Alpine Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ruston, Louisiana.
- Location
- 2401 North Service Road, Ruston, Louisiana 71270
- CMS Provider Number
- 195538
- Inspections on file
- 23
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Alpine Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified that the facility did not consistently provide the minimum required nursing staffing hours on certain weekends, based on review of PBJ staffing data and weekend staffing pattern forms for a fiscal quarter. On two separate weekend days, the total nursing hours actually provided fell below the calculated minimum required hours. In a subsequent interview, the administrator confirmed that the facility failed to meet the minimum staffing requirements on those days.
Nursing staff failed to follow medication administration and documentation requirements for two residents. For one resident with intact cognition and multiple medical conditions, an LPN left a cup containing four oral medications unattended at the bedside and did not remain with the resident to ensure the medications were taken, contrary to facility policy. For another resident with rhabdomyolysis, acute pulmonary edema, CKD, heart failure, and atrial flutter, physician orders for IV Lasix twice daily over several days were not documented as administered on multiple ordered times, and the DON and corporate nurse confirmed the absence of documentation. These issues reflect a lack of required competencies and adherence to medication administration procedures by licensed nursing staff.
Surveyors found that staff failed to follow Enhanced Barrier Precautions and infection control practices during catheter care and bathing for a dependent resident with an indwelling urinary catheter, PEG tube, and pressure ulcer, including not wearing gowns and reusing the same washcloth on genital, perineal, and leg areas, including over an open blister. In addition, a resident with respiratory and neurologic conditions had a nebulizer mask and Yankauer suction device left uncovered instead of stored in bags as required by facility policy, and another resident with chronic pulmonary disease had oxygen tubing left on the floor and not bagged when oxygen was not in use.
A resident with multiple chronic conditions and a cognitively intact BIMS score was self-administering a prescribed nasal spray that was kept on a dresser in the room, rather than secured as required by facility policy. The resident stated that staff provided new bottles as needed and that she administered the medication herself. Review of records and staff interviews showed there was no provider order for self-administration and no completed self-administration assessment or consent, despite facility policy requiring an interdisciplinary evaluation, documentation, and secure storage before allowing self-administration of medications.
A resident with a pressure ulcer did not receive a timely wound assessment by an RN upon discovery of skin breakdown. The resident, who was alert and oriented, reported a sacrum wound, but the initial assessment was conducted by an LPN/Wound Care Nurse. The first RN assessment occurred days later, leading to a deficiency in accurate assessment procedures.
The facility failed to display 'Oxygen in Use' signage outside the rooms of three residents receiving continuous oxygen therapy, as required by their policy. This deficiency was confirmed by the DON during observations.
The facility failed to assess entrapment risks before installing side rails for several residents, including those with severe cognitive impairments and mobility issues. Observations revealed side rails in use without prior assessments or physician orders, and interviews confirmed the absence of necessary documentation.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings at least quarterly, as required. Records showed meetings on specific dates, but there was no meeting between two of these dates, indicating a lapse. An interview with the administrator confirmed the absence of a meeting during this period.
A pharmacist failed to identify and report a medication irregularity for a resident prescribed Quetiapine Fumarate without an appropriate diagnosis. The facility's policy requires communication of medication issues to prescribers and leadership, but the pharmacist did not document or notify the necessary parties about the irregularity, as confirmed by the DON.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications. The resident, with multiple diagnoses including adjustment disorder with depressed mood and vascular dementia, was prescribed Quetiapine Fumarate without an appropriate diagnosis. The DON confirmed the lack of a suitable diagnosis for this antipsychotic medication.
Failure to Meet Minimum Weekend Nursing Staffing Requirements
Penalty
Summary
The facility failed to ensure sufficient nursing staff on all days to meet residents’ needs and to provide at least the minimum required staffing hours on certain weekends. Review of the facility’s PBJ Staffing Data Report for Fiscal Year Quarter 4 2025 (July 1 to September 30) showed that excessively low weekend staffing was triggered. Further review of the Staffing Pattern Forms for weekends in that quarter revealed that on 07/06/2025 the facility provided 255.70 nursing hours when 260.85 hours were required, and on 08/24/2025 the facility provided 271.20 nursing hours when 282 hours were required. In an interview on 01/12/2026 at 3:45 p.m., the administrator confirmed the facility did not provide the minimum required staffing hours on those two dates. No specific resident medical histories or conditions were described in the report, and the deficiency was based on documented staffing hours and administrative confirmation of failure to meet minimum staffing requirements on the identified weekends.
Failure to Ensure Competent Medication Administration and Documentation
Penalty
Summary
The deficiency involves failures in nursing staff competency related to medication administration for two residents. Facility policy for administering oral medications, revised April 2019, requires staff to remain with the resident until all medications have been taken. For one resident, admitted on 06/03/2022 with diagnoses including hemiplegia, muscle wasting, obesity, muscle weakness, pain, debility, and hypokalemia, a quarterly MDS showed intact cognition for daily decision making. On 01/11/2026 at 10:25 a.m., this resident was observed lying in bed with a medication cup containing four pills left unattended on the over-bed table; the resident stated these were his morning medications that he had not taken. At 10:30 a.m., the medications were still at the bedside when observed with the LPN responsible, who acknowledged the medications should not have been left at the bedside and that she should have stayed with the resident until the medications were swallowed. The DON later confirmed the nurse should not have left the medications unattended and should have remained until they were taken. For a second resident, admitted on 12/19/2025 with diagnoses of rhabdomyolysis, acute pulmonary edema, chronic kidney disease, heart failure, and atrial flutter, a physician order dated 12/31/2025 directed Lasix 10 mg/ml, 4 ml IV twice daily for edema for three days, with one dose to be given that day and then twice daily for three days. Review of the January 2026 MAR showed no documented evidence that Lasix was administered as ordered on 01/01/2026 at 8:00 p.m., 01/02/2026 at 8:00 a.m., and 01/03/2026 at 8:00 p.m. In an interview on 01/13/2026 at 4:45 p.m., the DON and Corporate Nurse confirmed there was no documentation of Lasix administration for those ordered times. These findings demonstrate failures to ensure licensed nurses had and applied the necessary competencies and skills to administer and document medications according to physician orders and facility policy.
Failure to Follow Enhanced Barrier Precautions and Sanitary Storage of Respiratory Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP), during urinary catheter care and bathing. One resident with metabolic encephalopathy, mild protein calorie malnutrition, a stage 3 sacral pressure ulcer, dementia, chronic kidney disease, benign prostatic hyperplasia with urinary retention, and an indwelling urinary catheter and PEG tube had an EBP sign posted on the room door. During observation of a bed bath and catheter care, two CNAs entered the room and provided care without donning gowns, despite facility guidance that gowns and gloves are to be used for high-contact care activities such as bathing and device care for residents with indwelling devices and wounds. One CNA performed catheter care and a bed bath without a gown, and the other washed the resident’s face without a gown. During the same bathing episode, the CNA providing catheter care used improper bathing technique that did not follow infection control practices. After placing soap into a washbasin, the CNA cleaned the resident’s penis with a washcloth and then placed the washcloth back into the soapy water. The CNA then retrieved the same washcloth and used it to wipe the resident’s buttocks, legs, and over an open blister on the leg, repeatedly returning the washcloth to the same basin of soapy water. The CNA continued to wash the resident’s lower legs with the same washcloth that had already been used on the genital and perineal areas and over the open blister. In a subsequent interview, the CNA acknowledged not using a gown and confirmed using the same washcloth after cleaning the resident’s penis. The facility also failed to store respiratory equipment in a sanitary manner for two additional residents. For one resident with a history including cerebrovascular accident, dysphagia, acute respiratory failure, protein calorie malnutrition, hypertension, and muscle wasting, a nebulizer mask was observed lying uncovered on a bedside table, and a Yankauer oral suction instrument was observed sitting uncovered on the suction machine, contrary to facility policy requiring such items to be stored in bags. For another resident with interstitial pulmonary disease, pulmonary fibrosis, chronic pulmonary edema, and mild intermittent asthma, an oxygen concentrator with humidifying water was present in the room, and the oxygen tubing attached to the concentrator was observed not stored in a bag and lying on the floor on multiple observations when the resident was not using oxygen. The DON later confirmed that the oxygen tubing should have been stored in a bag and was not stored correctly.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring assessment and authorization before allowing residents to self-administer medications. The facility’s Self-Administration of Medications policy states that residents have the right to self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, based on an assessment of the resident’s mental and physical abilities, including understanding of labels, purpose, dosage, timing, administration, and recognition of risks. The policy further requires completion of a Self Administration of Medications assessment form and a signed consent form, and specifies that medications for self-administration must be stored in a locked cabinet in the resident’s room, not accessible to other residents, with the resident responsible for reporting each dose used to nursing staff. Resident #1 was admitted with diagnoses including encephalopathy (unspecified), Parkinsonism (unspecified), essential tremor, COPD (unspecified), and shortness of breath, and had a BIMS score of 12 indicating cognitive intactness. Physician’s orders included Flonase (fluticasone propionate nasal spray) to be administered as one inhalation in both nostrils twice daily. On multiple observations over two days, surveyors noted a bottle of fluticasone on top of a dresser at the foot of the resident’s bed, rather than secured in a locked cabinet. The resident reported that she self-administered the fluticasone and that staff brought her a new bottle when needed. The DON confirmed the presence of the fluticasone bottle in the room, and the corporate RN confirmed that there was no physician order for self-administration and no completed self-administration assessment for this resident, despite the resident self-administering the medication and keeping it at bedside.
Failure to Conduct Timely RN Wound Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment was completed for a resident with a pressure ulcer. The deficiency was identified when a resident, who was alert and oriented, reported having a wound on the sacrum area. The resident was admitted with several diagnoses, including idiopathic pulmonary fibrosis and mild protein malnutrition. Despite the presence of a wound, a body assessment completed earlier did not record any skin issues. A nurse's note indicated that skin breakdown was reported and assessed by an LPN/Wound Care Nurse, who obtained new physician orders for preventive measures. However, the initial wound assessment was not completed by a registered nurse when the skin breakdown was first identified. The first wound assessment by an RN was conducted several days later, as confirmed by the Director of Nurses. This delay in assessment by a registered nurse upon the initial discovery of the skin breakdown constitutes the deficiency noted in the report.
Failure to Display Oxygen Use Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care by not displaying signage indicating oxygen use outside the rooms of three residents. The facility's Oxygen Administration policy, revised in October 2010, requires an 'Oxygen in Use' sign to be placed outside the resident's room. However, observations revealed that residents who were receiving continuous oxygen therapy did not have the required signage on their doors. This deficiency was noted for three residents, each with various medical conditions requiring oxygen therapy. Resident #29, with severe cognitive impairment and multiple diagnoses including heart failure and dementia, was observed receiving oxygen therapy without the necessary signage. Similarly, resident #316, who was alert and oriented, was also receiving oxygen therapy without the required sign. Resident #104, with a history of hypertension and atrial fibrillation, was observed on multiple occasions with oxygen in use but without the appropriate signage. The Director of Nursing confirmed the absence of the required signage for these residents.
Failure to Assess Entrapment Risks Before Side Rail Installation
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from side rails before their installation. This deficiency was observed in five residents who were reviewed for side rail use. The facility did not complete the required Side Rail Utilization Assessment and obtain consent for side rails prior to their implementation for these residents. Resident #40, who had severe cognitive impairment and required extensive assistance with daily activities, was observed with side rails in the raised position without a prior assessment for entrapment risks. Similarly, resident #55, who had no cognitive impairment but required assistance with mobility, also had side rails installed without an entrapment risk assessment. Both residents' medical records lacked physician orders for side rails, and interviews with the Director of Nursing confirmed the absence of necessary assessments. Resident #50, who was severely cognitively impaired and dependent on staff for all activities, had side rails installed without an entrapment risk assessment, despite having a care plan that included side rails for mobility. Resident #22, with severe cognitive impairment, had side rails installed without prior assessment or consent, which was only completed after the fact. Resident #104, also severely cognitively impaired, had side rails installed without an entrapment risk assessment. Interviews confirmed the lack of documentation for assessing entrapment risks before side rail installation for these residents.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly, as required. A review of records showed that the QAA meetings were held on 10/18/2023, 04/09/2024, 07/10/2024, and 10/30/2024. However, there was no record of a meeting between 10/18/2023 and 04/09/2024, indicating a lapse in the quarterly meeting schedule. An interview with the administrator on 12/04/2024 confirmed the absence of a quarterly meeting in January 2024, further substantiating the failure to adhere to the required meeting frequency.
Pharmacist Fails to Report Medication Irregularity
Penalty
Summary
The pharmacist at the facility failed to identify and report medication irregularities for a resident who was prescribed Quetiapine Fumarate without an appropriate diagnosis. The facility's policy requires the consultant pharmacist to communicate potential or actual problems related to medications to prescribers and facility leadership. However, during the monthly drug regimen review, the pharmacist did not document any irregularity regarding the use of Quetiapine Fumarate for the resident, who had multiple diagnoses including type 2 diabetes mellitus, spinal stenosis, and vascular dementia. An interview with the Director of Nursing confirmed that the pharmacist did not notify the facility, the DON, or the attending physician about the lack of an appropriate diagnosis for the antipsychotic medication prescribed to the resident. This oversight was identified during a review of the resident's electronic health records, which showed an order for Quetiapine Fumarate for mood related to adjustment disorder with depressed mood, but no corresponding diagnosis to justify its use.
Inappropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not have an appropriate diagnosis documented in the medical record for the use of Quetiapine Fumarate, an antipsychotic medication, for a resident. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, adjustment disorder with depressed mood, vascular dementia, and major depressive disorder, had an order for Quetiapine Fumarate to be administered twice daily for mood related to adjustment disorder with depressed mood. During an interview, the Director of Nursing confirmed that the resident did not have an appropriate diagnosis for the use of this antipsychotic medication.
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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