Central Guest House Healthcare & Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 10748 Joor Road, Baton Rouge, Louisiana 70818
- CMS Provider Number
- 195382
- Inspections on file
- 33
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Central Guest House Healthcare & Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with quadriplegia, severe cognitive impairment, and protein-calorie malnutrition had physician and RD orders for a NAS diet with double meats and a Magic Cup supplement with each meal as part of a comprehensive malnutrition plan. During a survey observation, the breakfast meal ticket showed a Magic Cup was ordered, but the item was missing from the tray. An LPN confirmed the supplement should have been present, the dietary supervisor stated kitchen staff must follow the meal ticket when preparing trays, and the DON acknowledged that ordered dietary supplements are required to be on the tray with meals.
Improper Freezer Food Storage: Surveyors observed multiple food items in the freezer stored in unsealed bags inside open cardboard boxes, including sausage patties, biscuit dough, diced ham, chicken breast patties, fish fingers, and egg rolls. The D M confirmed the items were open and not sealed, and the ADM stated the food should have been sealed and not left open to air.
A resident with a right BKA and severe cognitive impairment was observed in bed without his ordered shrinker sock in place, despite a sign indicating it should be worn while in bed. The resident stated he had not refused care, and staff, including CNAs, an LPN, and the DON, confirmed the shrinker sock should have been applied and that staff were expected to follow the physician’s order.
Failure to Shampoo Resident’s Hair During Scheduled Bathing: A resident who needed partial/moderate help with personal hygiene was scheduled for baths three times weekly and preferred morning showers, but her hair was not washed for weeks despite repeated requests. The resident reported an itchy scalp and oily, dirty hair, and a CNA confirmed the hair wash was not done during the bed bath and was not reported to the nurse. Staff acknowledged that washing hair was part of the bath and should have been completed when requested.
Failure to Administer Ordered Prednisone: A resident with COPD, cough, congestion, and other respiratory diagnoses was ordered Prednisone for 4 days, but the MAR and nursing notes showed doses were not given because staff were waiting on pharmacy. The resident was observed coughing up phlegm and stated she had been supposed to start a steroid but had not. An LPN confirmed the medication was not delivered and was not administered as ordered, and the NP confirmed the order was expected to be carried out.
Failure to Follow EBP During Catheter Care: A resident with an indwelling urinary catheter was on EBP per orders, care plan, and posted room signage requiring gloves and a gown for high-contact care, including catheter care and hygiene. During observation, a CNA provided catheter care and peri care without wearing a gown, and later confirmed the PPE was not worn as required; the DON confirmed staff were expected to follow EBP for residents with urinary catheters.
The facility did not ensure dietary staff with facial hair wore beard restraints while preparing food, as observed in the kitchen where three male aides with beards were preparing drinks without restraints. This was confirmed by the dietary manager and administrator, potentially affecting 155 residents.
A facility failed to complete a Significant Change in Status MDS Assessment within 14 days for a resident admitted to hospice care. The resident was admitted to hospice, but a review of their MDS assessments showed no submission reflecting this change. Interviews with staff confirmed the oversight.
The facility failed to accurately code MDS assessments for a resident's planned discharge and another resident's hospice services. Staff confirmed the discrepancies, acknowledging that the discharge was planned and hospice services were provided, but the MDS assessments did not reflect these statuses.
The facility failed to label insulin vials with the open date and did not discard medications by their expiration date, as observed in two medication carts. An LPN confirmed that insulin vials should be labeled and discarded after 28 days, and all medications should be discarded by their expiration date. The DON also confirmed these requirements.
A facility failed to maintain an effective infection prevention and control program as staff did not adhere to Enhanced Barrier Precautions (EBP) during high-contact care for a resident with a pressure ulcer and antibiotic resistance. Despite a posted EBP sign requiring gowns and gloves, staff members did not wear gowns during brief changes and wound care. Interviews confirmed the oversight, which had the potential to affect other residents on EBP.
The facility failed to post nurse staffing data in a prominent area accessible to residents and visitors. Observations during a tour revealed the absence of posted data, and interviews with staff confirmed that the information was kept in a binder behind the nurses' station, requiring residents or family members to request access. The facility administrator acknowledged the deficiency.
A resident reported an incident of verbal abuse by a CNA, which was not reported to the administrator or state survey agency within the required timeframe. The resident, who was cognitively intact, stated that the CNA cursed at him and waved her finger in his face. An LPN who witnessed the incident confirmed the verbal abuse but did not report it, and the administrator was unaware of the incident.
A facility failed to complete and transmit MDS assessments for a resident within the required timeframe. The Admission MDS and Quarterly MDS were found incomplete and in progress beyond the 14-day requirement. Interviews with the MDS coordinator and DON confirmed the delay in completion and transmission to CMS.
Failure to Provide Ordered Dietary Supplement With Meals
Penalty
Summary
The facility failed to ensure that a resident received ordered dietary supplements with each meal. The resident was admitted with diagnoses including quadriplegia, unspecified level of spinal cord injury, and unspecified protein-calorie malnutrition, and had a BIMS score of 5 indicating severe cognitive impairment. Physician orders dated 03/16/2026 directed that the resident receive a Magic Cup with meals. The most recent registered dietician assessment further specified a NAS diet with regular texture and thin consistency, double portion meats, Magic Cup with meals three times a day, liquid protein three times a day, a house supplement four times a day, and Glucerna in the evening with supper as part of a malnutrition plan to provide meals, snacks, and supplements to meet nutrient needs. On 04/20/2026 at 9:25 a.m., surveyors observed the resident’s breakfast tray and meal ticket, which documented a Magic Cup with meals; however, the Magic Cup was not present on the tray. At 9:34 a.m., this omission was confirmed during an observation of the tray and meal ticket with an LPN, who stated the tray did not have the ordered Magic Cup and that it should have. The dietary supervisor stated that Magic Cups came from the kitchen and that kitchen staff were responsible for preparing trays according to the meal ticket, confirming that if Magic Cups were on the ticket they should be on the tray. The DON also stated that if a resident had dietary supplements ordered with meals, they should be on the resident’s tray as ordered.
Improper Freezer Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed multiple food items in the freezer stored in unsealed bags inside open cardboard boxes, including a 10 pound bag of fully cooked sausage patties, a 1.2 ounce plastic bag of cheese and garlic biscuit dough, a 1.5 pound plastic bag of diced ham, a 10.35 pound plastic bag of fully cooked chicken breast patties, a 10 pound plastic bag of fish fingers, and a 1 pound bag of egg rolls. The dietary manager confirmed the items were open and not sealed and stated that all foods stored in the freezer should have been sealed and not left open to air. The administrator was later informed of the findings and stated the opened food items should have been sealed and not open to air in the freezer, and that they were not stored in accordance with professional standards for food service safety.
Failure to Apply Ordered Shrinker Sock to BKA
Penalty
Summary
The facility failed to implement Resident #114’s person-centered plan of care by not ensuring his shrinker sock was applied to his right below-the-knee amputation (BKA) as ordered. Resident #114 was admitted with an acquired absence of the right leg below the knee and had an annual MDS showing a BIMS of 06, indicating severe cognitive impairment. His physician’s order directed that the shrinker sock be applied to the right BKA anytime the prosthetic leg and silicone liner with screw were removed. During observations, Resident #114 was found lying in bed without the shrinker sock in place on his right BKA, despite a sign above his bed stating that the gray shrinker sock was to be worn while in bed. On two separate observations, he stated that he had not refused staff to apply the shrinker sock. Staff interviews confirmed that the sock should have been in place while he was in bed, that CNAs were responsible for applying it, and that he had not refused care. One CNA acknowledged she was assigned to him and had not attempted to apply the shrinker sock, and the DON confirmed staff were expected to follow the physician’s order.
Failure to Shampoo Resident’s Hair During Scheduled Bathing
Penalty
Summary
The facility failed to ensure a resident who required assistance with ADLs received the necessary services to maintain good grooming and personal hygiene when her hair was not shampooed. Resident #59 was admitted with diagnoses including abnormalities of gait and mobility, generalized muscle weakness, anxiety disorder, idiopathic progressive neuropathy, COPD with acute exacerbation, and acute on chronic respiratory failure with hypoxemia. Her MDS indicated she was cognitively intact with a BIMS of 15 and required partial/moderate assistance with personal hygiene. Her care plan noted that she preferred morning showers, and her ADL documentation showed she was scheduled for baths on Mondays, Wednesdays, and Fridays. Review of the bathing documentation showed no record that Resident #59’s hair was washed after 03/02/2026. The resident stated her hair had not been washed in about 3 weeks, her scalp itched, and her hair felt oily and dirty. A CNA confirmed the resident had requested her hair be washed during a bed bath but it was not done, and the CNA did not notify the nurse. Nursing staff confirmed that washing a resident’s hair was part of the bath and should have been done when requested. During observation, the resident’s hair was noted to be oily, with stray hairs sticking up and hair by the temples and ears appearing greasy and stuck to the side of her head.
Failure to Administer Ordered Prednisone
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure medications were accurately acquired, received, dispensed, and administered as ordered for one resident. Resident #162 was admitted with diagnoses including pneumonia, obstructive sleep apnea, cough, shortness of breath, acute upper respiratory infection, diastolic congestive heart failure, tobacco use, hypoxemia, COPD, and acute on chronic respiratory failure. Her quarterly MDS showed a BIMS of 15, indicating she was cognitively intact. A physician ordered Prednisone 20 mg, 2 tablets by mouth daily for 4 days beginning 03/20/2026 for cough and congestion related to COPD. The MAR showed Prednisone was not administered on 03/21/2026 and 03/22/2026. Nursing notes documented the medication was not given because staff were waiting on pharmacy. The resident was observed coughing up light tan phlegm, and she stated she had been supposed to start a steroid over the weekend but had not. An LPN confirmed the medication was not delivered from the pharmacy and that she did not administer it on those days. The NP confirmed she expected the Prednisone to be administered as ordered. The DON stated staff should have checked the emergency medication kits when the dose was not available, and confirmed the medication should have been administered as ordered.
Failure to Follow EBP During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 of 4 residents reviewed for infection control. Resident #135 was admitted with diagnoses including retention of urine, overactive bladder, urinary incontinence, and neuromuscular dysfunction of the bladder, and had physician orders and a care plan directing Enhanced Barrier Precautions (EBP) because of an indwelling urinary catheter. The facility’s EBP policy stated that residents with indwelling medical devices such as urinary catheters require gown and gloves during high-contact care activities, including hygiene and device care or use. On observation, S7CNA was providing catheter care and peri care to Resident #135 while not wearing a gown, despite the resident being on EBP and the posted sign outside the room stating that staff must wear gloves and a gown for high-contact resident care activities, including device care or use. During interview, S7CNA confirmed the resident was on EBP due to the urinary catheter and acknowledged that she did not wear a gown during catheter care and peri care and should have. S3DON also confirmed that staff were expected to follow EBP guidelines when providing high-contact care to residents with an indwelling medical device such as a urinary catheter.
Failure to Use Beard Restraints in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that dietary staff with facial hair wore beard restraints while preparing to serve food. During an observation in the facility's kitchen, three male dietary aides with beards were seen preparing drinks and placing lids on cups without wearing facial hair restraints. This was confirmed through interviews with the dietary manager and the administrator, who acknowledged that the staff should have been wearing beard restraints as per the facility's policy. This deficiency had the potential to affect any of the 155 residents receiving food from the facility's kitchen.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment within 14 days for a resident who was admitted to hospice care. The resident was admitted to the facility on an unspecified date and later admitted to hospice services on April 30, 2024. A review of the resident's MDS assessments from April 30, 2024, onward revealed that no Significant Change MDS was submitted to reflect the provision of hospice services. Interviews with the MDS coordinator and the Director of Nursing confirmed that the required assessment was not completed following the resident's admission to hospice, which was acknowledged as a necessary action that was overlooked.
Inaccurate MDS Coding for Discharge and Hospice Services
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the residents' status, leading to deficiencies in the documentation of discharge dispositions and hospice services. For one resident, the clinical record indicated a planned discharge home with Home Health Services, but the discharge MDS assessment was inaccurately coded as an unplanned discharge. Interviews with staff confirmed the discrepancy, acknowledging that the discharge was indeed planned and should have been coded as such. Another resident's clinical record showed they were admitted to hospice services, but the Quarterly MDS assessment failed to reflect this accurately. The section of the MDS that should have indicated hospice care was marked incorrectly, despite staff confirmation that the resident was receiving hospice services. These inaccuracies in MDS coding highlight the facility's failure to ensure accurate assessments of residents' statuses.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to accepted professional principles, as observed in two of the three medication carts reviewed. Specifically, insulin vials were not labeled with the date they were opened, and medications were not discarded by their expiration date. On Cart A, a bottle of Mucus Relief was found to be expired and still available for use. The LPN present confirmed that the medication should have been discarded by the manufacturer's expiration date. On Cart B, several vials of insulin belonging to different residents were found to be opened without being labeled with the open date, and one vial was labeled but not discarded after 28 days as required. Additionally, a tube of Premarin Vaginal Cream was available for use despite being past its expiration date. The LPN confirmed these observations and acknowledged that insulin vials should be labeled with the open date and discarded after 28 days, and all medications should be discarded by their expiration date. The Director of Nursing also confirmed these requirements during an interview.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) during high-contact resident care. Specifically, staff members S11CNA and S10LPN did not don gowns while performing brief changes and wound care for Resident #18, who was on EBP due to a pressure ulcer and resistance to multiple antibiotics. The facility's policy, effective from April 1, 2024, mandates the use of gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices, even if the resident is not known to be infected. During observations, it was noted that an EBP sign was posted on Resident #18's door, indicating the requirement for staff to wear gloves and gowns for high-contact care activities. However, both S11CNA and S10LPN confirmed in interviews that they did not wear gowns during the care provided, despite acknowledging the requirement. The Director of Nursing (S2DON) also confirmed that Resident #18 was on EBP and that staff were expected to wear gowns during such care activities. This oversight in following the facility's infection control policy had the potential to affect any of the 33 residents in the facility who had EBP implemented.
Failure to Post Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted in a prominent place readily accessible to residents and visitors. During a tour of the facility's common areas, it was observed that no nurse staffing data was posted. An interview with a staff member responsible for writing the nurse staffing data revealed that the information was kept in a binder behind the nurses' station, requiring residents or family members to ask to view it. The staff member confirmed that the data was not posted in a prominent area. Additionally, the facility administrator confirmed the lack of prominently posted nurse staffing data.
Failure to Report Verbal Abuse Incident Timely
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident and a certified nursing assistant (CNA) within the required timeframe. According to the facility's policy, any suspicion of verbal abuse must be reported to the administrator immediately and to the state survey agency within two hours. However, the incident involving the resident and the CNA was not reported as required. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported that the CNA waved her finger in his face and cursed at him, which made him feel angry. An interview with a Licensed Practical Nurse (LPN) who witnessed the incident confirmed that the CNA pointed her finger at the resident and called him a racist, which she acknowledged as verbal abuse. Despite being present during the incident, the LPN did not report it to anyone, acknowledging that she should have done so. The facility administrator was unaware of the incident and confirmed that such allegations should have been reported immediately to the state survey agency. The failure to report the incident in a timely manner constitutes a deficiency in the facility's adherence to its abuse prevention policy.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted in a timely manner for one resident. The facility's policy requires that all MDS assessments be completed and transmitted according to the most current Resident Assessment Instrument manual. However, a review of the clinical record for a resident revealed that both the Admission MDS with an Assessment Reference Date (ARD) of August 30, 2024, and the Quarterly MDS with an ARD of September 11, 2024, were incomplete and marked as in progress as of October 14, 2024. Interviews with the MDS coordinator and the Director of Nursing confirmed that these assessments were not completed within the required 14 days after the ARD date and had not been transmitted to the Centers for Medicare & Medicaid Services (CMS).
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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