Winnfield Nursing And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnfield, Louisiana.
- Location
- 915 1st Street, Winnfield, Louisiana 71483
- CMS Provider Number
- 195454
- Inspections on file
- 29
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Winnfield Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was not assisted to the dining room for meals as required by their care plan, despite being dependent on staff for eating and mobility. Staff interviews and observations confirmed that the resident remained in their room during meals, contrary to documented fall prevention measures.
The facility did not ensure that two residents' discharges were properly documented or that written instructions and discharge planning were provided, including the basis for discharge, medication reconciliation, and referrals for caregiver support. Staff interviews confirmed that required discharge documentation and procedures were not completed.
Two residents were discharged without complete discharge summaries, missing required information such as a recapitulation of their stay, final status at discharge, and medication reconciliation. Documentation was either incomplete or missing key details, and staff confirmed that the necessary discharge information was not provided or properly recorded.
A resident with a history of substance use and multiple behavioral health diagnoses was not care-planned for substance abuse, and ongoing concerns about drug diversion and active substance use were not addressed by staff. Provider notes documented the resident's diversion and abuse of medications, but these issues were not acted upon, and required monthly urine drug screens were not performed as ordered.
A resident's admission and Quarterly MDS assessments failed to accurately reflect their diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, and substance use/abuse, despite these being documented in the medical record and social services assessments. Staff interviews confirmed the omissions and acknowledged that these conditions should have been included in the MDS.
A resident with multiple behavioral health diagnoses was admitted without a baseline care plan being developed within 48 hours, as required by facility policy. The DON confirmed that no baseline care plan was created to address the resident's immediate needs after admission.
A resident with multiple behavioral health diagnoses, including substance abuse, suicidal ideations, and PTSD, was not provided with a comprehensive, person-centered care plan addressing these conditions. Staff confirmed that the care plan did not include interventions for these significant issues, contrary to facility policy.
A resident with multiple mental health diagnoses and a history of substance abuse was not referred for mental health services upon admission, despite facility protocols and identified needs. The resident did not receive timely or ongoing mental health evaluations, with gaps in monthly follow-up visits while on antipsychotic and antidepressant medications.
A resident with moderate cognitive impairment was physically abused by another resident during breakfast. The aggressor, also with moderate cognitive impairment, hit the victim in the face after a dispute over milk. The incident was witnessed by CNAs, and the facility's abuse prevention policy failed to prevent this occurrence.
The facility did not meet residents' nutritional needs by failing to serve the correct portion sizes as per the menu. During lunch, six residents on a regular diet received improper portions, with five receiving one small chicken leg and one receiving two small chicken legs, which were not a double portion. The menu specified a 3 oz. portion size for Baked Chicken, but the served portions were inadequate. This was confirmed by the Dietary Manager and Regional Director of Nutritional Services.
The facility failed to adhere to professional food safety standards, as evidenced by moldy bread, expired hot dog buns, and undated cornstarch in the dry storage area, along with an unsealed, undated pad of butter in the refrigerator. These deficiencies were observed with the Dietary Manager and could impact any resident consuming meals from the kitchen.
A resident with legal blindness and cognitive impairments did not have a call light within reach, as required by her care plan. Observations showed the call bell was placed across the room, and staff interviews confirmed the issue was due to the absence of an extension cord. The resident had to yell to communicate her needs.
A resident with mental health disorders was physically abused by another resident with a history of altercations. The incident occurred when one resident tapped the other on the shoulder, leading to a physical altercation. Despite the facility's policy on abuse prevention, the measures in place were insufficient to prevent the incident.
The facility did not thoroughly investigate an incident where a resident tapped another, leading to a physical altercation. Witness statements from staff present during the incident were not obtained, and necessary safety checks on the behavioral unit were not conducted. The administrator confirmed the investigation was incomplete.
A resident with dementia and depression experienced significant weight loss due to the facility's failure to document meal intake and provide one-on-one dining assistance as care planned. Observations showed the resident eating unsafely without supervision, and the DON acknowledged the lack of documentation and assistance.
A resident with multiple diagnoses, including Down's Syndrome and Dementia, was observed with long chin hairs over several days, despite regular bathing and no refusal of care. Staff acknowledged the need for shaving, but the issue persisted, impacting the resident's dignity and quality of life.
The facility failed to implement care plans for two residents, leading to a deficiency in monitoring and recording food intake. One resident, with severe cognitive impairment, experienced a 17% weight loss over three months due to unrecorded meal intake on 36 out of 39 days. Another resident, with dementia and intellectual disabilities, had a 12% weight loss over four months, with meal intake unrecorded on 32 out of 39 days. The DON acknowledged the failure to document as required.
A resident with moderate cognitive impairment and impaired mobility was found with a broken self-release belt buckle on his wheelchair. Despite reporting the issue to a nurse, the broken buckle was observed on multiple occasions, and staff confirmed the failure to address the problem promptly.
Failure to Implement Person-Centered Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident with multiple complex diagnoses, including schizoaffective disorder, bipolar type, type 2 diabetes, hypertensive heart disease, anxiety, a history of falling, and dementia with agitation. The resident was assessed as having severe cognitive impairment and was dependent on staff for eating, mobility, transfers, and personal hygiene. The care plan specifically instructed that the resident should be assisted to the dining room for all meals as part of fall prevention measures. Despite these documented care plan instructions, observations and staff interviews confirmed that the resident was not assisted to the dining room for breakfast or lunch on the day in question. The resident was found in her room with a lunch tray, having only consumed milk and leaving the rest of the food untouched. Multiple staff members, including CNAs and an LPN, acknowledged that the resident should have been assisted to the dining room for meals but was not, in direct contradiction to the care plan.
Failure to Document and Prepare Safe Resident Discharges
Penalty
Summary
The facility failed to ensure proper documentation and preparation for the discharge of two residents, as required by its own policies and regulatory standards. For both residents, there was no documentation in the medical record specifying the basis for their discharge, nor evidence that written discharge instructions were provided to or discussed with the residents or their responsible parties. Additionally, there was no documentation of discharge planning that addressed caregiver support or referrals to local contact agencies, despite the facility's policy requiring such actions. One resident, admitted with multiple complex diagnoses including a right tibia fracture, MRSA infection, diabetes, and a history of venous thrombosis, was noted to have intact cognition and expressed a desire to return home. The resident's insurance coverage ended, and although the resident was informed of the option to pay out of pocket, this discussion and the resident's refusal were not documented. The discharge form was only partially completed, and there was no record of medication reconciliation, discharge instructions, or coordination of care in the resident's file. The second resident, admitted for short-term therapy following a stroke and with diagnoses including Alzheimer's disease and hemiplegia, also had no documentation in the medical record regarding the reason for discharge or any instructions about medications provided at discharge. Progress notes indicated the resident was discharged home with medications and that a follow-up evaluation was planned, but there was no evidence of written instructions or comprehensive discharge planning. Interviews with facility staff confirmed that required documentation and discharge procedures were not completed for either resident.
Incomplete Discharge Summaries and Missing Required Documentation
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for two of three residents reviewed for discharge. For both residents, the discharge summaries were missing essential elements required by facility policy and federal regulations, including a recapitulation of the residents' stay with diagnoses, course of illness or treatment, pertinent lab, radiology, and consultation results, a final summary of the residents' status at the time of discharge, and a reconciliation of all pre-discharge medications with post-discharge medications. For one resident, the medical record review showed an incomplete discharge summary document, lacking the required information and only partially filled out. The document was provided to the resident at discharge, but it did not include a comprehensive summary of the resident's stay, status at discharge, or medication reconciliation. Interviews with facility staff confirmed that the discharge summary was not completed as required and that the responsibility for discharge documentation was not clearly followed. For the second resident, the discharge documentation included a progress note and a discharge summary form, but these also lacked critical information. There was no documentation of the reason for discharge, no list of medications provided at discharge, and no record of instructions given to the resident. The discharge summary form was not signed by the resident and did not include a summary of the resident's diagnoses, treatment course, or status at discharge. Staff interviews confirmed these omissions and acknowledged that the required documentation was not present in the resident's medical record.
Failure to Provide Behavioral Health Services and Monitor Substance Use
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of substance use and multiple behavioral health diagnoses, including adverse effects of methamphetamines, cannabis abuse, suicidal ideations, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. The resident's comprehensive care plan did not address their history of substance use/abuse, despite this being known at admission and confirmed by both the administrator and MDS coordinator. Additionally, the resident's Minimum Data Set (MDS) assessments did not indicate substance use/abuse or PTSD, contrary to the resident's medical history. Provider progress notes documented ongoing concerns, including drug diversion, active substance abuse within the facility, and the resident taking medications not prescribed to them. These concerns were not addressed by facility staff, and the administrator was unaware of these issues at the time of the resident's death. Furthermore, although there was a physician's order for monthly urine drug screens (UDS), these were not performed as ordered after the initial positive result for methamphetamine. Staff interviews confirmed that the required monthly UDS were not completed.
Inaccurate MDS Assessments for Resident with Psychiatric and Substance Use History
Penalty
Summary
The facility failed to ensure that both the admission and Quarterly Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. Specifically, the MDS assessments did not include the resident's diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, or substance use/abuse, despite these being documented in the resident's medical record and social services assessments. The resident's admission and Quarterly MDS both recorded a BIMS score indicating intact cognition and omitted critical psychiatric and substance use diagnoses. Interviews with facility staff confirmed that the resident's social services history and initial assessment identified PTSD, increased anxiety, and a history of substance use/abuse, but these were not reflected in the MDS assessments. The omission was acknowledged by both the Social Services Director and the Administrator, who confirmed that the relevant diagnoses and history should have been included in the MDS documentation.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan is required to be created promptly upon admission to address the resident's immediate needs until a comprehensive care plan is completed. Record review showed that the resident, admitted with multiple complex diagnoses including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder, did not have a baseline care plan in place. During an interview, the Director of Nursing confirmed that a baseline care plan was not developed for this resident, despite policy requirements.
Failure to Develop Comprehensive Care Plan for Resident with Complex Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident, as required by its own policy. The resident was admitted with multiple diagnoses, including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, a history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. Review of the resident's medical record and care plan revealed that the care plan did not address suicidal ideations, history of suicidal behavior, PTSD, or substance use/abuse. Facility staff interviews confirmed that these issues were not included in the care plan, despite the expectation that they should have been.
Failure to Provide Timely and Ongoing Mental Health Services
Penalty
Summary
The facility failed to provide mental health services in accordance with professional standards for a resident admitted with multiple mental health diagnoses, including PTSD, generalized anxiety disorder, bipolar disorder, major depressive disorder, and a history of substance abuse and suicidal behavior. Upon admission, the resident's social services assessment identified significant mental health needs, but a timely referral for mental health services was not made. Although facility protocol required automatic referral for residents with mental health diagnoses, this was not followed, and the resident was not referred for mental health services until several weeks after admission. Additionally, the facility did not ensure that mental health services were provided on a continual basis. After the initial psychiatric evaluation and two follow-up visits, there were no further mental health encounters documented for the resident, despite ongoing use of antipsychotic and antidepressant medications. Staff interviews confirmed that the resident should have been seen monthly by the mental health nurse practitioner, but this did not occur after the last documented visit.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #3, who has a history of schizoaffective disorder, bipolar type, anxiety disorder, major depressive disorder, depression, glaucoma, legal blindness, and cognitive communication deficit, was involved in an incident with Resident #5. Resident #3 has a BIMS score indicating moderate cognitive impairment. During breakfast, Resident #3 accused Resident #5 of taking her milk, which led to Resident #5 physically hitting Resident #3 in the face. This incident was witnessed by two CNAs who were present in the dining room. Resident #5, who also has a history of schizoaffective disorder, depressive type, anxiety disorder, diffuse traumatic brain injury, and cognitive social or emotional deficit following cerebrovascular disease, was identified as the aggressor in this incident. Resident #5 has a BIMS score indicating moderate cognitive impairment. The facility's incident report and witness statements confirm that Resident #5 made contact with Resident #3's face with her fist, resulting in discoloration to Resident #3's upper lip. The facility's policy on abuse prevention was not effectively implemented to prevent this incident of resident-to-resident abuse.
Failure to Meet Nutritional Needs Due to Improper Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the established portion sizes as outlined in the menu. During an observation of lunch preparation, it was noted that six residents on a regular diet were served improper portion sizes. Specifically, five residents received only one small chicken leg, and one resident received two small chicken legs, which were incorrectly considered a double portion. According to the facility's Production Sheet Main Menu, the portion size for Baked Chicken was specified as 3 oz. An interview with the Dietary Manager and the Regional Director of Nutritional Services confirmed that one chicken leg without the bone was approximately 2 oz., and residents should have been served two chicken legs to meet the 3 oz. portion size requirement.
Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety. During an observation of the kitchen's dry food storage area, a loaf of bread with mold was found, along with two packages of hot dog buns that had expired. Additionally, an opened and undated box of cornstarch was discovered. In the walk-in refrigerator, a used pad of butter was found unsealed and undated. These deficiencies were identified during an observation with the Dietary Manager and had the potential to affect any resident consuming meals from the facility's kitchen.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident #30, by not ensuring the availability of a call light within reach. Resident #30, who was admitted with diagnoses including legal blindness, major depressive disorder, schizoaffective disorder, and cognitive communication deficit, had a care plan that specified the need for a call light to be within reach due to her sensory and perception alterations. Despite this, observations revealed that the call bell was placed on a nightstand across the room, out of reach, and not accessible to the resident. Interviews with the resident and staff confirmed the deficiency. The resident expressed difficulty in locating the call bell at night due to her blindness. A CNA explained that the call bell was not in use because its cord would obstruct the walkway if positioned near the resident's bed. The RN confirmed the call bell's inaccessibility, attributing it to the absence of an extension cord, which the facility was awaiting. This situation left the resident to resort to yelling to communicate her needs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #76, who has a history of mental health disorders including Bipolar Disorder, Schizophrenia, and Dementia, was physically abused by Resident #68. The incident occurred when Resident #76 tapped Resident #68 on the shoulder, causing Resident #68 to become frightened and grab Resident #76's hair. This resulted in Resident #76 falling to the ground. The facility's policy on abuse prevention, which includes protection from resident-to-resident abuse, was not effectively implemented in this case. Resident #68, who has a history of altercations and is diagnosed with Paranoid Schizophrenia and other mental health conditions, was involved in the altercation. The incident was reported by a CNA who witnessed the event and intervened to separate the residents. Despite the facility's awareness of Resident #68's history of altercations, the measures in place were insufficient to prevent the incident. The facility's failure to ensure adequate supervision and intervention led to the physical abuse of Resident #76.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation of an incident involving resident-to-resident abuse. On August 11, 2024, a Certified Nursing Assistant (CNA) reported that while distributing snacks in the special care unit's common area, one resident tapped another on the shoulder, causing the second resident to become frightened and grab the first resident's hair. During the altercation, the first resident fell to the ground. The residents were immediately separated, and the second resident was placed on one-to-one supervision before being sent to a behavioral hospital the following day. The facility's investigation into the incident was incomplete. Witness statements were not obtained from the CNA, a Licensed Practical Nurse (LPN), or the Registered Nurse (RN) on duty at the time of the incident. The facility also failed to conduct body audits and safety rounds on all residents in the behavioral unit. The administrator confirmed that the investigation was not completed and acknowledged the failure to obtain necessary witness statements from staff who observed the incident.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not implementing appropriate interventions for weight loss. Specifically, the facility did not document the meal intake for a resident as care planned and failed to provide one-on-one assistance during meals. The resident, who had diagnoses including Major Depressive Disorder, Unspecified Dementia, Cellulitis, and Hypertension, experienced a significant weight loss of 17.15% over six months. The resident's care plan included interventions such as one-on-one dining assistance, monitoring food intake, and reporting any decline to the physician and dietician. Observations revealed that the resident was left unattended during meals, leading to unsafe eating behaviors, such as attempting to eat plastic wrap. The staff failed to document the resident's meal intake consistently, with numerous instances of missing documentation over several days. The Director of Nursing acknowledged these failures, confirming that the resident was care planned for one-on-one assistance with dining, which was not provided.
Failure to Maintain Resident's Personal Hygiene and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not maintaining her personal hygiene, specifically by allowing her to have long, curly chin hairs. The resident, who has multiple diagnoses including Down's Syndrome, Major Depressive Disorder, and Dementia, was observed on multiple occasions with facial hair that was approximately an inch long, covering her entire chin. Despite being bathed regularly and not refusing personal care, the resident's facial hair was not addressed by the staff. Interviews with the facility's staff, including CNAs and the DON, confirmed that the resident had been observed with long chin hairs over several days. The staff acknowledged the need for the resident to be shaved, yet the issue persisted over multiple observations. The resident's care plan indicated she required assistance with personal hygiene, but this aspect of her care was neglected, impacting her dignity and quality of life.
Failure to Monitor and Record Food Intake
Penalty
Summary
The facility failed to implement the care plans for two residents, resulting in a deficiency related to monitoring and recording food intake. Resident #1, who has severe cognitive impairment and a history of weight loss, was not monitored for food intake as required by their care plan. The care plan included interventions such as dietician evaluation, determining food preferences, and monitoring food intake at each meal. However, the Meal Report revealed that food intake was not recorded on 36 out of 39 days, leading to a significant weight loss of 17% over three months. Similarly, Resident #2, who has multiple diagnoses including dementia and moderate intellectual disabilities, also experienced a failure in care plan implementation. The resident's care plan required monitoring and recording food intake at each meal, but the Meal Report showed that this was not done on 32 out of 39 days. This lack of documentation coincided with a significant weight loss of 12% over four months. The Director of Nursing acknowledged the failure to document meal intake for both residents as instructed in their care plans.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition for Resident #3. Resident #3, who has a history of hypertension, cerebrovascular disease, type 2 diabetes mellitus, and insomnia, was observed with a broken self-release belt buckle on his wheelchair. The resident, who has moderate cognitive impairment and impaired mobility, reported the broken buckle to a nurse but could not recall which nurse. Despite this report, the broken buckle was observed on multiple occasions over several days, indicating a failure to address the issue promptly. On two separate observations, the broken buckle was noted, and interviews with the resident and staff confirmed the issue. The LPN acknowledged that the buckle should not have been broken and that nursing staff are responsible for routinely monitoring the self-release belt. The facility administrator also confirmed the broken buckle, highlighting a lapse in maintaining essential equipment in safe working condition for the resident.
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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