These incidents were confirmed by staff and documented in medical records.
A resident with Epilepsy, Bipolar Disorder, and Alcohol Abuse did not receive their prescribed Phenobarbital dose as ordered by the physician. The medication was not administered on a specific evening, and staff interviews confirmed the oversight. The DON acknowledged that medications should be administered and documented accurately.
A resident with a known allergy to Depakote was mistakenly administered the medication due to a failure in verifying allergies during a verbal order process. An LPN did not communicate the allergy to the psychiatrist, and an RN administered the medication without checking the MAR. The error was confirmed by the facility's nursing leadership.
A facility failed to limit PRN orders for psychotropic medications to 14 days, as required by policy. A resident with dementia, psychosis, and schizophrenia was prescribed Ativan without a stop date or duration, and it was administered multiple times. The DON confirmed the order exceeded 14 days without proper documentation.
The facility failed to notify the physician when three residents exhibited abnormal behaviors, including lethargy and unsteady gait, on the same day. Despite being reported to the RN, the physician was not informed. Additionally, over-the-counter sleep aids were found on the medication cart without the physician's knowledge.
The facility failed to report abuse allegations within the required timeframe for two residents. One resident experienced verbal abuse from a roommate, and another reported physical abuse by a CNA. Both incidents were not reported to the state survey agency within the required two-hour period, despite internal reporting. Staff interviews confirmed delays and inconsistencies in the reporting process, indicating lapses in communication and adherence to procedures.
The facility failed to limit PRN orders for psychotropic medications to 14 days and include stop dates for several residents. A resident with dementia and psychosis had a PRN order for Haldol without a stop date. Another resident with schizophrenia had PRN orders for Hydroxyzine and Olanzapine without specified durations. Additional residents with various psychiatric diagnoses had PRN orders for Haldol and Zyprexa without stop dates. The DON confirmed these medications should have had stop dates, indicating non-compliance with policy.
The facility failed to protect residents from physical abuse, with incidents involving three residents. A resident was pushed and hit by another in the dining room, confirmed by video and staff interviews. Another resident was pushed to the floor and punched in the dayroom, also confirmed by video. A third resident was forcefully pushed in a wheelchair into the hallway by a roommate, nearly hitting the railing, as observed by a CNA and confirmed by video.
A resident's care plan was not updated following a verbal altercation with another resident, despite facility protocol requiring such updates. The incident involved a threat of physical harm, and staff interviews confirmed the oversight in revising the care plan to include new interventions.
The facility failed to protect residents from abuse, resulting in three incidents. A resident was mentally abused by a CNA who made degrading comments about their bowel condition. Two residents with cognitive impairments were involved in a physical altercation, resulting in one resident being scratched. Another resident with severe cognitive impairment pushed a cognitively intact resident to the floor. These incidents were confirmed as abuse by the facility's staff.
A facility failed to provide necessary behavioral health care for a resident with severe cognitive impairment by not implementing and documenting increased behavior monitoring as required. Despite a physician's order for 15-minute checks, records showed multiple lapses in monitoring over several days. Staff interviews confirmed that the observations were not completed, indicating a failure to adhere to the facility's policy and provide the necessary care.
Failure to Complete Ordered Weekly Weights
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status by not implementing ordered weekly weights for 2 residents reviewed for tube feeding/nutrition. Resident #11 had diagnoses including Type 2 DM, GERD, and dysphagia, and his quarterly MDS showed severe cognitive impairment with a BIMS of 99. His physician ordered weekly weights starting 08/18/2025, and both the Nutrition Services Care Plan and the resident care plan identified weekly weight monitoring as an intervention, but the weight log did not show weekly weights documented for him. Resident #65 had metastatic prostate cancer and a care plan intervention for weekly weights due to need for adequate nutrition/hydration. His weight record showed documented weights on 11/04/2025, 11/10/2025, 12/07/2025, 12/09/2025, 12/10/2025, 12/18/2025, and 01/08/2026, but no weights were documented for the weeks of 11/17/2025, 11/24/2025, 12/01/2025, 12/22/2025, and 12/29/2025. Staff interviews confirmed that both residents were supposed to receive weekly weights and that the documented weights did not reflect the physician orders.
Insufficient CNA Staffing on Multiple Units
Penalty
Summary
The facility failed to provide sufficient numbers of CNAs on a 24-hour basis to meet resident needs and maintain resident safety for residents on multiple units, including residents on Unit 3 and Unit 5. The report states that the facility had 162 residents, with 24 residents on Unit 3 and 25 residents on Unit 5, yet staffing assignment sheets showed repeated shifts where only one CNA was assigned to those units when two CNAs were identified as needed. The staffing records from 01/01/2026 through 01/21/2026 documented multiple days in which Unit 3, Unit 5, or both were staffed with fewer CNAs than required. Resident #14 was admitted in 2015 and had diagnoses including Personal History of Traumatic Brain Injury and Morbid Obesity. Her MDS showed a BIMS of 15, indicating she was cognitively intact, and her care plan stated she was bed/chair bound, needed help from 2-plus staff for transfers, and was incontinent of bladder and bowel. She told surveyors that there were not enough CNAs on Unit 3 and that when she called for incontinence care, it often took about one hour for staff to respond. Staff interviews confirmed that Unit 3 often had only one CNA, that residents on the unit included several who required total care and two-person assistance, and that ADL and incontinence care were not being met timely with the staffing provided. On Unit 5, surveyors observed Resident #53 pacing, requesting a shower, and becoming agitated while waiting for assistance. Staff stated that one CNA could not complete all tasks timely on Unit 5, which had 25 residents, including 15 bed-bound residents and 3 residents who needed to be fed. Staff reported that rounding was not completed every 30 minutes when only one CNA was scheduled, and residents sometimes waited 30 minutes to 2 hours for bed baths or showers. A non-facility security officer also stated that residents on Unit 5 did not receive perineal care every 2 hours because of short staffing, that Resident #104 became agitated when his brief was wet and attempted to get up, and that security officers had to stand outside his room to ensure his safety when staff were not available. The DON, ADON, RNM, and other nursing staff confirmed that the facility was not staffed with enough CNAs to meet resident acuity and that one CNA could not timely and effectively carry out the ADLs of the residents on Unit 5.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure medications were stored properly in accordance with currently accepted professional principles. During observation of Medication Cart a with an LPN, two bottles of Latanoprost Ophthalmic Solution 0.005% were found for Resident #71 and Resident #131, both with an expiration date of 12/2025 and available for use. The LPN confirmed the bottles were expired and should not have been available for use. During a separate observation of Medication Cart b with another LPN, one bottle of Latanoprost Ophthalmic Solution 0.005% was found for Resident #65 with an expiration date of 12/2025 and available for use. That LPN also confirmed the medication was expired and should not have been available for use. The DON later stated nurses were responsible for checking medication carts for expired medications and confirmed expired medications should not have been available for use.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During observation of the dry storage room in Kitchen b, surveyors found an opened, half-full gallon container of soy sauce with no open date and a label stating "Refrigerate after opening," and the container was stored in the dry storage room rather than refrigerated. During a separate observation of Kitchen b, surveyors found an opened 16-ounce block of margarine with no open date and left unsealed. The facility policy titled Food Storage: Cold Foods stated that all foods are to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination. S16DM and S4RD both confirmed the soy sauce should have been refrigerated after opening and the margarine should have been sealed, labeled, and dated.
Oxygen Tubing Not Labeled With Date and Time
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured when the facility failed to label oxygen tubing with the date and time for Resident #54. The resident was admitted with diagnoses including COPD with acute exacerbations, pleural effusion, and atrial fibrillation, and the care plan directed staff to monitor for respiratory distress and provide O2 via nasal cannula as needed to keep saturations above 93%. Review of the facility's oxygen administration policy stated that date, time, oxygen flow rate, route, frequency, and duration of treatment should be documented, and tubing, cannula, or mask should be replaced at least every week when oxygen is used intermittently or as needed. On 01/20/2026, observations at 10:30 a.m. and 1:50 p.m. showed no date and time on the resident's oxygen tubing. During an observation at 2:00 p.m., an LPN confirmed the tubing was not labeled and should have been. On 01/22/2026, the DON stated she expected staff to label oxygen tubing with the date and time it was changed.
Failure to Maintain Functioning Wanderguard System for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a functioning assistance device for supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified psychosis, unspecified dementia, and schizophrenia, was assessed as severely cognitively impaired and required a wander/elopement alarm daily. Physician orders specified that the resident should have a Wanderguard bracelet checked every shift to ensure it was functioning and in place. However, no elopement risk assessment was completed for the resident. On multiple occasions, it was observed that the Wanderguard alarm did not sound when the resident exited a door with staff. Staff interviews confirmed that the resident frequently wandered and required the Wanderguard for safety, and that the malfunction had been reported to nursing leadership. The system had not been tested since a staff member responsible for testing was on leave, and facility leadership confirmed that elopement risk assessments were not conducted. The Wanderguard system was expected to alert staff if a resident exited the building, but it was not functioning as required.
Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents as outlined in its Facility Assessment. The assessment specified that each shift required 14 CNAs, 6 licensed nurses providing direct care, and 5 other nursing personnel with administrative duties. However, review of staff assignment sheets over several days showed that these staffing levels were not consistently met, with multiple shifts falling short of the required number of CNAs and licensed nurses. Staff interviews confirmed that these shortages resulted in unmanageable workloads, with CNAs and LPNs reporting that they were unable to complete 30-minute rounds or provide timely assistance to residents. Some staff were responsible for as many as 23 residents, and there were instances where units operated without a CNA, making it difficult to meet residents' needs and pass medications on time. Further interviews with staff, including the DON and administrative personnel, confirmed awareness of the staffing requirements in the Facility Assessment and acknowledged that the facility was not staffed according to these requirements during the reviewed period. Staff responsible for making assignments were unaware of the Facility Assessment's staffing requirements, leading to continued non-compliance. The deficiency had the potential to affect the entire resident census of 153, as the facility was unable to ensure that nursing and related services were provided to maintain the highest practicable well-being of each resident.
Failure to Ensure Accessible Call Bell System for Capable Residents
Penalty
Summary
The facility failed to ensure that residents who were physically capable of using the call bell system had call bells accessible and within reach. Observations on 04/28/2025 revealed that five residents were either lying in bed without a call bell available in the wall system or had the call bell placed behind the bed on the floor, making it inaccessible. Review of the facility's policy indicated that call lights should be kept within reach of residents, either clipped to sheets, tied to the side rail, or clipped to a bedside chair. Despite this policy, the call bells for these residents were not accessible as required. Record reviews showed that all five affected residents had no impairment of upper extremities, confirming their ability to use the call bell system. Interviews with facility staff, including an LPN, the program director, and the administrator, confirmed that these residents were physically able to use the call bell and that the call bells should have been accessible and within reach. The deficiency was identified through direct observation, record review, and staff interviews, all of which corroborated the lack of accessible call bells for these residents.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A urine-soiled brief was observed on the floor between a resident's bed and their roommate's bed during a morning observation. The soiled brief remained on the floor for at least five hours, as confirmed by subsequent observations. Staff interviews, including those with an LPN, the Director of Nursing, and the Director of Housekeeping, confirmed the presence of the soiled brief and acknowledged that it was not acceptable for it to remain on the floor in the resident's room. No information was provided regarding the resident's medical history or condition at the time of the deficiency.
Insufficient CNA Staffing on Unit 2B
Penalty
Summary
The facility failed to provide sufficient certified nursing assistant (CNA) staff to meet the needs of residents on Unit 2B, which was one of the two units reviewed for staffing. The facility's staffing pattern required two CNAs per shift for Unit 2B, but records and observations revealed that only one CNA was assigned during certain shifts. This staffing deficiency was observed on multiple occasions, with only one CNA present to care for 20 residents, leading to delays in care and assistance. Observations on Unit 2B showed residents tapping on the nurses' station glass windows, indicating a need for assistance. The lone CNA on duty struggled to manage the residents' needs, as multiple residents required two staff members for activities of daily living (ADL) assistance due to behaviors. Interviews with CNAs and LPNs confirmed that the acuity and behaviors of residents on Unit 2B were too much for one CNA to handle, resulting in residents waiting 20 to 30 minutes for assistance, which was deemed too long, especially for those with behavioral issues. Interviews with staff responsible for staffing decisions revealed a lack of a specific method to determine staffing needs, despite acknowledging that Unit 2B should be staffed with two CNAs due to the residents' behaviors and acuity. The staff confirmed that the current staffing was insufficient, and the deficiency had the potential to affect the well-being of the 20 residents residing on Unit 2B.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents, which was identified during a review of the Medication Administration Records (MAR) and interviews with staff. Resident #1, who had multiple diagnoses including Schizoaffective Disorder, Dementia, and Diabetes Mellitus-Type 2, did not have documented evidence of receiving or refusing medications from February 8 to February 10, 2025. Additionally, there was no documentation of insulin administration or blood glucose checks during this period. Interviews with nursing staff revealed that one nurse did not have access to the electronic MAR system and documented on paper MARs, which were not found in the resident's clinical record. Resident #2, who was diagnosed with conditions such as Diabetes Mellitus-Type 2 and Dementia, also had missing documentation for medication administration on February 13, 2025. The nurse responsible for administering the medications confirmed that she did not document the administration on the MAR as required. The facility's Director of Nursing (DON) acknowledged the lack of a current process for staff to follow if they could not access the electronic MAR system and confirmed that all medication administrations and glucose checks should have been documented. The facility's policy requires nurses to document medication administration immediately after administering medications and to use paper MARs if electronic access is unavailable. However, the review revealed that the binder containing paper MARs was outdated, and no current paper MARs were available for any residents. This deficiency in documentation practices had the potential to affect all 153 residents in the facility, as it compromised the accuracy and reliability of medication administration records.
Misappropriation of Resident Medications by RN
Penalty
Summary
The facility failed to prevent the misappropriation of resident property by a registered nurse (RN), identified as S4RN, which resulted in an Immediate Jeopardy situation. On the morning of February 1, 2025, two staff members observed S4RN placing medication packets belonging to two residents into her personal bag. These medications were due to be administered the previous evening, but S4RN falsely documented that the residents had refused them. The medications included critical prescriptions for conditions such as cardiac issues, hypertension, seizures, diabetes, and psychiatric disorders. Resident #1, who was severely cognitively impaired with a BIMS score of 00, had a range of diagnoses including Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder. Resident #2, also severely cognitively impaired with a BIMS score of 99, had diagnoses including Diabetes Mellitus-Type 2, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Essential Hypertension, Aphasia Following Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction. Both residents were unable to be interviewed due to their cognitive impairments. The incident was discovered during a shift change when S5LPN and another staff member noticed S4RN acting erratically and observed her placing medications into a crush bag and then into her personal bag. Upon further inspection, they found unopened medication packets with the residents' names and the scheduled administration time. Despite the potential for serious harm, both residents reportedly suffered no negative outcomes from the incident. The facility's policy on abuse and neglect, which prohibits the exploitation of residents, was clearly violated by S4RN's actions.
Delayed Reporting of Medication Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of property within the required timeframe for two residents. The incident involved a nursing supervisor who was observed placing medication packets belonging to two residents into her personal bag. This was witnessed by an LPN and a caregiver, who also found additional medication packets and a medication crush bag with white residue in the supervisor's personal bag. Despite the immediate discovery of the incident, the facility did not report it to the state survey agency until several days later. Resident #1, who has a history of Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder, was one of the residents affected. The incident was documented in the facility's records, but the notification to Adult Protective Services was delayed. Similarly, Resident #2, with diagnoses including Diabetes Mellitus-Type 2, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Essential Hypertension, Aphasia Following Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction, was also involved in the incident. Interviews with facility staff revealed a breakdown in communication and reporting procedures. The LPN who witnessed the incident reported it to a registered nurse supervisor, who then informed the Assistant Director of Nursing. However, the Director of Nursing and the Administrator were not informed of the full details, including the misappropriation of medications, until several days later. This delay in reporting violated the facility's policy and state regulations, which require immediate reporting of such incidents to the appropriate authorities.
Failure to Utilize PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff utilized appropriate personal protective equipment (PPE) during care for residents requiring Enhanced Barrier Precautions (EBP). This deficiency was observed in three residents who had chronic wound care needs and indwelling medical devices. The facility's policy required the use of gowns and gloves for high-contact resident care activities, such as dressing, bathing, providing hygiene, and device care. However, observations revealed that staff did not adhere to these guidelines. For instance, a nurse administered medications via a gastrostomy tube without wearing a gown, and a wound care nurse performed wound care on a resident with pressure ulcers without appropriate PPE. Additionally, there was a lack of signage indicating that the residents were on Enhanced Barrier Precautions, which contributed to staff being unaware of the need for PPE. Interviews with staff confirmed the absence of necessary signage and the failure to wear gowns during care activities. The Director of Nursing and other staff members acknowledged that the residents should have had signage on their doors and that staff should have worn gowns when performing care on residents with EBP in place.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain an environment that promotes quality of life through dignity and respect for a resident. Specifically, the facility did not ensure that residents were assisted with meals in a dignified manner. During an observation, a CNA was seen standing over a resident while feeding him, despite a chair being available. The resident, who was dependent on staff for eating assistance due to functional limitations in his upper extremities and other medical conditions, was not fed at eye level as per the facility's policy. The CNA admitted to not sitting while feeding the resident, and the Director of Nursing confirmed that the CNA should have been seated during the feeding process.
Failure to Implement Level II PASARR Recommendations
Penalty
Summary
The facility failed to incorporate Level II PASARR determination recommendations into the care planning for a resident diagnosed with Schizoaffective Disorder - Bipolar Type. The resident was admitted to the facility with recommendations for specialized services, including individual outpatient therapy and a psychiatric evaluation. However, a review of the resident's care plan and clinical records revealed no evidence that these recommendations were documented or implemented. Interviews with staff members confirmed that the necessary psychiatric evaluation had not been conducted, and outpatient therapy services were neither offered nor provided to the resident. The deficiency was attributed to a lack of an effective system to ensure the implementation of Level II PASARR recommendations. Staff interviews revealed a breakdown in communication and responsibility, with the social service counselor and medical records administrator each assuming the other was responsible for implementing the recommendations. The Director of Nursing and the Social Services Director confirmed the absence of a specific process to ensure that the recommendations were followed, leading to the oversight in the resident's care plan.
Inaccurate Documentation of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that nursing staff accurately documented pressure ulcer treatment for a resident with pressure ulcers, which did not meet professional standards of quality. The resident, who was cognitively intact and had diagnoses including pressure ulcers and paraplegia, had specific physician orders for wound care that included applying a non-adhering dressing and a wound vacuum to the left leg twice a week and as needed. However, on a specified date, the wound vacuum was not applied as ordered, and a dry dressing was used instead. Despite this, the treatment was documented as completed per the physician's orders. Interviews with the involved LPNs confirmed that the wound vacuum was not replaced as required, and a dry dressing was applied instead. The Director of Nursing also confirmed that the treatment was not completed as ordered and acknowledged the incorrect documentation. This deficiency had the potential to affect any of the 13 residents with pressure ulcers residing in the facility.
Failure to Implement Physician-Ordered Wound Vacuum Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a physician-ordered wound vacuum treatment. The resident, who was admitted with pressure ulcers and paraplegia, had a treatment plan that required a non-adhering dressing and a wound vacuum to be applied to a pressure injury on the left leg twice a week and as needed. However, during an interview and observation, it was noted that the wound vacuum was not in place, and a dry dressing was applied instead. This was confirmed by the resident and the LPNs involved in the treatment, who admitted to not replacing the wound vacuum as ordered. Further interviews with the wound care nurse and the Director of Nursing confirmed that the wound vacuum was not applied on the specified dates, despite being ordered to be in place at all times. The failure to implement the physician's orders for the wound vacuum treatment was observed over multiple days, indicating a lapse in following the facility's wound care policy and procedures. This deficiency had the potential to affect other residents with pressure ulcers in the facility.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by three separate incidents involving residents with varying levels of cognitive impairment. In the first incident, a resident with intact cognition was pushed out of his wheelchair by another resident with severe cognitive impairment over a dispute involving a drink. This incident was captured on video surveillance and confirmed by the facility's staff, who substantiated the allegation of resident-to-resident abuse. In the second incident, a resident with severe cognitive impairment was physically abused by another resident with moderate cognitive impairment. The aggressor approached the victim from behind and slapped him on the head while he was sitting in the day room. This incident was witnessed by staff members, who confirmed the occurrence of the abuse and the facility substantiated the allegation. The third incident involved a resident who was unable to complete a cognitive assessment and was physically assaulted by another resident with intact cognition. The aggressor admitted to hitting the victim over a disagreement about a cigarette, resulting in visible injuries including a skin tear and bruising. The facility's staff confirmed the occurrence of physical abuse, and the incident was documented in the resident's medical records.
Failure to Administer Medication as Ordered
Penalty
Summary
The provider failed to ensure that physician's orders were implemented for a resident, leading to a deficiency. Resident #13, who was admitted with diagnoses including Epilepsy, Bipolar Disorder, and Alcohol Abuse, had a physician's order for Phenobarbital 64.8 mg to be administered twice daily. However, a review of the Medical Administration Record (MAR) and the Individual Patient Controlled Drug Record revealed that the medication was not administered on the evening of September 4, 2024, as ordered. Interviews with the involved staff confirmed that the medication was not given, and it was acknowledged that it should have been administered according to the physician's orders. The Director of Nursing also confirmed that medications should be administered and documented accurately in compliance with physician's orders.
Medication Error Due to Allergy Oversight
Penalty
Summary
The facility failed to ensure that a resident did not receive a medication to which they were allergic, resulting in a medication error. Resident #10, who had a documented allergy to Depakote, was administered the medication despite this known allergy. The incident occurred when a verbal order for Depakote was given by a psychiatrist and received by an LPN, who failed to verify the resident's allergies before entering the order into the system. The allergy was documented on the resident's Medication Administration Record (MAR), but the LPN did not notice the absence of an allergy sticker on the resident's chart and did not communicate the allergy to the psychiatrist. Subsequently, an RN administered Depakote to the resident without checking the MAR for allergies, leading to the administration of a medication that the resident was allergic to. Interviews with the staff involved, including the LPN, RN, and the psychiatrist, confirmed the oversight in checking the resident's allergies before prescribing and administering the medication. The Director of Nursing and Assistant Director of Nursing acknowledged the error and confirmed that the proper protocol of verifying allergies was not followed, resulting in the medication error.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days, as required by their policy. Specifically, a resident with diagnoses including Unspecified Dementia, Unspecified Psychosis, and Schizophrenia was prescribed Ativan 1mg tablet by mouth every six hours as needed for agitation. This PRN order, written on December 11, 2023, did not include a stop date or duration, and was administered on multiple occasions in September 2024. During an interview, the Director of Nursing confirmed that the Ativan order was in place for longer than 14 days without an end date or documented duration, which is a violation of the facility's policy on psychotropic medications.
Failure to Notify Physician of Residents' Change in Condition
Penalty
Summary
The facility failed to notify the physician when three residents experienced a change in condition, which was identified during a review of abuse allegations. Resident #12, who had a history of Traumatic Brain Injury and severe cognitive impairment, exhibited abnormal behaviors such as lethargy, confusion, and unsteady gait on the morning of June 25, 2024. Despite these changes, the physician was not informed, although the RN on duty was notified of the resident's condition. Similarly, Resident #13, also with a history of Traumatic Brain Injury and severe cognitive impairment, showed signs of lethargy, unsteady gait, and repeated falls on the same day. The resident's abnormal behaviors were reported to the RN, but again, the physician was not notified. The resident continued to exhibit these behaviors throughout the day, requiring constant redirection and assistance. Resident #14, diagnosed with Schizoaffective Disorder and Vascular Dementia, was found to be very lethargic and unresponsive on June 25, 2024. The LPN on duty attempted to arouse the resident without success and reported the abnormal behavior to the RN. However, the physician was not made aware of the situation. Additionally, a box of Dollar General Sleep Aid and a bottle of Melatonin were found on the medication cart, which the physician confirmed he was not informed about.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for two residents, leading to a deficiency. For Resident #7, an incident occurred where another resident made a threatening and verbally abusive statement. The incident was discovered and reported internally, but the allegation of verbal abuse was not reported to the state survey agency within the required two-hour timeframe. Interviews with staff confirmed the delay in reporting, despite the facility's policy requiring immediate reporting of such incidents. For Resident #16, the resident was found with a bruise on the face and reported that a CNA had physically abused him the previous night. Although the incident was reported internally, it was not communicated to the state survey agency within the required two-hour period. Interviews with staff revealed inconsistencies in the reporting process, with some staff members denying knowledge of the abuse allegation or failing to report it to their supervisors. The facility's policies on abuse reporting were not followed, resulting in a failure to meet the regulatory requirement of reporting abuse allegations to the state survey agency within two hours. This deficiency highlights lapses in communication and adherence to established procedures among the facility's staff, as confirmed by multiple staff interviews.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days and included a specified duration for several residents. Resident #4 was admitted with diagnoses including Unspecified Dementia, Unspecified Psychosis, and Schizophrenia. The resident had a PRN order for Haldol, a psychotropic medication, without a stop date. Similarly, Resident #8, diagnosed with Schizophrenia, Panic Disorder Episodic, and Paroxysmal Anxiety, had PRN orders for Hydroxyzine and Olanzapine without specified durations or stop dates. The Director of Nursing (DON) confirmed these medications should have had stop dates. Resident #13, with diagnoses of Traumatic Brain Injury, Impulse Disorder, and Major Depressive Disorder, had PRN orders for Haldol in both injection and tablet forms, again without stop dates. Resident #14, diagnosed with Schizoaffective Disorder and Vascular Dementia, had a PRN order for Zyprexa without a stop date. The DON confirmed that these psychotropic medications should have been limited to 14 days and required a stop date, indicating a failure in adhering to the facility's policy and regulatory requirements.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving three residents. Resident #3, who was cognitively intact, was physically abused by Resident #4, who was severely cognitively impaired. The incident occurred in the dining room where Resident #4 forcefully pushed Resident #3's wheelchair against a table and struck him on the head. This was confirmed by video footage and interviews with the Director of Nursing (DON) and the Licensed Practical Nurse (LPN) who documented the incident. Another incident involved Resident #9, who was also cognitively intact, being physically abused by Resident #4. In the dayroom, Resident #4 approached Resident #9, pushed him to the floor, and began punching him. This altercation was witnessed by staff and confirmed through video footage. The DON acknowledged the incident as physical abuse after reviewing the footage and interviewing the involved parties. The third incident involved Resident #5, who had severe cognitive impairment, being pushed out of his shared room by Resident #6, who was moderately cognitively impaired. Resident #6 forcefully pushed Resident #5's wheelchair into the hallway, nearly causing it to hit the railing. This incident was observed by a Certified Nursing Assistant (CNA) and confirmed by video footage. The DON and other staff members considered this action to be a form of abuse due to the malicious intent behind it.
Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise the care plan for a resident following a verbal altercation with another resident. The incident occurred when one resident threatened another with physical harm, referencing a previous physical altercation between them. Despite the incident being documented in the nurse's notes and an incident report, the care plan for the threatened resident was not updated to include new interventions to address the behavior and prevent future incidents. Interviews with facility staff, including an LPN, the MDS coordinator, and the Director of Nursing, confirmed that the care plan should have been updated following the incident. The MDS coordinator acknowledged responsibility for updating care plans after incidents and confirmed that the care plan was not revised as required. The Director of Nursing also confirmed that the facility's protocol involves updating care plans with new interventions after incidents, which was not done in this case.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in three separate incidents involving different residents. In the first incident, a resident with a history of major depressive disorder and anxiety was subjected to mental abuse by a CNA. The CNA made degrading comments about the resident's bowel condition in a public area, causing the resident to feel embarrassed and degraded. This incident was witnessed by other staff members and led to the resident experiencing sadness and crying. In the second incident, two residents with severe cognitive impairments were involved in a physical altercation. One resident, who does not like noise and can become agitated, grabbed and scratched another resident's face after being bumped into several times. This incident was captured on surveillance video and confirmed as physical abuse by the facility's staff. The third incident involved a resident with severe cognitive impairment who physically pushed another resident to the floor. The resident who was pushed was cognitively intact and reported that they could not get out of the way fast enough. This altercation was also captured on video and confirmed as physical abuse by the facility's staff.
Failure to Implement and Document Increased Behavior Monitoring
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as outlined in their comprehensive care plan. Specifically, the facility did not implement and document increased behavior monitoring for a resident with diagnoses including Moderate Intellectual Disabilities, Schizophrenia, and Extrapyramidal Movement Disorder. The resident, who had a severe cognitive impairment, was supposed to be monitored every 15 minutes as per a physician's order. However, the facility's records showed multiple instances where this monitoring was not conducted or documented over a period of several days. Interviews with staff members, including LPNs and the Director of Nursing, confirmed that the required observations were not completed as per the facility's policy. The staff acknowledged that if the documentation was not completed, it indicated that the observations were not done. This lack of adherence to the observation protocol resulted in a failure to provide the necessary care and services to maintain the resident's highest practicable physical, mental, and psychosocial well-being.
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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