Consolata Rehab And Wellness Center On The Teche
Inspection history, citations, penalties and survey trends for this long-term care facility in New Iberia, Louisiana.
- Location
- 2319 East Main Street, New Iberia, Louisiana 70560
- CMS Provider Number
- 195618
- Inspections on file
- 22
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Consolata Rehab And Wellness Center On The Teche during CMS and state inspections, most recent first.
Dietary support functions were performed by untrained housekeeping and floor staff who assisted in the kitchen during staffing shortages. These staff were shown how to operate the dishwashing machine but were not trained to verify water temperature or chemical levels for proper sanitation. They reported that dishes remained partially wet after the rinse cycle and that the dietician instructed them to use dry towels to finish drying plates and cups before storing them, contrary to facility policy requiring air drying to avoid re-contamination. This practice had the potential to affect all residents receiving meals from the kitchen.
The facility did not maintain sufficient dietary staffing, resulting in frequent morning shifts with only one dietary worker responsible for preparing multiple regular, chopped, and pureed meals for residents. Dietary staff reported routinely working short and relying on staff from other departments to assist with dishwashing, even though these helpers were not trained in kitchen procedures and were only shown basic dishwashing tasks. The Dietary Manager and DON were aware that single-staff coverage occurred and that untrained non-dietary personnel were being used to support kitchen operations.
Surveyors found that kitchen staff did not follow facility policies for sanitary food service and equipment storage. A dusty fan was positioned close to a food prep table and was blowing directly onto desserts while they were being portioned. Ice scoops were kept in an uncovered bucket on a prep table shelf and were used to fill residents’ cups with ice before being returned to the uncovered container, despite policy requiring scoops to be stored to prevent contamination. Residents’ cups were stored upright and uncovered instead of inverted or covered as required. Infection control staff later confirmed that the fan should not have been directed at food and that ice scoops and cups should have been properly covered or inverted, while the dietary manager reported she was unaware of these storage requirements.
The facility failed to oversee and manage kitchen sanitation and monitoring practices, resulting in dusty equipment operating near exposed food, improperly stored cups and ice scoops, and water accumulation under the ice machine. Required logs for food line temperatures, refrigerator temperatures, coffee/hot beverage temperatures, QAC testing of the 3-compartment sink, and daily kitchen cleaning were incomplete or missing for multiple days. A cook reported a nonfunctioning soap dispenser for months, lack of sanitizer test strips, and absence of proper temperature-recording forms, leading staff to document on napkins. The contracted RD conducted only brief twice-monthly walkthroughs and was unaware of these issues, the dietary manager had no formal orientation and did not know required checks and equipment were not functioning or that supplies and forms were lacking, and the administrator was also unaware of the kitchen problems or equipment failures.
The facility failed to maintain safe and properly functioning kitchen equipment when staff did not report or monitor a longstanding leak under an ice machine and a broken soap dispenser at a three-compartment sink. Surveyors observed a large puddle of water beneath the ice machine, which the dietary manager and maintenance staff were unaware of, while a cook later reported the leak had been present for months but had not been reported. Surveyors also observed a cook manually adding pot and pan dish soap to the sink because the automatic dispenser had been broken for months, and the cook did not know the correct amount of soap to use, a problem the dietary manager also did not know about.
The facility failed to assess two residents for entrapment risks and did not obtain informed consent before using side rails. One resident, with a history of Hemiplegia and Bipolar Disorder, experienced entrapment resulting in a skin tear. Another resident with Vascular Dementia had side rails used without assessment or consent. The facility's policy requiring risk assessment and consent was not followed, leading to potential safety risks.
A resident with severe cognitive impairment was found with a serious leg injury of unknown origin, confirmed by X-ray as fractures. The facility's policy requires immediate reporting of such incidents to the state survey agency, but the Administrator failed to do so despite being informed by the DON. The oversight was acknowledged during interviews.
A facility failed to include the use of side rails in a resident's care plan, despite policy requirements. The resident, with conditions such as hemiplegia and bipolar disorder, had side rails in use without documentation in their Plan of Care. Observations and staff interviews confirmed the oversight.
A facility failed to maintain accurate medical records for a resident with chronic pain syndrome. The EMAR lacked documentation of Tylenol administration, despite the LPN's progress notes indicating the resident was in pain and assessed. The DON confirmed the documentation should have been completed.
A resident with specific dietary needs did not receive proper pleasure feedings due to inadequate training of CNAs. The resident's care plan required specific feeding techniques, including small bites, chin tucking, and remaining elevated post-meal. However, a CNA failed to follow these guidelines, and the DON did not ensure other staff were trained when the designated Restorative CNA was unavailable.
A resident was found with medication at their bedside without an order for self-administration or an assessment by the interdisciplinary team. The facility's policy requires such an assessment to ensure safety, but it was not conducted. Staff interviews confirmed the medication should not have been left with the resident, indicating a lapse in following the facility's procedures.
A facility failed to honor a resident's right to refuse care, specifically a bed bath, despite the resident's moderate cognitive impairment and multiple health conditions. The resident expressed a desire to refuse or delay the bath on days she did not feel well, but the CNA insisted on daily baths for all residents, disregarding the resident's choice and self-determination.
A resident's medical records were exposed when a medication cart was left unattended and unlocked outside the dining room area, allowing personal information to be visible to others. The facility's policy requires the use of a privacy screen when the computer is out of view, but an LPN confirmed she did not activate it, resulting in a breach of confidentiality.
A resident's care plan was not updated to reflect her wish to transfer to another facility, despite multiple requests and grievances. The resident's electronic health record and MDS assessment indicated a goal to remain in the facility, which was not revised by the interdisciplinary team. Interviews confirmed awareness of the resident's transfer request, but the care plan remained unchanged.
The facility failed to ensure medication carts were locked when unattended. Observations revealed that two medication carts were left unlocked and unattended in different areas of the facility. Staff confirmed that the carts should have been secured according to facility policy.
A resident with chronic health conditions and moderate cognitive impairment was unable to use the emergency call light in the bathroom due to a malfunction. The resident had to use a cellphone to contact a representative for help. The issue was confirmed by the surveyor, Administrator, and Maintenance Supervisor, but the DON was not informed, preventing interim accommodations.
A facility failed to notify a resident's physician when the resident's smoking privileges were revoked and nicotine mints were administered without a physician's order. The resident, who had intact cognition and was dependent on staff for care, was found to have nicotine mints in his room, provided by his grandmother. Interviews with staff revealed that the physician was not informed of these changes, leading to a deficiency in the resident's care plan.
A facility admitted a resident with a qualifying mental disorder without completing the required preadmission screening by the State Office of Behavioral Health. The resident's level 1 PASRR screening failed to include their diagnosis of Major Depressive Disorder, and no level 2 PASRR was completed. The Social Services Director confirmed the oversight during an interview.
The facility failed to develop comprehensive person-centered care plans within 7 days of completing the required MDS assessments for five residents with various diagnoses, as confirmed by the MDS Coordinator due to time constraints.
The facility failed to properly store and label respiratory equipment for two residents, leading to deficiencies in respiratory care. One resident's oxygen tubing and humidifier were found on the floor, while another's nebulizer and oxygen equipment were left open to air and not labeled. Staff confirmed these observations and acknowledged that the equipment should have been stored in a bag and labeled.
The facility failed to ensure proper medication storage and administration, including leaving medication at a resident's bedside, unattended medications on a cart, a controlled medication taped back into a blister pack, and improper storage of medications with food items in a refrigerator.
A resident's bathroom was found to have a copper-colored stain on the sink and toilet, a large paint blister on the wall, and a moderate build-up of dust on the ceiling vent. These conditions were confirmed by the Housekeeping/Maintenance Supervisor as unacceptable.
The facility failed to develop comprehensive care plans for two residents, one with Alzheimer's disease who was improperly positioned in an oversized wheelchair, and another with Parkinson's Disease who was not care planned for limited range of motion. Staff confirmed the lack of appropriate documentation and care planning for both residents.
A resident with Alzheimer's Disease and high risk for pressure ulcers had a stage 3 pressure ulcer identified, but the facility failed to assess and document the ulcer until three days later. Interviews with staff confirmed the delay in assessment and treatment.
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident with severe cognitive impairment. The resident was observed without a chair alarm, despite the care plan indicating its use. The resident had a history of falls, including incidents where the bed alarm was malfunctioning or not in place, leading to injuries. Interviews with staff confirmed these findings.
The facility failed to ensure proper medication management for two residents. One resident did not receive their prescribed Plavix due to a failure in the re-ordering process, while another resident's Percocet count did not match the reconciliation sheet, and the medication was not signed as given.
The facility failed to maintain an effective infection control program by not performing hand hygiene before preparing medications and after removing gloves following patient contact. Two LPNs were observed not following hand hygiene protocols, which was confirmed during interviews. This practice had the potential to affect the 70 residents in the facility.
The facility failed to post the most recent survey results in a place accessible to residents, family members, and legal representatives. The binder near the main entrance only contained older survey results, and the Administrator confirmed the absence of the latest complaint survey results.
Untrained Support Staff Improperly Operating Dishwasher and Drying Dishes
Penalty
Summary
The facility failed to ensure that dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service, specifically related to dishwashing and sanitization. The facility’s cleaning policy stated that once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry and that the use of towels may re-contaminate sanitized surfaces. The head of housekeeping services reported that, due to kitchen staffing shortages beginning in early 2026, housekeeping and floor staff were used to assist in the kitchen on their days off, including washing dishes. She acknowledged that she had not trained these staff members on the proper procedure for washing dishes. The cook confirmed that staff from other departments had been helping in the kitchen when they were short staffed and verified that towels should not be used to finish drying dishes after the dishwasher cycle, although dishes also should not be put away while still wet. Housekeeping and floor staff who assisted with dishwashing confirmed they had been instructed by the dietician on how to operate the dishwashing machine and how to load and unload racks, but they were not trained on checking water temperature or verifying chemical levels for proper sanitation. These staff members reported that after the rinse cycle, dishes remained partially wet and that the dietician had instructed them to use a dry towel to completely dry plates and cups before placing them in cabinets. One staff member stated he had been told about temperature and chemicals but assumed someone else checked them and did not perform these checks himself. The dietician confirmed that he had instructed these staff members on using the dishwashing machine and acknowledged that he should not have told them to use a dry towel to complete drying the dishes. This deficient practice had the potential to affect any of the 74 residents who received meals from the facility’s kitchen.
Insufficient Dietary Staffing and Use of Untrained Support Personnel
Penalty
Summary
The facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service for 74 residents receiving meals from the kitchen. Review of the dietary schedule for a two-week period showed multiple days when only one staff member was scheduled for the morning shift. During an observation of the kitchen, two dietary staff were present, and one staff member reported that on many days they had to work short and that staff from other departments were brought in to help. She confirmed that these non-dietary staff were not trained on kitchen procedures and were only shown how to wash dishes. On another morning observation, only one dietary staff member was present in the kitchen preparing multiple breakfast items, including regular, chopped, and pureed foods, with no other dietary staff scheduled or present. This staff member confirmed she was working alone and that the Dietary Manager was aware in advance that she was the only person scheduled for that shift. She also stated that when she did not have help, the DON would send staff from other departments to assist with dishwashing. Another dietary staff member corroborated that the kitchen was often short staffed and that untrained staff from other departments were used to wash dishes, confirming they had not been trained in kitchen procedures.
Unsanitary Food Prep, Ice Scoop, and Dishware Storage Practices in Kitchen
Penalty
Summary
The deficiency involves failure to follow professional standards and facility policies for sanitary food service, ice scoop storage, dishware storage, and equipment monitoring in the kitchen, potentially affecting 74 residents who received food from this area. During a kitchen observation, a black fan with visible dust on the grill and blades was positioned about two feet from a food prep table and was blowing directly toward the area where a staff member was cutting lemon pie and placing slices into individual bowls. Facility policy required food to be protected from contamination, and the Infection Control staff later confirmed the fan should not have been directed toward food preparation and should have been clean and free of visible dust. Further observations showed an uncovered white plastic bucket on a prep/condiment table shelf containing three ice scoops, including a large silver scoop that a staff member used to fill residents’ drinking cups with ice before returning it to the uncovered bucket, contrary to the facility’s ice scoop storage policy requiring scoops to be stored and maintained to prevent contamination. Additional observations revealed residents’ cups stored upright and uncovered on a black shelf, despite the facility’s dishware/utensil storage policy requiring items to be stored inverted or covered. In interviews, the Infection Control staff confirmed that ice is considered a food item and scoops should be covered when not in use, and that cups should be stored inverted. The Dietary Manager stated she was not aware that scoops needed to be covered or bagged and that cups had to be stored inverted or covered, and also confirmed that a fan should not have been used in the kitchen during meal prep.
Failure to Oversee Kitchen Sanitation, Monitoring, and Equipment in Dietary Services
Penalty
Summary
The facility failed to administer and oversee kitchen practices to ensure safe food service for 74 residents who consumed meals prepared there. Policy review showed written procedures for proper ice scoop storage, dishware/utensil storage, and three-compartment sink QAC (quaternary ammonium compound) testing, but surveyors found these were not being followed. During a kitchen tour, a black fan in active use had visible dust on its grill while a cook stood with her back to the fan slicing lemon pie on a prep table and placing slices into bowls for residents. Nearby, clear plastic cups were stored on an open shelf without being inverted or covered, contrary to the facility’s dishware storage policy. Further observations revealed an uncovered white plastic bucket containing three uncovered scoops and a large puddle of water on the floor beneath the ice machine, despite the facility’s policy requiring ice scoops to be stored and maintained to prevent contamination. Review of multiple monitoring logs showed significant gaps and missing documentation. The food line temperature log had entries only for a single date, the daily kitchen cleaning schedule showed only one recent entry for mopping the dish area and coffee station, and the three-compartment sink QAC log had only two entries noting “no strips” with no further documentation. Refrigerator temperature logs stopped at the end of one month, and the coffee/hot beverage temperature log contained numerous days with no recorded temperatures. On observation of three-compartment sink use, a cook was seen squeezing soap directly into the basin because the dispenser had not worked properly for about three months. She reported that there had been no test strips to check sanitizer concentration since a specific date and that staff lacked proper forms to record food line temperatures, resorting to writing temperatures on napkins. In interviews, the contracted RD stated she had little oversight of the dietary manager, made only twice-monthly walkthroughs for cleanliness, and was unaware of the kitchen issues, relying on dietary managers to maintain the kitchen. The dietary manager reported she had not been oriented to the kitchen, was unaware that required temperature and chemical checks were not being done, did not know the three-compartment sink was not functioning properly, and did not know staff lacked test strips and temperature forms. The administrator also stated he was not aware of the various kitchen issues or that some equipment was not working properly and indicated the RD was responsible for ensuring the dietary manager fulfilled her duties.
Failure to Maintain Safe and Properly Functioning Kitchen Equipment
Penalty
Summary
The facility failed to keep essential kitchen equipment in safe working condition by not ensuring timely reporting and monitoring of an ice machine leak and a malfunctioning three-compartment sink soap dispenser. During a kitchen observation, surveyors noted a large puddle of water pooled beneath the ice machine, and the dietary manager stated she was unaware of the leak. The maintenance staff member reported that kitchen staff had not informed him of any leak nor documented it in his maintenance logbook. A cook later stated that the ice machine had been leaking for at least three months but acknowledged she had not reported it to maintenance, assuming the dietary manager would address it. In the same kitchen observation, the three-compartment sink was found to have a non-functioning automatic soap dispenser. A cook was observed manually squeezing pot and pan dish soap into the sink basin and stated the dispenser had been broken for at least three months. When questioned, she admitted she did not know how much soap she was adding. The dietary manager also stated she was not aware that the three-compartment sink was not working properly.
Failure to Assess and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents were properly assessed for the risk of entrapment from side rails, and informed consent was not obtained prior to their installation. Resident #2, who had a history of Hemiplegia and Hemiparesis, Bipolar Disorder, and Major Depressive Disorder, was found with his left leg entrapped between the side rail and the mattress, resulting in a skin tear. Despite this incident, there was no evidence of an assessment for the risk of entrapment, nor was there informed consent from the resident or his representative for the use of side rails. Additionally, ongoing monitoring and supervision of the side rails were not conducted. Resident #3, diagnosed with Vascular Dementia and Hemiplegia, was also not assessed for the risk of entrapment before the use of side rails. The resident's care plan included the use of side rails for bed mobility and repositioning, but there was no informed consent obtained from the resident or their responsible party. Observations confirmed that both upper half side rails were in the upward position, yet no assessment or consent documentation was found in the resident's medical record. Interviews with the Director of Nursing confirmed the lack of assessments and informed consents for both residents. The facility's policy on side rails, which requires an assessment of risks and benefits and obtaining consent, was not followed. This oversight led to the continued use of side rails without proper evaluation and documentation, posing a potential risk to the residents' safety.
Failure to Report Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident's injury of unknown origin to the state survey agency within the required timeframe. The facility's policy mandates that any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be reported immediately, or within two hours if the incident involves serious bodily injury. However, in this case, the facility did not adhere to this policy. On October 23, 2024, a resident with severe cognitive impairment was found with a swollen and misaligned right lower leg, indicating a serious injury. An X-ray confirmed comminuted displaced fractures of the tibia and fibula. The Director of Nursing (DON) was informed of the injury on the same day and notified the Administrator. Despite this, the Administrator did not report the incident to the state survey agency as required. The failure to report was confirmed during interviews with both the DON and the Administrator. The Administrator acknowledged the oversight and confirmed that the resident was sent to the hospital for treatment of the injury, which was of unknown origin.
Failure to Document Side Rail Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident by not including the use of side rails in the Plan of Care. The facility's policy on physical restraints and side rails, last reviewed in January 2024, mandates that the use of side rails as assistive devices must be addressed in the resident's care plan. However, a review of the resident's medical record revealed that there was no documentation regarding the use of side rails, despite the resident having been admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, bipolar disorder, and major depressive disorder. An observation on November 21, 2024, noted that the resident's bed had the left upper side rail in the upward position and the right upper side rail in the downward position, with the bed's right side against the wall. A CNA confirmed that the side rails had been used in this manner since she began working at the facility a month prior. The Director of Nursing also confirmed that the use of side rails was not documented in the resident's Plan of Care, indicating a failure to adhere to the facility's policy and ensure the resident's care plan was comprehensive and person-centered.
Incomplete Documentation in EMAR for Pain Management
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of the sampled residents. Specifically, the Electronic Medication Administration Record (EMAR) for a resident was incomplete and inaccurately documented. The resident, who was admitted with diagnoses including Muscle Wasting and Atrophy, Osteoporosis, Osteoarthritis, and Chronic Pain Syndrome, had a physician's order for Tylenol to be administered as needed for pain. On a specific date, a Licensed Practical Nurse (LPN) was notified by a Certified Nursing Assistant (CNA) to assess the resident, who was in pain and unable to move or flex her right foot. Despite the LPN's progress notes indicating that the resident was assessed and in pain, there was no documentation in the EMAR that Tylenol was administered to the resident at that time. During an interview, the Director of Nursing (DON) confirmed that nurses are required to document all administered medications in the EMAR and acknowledged the absence of documentation for the administration of Tylenol, which should have been recorded.
Inadequate Training for Pleasure Feedings
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in administering pleasure feedings to a resident with specific dietary needs. The resident, who had a history of malnutrition, vitamin D deficiency, type 2 diabetes, and chronic kidney disease, required PEG tube feedings along with pleasure feedings. The resident's care plan, as outlined in a Speech Therapy Discharge Summary and Restorative Nursing Program Recommendations, specified that the resident should receive small bites and sips, be cued to tuck their chin and double swallow, and remain in an elevated position for at least thirty minutes after eating. However, during an observation, a CNA provided the resident with puree eggs and honey-thickened liquids through a straw without following these guidelines, failing to cue the resident appropriately and allowing the resident to lower their bed immediately after eating. Interviews revealed that the CNA was not aware of the specific feeding instructions and had not been trained on the resident's pleasure feeding protocol. The Director of Nursing (DON) had received the resident's restorative plan but did not ensure that other staff members were trained to administer the feedings when the designated Restorative CNA was unavailable. The facility's administrator acknowledged that the restorative program was specific and did not consider it feasible to train other CNAs on these tasks. This lack of training and communication led to the deficiency in care for the resident.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as required by their policy. The interdisciplinary team did not assess the resident's mental and physical abilities to determine if self-administration was clinically appropriate. The resident, who had a BIMS score indicating intact cognition, was observed with two medicine cups containing a liquid medication at their bedside. The medication was identified as magic mouthwash, which was prescribed for the resident's sore mouth. However, there was no physician's order allowing the resident to self-administer this medication, nor was there an assessment or care plan in place to support self-administration. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the medication should not have been left at the resident's bedside. The LPN denied leaving the medication and was unsure who did, while the Director of Nursing confirmed the absence of an order for self-administration. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, which requires a formal assessment and documented approval by the interdisciplinary team.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not accommodating a resident's choice to refuse care. The resident, who has moderate cognitive impairment and multiple health conditions including COPD, coronary artery disease, and depression, expressed a desire to refuse a bed bath on certain days when she did not feel well. Despite this, the facility's staff, specifically a CNA, did not honor the resident's request to refuse or delay the bath, insisting that all residents receive a daily bath regardless of their wishes. Interviews with the resident revealed that she was not allowed to refuse a bed bath, and her request to have a bath at a later time was not honored. The CNA confirmed that residents who do not go to the whirlpool receive a bed bath daily and did not acknowledge the resident's right to refuse care. The CNA stated that everyone wants to feel clean and did not provide an option for the resident to refuse a bath, even for hospice residents, indicating a lack of support for resident choice and self-determination.
Breach of Resident Confidentiality Due to Unattended Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, as observed during a survey. The incident involved a medication cart, identified as Medication Cart B, which was left unattended and unlocked outside the dining room area. This allowed the personal information of one resident to be visible to visitors and other residents. The facility's policy on the security of medication carts requires that a computer privacy screen be initiated when the computer is out of the nurse's view. However, during an interview, an LPN confirmed that she did not activate the privacy screen before leaving the cart unattended, leading to the breach of confidentiality.
Failure to Update Resident's Care Plan for Transfer Request
Penalty
Summary
The facility failed to ensure that a resident's person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for one of the sampled residents, who had expressed a desire to transfer to another facility. Despite the resident's grievance and multiple requests for transfer, the care plan continued to reflect the resident's goal to remain in the facility. The resident's electronic health record indicated that she was admitted with diagnoses including urinary tract infection, chronic kidney disease, schizophrenia, and bipolar disorder. Her 5-day Minimum Data Set (MDS) assessment also noted her goal to stay in the facility, which was not updated to reflect her current wishes. Interviews with the Social Service Director and the MDS coordinator revealed that the resident had repeatedly requested a transfer, and efforts were made to facilitate this, including communication with other facilities. However, these requests were denied, and the care plan was not updated to reflect the resident's current goal of transferring. The MDS coordinator acknowledged awareness of the resident's wish to transfer and confirmed that the care plan should have been revised to reflect this change.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as observed during a survey. On Hall A, Medication Cart A was found unlocked and unattended while an LPN was engaged in a personal phone call at the nurse's station. The LPN confirmed that the cart should have been locked before leaving it unattended. Similarly, on Hall B, Medication Cart B was observed unlocked and unattended near the nurse's station, with a visitor present in the hallway. The Assistant Director of Nursing confirmed that the cart should have been secured. Further observations revealed that Medication Cart B was again found unlocked and unattended outside the dining room area. An LPN confirmed that the cart should have been locked before leaving it unattended. These observations indicate a failure to adhere to the facility's policy requiring medication carts to be locked when not in use, posing a potential risk to the security of medications.
Non-Functional Call System in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that the resident call system was functioning properly for one of the sampled residents. The deficiency was identified when a resident, who had been admitted with multiple chronic conditions including Chronic Systolic Heart Failure and Type 2 Diabetes Mellitus, attempted to use the emergency call light in the bathroom but found it non-functional. The resident, whose cognitive status was moderately impaired, had an accident and was unable to summon help using the call light. Instead, he had to call his representative via cellphone, who then contacted the facility to get assistance for him. Upon investigation, the surveyor confirmed that the call light in the resident's bathroom did not work, as it failed to activate the indicator outside the room or alert the front desk. The facility's Administrator and Maintenance Supervisor both verified the malfunction during their checks. The Director of Nursing was not informed about the issue, which prevented any interim measures from being implemented to accommodate the resident's needs until the call light was repaired.
Failure to Notify Physician of Changes in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a resident's physician was consulted when there was a change in the plan of care. Specifically, the facility did not notify the physician when a resident's smoking privileges were revoked due to noncompliance with facility smoking policies. Additionally, the staff administered nicotine mints to the resident without a physician's order. This oversight was discovered during a review of the resident's care plan and electronic medical records, which showed no documentation of physician notification regarding these changes. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, Administrator, and Assistant Director of Nursing, revealed that the resident's physician was not informed of the changes in the resident's care plan. The Social Service Director noted that the resident's grandmother had purchased nicotine mints for the resident, which were being given to him by the CNAs. The Nurse Practitioner confirmed that she was not aware of the resident's loss of smoking privileges or the need for an order for nicotine mints. The Administrator and Assistant Director of Nursing acknowledged that they had not followed up with the physician regarding these changes, leading to the deficiency.
Failure to Complete PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a qualifying mental disorder was not admitted before a preadmission screening by the State Office of Behavioral Health (OBH) was completed. The resident, who was admitted with diagnoses including Anxiety Disorder, Unspecified Mood Disorder, and Major Depressive Disorder, had a level 1 PASRR screening dated 08/17/2023. However, the screening incorrectly indicated no suspected or diagnosed mental illness, and there was no level 2 PASRR completed. During an interview, the Social Services Director confirmed that the resident was admitted with a diagnosis of Major Depressive Disorder from another facility and acknowledged that this diagnosis should have been included in the level 1 screening.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan within 7 days of the completion of the required comprehensive assessment MDS for five residents. The residents involved had various diagnoses, including Hepatitis A, Type 2 Diabetes Mellitus, Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Heart Failure, Schizoaffective Disorder, Acute Kidney Failure, Anxiety Disorder, Depression, Chronic Pain Syndrome, Hypertension, Spinal Stenosis, Tachycardia, Dementia, and Congestive Heart Failure. Despite the completion of their Annual MDS assessments, their Electronic Health Records (EHR) did not contain the required comprehensive care plans. An interview with the Minimum Data Set Coordinator (MDSC) revealed that the comprehensive care plans for these residents were not developed due to time constraints and being months behind schedule. The MDSC confirmed the deficiency, acknowledging that the care plans were supposed to be completed but were not. This lapse affected the quality of care planning for the residents involved.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to properly store and label respiratory equipment for two residents, leading to deficiencies in respiratory care. For Resident #9, who has severe cognitive impairment and a history of acute and chronic respiratory failure, the oxygen tubing and humidifier were found on the floor, open to air, and not labeled. This was confirmed by an LPN who acknowledged that the equipment should have been stored in a bag and labeled with the date. The resident's care plan indicated a need for oxygen therapy as needed, but the facility did not adhere to its own policy or state and federal guidelines for equipment storage and labeling. Similarly, Resident #16, who has moderate cognitive impairment and chronic obstructive pulmonary disease, had a nebulizer with mouthpiece and tubing stored on the dresser, open to air, and without a date. The resident's oxygen tubing and humidifier were also in use but not labeled. A CNA confirmed these observations and acknowledged that the equipment should have been stored in a bag and labeled. The Assistant Director of Nursing and Infection Preventionist also confirmed that the facility's procedures were not followed in both cases, leading to the deficiencies observed by the surveyors.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflected current standards of practice. Specifically, medication was left at a resident's bedside without proper authorization or assessment for self-administration. Additionally, medications were left unattended on top of a medication cart, and a controlled medication was found taped back into a blister pack. Furthermore, medications were stored together with food items in a refrigerator, and some medications were not labeled with the resident's name. Resident #31 had Flonase allergy spray left on her bedside table without documented evidence of a request or assessment for self-administration. An LPN confirmed the medication should have been securely stored. Another LPN left multiple medications unattended on top of a medication cart while retrieving a narcotics binder. A random narcotic check revealed a Percocet tablet taped back into a punctured blister pack. Additionally, a tour of a resident's supplement refrigerator found medications stored with food items, and some medications were not labeled with the resident's name.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident diagnosed with Acute Embolism and Thrombosis of Unspecified Deep Veins of the Left Lower Extremity and Moderate Protein Calorie Malnutrition. On two separate observations, the resident's bathroom was found to have a copper-colored stain on the sink and toilet, a large paint blister on the wall, and a moderate build-up of dust on the ceiling vent. These findings were confirmed by the Housekeeping/Maintenance Supervisor, who acknowledged that the conditions were unacceptable.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive plan of care for two residents, leading to deficiencies in addressing their specific needs. Resident #13, diagnosed with Alzheimer's disease, was observed multiple times slouched in an oversized high back wheelchair, which was not appropriate for her size. Despite the family's insistence on using this wheelchair, the care plan did not document this insistence or address the issue. Interviews with staff, including the Director of Nursing and the Minimum Data Set Coordinator, confirmed the lack of documentation and appropriate care planning for the resident's positioning needs. Resident #17, diagnosed with Parkinson's Disease, Muscle Weakness, Repeated Falls, and Contracture of the Right Hand, was not care planned for her limited range of motion. Observations revealed that the resident's right hand was clenched in a fist without a hand roll, and she was unable to open her hand fully. Interviews with staff confirmed that the resident did not have a hand roll and that her limited range of motion was not addressed in her care plan, despite the problem existing at the time the comprehensive care plan was completed.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing. Resident #13, who was diagnosed with Alzheimer's Disease and assessed as high risk for pressure ulcer development, had a pressure ulcer identified on 01/22/2024. However, there was no evidence that an assessment of the pressure ulcer was done on the same day. The first documented assessment of the pressure ulcer was on 01/25/2024, three days after it was initially identified, and it was noted as a stage 3 pressure ulcer with specific measurements and characteristics. Interviews with the Assistant Director of Nursing Infection Preventionist (S3ADONIP) and the Director of Nursing (S2DON) confirmed the lack of timely assessment. S3ADONIP acknowledged identifying the pressure ulcer on 01/22/2024 but could not provide evidence of an assessment on that date. S2DON also confirmed that an assessment should have been done immediately when the pressure ulcer was identified, rather than three days later. This delay in assessment and treatment constitutes a failure to provide necessary care for the resident's pressure ulcer.
Failure to Ensure Adequate Supervision and Assistance to Prevent Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident diagnosed with unspecified dementia with other behavioral disturbances. The resident, who had a severely impaired cognition with a BIMS score of 3, was observed without a chair alarm attached to their wheelchair, despite the care plan indicating the use of bed and chair alarms as fall prevention measures. Interviews with CNAs confirmed the absence of the chair alarm during the observation. Additionally, the resident had a history of falls, including incidents where the bed alarm was either malfunctioning or not in place, leading to injuries such as a skin tear on the right forearm. The resident's electronic clinical record and progress notes revealed multiple falls, including one where the bed alarm was found to be malfunctioning and another where there was no documentation of the bed alarm being in place. Interviews with the Director of Nursing and the Assistant Director of Nursing Infection Preventionist confirmed these findings. The facility's failure to ensure the proper functioning and use of bed and chair alarms contributed to the resident's falls and subsequent injuries.
Failure to Ensure Proper Medication Management
Penalty
Summary
The facility failed to ensure that medications and pharmaceutical services were provided to meet the needs of two residents. For Resident #25, the facility did not re-order and administer Plavix, a blood thinner, as required. The resident's clinical record showed an order for Plavix 75 mg to be taken every other day. On two separate occasions, it was observed that the medication was not available in the medication cart, and the nurse had to call the pharmacy to order it. The Director of Nursing and Assistant Director of Nursing confirmed that the procedure for re-ordering medications was not followed, as they were not notified about the missing medication. For Resident #31, the facility failed to maintain a system to account for the usage and reconciliation of controlled medications. During a random narcotic check, it was found that the number of Percocet pills in the blister pack did not match the count on the narcotic reconciliation sheet. Additionally, the medication was not signed as given on the electronic medication administration record. Both the LPN and RN confirmed the discrepancy and acknowledged that the medication should have been reconciled and signed off at the time it was administered.
Failure to Perform Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not performing hand hygiene before preparing medications and after removing gloves following patient contact. On 04/02/2024, an LPN was observed drawing up insulin, administering it to a resident, and then removing her gloves without performing hand hygiene. She then proceeded to pour medications without sanitizing her hands. During an interview, the LPN confirmed that she did not perform hand hygiene and acknowledged that she should have done so after contact with the resident and removing her gloves. Another LPN was observed on the same day preparing medications without performing hand hygiene after handling a Hoyer lift. She confirmed during an interview that she did not perform hand hygiene before starting to prepare medications and acknowledged that she should have. The Assistant Director of Nursing, who is also the Infection Preventionist, stated that hand hygiene should be performed before and after patient contact and before donning and after removing gloves. This deficient practice had the potential to affect the 70 residents residing in the facility.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to ensure the most recent survey results were posted in a place readily accessible to residents, family members, and legal representatives. During an observation on 04/02/2024, it was noted that the survey results from a complaint survey conducted on 04/11/2023 were not included in the binder labeled LDH DHH Licensing survey, which was located near the facility's main entrance. The binder only contained results from annual surveys conducted on 03/22/2023 and 02/23/2022. The Administrator confirmed the absence of the most recent survey results in the designated area for public review.
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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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