Carroll Health And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Grove, Louisiana.
- Location
- 307 N Castleman St, Oak Grove, Louisiana 71263
- CMS Provider Number
- 195423
- Inspections on file
- 26
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 23 (2 serious)
Citation history
Health deficiencies cited at Carroll Health And Rehab Llc during CMS and state inspections, most recent first.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
A resident with severe cognitive impairment and a history of elopement exited the facility through a window and was found by police on a highway after staff failed to implement or communicate an elopement risk care plan. Additionally, three residents were found with loose, improperly secured bedrails, with staff confirming the need for repairs and lack of adherence to safety policies.
The facility did not ensure adequate nursing staff coverage on numerous weekends and specific dates, as confirmed by staffing records and the DON. This resulted in insufficient staff with appropriate competencies and skill sets to meet resident needs.
A resident who was cognitively intact did not receive their most recent quarterly financial statement as required by facility policy. The BOM stated that statements are mailed, but the resident reported not receiving it, and the SSD could not confirm delivery. An anonymous source also indicated that residents were not receiving their statements.
Surveyors found that multiple residents with complex medical needs were using wheelchairs with cracked, torn armrests and seats, as well as wheels with significant dirt and grime. These deficiencies were observed over several days and confirmed by the DON and Director of Maintenance, indicating a failure to maintain mobility equipment in safe and clean condition.
Surveyors identified a medication error rate of 19.35%, well above the acceptable 5% threshold, due to late administration of multiple medications to one resident and a missed dose of Thiamine Hydrochloride for another. LPNs either administered medications significantly past the scheduled time or failed to give a prescribed dose, with errors confirmed by both nursing staff and the DON.
The facility did not conduct or document a facility-wide assessment to determine necessary resources for competent care during daily operations and emergencies. The last assessment was completed over a year ago, as confirmed by the DON, a corporate RN, and a manager.
Surveyors found that the facility failed to obtain physician orders, conduct entrapment risk assessments, and update care plans for four residents using bedrails. Despite residents having various medical conditions and cognitive statuses, bedrails were observed in use without the required documentation or assessment, as confirmed by the DON.
Two residents with intact cognition were prescribed as-needed Klonopin for longer than 14 days without a specified stop date, despite pharmacist requests for clarification. The DON confirmed that the physician did not address the recommendations, resulting in continued use of psychotropic medications beyond the recommended duration.
A resident with a history of traumatic subdural hemorrhage, seizures, and encephalopathy was prescribed Valproic Acid with a physician order for monthly Depakote level monitoring. The facility did not obtain or document any Depakote lab results, and the DON confirmed that these labs were not drawn as required.
Surveyors found that an ice scoop used for serving ice to residents was stored inside an ice chest containing ice for resident use, a practice confirmed by the dietary supervisor and later reported to the DON. This action did not meet professional standards for food service safety.
The facility did not complete four quarterly Quality Assessment and Assurance (QAA) committee meetings with all required members present within the past year, as confirmed by record review and staff interviews.
A resident with an unstageable pressure ulcer did not have Enhanced Barrier Precautions (EBP) signage posted in their room as required by physician order and facility policy. The DON confirmed the absence of the necessary signage, indicating a lapse in the infection prevention and control program.
The facility did not provide at least 12 hours of required annual in-service training to several CNAs, as confirmed by record review and interview with the DON. Personnel files lacked documentation of the mandated training, including education in dementia care and abuse prevention.
The facility did not develop or implement care plans for two residents with severe cognitive impairment and elopement risk, nor for a resident with paraplegia and bilateral hand contractures. Staff confirmed the absence of these care plans, despite documented needs and assessments indicating the necessity for individualized interventions.
A resident with multiple risk factors for pressure ulcers, including immobility and a history of skin impairment, was observed multiple times without a pressure-reducing cushion in the wheelchair as required by the care plan. The DON confirmed the absence of the cushion, despite its documented necessity for pressure ulcer prevention.
Staff did not follow catheter care protocols for a resident with multiple health conditions, as the catheter bag and tubing were repeatedly observed lying on the floor and improperly stored, contrary to facility policy. Both an LPN and the DON confirmed these practices were not appropriate.
Four residents with open wounds and active infections continued to receive whirlpool baths, while staff failed to clean the whirlpool according to manufacturer guidelines. The whirlpool's disinfectant jets were not functioning, the disinfectant reservoir was empty, and cleaning procedures did not include all required steps, leading to inadequate infection control. Staff interviews confirmed a lack of knowledge and oversight regarding proper cleaning protocols.
A Wound Care Nurse in an LTC facility failed to maintain proper infection control during a wound care procedure. The nurse contaminated a jar of Silvadene Cream by using a bare hand to scoop the cream with a medication cup, which was not resident-specific. Additionally, a bottle of Dermal Wound Cleanser was placed on an unsanitized table and returned to the wound care cart without being sanitized, risking cross-contamination.
A resident with multiple health conditions suffered a burn injury after spilling hot noodles on his leg. The night LPN assessed the blisters but failed to notify the physician, only informing the oncoming nurse. The injury was later addressed by an RN who contacted the physician for treatment. This delay in communication was identified as a deficiency.
A resident with severe cognitive impairment and nicotine dependence was observed smoking unsupervised in the designated smoking area. Despite the care plan requiring supervision, the resident was left alone and discarded a lit cigarette butt onto the concrete instead of using the fire safety ashtray, indicating a lapse in supervision and adherence to safety protocols.
A facility failed to conduct quarterly Safe Smoking Evaluations for a resident with chronic schizophrenia, despite policy requirements. The resident was cognitively intact, but documentation was incomplete, with an incorrect date on one evaluation and no evidence of quarterly assessments. The deficiency was confirmed by facility staff.
The facility exhibited multiple environmental deficiencies, including water-stained and sagging ceiling tiles in the kitchen, dirty hallway floors, and inappropriate use of a box fan in the whirlpool room. Outside, various discarded items were found, and the laundry room had rotten wood and a wet floor with a black substance. These issues were confirmed by staff and had the potential to affect 51 residents.
The facility failed to ensure nursing staff demonstrated necessary competencies, as evidenced by missing documentation for wound care, tracheostomy care, and medication administration for four residents. A resident with paraplegia and a stage 3 wound lacked documented dressing changes, while another with a stage 4 pressure ulcer had missing dressing change records. A resident with multiple diagnoses had undocumented wound care, and a resident with a tracheostomy had missing records for tracheostomy care and medication administration. Interviews confirmed these documentation lapses.
A facility failed to report and investigate an incident where a resident was found with illegal drugs. The resident, who was cognitively intact and used a wheelchair, was acting unusually and admitted to smoking marijuana. Staff found marijuana in his belongings and disposed of it without completing an Accident and Incident Report or conducting a thorough investigation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. Despite the resident's medical conditions and physician's orders for wound care, observations revealed the absence of an EBP sign on the resident's door. Interviews confirmed the oversight, highlighting a lapse in following infection control procedures.
The facility failed to conduct weekly skin assessments for residents with pressure ulcers, as required by their policy. A resident with a stage 3 pressure ulcer, another with a stage 2 ulcer, and a third with a stage 4 ulcer did not have documented weekly assessments. Interviews with the Interim DON and an RN confirmed the lack of assessments, acknowledging the oversight.
A resident in an LTC facility was subjected to verbal and mental abuse by another resident, who used racial slurs and derogatory comments about the victim's medical condition. Despite staff intervention, the aggressive behavior continued, causing distress to the victim. The facility failed to protect the resident from abuse, violating their rights.
A resident in an LTC facility experienced verbal and mental abuse from another resident, involving racial slurs and threats. Despite the facility's policy requiring immediate reporting, the incidents were not promptly reported to the Administrator or the State Survey Agency. Staff members witnessed the abuse but failed to notify the appropriate authorities within the required timeframe.
The facility was cited for non-compliance with laws and regulations due to the S1Administrator's response time being over one hour. The S1Administrator lived 1.5 hours away from the facility, as confirmed by her employee file and interviews, leading to a response time that did not meet the required standards.
The facility experienced a shortage of essential care supplies, such as wipes and toilet paper, affecting resident care. Several residents reported the lack of supplies, and staff confirmed the issue was due to a recent change in medical supply vendors, causing delivery delays. The shortage impacted the facility's ability to meet the needs of all residents.
The facility failed to maintain a clean and safe environment, affecting all residents. Observations revealed a black substance in toilets, foul odors, and dirt and grime in rooms and hallways. Interviews confirmed inadequate cleaning practices, with the administrator acknowledging the need for thorough cleaning.
A resident reported a $100 theft from his wallet, which he discovered after seeing a staff member exit his room. The facility administrator was informed four days later but failed to report the incident to the state agency and law enforcement within the required 24-hour period, violating federal reporting requirements.
A resident reported a $100 bill missing from his wallet after seeing the Housekeeping/Laundry Supervisor exit his room. The facility delayed investigating the allegation, failing to suspend the staff member or promptly review video footage. The administrator admitted to being busy, which contributed to the delay. Video evidence later contradicted the staff member's denial of entering the room, leading to her termination for dishonesty. The facility's inaction resulted in a deficiency in handling the situation according to their policy.
The facility failed to maintain proper hygiene and grooming for residents unable to perform activities of daily living. A resident with severe cognitive impairment was observed with food debris on clothing and unclean fingernails, while two other residents had long, dirty fingernails despite care plans requiring weekly nail care. Staff did not provide necessary assistance, as confirmed by an RN.
The facility failed to ensure that CNAs demonstrated competency in necessary skills and techniques to care for residents, as identified through assessments and care plans. A review of personnel records for five CNAs revealed no documented evidence of skills checks or competency evaluations, despite their hire dates ranging from 2021 to 2024. An interview with the Regional HR confirmed the absence of such documentation.
Two residents experienced medication administration errors, resulting in a 12.12% error rate. An LPN failed to administer Losartan and Carboxymethyl Cellulose Sodium to one resident, while another resident received Vitamin D3 daily instead of weekly and Seroquel in the morning instead of at bedtime. These errors were confirmed by an RN.
The facility failed to defrost chicken breasts properly, as observed during a kitchen visit. The chicken was submerged in water without running cold water and placed directly in the sink, contrary to the facility's policy. This practice could potentially affect 44 residents receiving meals from the kitchen, as confirmed by the Dietary Manager.
The facility did not have documented evidence of conducting a QAA meeting for the first quarter of 2024, as required. This was confirmed by the administrator during an interview, indicating a failure to meet the quarterly meeting requirement.
The facility failed to implement Enhanced Barrier Precautions for residents with wounds and colostomies, as required by their policy. Despite having conditions that necessitated such precautions, no residents were on enhanced barrier precautions. Interviews with staff confirmed this oversight, indicating a lapse in following infection control protocols.
The facility did not designate a qualified individual as the Infection Preventionist responsible for the infection prevention and control program. A review of records showed no evidence of a designated staff member, and the administrator confirmed this absence.
The facility failed to maintain an effective pest control program, resulting in a persistent fly infestation affecting all residents. Observations revealed flies in hallways and rooms, including a room with a urine smell and flies on a breakfast tray. Residents confirmed the issue, using fly swatters in their rooms. The facility's pest control policy was not effectively implemented, as confirmed by the administrator.
The facility failed to provide required in-service training for five nurse aides, lacking documentation for dementia management and resident abuse prevention training. Additionally, two aides did not complete the mandated 12 hours of annual training. These deficiencies were confirmed through personnel record reviews and an HR interview.
The facility failed to complete and transmit discharge MDS assessments within 14 days for three residents. A review of medical records showed that a resident was admitted and discharged without a timely assessment. Another resident was readmitted and discharged, and a third resident was admitted and discharged, all without the required timely assessments. The MDS Coordinator confirmed these assessments were not performed and transmitted on time.
The facility failed to provide proper respiratory care for two residents. One resident received oxygen therapy at a higher rate than prescribed, and another had a nebulizer mask and tubing improperly stored. These actions were inconsistent with professional standards and the facility's policies.
The facility failed to conduct State Adverse Actions checks for CNAs upon hire and monthly thereafter, affecting five CNAs. Additionally, the CNA registry was not verified upon hire for one CNA. This oversight was confirmed by the Regional HR representative, indicating a lapse in compliance with state regulations.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Prevent Elopement and Maintain Safe Bedrail Conditions
Penalty
Summary
The facility failed to have an adequate system in place to ensure residents at risk for elopement were properly supervised, resulting in an Immediate Jeopardy situation for one resident. This resident, who had vascular dementia, hemiplegia, cerebrovascular accident, heart failure, and mild cognitive impairment, was assessed as being at risk for elopement upon admission. Despite this, there was no documented evidence of a care plan addressing elopement risk, and staff were not adequately informed of the resident's risk status. The resident exited the building through a window and was found by police pacing on a highway nearly a mile from the facility, before being returned without injury. Staff interviews revealed that CNAs were unaware of the resident's elopement risk and did not notify nursing staff when the resident was missing, assuming he was elsewhere. The DON confirmed that only the day shift nurse was informed of the risk, and no comprehensive communication or care plan was in place for the resident's elopement risk prior to the incident. Additionally, the facility failed to ensure that the environment was free from accident hazards by not properly securing bedrails for three residents. Observations over several days showed that quarter or half bedrails on the beds of these residents were loose and not properly attached. Both the DON and the Director of Maintenance confirmed the bedrails were not secured and required repair. The facility's policy required correct installation and maintenance of bedrails, including following manufacturer instructions and regular inspections, but these procedures were not followed for the affected residents. The deficiencies were identified through observations, record reviews, and staff interviews. The lack of proper communication, documentation, and adherence to facility policies contributed to the failure to prevent elopement and to maintain a safe environment regarding bedrail use. The issues were confirmed by multiple staff members, including the DON, CNAs, and the Director of Maintenance, who acknowledged the lapses in supervision, communication, and equipment maintenance.
Removal Plan
- DON or Designee will screen all new admits or readmits for potential wandering and/or elopement, including history and current cognitive status and continue with ongoing elopement risk assessments.
- Hourly observations for Resident #73 was initiated.
- Hourly observations for all high risk for elopement residents were initiated.
- Ensured all high risk for elopement residents had on orange wristbands.
- Maintenance Director secured all windows.
- DON or Designee will be responsible for updating the elopement binders for all high-risk new admissions and readmissions for elopement. To be placed at each nurses station with face sheets continuously.
- Elopement policy updated to include: any elopement risk resident will wear an orange wrist band as an identifier.
- Charge nurses will meet with all staff (CNAs, nurses, any other direct/indirect care staff) at beginning of each shift to communicate high risk elopement residents.
- DON and ADON inserviced nurses to complete hourly observations of high risk elopement residents and document on monitoring tool – completed inservice.
- DON inserviced MDS nurse to update care plan to reflect elopement risk residents.
- Inservice was completed by DON and ADON to all staff on elopement risk and orange wristbands.
- Education also added to the new hire orientation process.
- DON or Designee will observe and document high risk elopement residents’ behaviors for initial period in facility after new admission or readmission.
- Inserviced staff began using the hourly observations monitoring tool for Resident #73.
- DON or Designee will monitor the completion of the hourly observations of high risk residents and the documentation on monitoring tool is complete.
- Inserviced staff began using the hourly observations monitoring tool for all high risk elopement residents.
- Maintenance Director will monitor windows to random rooms. All findings will be reported to Quality Assurance (QA) committee.
- Hourly monitor tool binder on high risk elopement residents to be completed for the initial period after new admission or readmission.
- DON or Designee will monitor orange wristbands to ensure it is intact and to be changed as needed if soiled or dislodged on high risk residents.
- DON or Designee will complete elopement drills. All findings will be reported to the QA committee.
Failure to Maintain Sufficient Nursing Staff on Multiple Dates
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of all residents. Payroll-Based Journal (PB&J) Staffing Reports and personnel staffing patterns revealed that the facility had excessively low weekend staffing during the second quarter of Fiscal Year 2025, specifically from January through March. Additionally, there were multiple specific dates in January, February, March, and June 2025 where staffing was found to be insufficient. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not meet the required staffing hours on the identified dates. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Resident with Quarterly Financial Statements
Penalty
Summary
The facility failed to ensure that a resident's individual financial records were made available through quarterly statements as required by policy. Review of the facility's Resident Funds policy indicated that each resident should have access to their financial records via quarterly statements. For one resident, who was found to be cognitively intact with a Brief Interview of Mental Status score of 14, interviews and record reviews revealed that the resident had not received the most recent quarterly statement. The Business Office Manager confirmed that statements are mailed, but the resident reported not receiving it, and the Social Services Director could not recall if the statements were delivered. An anonymous source also stated that residents were not receiving their quarterly statements.
Failure to Maintain Wheelchairs in Good Repair and Cleanliness
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents who used wheelchairs. Observations over multiple days revealed that the wheelchairs of four residents had cracked, torn, or otherwise damaged armrest padding and seats, and in some cases, a build-up of dirt and grime on the wheels. These deficiencies were confirmed by both the Director of Nursing and the Director of Maintenance during joint inspections. The affected residents had significant medical histories, including acquired limb absence, diabetes, epilepsy, Alzheimer’s disease, schizophrenia, major depressive disorder, paraplegia, bipolar disorder, anxiety disorder, alcohol abuse, hypertension, cerebrovascular disease, aphasia, and seizure disorders. All required wheelchairs for ambulation and varying levels of assistance with activities of daily living. The observations specifically noted that the damaged and unclean wheelchairs were in use by the residents in hallways and their rooms, and that the issues persisted over several days. The facility staff acknowledged the need for repair and cleaning of the wheelchairs during the survey. The report documents that the facility did not ensure that residents’ wheelchairs were maintained in good repair, directly impacting the environment provided to these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 19.35% error rate during the observed medication administration pass. Out of 31 opportunities, there were 6 medication errors involving two residents. For one resident, a LPN administered five prescribed medications, including Norvasc, Colace, Ferrous Sulfate, Levaquin, and Xarelto, significantly later than the scheduled time. The medications were due at 9:00 a.m. but were not given until 10:40 a.m., exceeding the facility's policy of administering medications within one hour of the prescribed time frame. Both the LPN and the DON confirmed the late administration during interviews. Another resident did not receive a scheduled dose of Thiamine Hydrochloride 100 mg at the prescribed 9:00 a.m. time. The LPN responsible for this medication pass failed to administer the medication, initially believing it was unavailable. However, upon further review, the medication was found on the LPN's medication cart, and the LPN acknowledged being unaware of its presence during the morning pass. These actions and inactions directly contributed to the elevated medication error rate identified during the survey.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review showed that the last facility assessment was completed on 06/25/2024. During an interview, the DON, a corporate RN, and a manager confirmed that no subsequent facility assessment had been performed or documented since that date. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Assess, Document, and Care Plan Bedrail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bedrails for four residents. Specifically, the facility did not obtain physician orders for the use of bedrails, did not assess residents for the risk of entrapment prior to installing bedrails, and did not update care plans to reflect the use of bedrails. These deficiencies were identified through observations, interviews, and record reviews. For each of the four residents reviewed, there was no documentation of a physician's order authorizing the use of bedrails, no entrapment risk assessment completed before installation, and no care plan developed to address the use of bedrails. The residents involved had varying medical histories, including chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, acute kidney failure, cirrhosis of the liver, paraplegia, bipolar disorder, diabetes mellitus, morbid obesity, and muscle weakness. Cognitive assessments indicated that most residents had no or only moderate cognitive impairment, and none had upper or lower extremity impairments that would have necessitated bedrail use without proper assessment. Observations on multiple dates confirmed that the residents were in bed with bedrails in place, despite the lack of required documentation and assessments. Interviews with the DON confirmed the absence of physician orders, entrapment risk assessments, and care plans for all four residents using bedrails.
Failure to Ensure Timely Review and Limitation of Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that residents were free from chemical restraints and that psychotropic medications were not used for purposes of discipline or convenience, but only as required to treat medical symptoms. Specifically, two residents with intact cognitive function were prescribed Klonopin, a psychotropic medication, on an as-needed basis for periods exceeding 14 days. In both cases, the pharmacist requested that the prescribing physician provide a specific duration and stop date for the medication, but these requests were not addressed by the physician. For one resident with diagnoses including COPD, peripheral vascular disease, hypertension, major depressive disorder, and dementia without behavioral disturbance, the as-needed Klonopin order remained active beyond 14 days without a stop date. Similarly, another resident with diagnoses of edema, heart failure, depressive disorder, and anxiety had an as-needed Klonopin order for alcoholism that also lacked a specified duration or stop date, despite the pharmacist's recommendation. The DON confirmed in both cases that the orders were not updated as requested and remained in place for longer than 14 days.
Failure to Monitor Lab Results for Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring required laboratory results for an anti-seizure medication. A review of the resident's care plan indicated that lab and diagnostic work should be obtained as ordered and results reported to the physician. The resident had active physician orders for Valproic Acid to be administered daily and a standing order for monthly Depakote (Valproic Acid) level testing. However, there was no documentation of any Depakote lab results in the resident's chart, and the Director of Nursing confirmed that these levels were not drawn during the resident's stay. This lack of monitoring occurred despite the resident's diagnoses, which included traumatic subdural hemorrhage, seizures, altered mental status, and encephalopathy.
Improper Storage of Ice Scoop in Ice Chest
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, on two separate occasions, an ice scoop used for serving ice to residents was found stored inside an ice chest that contained ice intended for resident use. This practice was confirmed by the dietary supervisor during the observation. The DON was later informed of the dietary staff's method of storing the ice scoop in the ice chest containing resident ice. No information regarding the medical history or condition of any specific residents was provided in the report.
Failure to Hold Quarterly QAA Committee Meetings with Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly with all required members present. Record review showed that QAA committee meetings with the required staff were documented on three occasions within the past year. During interviews, both a corporate RN and the Director of Nursing confirmed that four quarterly QAA committee meetings with all required staff present had not been completed in the past year.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) as ordered for a resident with a pressure ulcer. Specifically, observations on multiple dates revealed that there was no EBP signage posted in the resident's room, despite a physician's order for EBP and the facility's policy requiring the use of gown and gloves during high-contact care activities for residents with wounds or indwelling medical devices. The resident involved had an unstageable pressure ulcer of the left heel and was cognitively intact according to a recent assessment. The Director of Nursing confirmed that EBP signage should have been posted but was not present at the time of observation.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to provide the required annual in-service training of at least 12 hours to ensure the continued competence of Certified Nursing Assistants (CNAs). Record reviews for three CNAs showed no documented evidence of completion of the mandated annual training hours. Specifically, personnel files for CNAs hired on 07/02/2021, 04/19/2023, and 05/30/2012 lacked documentation of 12 hours of annual in-service education. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the required training had not been provided to these staff members. The deficiency was identified through both record review and staff interview, with no evidence found in the personnel files to support that the CNAs had received the necessary annual training, including education in dementia care and abuse prevention.
Failure to Develop and Implement Comprehensive Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with identified risks and needs. Specifically, two residents with severe cognitive impairment and documented risk for elopement did not have care plans addressing their elopement risk upon admission, as confirmed by both record review and interviews with the Director of Nursing. Additionally, a resident with paraplegia and bilateral hand contractures did not have an active care plan to address her contractures, despite observations of her condition and her reports of inconsistent interventions such as the use of wash cloths and braces. Interviews with facility staff, including the Director of Nursing and Therapy Director, confirmed the absence of required care plans for these residents. The lack of documented, measurable objectives and timeframes to address the residents' medical, nursing, and psychosocial needs was evident in the records and through staff acknowledgment, indicating a failure to meet regulatory requirements for comprehensive care planning based on the residents' assessments.
Failure to Provide Pressure-Relieving Device for At-Risk Resident
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for one resident. According to the facility's policy, nursing staff are required to assess and document significant risk factors for pressure ulcers and implement appropriate interventions. A review of the resident's records showed that the individual was at risk for developing pressure ulcers, as indicated by a Braden Score of 18, and had a care plan intervention to place a cushion on the seat of his wheelchair. The resident had multiple diagnoses, including dementia, epilepsy, abnormal posture, melanoma of the scalp, and age-related disability, and used a wheelchair for ambulation. Despite the care plan intervention, observations on multiple occasions revealed that the resident's wheelchair did not have a pressure-reducing device in the seat. The wheelchair was observed at the bedside without a cushion, and Velcro was present where a cushion should have been attached. The DON confirmed that the resident previously had a cushion in the chair and acknowledged that it was needed but not present during the observations. This failure to ensure the presence of a pressure-relieving device in the wheelchair constituted a deficiency in pressure ulcer prevention care.
Failure to Maintain Proper Catheter Care Practices
Penalty
Summary
Facility staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, as required by the facility's Urinary Catheter Care Policy. The policy specifies that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated urinary tract infections. Observations on multiple occasions revealed that the resident's catheter bag was lying on the floor inside a plastic bag, and the catheter tubing was also found directly on the floor. Interviews with an LPN and the DON confirmed that the catheter bag and tubing should not have been on the floor or stored in a trash bag. The resident involved had diagnoses including diabetes mellitus, heart disease, urinary retention, and dementia, with moderate cognitive impairment noted on assessment.
Failure to Maintain Sanitary Whirlpool Practices for Residents with Open Wounds
Penalty
Summary
The facility failed to maintain a sanitary environment and prevent the transmission of communicable diseases and infections for four residents who were reviewed for infection control. Certified Nursing Assistant (CNA) staff did not clean the whirlpool according to the manufacturer's guidelines, and the facility's policy and procedure for whirlpool cleaning did not align with these guidelines. Observations revealed that the whirlpool's disinfectant jets were not functioning, the disinfectant reservoir was empty, and the cleaning process did not include the use of a brush or proper attention to the swivel lift chair. The CNA responsible for cleaning the whirlpool was unaware of the location of the disinfectant reservoir and did not report the malfunction to her supervisor. All four residents involved had open wounds and were receiving antibiotics for wound infections. These residents continued to receive whirlpool baths three times a week despite their open wounds and ongoing infections. Medical records and interviews confirmed that each resident had a documented wound infection, with cultures showing the presence of various pathogens, including MRSA, Pseudomonas aeruginosa, and Vancomycin-resistant Enterococcus. The residents' wounds were actively being treated with antibiotics as ordered by their physicians. Interviews with facility staff, including the CNA, the wound care LPN/infection preventionist, the maintenance supervisor, and the Director of Nursing (DON), confirmed that the whirlpool was not being cleaned per manufacturer guidelines and that the facility's policy did not require such cleaning. The maintenance supervisor had not been checking the disinfectant reservoir, and the DON had not monitored the cleaning process since assuming her role. The DON acknowledged that residents with open wounds should not have been using the whirlpool and that the current cleaning procedures were inadequate to prevent the spread of infections.
Infection Control Breach During Wound Care Procedure
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the Wound Care Nurse (WCN) during a wound care procedure for a resident. The WCN contaminated a jar of Silvadene Cream 1% by using a bare hand to retrieve a medication cup from the wound care cart and then dipping the cup into the cream. This action resulted in both the inside and outside of the medication cup coming into direct contact with the topical cream. The cream was not specific to the resident but was available for any resident who might require it, increasing the risk of cross-contamination. Additionally, the WCN placed a bottle of Dermal Wound Cleanser (DWC) on the resident's over-the-bed table without sanitizing the table beforehand. After completing the wound care procedure, the WCN returned the bottle of DWC to the wound care cart without sanitizing it, placing it next to other wound care supplies. These actions were confirmed by the WCN, who acknowledged not using proper infection control techniques. The facility's administrator was notified of these findings.
Failure to Notify Physician of Resident's Burn Injury
Penalty
Summary
The facility failed to immediately consult a resident's physician when there was a change in the resident's condition, specifically when blisters were observed on the resident's skin. The incident involved a resident who was readmitted to the facility with multiple diagnoses, including Type 1 diabetes and hypertensive chronic kidney disease. On the night of the incident, the resident accidentally spilled hot noodles on his right thigh, resulting in blisters. The night nurse, an LPN, assessed the resident and observed the blisters but did not notify the physician. Instead, she informed the oncoming nurse during the morning report. Later that morning, another nurse, an RN, was informed by the resident about the burn and assessed the injury after the resident returned from dialysis. The RN observed a large blister, some of which had burst, and subsequently contacted the physician to receive an order for Silvadene cream to treat the burn. The delay in notifying the physician about the resident's condition change was identified as a deficiency in the facility's practice.
Resident Smoking Unsupervised Leads to Safety Hazard
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who was diagnosed with dementia and nicotine dependence, was observed smoking unsupervised in the designated smoking area. Despite the care plan indicating the need for supervision while smoking, the resident was left alone and subsequently tossed a lit cigarette butt onto the concrete instead of using the fire safety ashtray provided. This incident highlights a lapse in supervision and adherence to the care plan designed to prevent accidents.
Failure to Conduct Quarterly Safe Smoking Evaluations
Penalty
Summary
The facility failed to adhere to its smoking policy by not ensuring that a Safe Smoking Evaluation was completed quarterly for a resident. The policy mandates that residents who smoke should be assessed on admission, quarterly, and when there is a significant change in their ability to handle smoking products. However, the medical record of a resident admitted to the facility showed incomplete documentation regarding their smoking status. Initially, a Safe Smoking Evaluation sheet was found with the words 'non-smoker' handwritten, but it lacked any further information or a date. A subsequent evaluation sheet dated incorrectly as 01/09/2024, later corrected to 01/09/2025, indicated the resident was a safe smoker, yet there was no evidence of quarterly evaluations being conducted. The resident in question had a diagnosis of chronic schizophrenia and was assessed as cognitively intact with a Brief Interview for Mental Status score of 15, indicating sound daily decision-making skills. Despite this, the facility did not maintain consistent documentation of the resident's smoking evaluations as required by their policy. The deficiency was confirmed during an interview with the facility's social services staff and the administrator, who acknowledged the absence of documented quarterly evaluations for the resident.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and staff, as evidenced by multiple environmental concerns both inside and outside the building. Observations revealed that the kitchen ceiling had acoustic suspended tiles with old water stains, sagging tiles, and two holes. The Dietary Manager confirmed these issues. Additionally, the hallway floors throughout the facility were observed to have a buildup of dirt and grime, which was acknowledged by the Administrator. In the whirlpool room, a window was found open with a box fan placed in it, but the screen was not attached, which was confirmed as inappropriate by the Administrator. Further environmental issues were noted outside the facility, where various discarded items such as mop buckets, barrels, an old mattress, a bed frame, pieces of sheet rock, a shower chair, a Christmas tree, a broken glass picture frame, and rusted pipes were observed on the ground. Inside the laundry room, rotten wood was found behind the clean sink and eye wash station, and the floor was wet with a black substance present. These conditions were confirmed by the Laundry Worker. The Administrator was informed of these environmental issues, which had the potential to affect the 51 residents residing in the building.
Deficiencies in Nursing Staff Competency and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to care for residents' needs, as evidenced by the lack of documentation for wound care, tracheostomy care, and medication administration for four residents. For one resident with paraplegia and a stage 3 wound, the facility did not document daily dressing changes on multiple occasions as ordered by the physician. Similarly, another resident with a stage 4 pressure ulcer did not have documented evidence of dressing changes on specified days, despite physician orders. Another resident with multiple diagnoses, including type 2 diabetes and end-stage renal disease, had an order for wound care that was not documented six times in November. There was no documentation of the resident refusing care, indicating a failure in recording the necessary wound care procedures. Additionally, a resident with chronic respiratory failure and a tracheostomy had multiple instances of undocumented tracheostomy care, suctioning, and medication administration over two months, despite specific physician orders and care plan interventions. Interviews with the Director of Nursing and a Registered Nurse confirmed the lack of documentation for the required care and treatments for these residents. This lack of documentation suggests that the facility did not ensure that nursing staff were competent in performing and recording essential care tasks, leading to deficiencies in the care provided to these residents.
Failure to Investigate and Report Incident Involving Illegal Drugs
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, the facility did not complete an Accident and Incident Report or conduct a thorough investigation after a resident was found with illegal drugs. The resident, who was cognitively intact and used a wheelchair for locomotion, was discovered in the smoking area acting unusually, with dilated eyes and a strong marijuana odor. The resident admitted to smoking marijuana and taking a pill, leading to his transfer to the emergency department for evaluation. The facility's staff, including an LPN and an RN, found marijuana in the resident's belongings and disposed of it by flushing it down the toilet, as directed by the Administrator. However, the facility did not follow its policy to document and investigate the incident thoroughly. The Administrator confirmed that no Accident and Incident Report was completed, and no investigation was conducted to determine how the resident obtained the marijuana. Interviews with staff and the resident revealed inconsistencies in the handling and reporting of the incident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident who required such precautions. The policy, dated April 1, 2024, outlines the use of gown and glove during high-contact care activities for residents colonized or infected with multidrug-resistant organisms (MDROs) or those at increased risk of MDRO acquisition. Resident #2, who was admitted with multiple diagnoses including severe sepsis and abscess of the vulva, required substantial assistance with daily activities and had a physician's order for wound care. Despite these conditions, observations on November 4 and November 6, 2024, revealed the absence of an EBP sign on the resident's door. Interviews conducted on November 12, 2024, with the infection preventionist and the Director of Nursing confirmed the oversight. The infection preventionist stated that he is responsible for posting EBP signs and notifying staff verbally about residents on EBP. However, it was confirmed that the necessary signage was not posted for resident #2, indicating a lapse in following the facility's infection control procedures.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that residents with wounds or a history of wounds received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not perform weekly skin assessments for three residents, all of whom had significant medical conditions including pressure ulcers. The facility's policy required weekly skin evaluations and documentation of any skin abnormalities, but these assessments were not conducted for the residents in question. Resident #1 had multiple diagnoses, including a stage 3 pressure ulcer and paraplegia, yet no weekly skin assessments were documented. Similarly, Resident #2, with a stage 2 pressure ulcer, and Resident #3, with a stage 4 pressure ulcer, also lacked documented weekly skin assessments. Interviews with the Interim Director of Nursing/Wound Care Nurse and a Registered Nurse confirmed the absence of these assessments, acknowledging that the facility had not been completing them as required.
Verbal and Mental Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by another resident, which is a violation of the residents' rights to be free from abuse. The incident involved a resident who was cognitively intact and required assistance with daily activities due to multiple medical conditions, including diabetes, renal disease, and depression. This resident was subjected to verbal abuse by another resident who had a history of being verbally aggressive towards others. The first incident occurred when the aggressive resident entered a dining area where the victim was using a gaming monitor with headphones. The aggressive resident played loud music and, upon being asked to lower the volume, began cursing and using racial slurs against the victim. Despite intervention by an LPN, the aggressive resident continued to verbally threaten the victim. The second incident involved the aggressive resident making derogatory comments about the victim's incontinence while waiting for assistance from a CNA. These incidents were reported to staff, including the social worker and the administrator, who confirmed the verbal and mental abuse. Interviews with staff and the victim revealed that the aggressive resident's behavior made the victim uncomfortable and angry. The facility's failure to prevent these incidents and protect the victim from abuse highlights a deficiency in adhering to their abuse prevention policy. The aggressive resident was eventually discharged from the facility, but the incidents had already caused distress to the victim.
Failure to Report Verbal and Mental Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that an alleged violation involving verbal and mental abuse was reported immediately to the Administrator and Director of Nursing, as well as to the State Survey Agency within the required timeframe. The incident involved resident #4, who was cognitively intact and required assistance with daily activities, and resident #1, who verbally abused and threatened resident #4 on multiple occasions. Despite the facility's policy requiring immediate reporting of such incidents, the abuse was not reported promptly. On 08/25/2024, resident #4 reported an incident where resident #1 played loud music and verbally abused him with racial slurs and threats. This incident was witnessed by S9LPN and S10LPN, who intervened but failed to report the incident to the Administrator. Additionally, another incident occurred over the weekend of 09/07/2024 or 09/08/2024, where resident #1 harassed resident #4 with derogatory comments about his condition. This incident was reported to S5Social Worker on 09/10/2024, who then informed the Administrator. Interviews with staff confirmed that the incidents were not reported to the Administrator or the State Survey Agency as required by the facility's abuse prevention policy. The Administrator and Director of Nursing were not informed of the incidents in a timely manner, leading to a failure in reporting the abuse to the appropriate authorities within the mandated timeframe.
Administrator's Response Time Exceeds Compliance Standards
Penalty
Summary
The facility was found to be non-compliant with applicable Federal, State, and Local laws, regulations, and codes due to the response time of the S1Administrator. During an interview, the S1Administrator disclosed that she resided 1.5 hours away from the facility. This was corroborated by a review of her employee file, which confirmed her residence was at least a 1.5-hour drive from the facility. In a subsequent interview, the S1Administrator confirmed that her response time from her residence to the facility exceeded one hour.
Supply Shortages Affect Resident Care
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of its residents, as evidenced by a shortage of essential care supplies such as wipes, toilet paper, and briefs. This deficiency was identified through record reviews and interviews with residents and staff. Resident #17, with no cognitive impairment, reported that the facility sometimes runs out of wipes. Similarly, Resident #26, also with no cognitive impairment, mentioned a lack of wipes for care. Resident #29, who has moderately impaired cognition, was observed to have no toilet paper or paper towels in his bathroom over several days, despite requesting them. During a Resident Council meeting, additional residents voiced complaints about the lack of toilet paper and wipes. Interviews with facility staff, including CNAs and the Assistant Director of Nursing (ADON), revealed that the facility had been experiencing a shortage of supplies, particularly wipes and briefs, due to a recent change in medical supply vendors. This change caused delays in the delivery of necessary items, leading to a limited supply available for resident care. The ADON confirmed the shortage and acknowledged the impact on resident care. The facility's administrator was informed of these concerns, highlighting the potential impact on all 44 residents residing in the facility.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Observations over several days revealed a persistent black substance in the toilets of several residents' bathrooms, including those of residents #17, #23, #26, #11, #8, #49, and #27. Additionally, foul odors were noted in the bathrooms of residents #23 and #29, with resident #29's room also having a noticeable urine odor. The cleanliness issues extended beyond individual rooms, with dirt, grime, and spills observed on doors, floors, and baseboards in various rooms and hallways, affecting all nine sampled residents and potentially impacting all 44 residents in the facility. Interviews with residents and staff further confirmed the facility's inadequate cleaning practices. Resident #15 reported that his room was not being cleaned properly, and an interview with the facility's administrator, S1Administrator, acknowledged the need for a thorough cleaning of the facility. The observations and interviews collectively highlight a significant deficiency in maintaining a clean and safe environment, which is a fundamental right of the residents.
Failure to Timely Report Suspected Theft
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. This deficiency was identified during a review of a case involving a resident who reported a theft of a $100 bill from his wallet. The resident, who was cognitively intact, had left his wallet in his room and later discovered the money missing after seeing a staff member exit his room. The resident reported the incident to the facility's administrator and Director of Nursing four days after the alleged theft occurred. The administrator acknowledged receiving the report from the resident but did not notify the state agency and local law enforcement within the required 24-hour timeframe. The report to the state agency was made eight days after the incident, and no report was made to law enforcement. This failure to report in a timely manner is a violation of the facility's abuse prevention policy and the federal requirement to report suspected misappropriation of resident property promptly.
Failure to Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure a timely and thorough investigation of an alleged misappropriation of resident property, specifically involving a $100 bill reported missing by a resident. The resident, who was cognitively intact, reported the incident to the facility's administrator, stating that he had left his wallet containing $1,000 in his room and later found $100 missing after seeing the Housekeeping/Laundry Supervisor exit his room. Despite the resident's report, the facility did not immediately suspend the staff member involved or promptly investigate the allegation. The facility's administrator delayed obtaining staff witness statements and reviewing video surveillance footage, which showed the Housekeeping/Laundry Supervisor entering and exiting the resident's room. The administrator admitted to being busy due to the resignation of the Director of Nursing and Assistant Director of Nursing, which contributed to the delay in the investigation. The facility's policy required immediate suspension of any employee accused of misappropriation pending investigation, which was not followed in this case. The investigation was further hampered by the Housekeeping/Laundry Supervisor's false statement denying entry into the resident's room, which was contradicted by video evidence. The administrator acknowledged the failure to suspend the staff member and the delay in reviewing surveillance footage, which ultimately led to the decision to terminate the Housekeeping/Laundry Supervisor for dishonesty during the investigation. The facility's inaction and delayed response to the resident's allegation resulted in a deficiency in handling the situation according to their abuse prevention policy.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #6, who had severe cognitive impairment and required substantial assistance with personal hygiene, was observed multiple times with food debris on his clothing and long, dirty fingernails. Despite the presence of staff, no assistance was provided to clean the resident or maintain his hygiene, as confirmed by a registered nurse. Similarly, residents #17 and #23, who required assistance with personal hygiene, were observed with long, unclean fingernails. Resident #17, who had no cognitive impairment, and resident #23, who had moderate cognitive impairment, both had care plans indicating the need for weekly nail care. However, observations revealed that their fingernails were long and dirty, and this was confirmed by a registered nurse. These findings indicate a failure by the facility to adhere to the care plans and physician orders for maintaining the residents' personal hygiene.
Lack of Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This deficiency was identified through a review of personnel records for five CNAs (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA), which revealed a lack of documented evidence of skills checks or competency evaluations. The hire dates for these CNAs ranged from 2021 to 2024, yet none had documented competency evaluations in their records. An interview with the Regional Human Resources representative confirmed the absence of documentation for competency evaluations and skills checks for the CNAs in question. This lack of documentation indicates that the facility did not ensure that these CNAs were adequately assessed for their ability to meet the care needs of residents, as required by the facility's standards and regulations.
Medication Administration Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 12.12% due to four errors out of 33 opportunities. For Resident #41, the Licensed Practical Nurse (LPN) did not administer the prescribed high blood pressure medication, Losartan 25 mg, at the scheduled time of 9:00 a.m. Additionally, the eye medication Carboxymethyl Cellulose Sodium was not administered because it was unavailable. These omissions were confirmed by a Registered Nurse (RN) during interviews. For Resident #13, the LPN administered Vitamin D3 50,000 IU daily instead of the prescribed weekly dosage, as indicated in the physician orders. Furthermore, the antipsychotic medication Seroquel 25 mg, which was ordered for bedtime, was incorrectly administered during the morning medication pass. These errors were also confirmed by the RN during interviews, highlighting a significant deviation from the prescribed medication regimen.
Improper Food Defrosting in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by improperly defrosting chicken breasts. During a follow-up visit to the kitchen, it was observed that a large amount of chicken breasts were submerged in water in the kitchen sink without running cold water, contrary to the facility's policy for safely thawing food. The policy specifies that food should be thawed in cold water with running tap water to prevent bacterial growth, and the food should be kept in its original container or a plastic bag to protect the kitchen sink and counter from germs. However, the chicken breasts were placed directly in the sink without any container. An interview with the Dietary Manager confirmed that the staff did not defrost the chicken breasts properly according to the facility's policy. This deficient practice had the potential to affect 44 residents who received meals served from the kitchen.
Lack of Quarterly QAA Meeting Documentation
Penalty
Summary
The facility failed to have documented evidence of conducting a Quality Assessment and Assurance (QAA) meeting at least quarterly for the year 2024. A review of the QAA binder revealed no documentation of a QAA meeting for the first quarter of 2024 to address facility issues. This was confirmed during an interview with the administrator, who acknowledged the absence of documented evidence for the required meeting.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions Policy for five residents who were reviewed for such precautions. According to the policy, Enhanced Barrier Precautions are necessary for residents with infections or colonization with CDC-targeted Multi Drug-Resistant Organisms (MDRO) when contact precautions do not apply, or for residents with wounds and/or indwelling medical devices that cannot be covered or contained. The policy specifies that gown and glove use is required during high-contact resident care activities for those known to be colonized with MDRO or at increased risk of MDRO acquisition. Despite this, observations and interviews revealed that no residents were on enhanced barrier precautions at the time of the survey. The report specifically identified five residents who should have been on enhanced barrier precautions due to their medical conditions. These residents had wounds and, in some cases, colostomies, which according to the facility's policy, warranted the use of enhanced barrier precautions. Interviews with the Director of Nursing and the Administrator confirmed that there were no residents on isolation, and further confirmation from the Clinic Operations Consultant indicated that these residents should have been on enhanced barrier precautions. This oversight highlights a failure to adhere to the facility's own infection prevention and control protocols.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist responsible for the infection prevention and control program. A review of the facility's Infection Control Records showed no documented evidence of a designated staff member for this role. During an interview, the administrator confirmed the absence of a designated Infection Preventionist.
Persistent Fly Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent issue with flies affecting all 44 residents. Observations revealed flies in the hallways and rooms of several residents, including those of residents #11, #27, #29, and #49. Resident #29's room was noted to have a urine smell and multiple flies, with flies observed on his breakfast tray. Interviews with residents #11 and #49 confirmed the presence of flies, with both residents using fly swatters in their rooms. The Resident Council meeting further highlighted complaints from multiple residents about the fly issue throughout the building. The facility's Pest Control Policy, dated May 2008, states that an ongoing pest control program should ensure the building is free of insects and rodents. However, interviews with the S1Administrator confirmed the ongoing problem with flies. The deficiency affected all sampled residents and had the potential to impact all residents in the facility, indicating a significant lapse in maintaining a pest-free environment as per the facility's policy.
Deficiency in Nurse Aide Training
Penalty
Summary
The facility failed to provide necessary in-service training for nurse aides, resulting in a deficiency. Specifically, five nurse aides (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) did not receive required training in key areas. S20CNA, S21CNA, S22CNA, and S23CNA lacked training in resident abuse prevention, while S20CNA, S23CNA, and S24CNA did not receive dementia management training. Additionally, S21CNA and S24CNA, who had been employed for over a year, did not complete the mandated 12 hours of annual in-service training. These deficiencies were confirmed through personnel record reviews and an interview with S3Regional Human Resources, who acknowledged the absence of documentation for the required training.
Failure to Timely Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments within 14 days after residents were discharged, as required. This deficiency was identified for three residents during a review of their medical records. Resident #10 was admitted and later discharged without a timely discharge MDS assessment. Similarly, resident #31 was readmitted and then discharged, and resident #40 was admitted and discharged, both without the required timely assessments. An interview with the MDS Coordinator confirmed that the discharge MDS assessments for these residents were not performed and transmitted in a timely manner.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the comprehensive person-centered care plan for two residents. Resident #20, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and vascular dementia, was observed receiving oxygen therapy at 5.5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing, who noted that the oxygen flow had been increased during a recent respiratory exacerbation but should have been adjusted back to the prescribed rate. The resident was unable to adjust the oxygen flow independently, leading to the continued administration of an incorrect oxygen rate. Resident #34, diagnosed with chronic systolic congestive heart failure, was found to have a nebulizer mask and tubing that were not stored in a plastic bag when not in use, as required by the facility's policy. The nebulizer equipment was observed uncovered and undated in the resident's room, despite the policy stating that it should be replaced weekly and stored properly. The Director of Nursing confirmed the oversight, acknowledging that the nebulizer mask and tubing should have been stored in a labeled plastic bag when not in use.
Failure to Conduct Required Checks for CNAs
Penalty
Summary
The facility failed to ensure that the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNAs) both initially upon hire and monthly thereafter. This deficiency was identified for five CNAs, specifically S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA. Additionally, the facility did not verify the CNA registry upon hire for S20CNA. The personnel files reviewed showed no documented evidence of these checks being conducted, which is a requirement for maintaining compliance with state regulations. The personnel files revealed various hire dates for the CNAs, ranging from 2021 to 2024, yet none had the required State Adverse Actions checks documented. An interview with the Regional Human Resources representative confirmed the absence of documentation for these checks. This oversight indicates a systemic failure in the facility's hiring and monitoring processes for CNAs, potentially compromising the quality of care provided to residents.
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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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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