Center Point Health Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 8225 Summa Avenue, Baton Rouge, Louisiana 70809
- CMS Provider Number
- 195483
- Inspections on file
- 46
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Center Point Health Care And Rehab during CMS and state inspections, most recent first.
The facility failed to provide sufficient LPN staffing on a high-acuity hall, resulting in late administration of scheduled morning medications. Despite a facility assessment calling for 1 LPN per 23.5 residents, only 2 LPNs were assigned to each of three halls, including one hall with very sick residents requiring both LTC and skilled care. On that hall, one LPN was responsible for 24 LTC residents and another for 25 skilled residents, and both reported and were observed completing 7:30 a.m. and 8:00 a.m. medication passes much later in the morning. The ADON, a nurse practitioner, and the administrator all confirmed the staffing pattern and acknowledged that the hall had higher-acuity residents and that 2 LPNs were not sufficient to complete nursing tasks, including medication administration, on time.
A resident with a gastrostomy and post-cerebral infarction dysphagia had physician orders for continuous Jevity 1.5 at 70 ml/hr with 170 ml water flush every four hours, but surveyors twice observed the feeding infusing at 50 ml/hr with 165 ml flushes every five hours. The same tube feeding bag, labeled as started the previous day, remained in use beyond 24 hours. An LPN confirmed the feed and flushes were not administered per orders and that the bag should have been changed after 24 hours, and the ADON acknowledged that facility practice requires tube feeding and water bags to be changed every 24 hours and that nurses are expected to follow the ordered rates.
Surveyors identified a 60% medication error rate during a med pass when an LPN failed to administer a prescribed Hydralazine dose because the drug was not available or ordered from the pharmacy, and multiple residents received extensive morning medication regimens well beyond the facility’s allowed 1‑hour window before and after scheduled times. Staff, including LPNs and the administrator, confirmed that morning medications were expected to be given within a defined time frame and that doses given after that window were considered late, resulting in numerous counted errors across several residents.
Surveyors found that the facility failed to ensure an ordered antihypertensive medication was available and administered as prescribed. A resident with essential HTN had a standing order for Hydralazine 10 mg PO BID, but during a medication pass an LPN did not have the drug on the cart or in storage, and confirmed it was not in the facility. Record review showed the last dose was given the prior evening and that the next scheduled morning dose was not documented as administered. The LPN acknowledged the medication had not been reordered in advance as required by facility policy, and the administrator confirmed that medications ordered by physicians are expected to be available at all times and refilled before running out.
A resident with a history of alcohol abuse was discharged to a rehab center without a documented discharge plan, interdisciplinary team involvement, or a comprehensive discharge summary. Staff interviews confirmed that required assessments, documentation of the resident's intent, and post-discharge planning were not completed, in violation of facility policy.
Two residents were transferred to hospitals or rehabilitation facilities without receiving the required written notice specifying the duration of the bed-hold policy at the time of transfer. Record reviews and staff interviews confirmed that neither the residents nor their responsible parties received or signed the necessary documentation, despite facility policy requiring this notification during such events.
The facility failed to develop a comprehensive assessment addressing staff training and competency in non-pharmacological interventions for residents with Schizophrenia, PTSD, and SUD. Personnel files of four staff members lacked evidence of such training or competency evaluations. The facility administrator confirmed these deficiencies.
A facility failed to ensure the accuracy of an MDS Assessment for a resident with Schizoaffective Disorder and PTSD. The resident's diagnoses were not recorded in the MDS, and the most recent Gradual Dose Reduction (GDR) attempt and physician's response were also omitted. Staff confirmed these inaccuracies during interviews.
A facility failed to create a comprehensive care plan for a resident with Schizoaffective Disorder and PTSD, as required by their policy. The oversight was confirmed by staff, including the MDS Coordinator and DON, who acknowledged the care plan did not reflect the resident's needs. This deficiency had the potential to impact the entire resident census.
A facility failed to update a resident's diet order in the electronic medical record, despite a change from a mechanical soft diet with honey thickened liquids to a regular texture with thin liquids. Staff interviews confirmed the discrepancy, as the nurse who signed the diet requisition form did not update the electronic record, leading to inaccurate documentation.
The facility did not post required nurse staffing data, including resident census and hours worked by RNs, LPNs, and CNAs, at multiple nursing stations. Staff responsible for posting the data were unaware of the requirements, leading to incomplete information being displayed.
The facility failed to coordinate PASARR Level II assessments and care plans for two residents. One resident's PASARR Level II was not resubmitted after expiration, and another resident's care plan was not updated with Level II recommendations due to communication breakdown among staff.
A resident with multiple medical conditions, including pressure ulcers and dysphagia, experienced significant weight loss due to the facility's failure to provide a prescribed Boost supplement with meals. Despite physician orders and dietician recommendations, the supplement was not included on meal trays or communicated to nursing staff, resulting in continued weight loss.
A resident with chronic pain did not receive prescribed narcotic pain medication due to the facility running out, and the administration was not documented on the MAR. Staff interviews revealed lapses in reordering medication and documentation, violating facility policies.
The facility failed to serve meals at regular times for residents on Hall B, with lunch scheduled for 12:30 p.m. but often served as late as 2:00 p.m. Observations and interviews confirmed the delay, including a resident council meeting where residents reported late lunch service. Staff acknowledged the issue, confirming that the late service was unacceptable and contrary to the facility's policy.
The facility failed to maintain sanitary conditions in the kitchen, affecting food storage, preparation, and distribution for 141 residents. Staff did not adhere to attire policies, with one member not wearing a facial hair restraint and another without a hairnet. Observations revealed unsanitary conditions, including outdated food, unsealed items, and insect activity. Staff confirmed these issues, acknowledging the need for proper food safety and hygiene practices.
The facility failed to maintain an effective pest control program, leading to the presence of roaches, flies, and gnats throughout the premises. Observations revealed live pests in various rooms and common areas, with residents confirming frequent sightings. The pest control company was unable to complete scheduled treatment due to the facility's lack of preparation and staffing issues.
The facility did not complete and transmit a Discharge MDS assessment for a resident as required by policy. The assessment should have been completed within 14 days of discharge and transmitted to the CMS system. Staff confirmed the oversight during interviews.
The facility failed to maintain a Level 1 PASRR form for a resident with cognitive impairment and did not conduct a Level II PASRR for another resident with Bipolar Disorder. Staff relied on external screenings, leading to oversight in necessary evaluations.
A resident with multiple diagnoses, including diabetes and dementia, had a physician's order for weekly nurses' notes, which were not documented despite being acknowledged by nursing staff. Interviews with LPNs and the DON confirmed the lack of documentation, highlighting a deficiency in meeting professional standards of care.
A resident's medications were found unsecured on top of a refrigerator in her room, contrary to the facility's policy requiring drugs to be stored in locked compartments. The resident, who was cognitively intact, had medications including Oscal Vit D, Diltiazem, and Tylenol, which were part of her active physician's orders. An LPN and the ADON confirmed that medications should not be left unsecured.
A resident with severe cognitive impairment had a DNR status in their advance directive, but the facility's EHR incorrectly listed them as full code. Staff interviews confirmed the inconsistency between the hard copy chart and the EHR, and the DON acknowledged the mismatch.
A facility failed to coordinate hospice care services effectively, resulting in missing documentation for a resident's hospice care. The facility's policy required maintaining specific hospice care information, but the resident's records lacked a plan of care, physician certification, and other necessary documents. Interviews with the DON and hospice nurse confirmed these omissions.
A facility failed to adhere to its infection control policy when two staff members did not wear the required PPE during peg tube care for a resident on Enhanced Barrier Precautions. Despite clear signage and policy guidelines, the staff acknowledged their oversight, and the DON confirmed the necessity of PPE in such cases.
A resident with a PEG tube was not consistently receiving her tube feedings as ordered due to her wheelchair not accommodating the feeding apparatus. Staff frequently disconnected her feeding to allow her mobility around the facility, despite her care plan requiring continuous feeding for 20 hours a day. The facility's administration acknowledged the resident's right to mobility while receiving her prescribed nutrition.
A resident with a PEG tube was not consistently receiving her prescribed enteral feedings as ordered by the physician. Despite being NPO and requiring continuous feeding from 6:00 p.m. to 2:00 p.m., observations and staff interviews revealed that the feedings were not always administered, and there was no documentation of refusals. The resident, who liked to move around the facility, confirmed that staff sometimes did not reconnect her feedings, and the ADON acknowledged the lack of proper documentation.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications by prescribing Escitalopram Oxalate and Lorazepam with a diagnosis of Dementia, which is not an acceptable diagnosis for these medications. Interviews with staff confirmed the inappropriate diagnosis, highlighting a deficiency in the facility's adherence to its policy on psychotropic drug use.
A resident with muscle wasting and type 2 diabetes did not receive the prescribed double portions of protein and vegetables, as confirmed by an observation of their lunch tray. Despite the facility's policy requiring adherence to physician's dietary orders, the resident was served single portions, which was acknowledged by a staff member.
Insufficient LPN Staffing Leading to Late Medication Administration on High-Acuity Hall
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient LPN staffing to meet residents’ needs in accordance with its own facility assessment and to ensure timely medication administration. The facility assessment dated 05/02/2025 specified a need for 1 LPN per 23.5 residents on all shifts. On 04/20/2026, the facility census showed 52 residents on Hall A, 53 on Hall B, and 49 on Hall C, with posted staffing indicating 6 LPNs scheduled on day, evening, and night shifts, or 2 LPNs per hall. Observations on 04/20/2026 from 8:33 a.m. to 9:57 a.m. revealed only 2 LPNs providing resident care across Halls A, B, and C. During this time, one LPN on Hall C was observed administering a resident’s 7:30 a.m. and 8:00 a.m. medications at 9:57 a.m., and confirmed the medications were late, attributing the delay to high resident acuity and insufficient staffing with only 2 LPNs. Further observations and interviews on Hall C showed repeated late administration of scheduled morning medications due to staffing levels. Another LPN on Hall C was observed at 10:40 a.m. administering an 8:00 a.m. medication and confirmed it was late, again citing high acuity and inadequate staffing. Both LPNs reported that Hall C previously had 3 LPNs but had been reduced to 2 over the prior two weeks, despite caring for a mix of LTC and skilled residents, with one LPN assigned 24 LTC residents and the other 25 skilled residents. They stated that on 04/20/2026 and 04/21/2026, completion of 7:30 a.m. and 8:00 a.m. medication passes extended as late as after 11:00 a.m. and 10:00 a.m., and confirmed that the late medication administration was due to having only 2 LPNs on Hall C. The ADON and a nurse practitioner both stated that Hall C residents were high acuity and that 2 LPNs were not sufficient, while the administrator confirmed the staffing pattern of 2 LPNs per hall and acknowledged reliance on LPNs managing up to 25 residents each, despite the facility assessment standard of 1 LPN per 23.5 residents.
Failure to Follow Tube Feeding Orders and 24-Hour Bag Change Protocol
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services for a resident receiving enteral nutrition via a feeding tube. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, cerebral infarction, dysphagia following cerebral infarction, and gastrostomy status. Physician orders dated 10/23/2025 directed continuous Jevity 1.5 at 70 ml per hour with 170 ml water flush every four hours. On 03/30/2026 at 11:35 a.m., the resident’s tube feeding was observed infusing at 50 ml per hour, with the pump set to deliver a 165 ml flush every five hours, which did not match the physician’s orders. The feeding bag was labeled as started on 03/29/2026 at 5:40 a.m. A subsequent observation on 03/30/2026 at 2:37 p.m. showed the same incorrect infusion rate and water flush settings, and the same feeding bag labeled as started the previous day at 5:40 a.m. During an interview at 2:40 p.m., an LPN confirmed that the tube feeding was not infusing at the ordered rate and that tube feeding and water flushes should be administered as ordered. The LPN also confirmed that the tube feeding bag should have been changed after 24 hours and had not been changed. In a later interview, the ADON stated that tube feedings and water bags are to be changed every 24 hours and confirmed it was not acceptable for a tube feeding labeled with the prior day’s date and time to still be infusing beyond 24 hours, and that nurses are expected to administer tube feedings and water flushes per physician orders.
High Medication Error Rate Due to Omitted and Late Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying a 60% error rate during a medication administration observation involving five residents and 65 opportunities, resulting in 39 errors. The facility’s medication administration policy, revised 04/2022, required staff to compare medications with the MAR for correct resident, medication, dose, route, and time, and to administer medications within 60 minutes before or after the scheduled time unless otherwise ordered. For one resident, Hydralazine 10 mg ordered twice daily at 8:00 a.m. and 5:00 p.m. was not administered because the medication was not available in the facility and had not been ordered from the pharmacy, as confirmed by the LPN at the time of observation. For other residents, surveyors observed multiple medications being administered outside the facility’s required time frame. One resident with multiple scheduled morning medications, including Arginaid, Acetaminophen ER, Vitamin C, a multivitamin with minerals, Ferrous Gluconate, Vitamin B12, Ipratropium-Albuterol, Spironolactone, Metoprolol Succinate ER, Jardiance, and Furosemide, received these medications at 10:47 a.m., which the LPN confirmed was late given that morning medications were to be administered between 8:00 a.m. and 10:00 a.m. Additional residents with extensive 8:00 a.m. medication regimens, including antihypertensives, antiplatelets, antidepressants, vitamins, and other chronic medications, were observed receiving their morning doses after 10:00 a.m. The LPNs and the administrator confirmed that nurses were expected to administer medications within one hour before and one hour after the scheduled time, and that medications given at or after 10:00 a.m. were considered late, establishing that these administrations constituted medication errors contributing to the elevated error rate.
Failure to Maintain Availability of Ordered Antihypertensive Medication
Penalty
Summary
Surveyors identified that the facility failed to ensure prescribed medications were available for administration, as required by its own "Medication Reordering" policy. That policy stated that acquisition of medications should be completed in a timely manner to ensure timely administration, and that nurses must monitor remaining supply and reorder medications early enough to prevent omissions. During a medication pass observation and interview on 02/18/2026 at 9:36 a.m., an LPN did not have Hydralazine HCL 10 mg on the medication cart or in the medication storage room for a resident. The LPN confirmed that the medication was not available anywhere in the facility at that time. Record review showed the resident had been admitted with diagnoses including essential hypertension and had a current physician order for Hydralazine HCL 10 mg by mouth twice daily, with a start date of 01/06/2025. The Medication Administration Record indicated the last dose of Hydralazine 10 mg was given on 02/17/2026 at 5:00 p.m., and there was no documented evidence that the 8:00 a.m. dose on 02/18/2026 was administered. The LPN confirmed the medication had not been reordered from the pharmacy as of 02/18/2026, despite the ability of any nurse administering medications to reorder it up to seven days in advance to prevent running out. In a subsequent interview, the administrator confirmed that medications ordered by the physician should always be available for administration and that nurses were expected to request refills before supplies were exhausted.
Failure to Develop and Document Effective Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was reviewed for discharge. Specifically, the facility did not identify the resident's discharge needs or develop a discharge plan tailored to those needs. There was no evidence that the interdisciplinary team was involved in an ongoing process to create or update the discharge plan, nor was there documentation that the resident had been asked about their interest in returning to the community. Additionally, the resident's medical record lacked a comprehensive discharge summary, including a post-discharge plan of care, arrangements for follow-up care, and documentation of where the resident planned to reside after discharge. The resident in question had a history of alcohol abuse and had resided at the facility for several years. He was cognitively intact, as indicated by a BIMS score of 15, and expressed interest in going to rehab, with the expectation of returning to the facility after treatment. However, staff interviews revealed conflicting understandings of the resident's discharge intentions, with some staff expecting the rehab center to assist with permanent placement after the treatment program. There was no documentation in the clinical record reflecting the resident's intent to discharge, involvement in discharge planning, or a completed discharge summary. Interviews with facility staff, including the administrator, social worker, nurse practitioner, and director of nursing, confirmed the absence of required documentation and processes. The staff acknowledged that the resident's intent to discharge, assessment of self-care capability, discharge order, and summary were not present in the medical record. The facility's own policy required these elements, but they were not followed in this case, resulting in a deficiency related to discharge planning and documentation.
Failure to Provide Written Bed-Hold Policy Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice specifying the duration of the bed-hold policy to residents or their responsible parties at the time of transfer to a hospital or rehabilitation facility for two out of three sampled residents. According to the facility's own policy, written information regarding bed-hold practices must be given both at admission and at the time of transfer for hospitalization or therapeutic leave. However, record reviews and interviews confirmed that there was no documented evidence that such notice was provided to the affected residents or their representatives during their transfers. One resident, admitted with conditions including unsteadiness, morbid obesity, and a need for assistance with personal care, was transferred to a rehabilitation hospital and confirmed in an interview that no written bed-hold information was provided or signed prior to transfer. Another resident, admitted with a displaced bimalleolar fracture and gait abnormalities, was transferred to a local hospital for surgery, and again, no documentation or confirmation of written bed-hold notice was found. Facility staff, including the DON and administrator, acknowledged the absence of required documentation for both residents at the time of their transfers.
Deficiency in Staff Training and Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to develop a comprehensive facility assessment that addressed staff training for skills and non-pharmacological interventions, as well as the process to evaluate the competency of skill sets necessary to meet the mental and psychosocial health needs of residents diagnosed with Schizophrenia Disorder, Post Traumatic Stress Disorder (PTSD), and Substance Use Disorder (SUD). The facility's assessment did not outline the process for staff training and ensuring competency in non-pharmacological interventions for these conditions. Additionally, there was no documented evidence of training materials or competency evaluation materials for non-pharmacological interventions related to these mental health diagnoses. The personnel files of four staff members, including two LPNs, one RN, and one MSW, lacked documented evidence of training for non-pharmacological interventions for Schizophrenia and SUD or competency evaluations to ensure the necessary skill sets to meet the mental and psychosocial health needs of the resident population. An interview with the facility administrator confirmed these deficiencies, acknowledging the absence of a process to ensure staff competency in non-pharmacological interventions for residents with Schizophrenia, PTSD, and SUD.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessments for a resident, which was identified during a review of the resident's clinical records and interviews with facility staff. The resident, who was admitted to the facility, had active diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD) as documented in a Psychiatry Progress Note. However, the MDS Assessment for this resident did not reflect these diagnoses, as the relevant sections for Schizophrenia and PTSD were left unchecked. Additionally, the facility did not accurately document the resident's most recent Gradual Dose Reduction (GDR) attempt and the physician's response. The resident's GDR, performed earlier, indicated that the medications Seroquel and Vistaril were reviewed, and the physician deemed a dose reduction inappropriate due to the resident's condition. However, the MDS Assessment failed to record the GDR attempt, the date of the last attempted GDR, and the physician's documentation of the GDR being clinically contraindicated. Interviews with the MDS Coordinator, Director of Nursing, and Administrator confirmed these omissions, acknowledging that the MDS Assessments should accurately reflect the resident's status.
Failure to Develop Comprehensive Care Plan for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to develop a trauma-informed, comprehensive person-centered care plan for a resident diagnosed with Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD). This deficiency was identified during a review of the resident's clinical records, which revealed the absence of a care plan addressing these specific diagnoses. The facility's policy mandates that care plans be reviewed and revised upon a resident's status change, yet this was not adhered to in the case of the resident in question. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the oversight. Both staff members acknowledged that the resident's care plan did not accurately reflect their current medical and psychosocial needs, as required by the facility's policy. This lapse in care planning had the potential to affect the facility's entire resident census of 147 individuals.
Failure to Update Resident's Diet Order in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for a resident who was reviewed for therapeutic diets. The resident, who was admitted to the facility with diagnoses including Unspecified Cerebral Infarction and Pneumonitis Due To Inhalation of Food and Vomit, had a diet order that was not updated in the electronic medical record. Initially, the resident was prescribed a mechanical soft diet with honey thickened liquids, but on a later date, the diet was upgraded to a regular texture with thin liquids as per pharyngogram results. Despite this change, the electronic medical record did not reflect the updated diet order. Interviews with facility staff, including the Registered Dietitian (RD), Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed that the electronic record should have been updated to reflect the current diet order. The RD and ADON reviewed the resident's physician orders, handwritten diet order, diet requisition form, and meal tickets, all of which indicated the updated diet. However, the nurse who signed the diet requisition form failed to update the electronic record, resulting in a discrepancy between the resident's actual diet and the documented orders.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis, which included the total resident census number and the total number and actual hours worked for both licensed and unlicensed nursing staff. This deficiency was observed at multiple nursing stations (J, K, and L) on the same day. The nurse staffing data sheets at these stations did not include the required information for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The absence of this information was confirmed through observations and interviews with staff members responsible for posting the data. Interviews with various staff members, including Assistant Directors of Nursing (ADONs) and a Certified Nurse Aide (CNA), revealed a lack of awareness regarding the requirement to include specific staffing information on the posted sheets. Each staff member confirmed that the necessary data, such as the resident census and the total and actual hours worked by nursing staff, was missing from the sheets they were responsible for posting. The Director of Nursing (DON) also confirmed the omission of this critical information and was unaware that it should have been included.
Failure to Coordinate PASARR Level II Assessments and Care Plans
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) Level II for two residents. For one resident, the facility did not refer for a Level II resident review after the expiration of a six-month temporary effective period. The resident was admitted with diagnoses including unspecified dementia, psychotic disturbance, and other mental health conditions. Despite the expiration of the PASARR Level II, no resubmission was made, and no recommendations were documented. Interviews with staff confirmed the oversight, with the PASARR not being resubmitted due to a misunderstanding that it was only necessary if private pay ended or a significant change occurred. For another resident, the facility failed to incorporate PASARR Level II recommendations into the resident's care plan. This resident was admitted with conditions such as cerebral infarction sequelae and severe major depressive disorder with psychotic symptoms. Although approved for Level II services, the care plan was not updated to reflect this. Staff interviews revealed a communication breakdown, where the staff responsible for PASARRs did not notify the MDS nurses, who were responsible for updating care plans, resulting in the omission of necessary care plan updates.
Failure to Provide Nutritional Supplements Leads to Resident Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss. The resident, who was moderately cognitively impaired and had multiple medical conditions including pressure ulcers and dysphagia, experienced a weight drop from 204 pounds in April to 170 pounds by mid-June. Despite a physician's order for a Boost supplement with meals to address the weight loss, the supplement was not provided. Observations and interviews revealed that the Boost supplement was not included on the resident's meal trays or meal tickets, and the order was not properly communicated to the nursing staff. Interviews with various staff members, including CNAs, LPNs, the dietician, and the ADON, confirmed that the Boost supplement was not administered as ordered. The dietician had recommended the supplement due to the resident's weight loss and wounds, but the order was not entered into the Medication Administration Record (MAR), leading to a lack of awareness and action by the nursing staff. The oversight in providing the necessary nutritional supplement contributed to the resident's continued weight loss, as confirmed by the staff involved.
Deficiency in Pain Management and Documentation
Penalty
Summary
The facility failed to ensure that physician-ordered narcotic pain medication was available for administration to a resident, leading to a deficiency in pain management. The resident, who had a history of bilateral below-knee amputations and chronic pain, was prescribed Oxycodone-Acetaminophen to manage phantom pain. However, the facility ran out of the medication, and the resident was left without it for a whole day, despite requesting it every eight hours. Interviews with staff confirmed that the medication was not reordered in a timely manner, resulting in the resident experiencing unmanaged pain. Additionally, the facility did not document the administration of as-needed narcotic pain medication on the Medication Administration Record (MAR) for the same resident. The resident's Individual Narcotic Record showed that the medication was administered on several occasions, but these administrations were not recorded on the MAR. The LPN responsible for administering the medication admitted to sometimes forgetting to document it on the MAR, which is a violation of the facility's Controlled Substance Administration & Accountability policy. The facility's policies require a systematic approach to ensure medications are reordered when low and that all controlled substances are accurately documented. However, the failure to notify the nurse practitioner in time to reorder the medication and the lack of documentation on the MAR contributed to the deficiency. Interviews with staff, including the Assistant Director of Nursing, confirmed these lapses in protocol, which resulted in the resident not receiving their prescribed pain management medication as needed.
Late Meal Service on Hall B
Penalty
Summary
The facility failed to serve meals at regular times comparable to normal community meal times for residents on Hall B. According to the facility's policy, residents should receive at least three meals daily without extensive time lapses between meals, with lunch scheduled for 12:30 p.m. However, observations and interviews revealed that meals were often served late. Resident #132 reported receiving lunch as late as 2:00 p.m., and on the day of observation, his lunch tray was not delivered until 2:05 p.m. This delay was confirmed by multiple observations and interviews, including a resident council meeting where another resident from Hall B also reported receiving lunch at 2:00 p.m. Interviews with staff, including S6DM and S1ADM, confirmed that lunch for Hall B should be served at 12:30 p.m. and acknowledged that the 2:00 p.m. lunch service was unacceptable. S1ADM admitted there had been past complaints about meal service times, although he was unaware of recent issues until informed of the specific incident involving Resident #132. The facility's failure to adhere to scheduled meal times resulted in a deficiency in meeting the nutritional needs and preferences of the residents on Hall B.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the storage, preparation, and distribution of food for 141 residents. Observations revealed that staff members did not adhere to the facility's policy on attire, as one staff member with facial hair was not wearing a restraint, and another was not wearing a hairnet. These lapses in personal hygiene standards were confirmed by the staff during interviews. The kitchen inspection uncovered multiple issues with food storage and cleanliness. In the refrigerator, there were dented milk cartons, an unlabeled sandwich, unsealed bags of grapes and lettuce, and outdated containers of peaches and pudding. The dry goods storage area was disorganized, with loose packets of sugar and sweetener on the floor, and a scoop left in a bulk container of rice. Additionally, the drink dispensing table and food preparation areas were found to be unsanitary, with loose drink spouts, a lidless trash barrel, and evidence of insect activity. Interviews with staff confirmed these findings, acknowledging that food should be sealed, labeled, and dated, and that equipment should be properly maintained. The presence of a roach and the condition of the food preparation tables, which were cluttered with crumbs and debris, further highlighted the lack of adherence to sanitary protocols. The facility's administrator was informed of these deficiencies and confirmed the expectations for food safety and staff attire.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of various pests, including roaches, flies, and gnats, throughout the premises. Observations made over several days revealed live roaches in multiple rooms, including bathrooms and hallways, as well as flies and gnats swarming around residents and in common areas. Interviews with residents confirmed frequent sightings of these pests, with some residents noting that staff were aware of the issue and had attempted to spray for bugs. The pest control company representative stated that the facility was scheduled for an annual treatment, which was not completed due to the facility's lack of preparation. The facility administrator acknowledged the seasonal nature of pest issues and cited insufficient staffing as a reason for not being able to remove residents from their rooms for treatment. This deficiency had the potential to affect all 142 residents residing in the facility.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of a Discharge Minimum Data Set (MDS) assessment for a resident. According to the facility's policy, a Discharge Assessment must be completed within 14 days of the discharge date and transmitted to the designated CMS system within 14 days of completion. However, the clinical record review revealed that a resident, who was admitted and later discharged from the facility, did not have an electronically transmitted discharge MDS assessment. Interviews with the staff responsible for MDS assessments confirmed that the Discharge MDS Assessment was not completed as required.
Failure in PASRR Documentation and Evaluation
Penalty
Summary
The facility failed to maintain a record of the Level 1 Pre-admission Screening and Resident Review (PASRR) form for Resident #37, who was admitted with diagnoses including Other Sequelae of Cerebral Infarction, Unspecified Mood Affective Disorder, and Recurrent Severe Major Depressive Disorder with Psychotic Symptoms. Despite being assessed as moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 11, there was no documentation of the Level 1 PASRR form in the resident's file. Interviews with staff members confirmed the absence of this crucial documentation. Additionally, the facility did not conduct an accurate Pre-admission Screening for Resident #46, who was admitted with diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. The resident was assessed as cognitively intact with a BIMS score of 14, yet was not considered for a Level II PASRR despite having a serious mental illness diagnosis. The resident's care plan and medical records indicated active treatment for Bipolar Disorder, but no Level II PASRR evaluation was completed. Interviews with staff revealed a reliance on the initial screening process conducted by external personnel, leading to an oversight in the required Level II PASRR evaluation. The staff responsible for PASRR evaluations and MDS coordination assumed that the initial Level I screenings were completed accurately by external sources, resulting in a lack of verification and follow-up for necessary Level II evaluations. This assumption led to the failure in ensuring proper documentation and evaluation for residents with mental disorders, as evidenced by the cases of Residents #37 and #46.
Failure to Document Weekly Nurses' Notes
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality, specifically in the documentation of weekly nurses' notes for a resident. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Essential Primary Hypertension, and Vascular Dementia, had a physician's order for weekly nurses' notes to be documented every Friday during the 2:00-10:00 p.m. shift. However, a review of the resident's Treatment Administration Record (TAR) for May and June 2024 showed checkmarks indicating acknowledgment of the task, but no corresponding nurses' notes were documented on the specified dates. Interviews with the nursing staff, including two LPNs and the Assistant Director of Nursing (ADON), confirmed that the checkmarks on the TAR indicated acknowledgment of the task, but the actual documentation of the nurses' notes was not completed. The Director of Nursing (DON) also confirmed the lack of documentation and stated that the expectation was for nursing staff to document at least weekly on a resident, which was not done for this resident. This oversight in documentation was identified as a deficiency in meeting professional standards of quality care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by their policy and professional principles. During an observation, it was noted that a resident had three loose pills on top of her bedroom refrigerator, which were identified as Oscal Vit D, Diltiazem, and Tylenol. These medications were not under the direct observation of nursing staff, nor were they stored in a locked compartment, which is a violation of the facility's medication storage policy. The resident involved was cognitively intact, as indicated by a BIMS score of 14, and had been admitted with diagnoses including age-related cognitive decline, shortness of breath, hypertension, atrial fibrillation, and heart failure. The medications found were part of her active physician's orders. The LPN confirmed that the medications should not have been left unsecured, and the Assistant Director of Nursing also confirmed that medications should not be left at the bedside.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. This deficiency was identified during a review of the medical records for a resident with severe cognitive impairment, who had an advance directive indicating a Do Not Resuscitate (DNR) status. However, discrepancies were found between the resident's hard copy chart and the electronic medical record (EHR), with the EHR indicating a full code status instead of DNR. Interviews with staff, including LPNs and the Director of Nursing (DON), confirmed the inconsistency between the hard copy chart and the EHR. The hospice nurse also confirmed that the resident was a DNR as per the new advance directive signed by the resident's personal health care representative and the hospice physician. Despite this, the facility's EHR continued to reflect a full code status. The DON acknowledged that both the EHR and the hard chart should have matched the resident's DNR status, but they did not. This inconsistency in the resident's code status documentation led to the deficiency identified by the surveyors.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to coordinate hospice care services effectively, resulting in a deficiency related to the management of hospice care documentation for a resident. The facility's agreement with a local hospice company and its internal policy required the designated interdisciplinary team member to obtain and maintain specific hospice care information, including the most recent hospice plan of care, physician certification and recertification of terminal illness, hospice medication information, and physician orders. However, upon review, it was found that the hospice medical records for a resident admitted to hospice services did not contain the necessary documentation, such as the plan of care, physician certification/recertification, current/standing orders, or hospice care team assessments. Interviews conducted with the Director of Nursing (DON) and the hospice nurse confirmed the absence of required documentation in the resident's hospice binder. The DON acknowledged the responsibility for ensuring that each hospice resident's binder was up to date in collaboration with the hospice care team. Despite this responsibility, the necessary hospice documentation was missing from the resident's records, indicating a lapse in the facility's coordination and management of hospice care services.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members during the care of a resident. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, mandates the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms. However, during an observation, it was noted that two staff members, S13TN and S16CNA, did not wear the required PPE while providing peg tube care and repositioning a resident who was on Enhanced Barrier Precautions. The resident in question was admitted with diagnoses including Malignant Neoplasm of the Larynx and Gastrostomy Status, necessitating the use of a peg tube. Despite a sign on the resident's door indicating the need for Enhanced Barrier Precautions, both staff members failed to don the appropriate PPE. Interviews with the staff confirmed their awareness of the resident's precautionary status and their acknowledgment of the oversight. The Director of Nursing also verified the requirement for PPE use in such situations and confirmed the lapse in protocol adherence by the staff.
Failure to Accommodate Tube Feeding Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident requiring tube feeding management. The resident, who has a PEG tube due to conditions such as cerebral infarction, muscle wasting, atrophy, dysphagia, and gastrostomy status, was observed on multiple occasions without her tube feeding connected as per the physician's orders. The resident's care plan indicated she was at risk for inadequate nutrition and aspiration, and her feeding schedule was clearly outlined to run from 6:00 p.m. to 2:00 p.m. the following day, with a four-hour break. However, observations and interviews revealed that the resident's tube feeding was not consistently administered during the scheduled times. Interviews with staff, including LPNs and CNAs, confirmed that the resident often requested her tube feeding to be disconnected so she could propel herself around the facility in her wheelchair. The staff acknowledged that the resident's wheelchair did not accommodate her PEG tube feedings, which led to her being disconnected from the feeding when she was out of bed. Despite the resident's cognitive impairment, she was described as compliant with her care and did not refuse feedings. The staff's actions of disconnecting the tube feeding were based on the resident's desire for mobility and freedom within the facility. The facility's administration, including the ADON and DON, confirmed that the resident should have been able to move freely while still receiving her tube feedings as ordered. The medical provider also confirmed the resident's feeding schedule and her preference for mobility. The deficiency arose from the facility's failure to ensure the resident's wheelchair accommodated her tube feeding, resulting in her not receiving the prescribed nutrition during the times she was mobile, which was not in accordance with her care plan and physician's orders.
Failure to Administer PEG Tube Feedings as Ordered
Penalty
Summary
The facility failed to ensure that a resident received enteral feedings as ordered by the physician. Resident #19, who was admitted with diagnoses including Cerebral Infarction, Muscle Wasting and Atrophy, Dysphagia, and Gastrostomy Status, was observed not receiving her prescribed PEG tube feedings. Her care plan indicated she was NPO and required tube feeding to prevent aspiration due to dysphagia. The physician's orders specified continuous feeding from 6:00 p.m. to 2:00 p.m. the following day, with a four-hour break. However, observations and interviews revealed that the resident's feedings were not consistently administered as scheduled, with no documentation of refusals or held feedings. Interviews with staff, including LPNs and CNAs, confirmed that Resident #19's feedings were sometimes not connected as ordered. The resident herself stated that staff occasionally failed to reconnect her tube feedings. Staff members noted that the resident liked to propel herself around the facility and would request disconnection of her feeding tube, but there was no indication that she refused feedings. The Assistant Director of Nursing confirmed that the feedings should have been administered as ordered and acknowledged the lack of documentation when feedings were not given as prescribed.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not have an acceptable diagnosis for the use of antidepressant and anti-anxiety medications for one of the residents reviewed. The facility's policy on the use of psychotropic drugs states that such medications should only be administered to treat a specific condition that is diagnosed and documented in the clinical record. However, the resident in question was prescribed Escitalopram Oxalate and Lorazepam with a diagnosis of Dementia, which is not an acceptable diagnosis for these medications. Interviews with facility staff, including a Nurse Practitioner, an LPN, and the Director of Nursing, confirmed that the resident's medications were ordered with a diagnosis of Dementia. All staff members acknowledged that Dementia was not an appropriate diagnosis for the prescribed psychotropic medications. The failure to ensure an appropriate diagnosis for the use of these medications constitutes a deficiency in the facility's adherence to its policy and regulatory requirements.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident received a therapeutic diet as ordered by the physician. The resident, who was admitted with diagnoses including muscle wasting, atrophy, and type 2 diabetes mellitus, had a physician's order for double portions of protein and vegetables with all meals. However, during an interview, the resident reported frequently not receiving the ordered double portions. This was confirmed through an observation of the resident's lunch tray, which contained single portions of red beans and rice, sausage, and greens, instead of the prescribed double portions. The facility's policy, last approved in May 2023, mandates that dietary and nursing staff provide therapeutic diets in the appropriate form and nutritive content as prescribed by a physician. Despite this policy, the resident's lunch meal ticket indicated that double portions were required, yet the resident was served single portions. An interview with a staff member present during the observation confirmed that the resident was not served the correct portions, highlighting a failure in adhering to the prescribed dietary orders.
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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