Amelia Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Louisiana.
- Location
- 903 Center Street, Lafayette, Louisiana 70501
- CMS Provider Number
- 195469
- Inspections on file
- 22
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Amelia Manor Nursing Home during CMS and state inspections, most recent first.
Failure to notify the State Ombudsman Office of a resident discharge. A resident admitted for short-term respite care with multiple neurologic and psychiatric diagnoses was discharged, but the record showed no evidence that the Ombudsman was notified. The SSD stated non-emergent discharges were usually reported by email, but she could not provide proof of notification and said she was unaware a written Notice of Transfer also needed to be sent after discharge.
A resident with dysphagia, severe protein calorie malnutrition, and a gastrostomy had an enteral feeding order requiring the formula container, syringe, and administration set to be labeled with the resident's name, date, time, and nurse's initials. During observation, the tube feeding bag had no label, and an LPN confirmed it should have been labeled.
A resident with intact cognition and respiratory treatment orders received albuterol nebulizer treatments, but staff left the nebulizer tubing and mask on the resident’s refrigerator without dating, initialing, or storing them in a bag after use. The LPN confirmed she administered the treatments and did not follow the facility’s policy for labeling and storage of the nebulizer equipment.
Hand hygiene was not maintained during wound care for a resident with a stage 4 sacrococcygeal pressure ulcer and a left knee abrasion. An RN changed gloves multiple times while treating both wounds but did not sanitize hands between glove changes or after glove removal, despite the facility policy requiring hand hygiene before moving from a soiled body site to a clean body site on the same resident and after glove removal. The nurse acknowledged she knew hand hygiene was required but forgot, and the infection control nurse confirmed the policy.
The facility did not post complete daily nurse staffing information, omitting total projected and actual hours worked by licensed and unlicensed personnel responsible for resident care. Observations and interviews confirmed the deficiency, with the Ward Clerk and DON acknowledging the incomplete postings.
A facility failed to implement a care plan for a resident requiring a left hand splint due to cerebral infarction. Despite a physician's order and care plan intervention, observations revealed the splint was not applied during the day as required. This was confirmed by a CNA and an LPN, highlighting a lapse in following the prescribed care plan.
A resident with severe cognitive impairment was found with injuries and later diagnosed with a femoral fracture. The facility failed to report the incident to the state survey agency within the required two-hour timeframe due to communication failures among staff, including unsuccessful contact attempts with the on-call ADON and delayed notification to the Administrator.
A facility failed to accurately code a resident's MDS assessment regarding the use of a wander guard. The resident, diagnosed with Alzheimer's and other conditions, had a history of wandering and an active order for a Wander Alert Bracelet. However, the MDS inaccurately indicated that the wander guard was not used, a discrepancy confirmed by the MDS Coordinator.
A CNA failed to follow infection control protocols by not wearing PPE or performing hand hygiene when caring for a resident on contact precautions due to Norovirus. The CNA also did not disinfect equipment after use, despite clear signage and facility policies requiring these actions.
Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure the State Ombudsman Office was notified of a resident discharge for 1 of 1 discharge record reviewed. Resident #87 was admitted for short term respite care and had diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, spastic hemiplegia affecting the right dominant side, bipolar disorder, major depressive disorder, recurrent moderate, and anxiety disorder. Review of the facility's Notice of Transfer or Discharge form showed the resident was discharged on 02/23/2026, but there was no evidence that the State Ombudsman Office was notified of the discharge. During interview, the SSD stated that for non-emergent discharges nurses provided a slip so she could notify the State Ombudsman Office by email, but she was unable to provide a copy of an email for this resident. In a later interview, the SSD stated she was unaware that she needed to send a copy of the written Notice of Transfer for non-emergency discharges to the State Ombudsman Office after a resident was discharged.
Unlabeled Tube Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident's enteral feeding was properly labeled. Resident #2 was admitted with diagnoses including dysphagia, severe protein calorie malnutrition, and encounter for attention to gastrostomy. The resident had a physician's order for enteral feeding every night shift that required the feeding administration set to be changed daily and the formula container, syringe, and administration set to be labeled with the resident's name, date, time, and nurse's initials. During an observation on 04/06/2026 at 9:27 a.m., the resident's tube feeding bag and administration set were observed, and the formula bag had no label. During an interview later that morning, an LPN stated that tube feeding bags should be labeled with the resident's name, date, time, and nurse's initials, and confirmed that the resident's tube feeding bag was not labeled and should have been.
Nebulizer Tubing and Mask Not Labeled or Stored Properly
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for one resident who had diagnoses including primary lateral sclerosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential primary hypertension. The resident’s quarterly MDS indicated a BIMS score of 15, showing intact cognition. A physician order dated 06/02/2025 directed staff to change the nebulizer tubing and mask weekly on Friday afternoon if used and to date and initial the tubing every Friday night shift. After the resident received albuterol sulfate nebulizer treatments, observations on 04/06/2026 and 04/07/2026 showed the nebulizer mask attached to tubing laying across the top of the resident’s refrigerator and later across the refrigerator, with the tubing and/or mask not labeled with a date and not stored in a bag. The resident stated the nurse removed it after treatment and placed it on the refrigerator. The LPN who administered the treatments confirmed the tubing was not dated or initialed and was not in a bag, and stated she should have labeled it and stored it properly. Facility staff responsible for infection control and the ADON confirmed the facility policy required nebulizer tubing to be labeled with a date and the mask to be stored in a bag when not in use.
Hand Hygiene Not Maintained During Wound Care
Penalty
Summary
The facility failed to ensure infection control practices were maintained during wound care for one resident with a stage 4 sacrococcygeal pressure ulcer and a left knee abrasion. The resident’s physician orders directed daily wound care for both sites, including cleansing, application of collagen and topical medication, and dressing changes. During an observation of wound care, the nurse removed soiled dressings, changed gloves multiple times, and did not perform hand hygiene between glove changes or after glove removal while caring for the resident’s knee wound and then the sacrococcygeal wound. The facility’s hand hygiene policy stated that hand hygiene is indicated before moving from a soiled body site to a clean body site on the same resident and after glove removal. During the observed treatment, the nurse cleaned the wound, changed gloves, and continued care without sanitizing her hands between glove changes, and she confirmed in interview that she knew hand hygiene was required but forgot. The infection control nurse stated the facility’s policy was to perform hand hygiene before applying and after removing gloves during wound care and anytime gloves were used for resident care.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the total number and actual hours worked by licensed and unlicensed personnel responsible for resident care per shift. On March 19, 2025, at 11:29 AM, an observation revealed that the posted staffing information near the staff time clock, dining room, and nurse's station did not include the required details of projected and actual hours worked. During an interview at 12:30 PM, the Ward Clerk (S7WC) stated that she was responsible for filling out the Nursing Staffing Information and confirmed that it was only posted on the bulletin board near the time clock. At 12:33 PM, the Director of Nursing (S2DON) confirmed that the posting lacked the necessary information regarding the hours worked by the staff directly responsible for resident care.
Failure to Implement Care Plan for Resident's Splint
Penalty
Summary
The facility failed to implement a care plan for a resident, specifically regarding the application of a left hand splint. The resident, who was admitted with a diagnosis including cerebral infarction, had a physician's order dated 02/06/2025, and a care plan intervention initiated on 02/07/2025, both indicating that a left hand splint should be worn during the day and removed at night and for showers. However, on 03/18/2025, observations at 9:27 AM and 10:07 AM revealed that the splint was not on the resident's left hand. This was confirmed by a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) during interviews and observations, indicating a failure to adhere to the prescribed care plan.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident with serious bodily injury within the required timeframe. The resident, who had severe cognitive impairment, was found on the floor with bruising and a skin tear, and later diagnosed with an acute intertrochanteric femoral fracture. The incident was not reported to the state survey agency within the mandated two-hour window, as required by the facility's policy and state regulations. The delay in reporting was due to a series of communication failures among the staff. The LPN who received the x-ray results attempted to contact the on-call Assistant Director of Nursing (ADON) but was unsuccessful. The ADON, who was on call, did not hear the phone and only learned of the incident the following morning. The Director of Nursing (DON) and the Administrator were informed of the incident, but the report to the state survey agency was not submitted until the following day, exceeding the two-hour reporting requirement.
Inaccurate MDS Assessment for Wander Guard Use
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected their status, specifically regarding the use of a wander guard. The resident, who was admitted with diagnoses including Alzheimer's Disease, Peripheral Vascular Disease, and Hypertension, had a Brief Interview for Mental Status (BIMS) score indicating an inability to cooperate. Despite having a history of wandering and an active physician's order for a Wander Alert Bracelet, the resident's most recent MDS assessment incorrectly indicated that a wander guard was not used. This discrepancy was confirmed during an interview with the Minimum Data Set Coordinator, who acknowledged that the MDS should have been coded to reflect the daily use of the wander guard.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a certified nursing assistant (CNA) who did not adhere to established protocols for contact precautions. The CNA entered the room of a resident who was on contact isolation due to Norovirus without wearing the required personal protective equipment (PPE), which included gloves and a gown. Additionally, the CNA did not perform hand hygiene before entering or after exiting the resident's room, nor did she disinfect the vital sign machine and blood pressure cuff after use. The resident in question was experiencing diarrhea, a condition that necessitated contact precautions to prevent the spread of infection. Despite the presence of a sign on the resident's door indicating the need for contact precautions, the CNA failed to notice it and did not follow the necessary procedures. The Infection Control Registered Nurse confirmed that staff should perform hand hygiene and use appropriate PPE when contact precautions are in place, and that equipment should be sanitized before and after use. This oversight in infection control practices was identified during observations and interviews conducted by the surveyors.
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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