Cypress At Lake Providence
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Providence, Louisiana.
- Location
- 5976 Us-65 North, Lake Providence, Louisiana 71254
- CMS Provider Number
- 195585
- Inspections on file
- 26
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cypress At Lake Providence during CMS and state inspections, most recent first.
Two residents with multiple chronic conditions, including schizoaffective disorder, legal blindness, paraplegia, heart failure, and multiple myeloma, were found in rooms that were not kept clean or in good repair. Surveyors observed dirt and grime on bed frames, bed rails, over-bed table frames, and furniture surfaces, as well as a missing nightstand drawer and a white powdery substance on an air conditioner vent for one resident. For the other resident, surveyors noted dirty and stained floors and furniture, along with an over-bed table with broken and missing veneer exposing particle board. These conditions were confirmed during observations with the facility Administrator.
The facility did not obtain or document informed consent for the use of psychotropic medications for five residents with various psychiatric and medical conditions. Despite some residents being cognitively intact and capable of providing consent, staff confirmed that no consents were present in the medical records for medications such as antipsychotics, antidepressants, and antianxiety agents.
The facility did not post the results of three recent surveys, making only the previous annual survey results accessible to residents. This was confirmed by the administrator, who acknowledged that the more recent survey outcomes, which included deficiencies, were not available for resident review.
Several residents did not have accurate MDS assessments, with omissions including unreported pressure ulcers, falls, and wounds. Required quarterly risk assessments for skin and falls were not completed as scheduled. Staff interviews and record reviews confirmed that these inaccuracies and missed assessments did not reflect the residents' true clinical status.
Several residents with significant medical and cognitive needs did not receive adequate assistance with bathing and personal hygiene, including nail and facial hair care. Observations and interviews revealed that residents had long, dirty fingernails or lengthy facial hair, and documentation showed that scheduled baths were frequently missed without record of refusals or alternative care. Nursing staff and the DON confirmed these deficiencies during the survey.
The facility did not implement or update appropriate interventions after falls for two residents—one with severe cognitive impairment and another with intact cognition but at risk for falls. In both cases, falls were not consistently addressed in the care plans, and new interventions were not documented or attempted after each incident, as confirmed by the DON.
The facility did not assess three residents for bed rail entrapment risk, failed to obtain informed consent or physician orders, and did not update care plans to reflect bed rail use. Observations confirmed bed rails were in use without required documentation or assessments, as verified by the Regional Director of Clinical.
Nursing staff did not follow physician orders to notify the physician when a resident with diabetes had multiple blood glucose readings above 401, as required. Documentation was lacking for these events, and the DON confirmed that notifications were not recorded.
A physician did not provide an adequate clinical rationale when declining a pharmacist's recommendation for a gradual dose reduction of antipsychotic and antidepressant medications for a resident, responding only with 'severity.' Additionally, the facility's pharmacist failed to identify and report irregularities related to necessary lab monitoring for two residents prescribed Levothyroxine and Atorvastatin Calcium, as confirmed by the DON and Regional Director of Clinical.
Surveyors observed flies throughout the facility on multiple days, with several residents reporting and being seen swatting flies away from their food in their rooms. The administrator confirmed the ongoing presence of flies in resident rooms and hallways.
The facility did not provide or document required dementia care, abuse prevention, and skills training for several CNAs, as confirmed by the DON during review of personnel records.
A resident with intact cognition was moved to a different room following a conflict with a roommate, but neither the resident nor her responsible party received the required written notice explaining the reason for the move. The DON confirmed that only verbal notification was provided, contrary to facility policy.
A resident was discharged from Medicare Part A skilled services by the facility before exhausting their benefit days, but was not given the required CMS-10055 and CMS-10123 notices. Documentation of these notices was not found, and the Clinical Reimbursement Specialist confirmed they could not locate the completed forms.
Surveyors found that multiple residents' rooms had unclean air/heating units with visible grime and dust, dead insects on bathroom walls, heavy lint on ceiling vents, and improperly positioned toilet lids. Facility leadership confirmed these environmental deficiencies during observations and interviews.
A resident with severe cognitive impairment and multiple medical conditions was prescribed antipsychotic and antianxiety medications, but staff failed to document monitoring for side effects and behaviors as required by the care plan. Review of medication records and staff interviews confirmed the absence of this monitoring over several weeks.
Surveyors found that the facility did not follow care plans for two residents: one was not provided with a smoking apron while smoking despite supervision, and another did not have a fall mat placed at the bedside as required, even after experiencing previous falls. Staff confirmed these lapses and that care plans were not individualized to resident needs.
Surveyors found that three residents requiring respiratory care did not receive services consistent with professional standards, as nebulizer mouthpieces were not stored in bags when not in use and required oxygen use/no smoking signage was not posted outside a resident's room. The DON confirmed these practices did not meet facility policy.
Two residents did not receive their prescribed medications because the facility did not have Vitamin D-2 and Farxiga available for administration. During medication pass observations, an LPN and the DON confirmed that these medications were not present on the medication cart or in the medication room, despite active physician orders.
A resident with significant medical conditions, including heart failure and chronic kidney disease, was prescribed a daily diuretic. Facility records showed no documented monitoring for edema on multiple occasions over two months. Facility leadership confirmed that edema monitoring should have been performed and documented while the resident was on the diuretic.
Two residents did not receive their prescribed daily medications because the medications were not available on the medication cart or in the facility at the time of administration. An LPN confirmed the omissions, resulting in a medication error rate of 7 percent, which exceeds the acceptable threshold.
Two residents were found with medications left unsecured at their bedsides, including one who self-administered a nasal spray without an active order and another with night medications left from the previous night. An LPN and the DON confirmed these findings, indicating a failure to store drugs and biologicals in locked compartments as required.
The facility did not conduct or document quarterly QAA meetings with the required committee members, as confirmed by record review and administrator interview.
A resident with cerebral infarction and dysphasia, who required medications to be crushed and flushed via tube feeding, had a used syringe improperly stored with liquid remaining in the tip and the plunger still inserted. The DON confirmed the syringe should have been rinsed and disassembled before storage.
Surveyors found that daily nurse staffing data was not posted in a prominent or accessible location on two consecutive days. The DON confirmed the omission, which had the potential to affect all 68 residents, as required staffing information was not available to residents or visitors.
The facility did not report two separate incidents—one involving a resident with a head laceration of unknown origin and another involving verbal abuse by a CNA—within the required 2-hour timeframe to the administrator and State Survey Agency. In both cases, delays in reporting were confirmed through interviews and record reviews, despite facility policy and regulatory requirements.
A CNA verbally abused a resident with cognitive and behavioral disorders by raising his voice and using inappropriate language after the resident grabbed his wrist during care. The incident was overheard by an agency LPN, reported to the DON, and confirmed as verbal abuse per facility policy.
A resident with significant pain-related diagnoses did not receive prescribed Oxycodone-Acetaminophen for several days because the medication was not available. Despite the care plan requiring timely pain management, staff were unable to provide the ordered medication, leading to the resident experiencing unrelieved pain and distress. Alternative pain relief was offered but refused, and non-pharmacological interventions were ineffective. The absence of the medication and the resulting lack of appropriate pain management were confirmed by staff and documentation.
A resident with moderate cognitive impairment was sexually abused twice by another resident after the facility failed to provide required 1:1 supervision. Despite policy requiring continuous monitoring following the first incident, the accused resident was left unsupervised and entered the victim's room again, resulting in a second allegation of abuse. Staff interviews and video evidence confirmed the lack of supervision.
A facility failed to provide required 1:1 supervision for a resident after an initial allegation of sexual abuse, resulting in a second incident where the same resident entered another's room and inappropriate contact was again alleged. Despite staff instructions, the assigned CNA did not maintain continuous observation, and video evidence confirmed the lack of supervision. Both residents involved had moderate cognitive impairment and complex medical histories.
The facility failed to report an abuse incident within the required timeframe. Two residents were involved in an altercation where one hit the other with a walker. Despite no injuries being found, the incident was not reported to the state agency until the next day, violating the facility's policy of reporting within two hours.
A cognitively impaired resident was physically abused by a CNA, who punched the resident multiple times after the resident grabbed the CNA's necklace. The incident was observed by two other CNAs, and the resident sustained bruising and scratches. The facility's investigation confirmed the abuse, and the CNA was arrested.
The facility failed to maintain an effective pest control program, resulting in multiple flies throughout the facility, including on residents' beds and dressings. The Regional Director of Clinical confirmed the facility's failure to ensure a pest-free environment for the residents.
The facility failed to ensure that the code status for two residents was documented and available for staff review. The advance directives were found in the Social Service Director's office and not in the residents' electronic records, as required.
The facility failed to maintain a safe, clean, comfortable, and homelike environment for four residents. Issues included unsecured light fixtures, holes in walls, exposed water pipes, and unsecured bathroom fixtures. These deficiencies were confirmed by the Administrator and Maintenance Supervisor.
The facility failed to provide necessary grooming and hygiene services to residents who were unable to perform these tasks themselves. Multiple residents were observed with long, dirty fingernails, unkempt beards, and strong body odors, despite their expressed needs and the confirmation of these issues by the DON.
The facility failed to provide adequate wound care and follow physician orders for several residents. One resident had new wounds that were not identified or reported, another had an unreported wound on his scrotum, and a third was observed without a prescribed hand roll for two months. These deficiencies indicate lapses in wound assessment, documentation, and adherence to care plans.
The facility failed to ensure proper documentation of medication administration for a resident with multiple diagnoses, leading to a deficiency in ensuring resident safety and well-being. Interviews revealed that the medications were not signed out when administered, indicating a lapse in adherence to the facility's medication administration policy.
The facility failed to ensure an RN provided services for 8 consecutive hours on specific dates. Review of PBJ Data time sheets revealed no staffing hours for the RN, and the Administrator confirmed the absence of documentation to prove RN coverage.
The pharmacist failed to report irregularities in the drug regimen review for three residents. For one resident, missing lab results were not addressed, while for two other residents, the lack of edema monitoring while on Furosemide was not reported. The ADON and DON confirmed these deficiencies.
The facility failed to ensure residents' drug regimens were free from unnecessary drugs by not performing edema checks for two residents on diuretics and not obtaining ordered lab tests for another resident. This was confirmed through record reviews and staff interviews.
The facility failed to store, prepare, and distribute food in accordance with professional standards, including improper temperature maintenance, lack of labeling, and inadequate training of the Dietary Manager. These deficiencies had the potential to affect all residents receiving meals from the kitchen.
The facility failed to provide sufficient nursing staff, not meeting the required 2.35 hours of care per patient per day on 11 out of 65 days. Two residents reported delays in care, especially during the night shift, which was confirmed by the DON.
The facility failed to provide the required CMS forms to inform two residents of changes in their Medicare covered services upon discharge, as confirmed by the facility's administrator and MDS nurse.
A resident with severe cognitive impairment was physically abused by a CNA, and the incident was not reported immediately by the witnessing CNAs. The abuse was only reported the following day, violating the facility's policy for immediate reporting of abuse allegations.
The facility failed to conduct a required quarterly smoking assessment for a resident with chronic conditions, despite policy mandates and the resident being assessed as an unsafe smoker. This lapse was confirmed by the facility's Director of Nursing and the Regional Director of Clinical.
The facility failed to ensure monthly State Adverse Actions Website checks for CNAs S23CNA, S24CNA, and S25CNA. Personnel files showed the first documented check on 05/03/2024, with no prior monthly checks. The S1Administrator confirmed the absence of documentation for the required checks before this date.
The facility failed to maintain safe resident care equipment for two residents, one with severe cognitive impairment and another with intact cognition, both requiring wheelchairs. Observations revealed a missing rubber cover on one resident's wheelchair handle and a torn armrest on another's wheelchair, issues that were confirmed by staff but not timely addressed.
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. Multiple residents were unaware of where the state inspection results were located. An observation revealed that the state inspection results were not labeled and were stored in a clear plastic bin on the wall, out of reach for residents in wheelchairs.
Failure to Maintain Clean and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents by not keeping their beds, furniture, and room fixtures clean and in good repair. For Resident #2, who was admitted with diagnoses including schizoaffective disorder, legal blindness, type 2 DM, peripheral vascular disease, seizures, and depression and had a BIMS score of 15 indicating no cognitive impairment, surveyors observed dirt and grime on the bed frame, bed rails, over-bed table frame, and the top of the nightstand. The top drawer of the nightstand was missing, and a white powdery substance was observed covering the air conditioner vent. These conditions were confirmed during a joint observation with the Administrator. For Resident #3, who had diagnoses including paraplegia, generalized muscle weakness, hypertensive heart disease with heart failure, and multiple myeloma not in remission, and a BIMS score of 12 indicating moderate cognitive impairment, surveyors observed dirt and stains on the bed frame, bed rails, over-bed table frame, and floor. Additionally, the over-bed table had broken and missing veneer, leaving exposed particle board. These environmental deficiencies were also confirmed during an observation with the Administrator.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for the use of psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents. Record reviews and staff interviews confirmed that for five residents with various diagnoses such as bipolar disorder, depression, dementia, schizophrenia, and schizoaffective disorder, there was no documented evidence of informed consent for the administration of these medications. The medications in question included Haldol, Seroquel, Escitalopram, Zyprexa, Clonazepam, Divalproex, Clozapine, Mirtazapine, Lorazepam, Sertraline, Depakote, and Geodon. Interviews with the Director of Nursing and the Regional Director of Clinical confirmed the absence of required consents in the residents' medical records. Some of the residents were noted to be cognitively intact based on their BIMS scores, indicating they were capable of providing consent. Despite this, the facility did not obtain or document consent for the use of psychotropic medications, as required, for any of the five residents reviewed.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the results of its most recent surveys were posted and accessible to residents. During an observation on 05/21/2025, it was found that only the results of the annual survey dated 05/08/2024 were available in the survey results binder for residents to view. However, the facility had undergone three additional surveys after the annual survey—on 09/26/2024, 04/01/2025, and 04/23/2025—which resulted in deficiencies, but the results of these surveys were not posted. This was confirmed during an interview with the facility administrator, who acknowledged that the results of the three subsequent surveys had not been made available to residents.
Inaccurate MDS Assessments and Missed Risk Evaluations
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of several residents, resulting in multiple deficiencies. For one resident with a history of cerebrovascular disease, neuropathy, and dementia, the quarterly MDS did not document a stage 3 pressure ulcer that was present and facility-acquired, nor was a Braden scale risk assessment completed quarterly as required. Interviews with nursing staff and record reviews confirmed that the pressure ulcer was omitted from the MDS and that the last Braden assessment had not been updated for several months. Another resident with severe cognitive impairment and multiple comorbidities experienced two falls prior to the quarterly MDS assessment, but these incidents were not documented in the MDS. Additionally, the required quarterly fall risk assessment was not completed, with the last assessment dated several months prior. Staff interviews confirmed the omission of the falls from the MDS and the lack of timely risk assessment. A third resident with severe cognitive impairment suffered a fall resulting in a laceration and stitches, but the MDS inaccurately recorded the number of falls with injury. In another case, a resident with traumatic brain injury and reduced mobility had pressure ulcers on admission, but the quarterly MDS did not reflect the presence of these wounds. Staff interviews and record reviews consistently confirmed that the MDS assessments were inaccurate and did not align with the residents' actual clinical conditions.
Failure to Provide Adequate Bathing and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for residents who were unable to perform activities of daily living independently. Multiple residents with significant medical conditions and cognitive impairments were observed to have unmet hygiene needs, including inadequate bathing and nail care. For example, one resident with cerebrovascular disease and major depression, who was cognitively intact and required assistance with personal hygiene, was found to have long, dirty fingernails despite having requested staff assistance to trim them. A licensed practical nurse confirmed the need for nail care after direct observation. Another resident with severe obesity, diabetes, and multiple mobility issues, who required maximal assistance for bathing and hygiene, reported not receiving scheduled bed baths. Documentation confirmed that this resident received significantly fewer baths than scheduled, with no record of refusals or alternative care provided. The director of nursing verified the lack of documentation for missed baths. Similarly, a resident with dementia and muscle weakness, requiring substantial assistance, was observed on multiple occasions to have very long fingernails, which was acknowledged by the director of nursing during an in-room observation. Additionally, a resident with cerebral infarction, diabetes, and psychiatric diagnoses, who was cognitively intact and required substantial assistance with personal hygiene, was observed to have lengthy facial hair on multiple occasions. Bathing documentation for this resident was also incomplete, with only a few baths recorded over a two-month period despite a regular schedule. Staff interviews confirmed the expected bathing schedule, and the director of nursing acknowledged the lack of documentation for completed baths.
Failure to Implement and Update Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure that two residents remained as free from accident hazards as possible by not implementing appropriate or new interventions after each fall. For one resident with severe cognitive impairment and multiple comorbidities, including dementia and heart failure, the care plan did not include interventions for all documented falls, and the intervention that was implemented—reminding the resident to call for assistance—was not appropriate given the resident's cognitive status. Additionally, two subsequent falls were not addressed with any new interventions or updates to the care plan. Another resident, who had intact cognition but was at risk for falls and required assistance with activities of daily living, experienced a fall that was not addressed in the care plan, and there was no documented evidence that any intervention was attempted after the incident. The Director of Nursing confirmed that new interventions were not implemented for either resident following their respective falls, and that the care plans were not updated to reflect these incidents.
Failure to Assess, Obtain Consent, and Document Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for three residents. Specifically, the facility did not assess residents for the risk of entrapment prior to the installation of bed rails, did not obtain informed consent from the residents or their representatives, did not secure physician orders for bed rail use, and did not update the residents' care plans to reflect the use of bed rails. These deficiencies were identified through record reviews, observations, and staff interviews. For one resident with diagnoses including type 2 diabetes, muscle weakness, heart failure, chronic kidney disease, and a history of repeated falls, there was no documentation of a bed rail assessment, informed consent, physician order, or care plan entry for the use of bilateral quarter bed rails, despite repeated observations of the resident with bed rails in the upright position. Another resident with acute necrotizing hemorrhagic encephalopathy, schizophrenia, muscle weakness, seizures, and lack of coordination was also observed with a quarter bed rail in use, but similarly lacked documentation of assessment, consent, physician order, or care plan inclusion for the bed rail. A third resident, who was cognitively intact and able to transfer with standby assistance, was observed with a right upper quarter bed rail in use. Record review confirmed the absence of a physician's order, care plan, or bed rail assessment for this resident. In all three cases, the Regional Director of Clinical confirmed that the required assessments, consents, orders, and care plan updates had not been completed prior to or during the use of bed rails.
Failure to Notify Physician of Elevated Blood Glucose Readings
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to follow physician orders for a resident with diabetes. Medical record review showed that the resident was admitted with a diagnosis of diabetes and had physician orders for accu-checks four times daily, with instructions to administer 10 units of insulin and notify the physician if results were 401 or greater. On multiple occasions, the resident's blood glucose readings exceeded 401, but there was no documentation that the physician was notified as required. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding physician notification for these elevated readings.
Failure to Document Clinical Rationale and Monitor Medication Irregularities
Penalty
Summary
The facility failed to ensure that a physician documented an adequate clinical rationale for denying a gradual dose reduction for a resident prescribed antipsychotic and antidepressant medications. Specifically, the physician declined the pharmacist's recommendation for a gradual dose reduction of Seroquel and Escitalopram, providing only the single word 'severity' as justification, which did not meet the facility's policy requirement for a valid clinical rationale. This was confirmed by the Director of Nursing, who acknowledged the lack of an adequate response from the physician. Additionally, the facility's consultant pharmacist did not identify or report irregularities related to the monitoring of prescribed medications for two residents. One resident, prescribed Levothyroxine, did not have appropriate monitoring of thyroid levels identified or reported by the pharmacist. Another resident, prescribed Atorvastatin Calcium, did not have the need for lipid panel monitoring identified or reported. The Regional Director of Clinical confirmed that these irregularities related to necessary lab work monitoring were not recognized by the pharmacist during the monthly drug regimen review.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies throughout the building on all days of the survey. Multiple residents reported ongoing issues with flies in their rooms, specifically during meal times, which required them to actively shoo flies away from their food. Surveyors directly observed several flies in the rooms of three residents on multiple occasions, and these residents confirmed that flies remained a persistent problem in their rooms and in the hallways. The administrator acknowledged awareness of the issue, confirming the presence of flies throughout the facility during the survey period.
Lack of Required Training and Competency Documentation for CNAs
Penalty
Summary
The facility failed to ensure that required dementia management and abuse prevention training was completed for two certified nursing assistants, as there was no documented evidence of this training in their personnel records. Additionally, four certified nursing assistants did not have documented evidence of competencies and skills training in their records. These deficiencies were confirmed by the Director of Nursing, who acknowledged the lack of documentation for dementia management, abuse prevention, and competencies/skills training for the affected staff members. The review of personnel records specifically identified missing documentation for dementia management and abuse prevention training for two staff members, and missing competencies and skills training for four staff members. The findings were based on both record review and confirmation through interview with facility leadership.
Failure to Provide Written Notice for Resident Room Change
Penalty
Summary
A deficiency occurred when the facility failed to provide written notice, including the reason for a room change, to a resident prior to moving her to a different room. The facility's policy requires that residents and their representatives receive a written explanation when a room change is initiated by the facility. In this case, the resident, who had intact cognition as indicated by a BIMS score of 15, was moved after an incident involving conflict with her roommate. Documentation in the medical record and interviews confirmed that the resident was verbally informed of the room change by the DON, but neither the resident nor her responsible party received the required written notice. The resident expressed dissatisfaction with the move, and the DON acknowledged that the facility did not follow its policy regarding written notification for room changes.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident, who was receiving Medicare Part A skilled services and had days remaining in their benefit period, with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS-10055) and Notice of Medicare Non-coverage (NOMNC, CMS-10123) prior to facility-initiated discharge from Medicare Part A services. Record review showed that the resident's skilled services episode began on 01/05/2025, with the last covered day on 02/03/2025, and the discharge from Medicare Part A was initiated by the facility before benefit days were exhausted. Documentation confirming that the required notices were provided to the resident was not found. An interview with the Clinical Reimbursement Specialist confirmed the absence of the completed forms for this resident.
Failure to Maintain Clean and Homelike Resident Environments
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents. In one resident's room, the air/heating unit had visible grime and debris on the air vents during multiple observations. Another resident's room was found to have grime and dust on the air/heating unit vents, which was confirmed by both the DON and Maintenance Director as needing cleaning. Additionally, a third resident's room had numerous dead flying insects stuck to the bathroom walls, heavy lint buildup on the bathroom ceiling vent, a toilet lid that was ajar with the inside visible, and black buildup inside the air conditioner unit. These conditions were confirmed by facility leadership during an observation and interview.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects and behaviors associated with psychotropic medications. The resident in question had multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, kidney failure, unspecified dementia with behavioral disturbance, and a history of substance abuse. The resident's care plan included interventions to administer medications as ordered and to monitor and document for side effects and effectiveness, as well as to review medications for possible causes of cognitive deficits. Despite these care plan interventions, a review of the Medication Administration Record (MAR) for April and May 2025 showed no documented evidence that staff monitored for side effects and behaviors every shift for the antipsychotic and antianxiety medications prescribed to the resident. This lack of documentation was confirmed during an interview with the Regional Director of Clinical, who acknowledged that there was no evidence of monitoring for the specified periods. The failure to monitor and document as required led to the cited deficiency.
Failure to Implement Care Plans for Smoking Safety and Fall Prevention
Penalty
Summary
The facility failed to implement the care plans for two residents as observed and documented by surveyors. One resident, with diagnoses including heart disease, COPD, diabetes, and moderate intellectual disabilities, was care planned to wear a smoking apron and be supervised while smoking. Despite this, the resident was observed on multiple occasions in the designated smoking area holding a lit cigarette without wearing the required smoking apron, even though staff were present and aware of the care plan requirements. Another resident, with a history of traumatic brain injury, reduced mobility, and moderate cognitive impairment, was care planned to have a fall mat placed at the bedside due to previous falls. However, repeated observations showed that the fall mat was propped against the wall away from the bed and not in use as intended. Staff interviews confirmed that the fall mat was not in place according to the care plan, and the care plan had not been individualized to the resident's needs.
Failure to Properly Store Respiratory Equipment and Post Oxygen Use Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such services, as evidenced by improper storage of nebulizer mouthpieces and lack of required oxygen use signage. For one resident with diabetes and shortness of breath, observations revealed the nebulizer mouthpiece was left exposed on a bedside dresser and on the bed, rather than being stored in a plastic bag as required. Another resident with COPD and multiple comorbidities also had a nebulizer mouthpiece left unbagged on the bedside table during multiple observations. In both cases, the DON confirmed that the mouthpieces should have been stored in bags when not in use. Additionally, a resident with morbid obesity, type 2 diabetes, COPD, and other conditions was observed receiving continuous oxygen therapy without any signage posted outside the room to indicate oxygen was in use and that smoking was prohibited. The DON confirmed that such signage should have been present. These failures were identified through observations, interviews, and record reviews, and involved three residents who required respiratory care.
Failure to Provide Prescribed Medications Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not ensuring that prescribed medications were available for administration. During a medication pass, it was observed that Vitamin D-2 400 units, ordered daily for one resident, was not present on the medication cart or in the medication room, and staff confirmed it was not available in the facility. Similarly, Farxiga 10 mg, also ordered daily for another resident, was not available on the cart or in the medication room, with staff and the Director of Nursing confirming its absence. These deficiencies were identified through direct observation, record review, and staff interviews, indicating that the facility did not have the necessary medications on hand for administration as ordered by physicians.
Failure to Monitor for Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring for edema while the resident was prescribed a diuretic. Record review showed that a resident with multiple diagnoses, including heart failure, chronic kidney disease, and dementia, was ordered Hydrochlorothiazide, a diuretic, to be administered daily. However, there was no documented evidence of edema monitoring for 13 instances in April and 16 instances in May, as indicated in the Medication Administration Records. Interviews with the DON and Regional Director of Clinical confirmed that monitoring for edema should have occurred and that there was no documentation of such monitoring during the specified periods.
Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 2 errors out of 27 observed medication administration opportunities, resulting in a 7 percent error rate. During a medication pass, a Licensed Practical Nurse (LPN) was unable to administer Vitamin D-2 400 units to one resident and Farxiga 10 mg to another resident because both medications were not available on the medication cart or in the facility at the time of administration. These omissions were confirmed by the LPN and verified through review of the physician's orders, which indicated that both residents were to receive these medications daily. The lack of medication availability directly led to the errors by omission.
Failure to Secure Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored properly in locked compartments, as required by policy and regulation. In one instance, a resident with a history of depression, bipolar disorder, and other medical conditions was observed to have a bottle of Flonase nasal spray on her bedside table and reported self-administering the medication as needed. Review of her medical record revealed there was no active order for Flonase, and the DON confirmed the medication was at the bedside and being self-administered. In another case, a resident with moderate cognitive impairment and multiple diagnoses was found with a medication cup containing two tablets on his bedside table, which were identified by an LPN as his night medications that should have been administered the previous night. There was no documentation of medication refusal for this resident, and the DON was notified of the incident. These observations demonstrate that medications were left unsecured at residents' bedsides, contrary to facility policy and accepted professional standards.
Failure to Hold and Document Required QAA Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required committee members present, as required. This deficiency was identified through record review and interview, which revealed that there was no documentation of any QAA meetings being held since the previous annual survey. During an interview, the administrator confirmed that the facility was unable to locate records of these meetings.
Improper Storage of Used Tube Feeding Syringe
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring proper storage of a used tube feeding syringe for a resident with cerebral infarction and dysphasia. Medical records indicated that the resident required medications to be crushed and flushed with water before and after administration. During observation, the syringe used for medication administration was found with an orange-colored liquid in the tip and the plunger still inserted, rather than being rinsed and disassembled as required. The DON confirmed in an interview that the syringe should have been properly cleaned and stored after use.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing data was posted in a prominent and accessible location as required. On two consecutive days, surveyors were unable to locate the daily staffing information for those dates during their observations. During an interview and observation, the DON confirmed that the daily staffing information had not been posted. This deficiency had the potential to affect any of the 68 residents residing in the facility, as the required staffing information was not made available to residents or visitors.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the State Survey Agency, as required by policy and regulation. Specifically, two residents were involved in separate incidents where timely reporting did not occur. One resident with multiple diagnoses, including chronic obstructive pulmonary disease, schizophrenia, and acute kidney failure, was found in bed with a laceration to the back of the head. The injury was classified as of unknown origin, and the resident was unable to communicate about the incident due to cognitive impairment. The incident was discovered by a CNA, and although the resident was sent to the hospital for treatment, the facility did not report the injury to the State Survey Agency within the required 2-hour timeframe, instead reporting it the following day. In a separate incident, another resident with significant cognitive and behavioral issues, who required one-on-one care, was involved in an episode where a CNA was overheard raising his voice and using inappropriate language after the resident grabbed his wrist. The agency LPN who overheard the incident did not report it to the DON immediately or within 2 hours, and the DON subsequently delayed reporting to the administrator. The administrator also failed to submit a report to the State Survey Agency within the required 2-hour window. These failures were confirmed through interviews and record reviews.
Verbal Abuse by CNA Toward Resident with Behavioral Challenges
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) verbally abused a resident with significant cognitive and behavioral challenges. The resident, who had diagnoses including anoxic brain damage, psychotic disorder, and required moderate to maximal assistance with activities of daily living, was on a 24-hour one-on-one care plan due to aggressive behaviors. During care, the resident grabbed the CNA's wrist, causing pain. In response, the CNA raised his voice and used inappropriate language toward the resident, which was overheard by an agency LPN. The CNA immediately apologized after the incident. The facility's policy prohibits all forms of abuse, including verbal abuse, and requires staff to maintain professional behavior even in challenging situations. The incident was reported by the agency LPN to the Director of Nursing (DON), who subsequently notified the administrator. The investigation confirmed that the CNA's conduct constituted verbal abuse, as defined by the facility's policy, due to the use of raised voice and inappropriate language in response to the resident's actions.
Failure to Provide Prescribed Pain Medication Due to Unavailability
Penalty
Summary
A resident with multiple complex medical conditions, including lumbar radiculopathy, open lumbar fracture, and chronic pain, was admitted with an order for Oxycodone-Acetaminophen 10-325 mg to be administered every 8 hours as needed for pain. Review of the medication administration records showed that the resident received this medication regularly in March, but it was not administered from April 1 through April 3. The controlled drug record confirmed that the medication was not available during this period. The resident's care plan specified that analgesia should be administered as ordered and that staff should anticipate and respond immediately to complaints of pain. During the period when the medication was unavailable, the resident expressed agitation and distress due to unrelieved pain, as documented in nurse's notes and confirmed in interviews with both the resident and staff. The nurse offered alternative pain relief options, such as Tylenol and ibuprofen, which the resident refused, and attempted non-pharmacological interventions without success. Both the DON and a corporate RN confirmed the unavailability of the prescribed pain medication for several days, resulting in the resident not receiving pain management in accordance with professional standards, the care plan, or the resident's preferences.
Failure to Provide 1:1 Supervision Results in Repeat Sexual Abuse Incident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, resulting in two separate incidents of alleged abuse. The first incident occurred when one resident entered another's room and touched her breast, as reported by the victim and confirmed by video footage. The accused resident was removed from the facility by law enforcement following this event. After the accused resident was returned to the facility by law enforcement, the facility's policy required 1:1 supervision for the resident to prevent further abuse. However, the assigned staff member did not provide continuous monitoring, as she also responded to other call lights on the unit. Video footage confirmed that the accused resident was left unsupervised and subsequently entered the victim's room a second time, where another allegation of sexual abuse was made. Both residents involved had moderate cognitive impairment, as indicated by their BIMS scores. The facility's own policies required immediate and continuous visual monitoring for residents placed on 1:1 care, but this was not implemented. Staff interviews and documentation confirmed that the required supervision was not maintained, directly leading to the second incident of alleged abuse.
Removal Plan
- Full body assessment completed on resident #1.
- Resident #1 was offered to be evaluated at the emergency room and declined.
- Police notified and the accused resident #2 was taken into custody.
- Accused resident #2 was placed on 1:1 upon return to facility.
- DON/Designee has put daily monitors in place for each shift for resident #1 that staff will ask resident if she feels safe in the facility with no psycho-social harm exhibited.
- DON/Designee has in-serviced all employees and agency personnel and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse (noting sexual and verbal), and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal return demonstrations of types of abuse, signs, and proper reporting procedures.
- A Statewide Incident Management System (SIMS) report was initiated.
Failure to Implement 1:1 Supervision After Abuse Allegation
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting abuse, specifically by not providing required one-to-one (1:1) supervision for a resident following an allegation of sexual abuse. After an initial incident in which a resident with moderate cognitive impairment reported that another resident entered her room and touched her breast, the alleged perpetrator was removed from the facility by law enforcement. However, upon the resident's return, the facility did not ensure continuous 1:1 monitoring as required by their own policy. Despite instructions for 1:1 supervision, the assigned staff member did not remain with the resident at all times and responded to other call lights, leaving the resident unsupervised. Video footage confirmed that the resident was left alone and subsequently entered the same resident's room a second time, where another allegation of inappropriate touching was made. Staff interviews and documentation revealed inconsistencies in monitoring and reporting, with some staff initially doubting the second incident and failing to provide accurate accounts of their supervision. The residents involved both had moderate cognitive impairment and complex medical histories, including conditions such as hemiplegia, aphasia, Parkinson's disease, and schizoaffective disorder. The failure to provide mandated supervision after a substantiated abuse allegation directly contradicted facility policy and resulted in a second incident of alleged abuse, constituting a deficiency and Immediate Jeopardy situation.
Removal Plan
- Resident #2 remained on 1:1 care and was sent to in-patient psych.
- Resident #1 was offered to be evaluated at ER and declined.
- Police notified of the second occurrence.
- Full body skin assessment of Resident #1 completed.
- DON/Designee has put daily monitors in place for each shift for resident #1 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited.
- DON/Designee has in-serviced all employees and agency personnel and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse, sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures.
- Staff involved received disciplinary action and resigned from her position at the facility.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe, as mandated by state law. The incident involved two residents, one of whom attempted to push the other out of a wheelchair and subsequently hit him in the back of the head with a walker. The resident who was struck refused medical evaluation, stating he was not seriously hurt. The incident was witnessed by staff, who separated the residents immediately. The facility's policy requires that any reasonable suspicion of a crime involving serious bodily injury be reported within two hours, but the incident was not reported to the state survey agency until the following morning. Resident #6, who was cognitively intact, and resident #7, who had moderate cognitive impairment, were involved in the altercation. The nurse's notes confirmed that there were no visible injuries to either resident following the incident. The Director of Nursing and the medical director were informed, but the exact time of notification was not documented. The delay in reporting the incident to the state agency was confirmed by the facility's administrator, indicating a failure to adhere to the established reporting procedures.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and psychosocial abuse by a Certified Nursing Assistant (CNA). The incident involved a cognitively impaired resident with multiple diagnoses, including major depressive disorder, dementia with behavioral disturbance, and anxiety. On the day of the incident, the resident was observed by two other CNAs being punched in the face, chest, and side multiple times by S4CNA after the resident grabbed the CNA's necklace. The resident sustained bruising and scratches as a result of the abuse. The facility's policy and procedure for Freedom from Abuse, Neglect, and Exploitation, dated March 2023, was not followed. The resident's medical records indicated a need for one-on-one care at all times, which was in place at the time of the incident. Despite this, the abuse occurred, and the resident was found with visible injuries by the oncoming shift CNAs, who immediately reported the incident to the Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON). The facility conducted an investigation, during which S4CNA initially denied any wrongdoing but later admitted to hitting the resident. The local Sheriff's department was notified, and S4CNA was arrested. Interviews with staff and review of statements confirmed the abuse, highlighting a significant failure in ensuring the resident's safety and adherence to the facility's abuse prevention policies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a pest-infested environment that affected four sampled residents and potentially all 82 residents in the facility. Observations over three days revealed multiple flies throughout the facility, including the dining room, resident hallways, and common areas. Specific incidents included flies on a resident's sheet near his head, three flies near another resident's bed, a fly on a dressing on a resident's leg, and a fly landing on a resident's face. The Regional Director of Clinical confirmed the facility's failure to ensure a pest-free environment for the residents.
Failure to Ensure Residents' Code Status Documentation
Penalty
Summary
The facility failed to ensure that the residents' code status was obtained and available for staff to review for two residents. For Resident #188, a review of the record revealed no documentation of an advance directive indicating the resident's code status. An interview with the Social Service Director (SSD) revealed that the advance directive was in the social folder in her office and not available to staff. The SSD mentioned that she is new and in the process of going through each resident's record and social folder. Similarly, for Resident #186, a review of the record also revealed no documentation of an advance directive indicating the resident's code status. The Director of Nursing (DON) confirmed that social services usually obtain the residents' advance directive upon admission. An interview with the SSD revealed that the advance directive was in the social folder in her office and not available to staff. Both the DON and the Regional Director of Clinical confirmed that the advance directive should have been obtained upon admission and entered into the resident's electronic record for staff review.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for four residents. Observations of Resident #44's room revealed a metal fluorescent light fixture that was only secured on one side and was leaning down, posing a potential safety hazard. This was confirmed by the Administrator and Maintenance Supervisor. Resident #83's room had multiple issues, including vertical holes in the wall behind the bed, gouged areas with missing paint, and a closet door that was not secured. Additionally, the bathroom had a toilet paper holder lying on the floor with small holes in the wall where it was previously attached. These issues were also confirmed by the Administrator and Maintenance Supervisor during their observation. Resident #64's room had a large hole in the wall next to the bed, exposing water pipes, and a folded blanket placed on the bathroom floor behind the toilet. These conditions were confirmed during an observation with the Administrator and Maintenance Director. Resident #74's bathroom had a large hole with exposed water pipes next to the toilet, which was also confirmed by the Administrator and Maintenance Director. These deficiencies indicate a failure to provide a safe and comfortable living environment for the residents, as required by the facility's policy for Physical Environment dated March 2023.
Failure to Provide Necessary Grooming and Hygiene Services
Penalty
Summary
The facility failed to ensure that residents who are unable to perform activities of daily living received the necessary services to maintain good grooming and personal hygiene. Resident #26, who had multiple diagnoses including hemiplegia, aphasia, and vascular dementia, was observed with long, dirty fingernails and an unshaven beard. Despite the resident's cognitive intactness and expressed need for grooming, the issues were not addressed even after being confirmed by the Director of Nursing (DON). Similarly, Resident #64, who required partial assistance with bathing and hygiene, was observed with a strong urine and body odor, dirty fingernails and toenails, and stained clothing. These conditions persisted over multiple days and were confirmed by the DON as needing attention. Resident #60, who required extensive assistance for all activities of daily living, was also observed with dirty and untrimmed fingernails and toenails. This was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), as well as the DON and the Regional Director of Clinical. Resident #44, who had severe cognitive impairment and required moderate assistance with personal hygiene, was observed with grime under their fingernails on multiple occasions. The DON confirmed the need for nail cleaning and trimming. Lastly, Resident #71, who was dependent on staff for personal hygiene, was observed with long, dirty fingernails and an unkempt beard and mustache. The resident expressed a desire for grooming assistance, which was not provided, and the DON confirmed the need for nail and beard trimming. These observations indicate a systemic failure to provide necessary grooming and hygiene services to residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for several residents. Resident #26, who was admitted with multiple diagnoses including hemiplegia, type 2 diabetes, and calciphylaxis wounds, had new wounds that were not identified or reported by the CNAs or floor nurses. These new wounds included areas on the left gluteal fold, right heel, left heel, and left inner knee, which were discovered during a wound treatment session. The Assistant Director of Nursing confirmed that these areas had not been previously identified or reported, indicating a failure in the facility's wound assessment and reporting process. Resident #39, who had diagnoses including stage 4 pressure ulcers, dementia, and bilateral above-the-knee amputation, was found to have an unreported wound on his right scrotum. Despite a CNA noticing redness and a small crack in the skin a week prior, this information was not properly documented or communicated to the treatment nurse. The wound was only identified and assessed after the surveyor's observation, revealing a significant lapse in the facility's wound care and documentation procedures. Resident #60, diagnosed with cerebral infarction and hemiplegia, was observed without a hand roll in his right hand, which was ordered to prevent contractures. Staff interviews confirmed that the hand roll had not been in place for at least two months, indicating a failure to follow physician orders and care plans. This deficiency highlights the facility's failure to ensure that prescribed treatments and preventive measures are consistently implemented for residents, compromising their care and well-being.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not have documentation of medications administered for one resident (#16) out of five residents reviewed for unnecessary medications. The facility's Pharmacy Services Medication Administration Policy aimed to provide residents with safe and accurate medication administration, but this was not adhered to in the case of resident #16. The resident had multiple diagnoses, including major depressive disorder, dementia with behavioral disturbance, and anxiety, and required extensive assistance with activities of daily living. The physician's orders for May 2024 included several medications to be administered at specific times, but there was no documented evidence of these medications being administered on two specific dates at 6:00 p.m. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the medications were not signed out when administered. The DON was unsure why the medications were not documented, and the LPN admitted to forgetting to sign out the medications on the specified dates. This lack of documentation and adherence to the medication administration policy indicates a deficiency in the facility's ability to ensure the safety and well-being of its residents through proper medication management.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day on 12/23/2023, 12/25/2023, 12/26/2023, and 12/30/2023. Review of the facility's Payroll Based Journal (PBJ) Data time sheets for these dates revealed no staffing hours for the RN, indicating that no RN worked the required 8 consecutive hours on those dates. An interview with the Administrator on 05/08/2024 confirmed the absence of documentation or time sheets to prove that an RN worked for the required hours on the specified dates.
Pharmacist Fails to Report Irregularities in Drug Regimen Review
Penalty
Summary
The pharmacist failed to report any irregularities to the attending physician, medical director, and director of nursing for three residents during the monthly drug regimen review. For Resident #26, the pharmacist did not address missing laboratory results that were ordered, including Chemistry 14, Glycated Hemoglobin (A1C), liver function tests (LFT), complete blood count (CBC), prostatic-specific antigen (PSA), and lipids. The Assistant Director of Nursing (ADON) confirmed that the pharmacist did not report the missing labs for Resident #26 during the drug regimen reviews for February, March, and April 2024. For Resident #64, the pharmacist did not address the lack of monitoring for edema while the resident was receiving Furosemide (Lasix). The medication administration records for April and May 2024 showed no documentation of edema checks prior to administering Lasix. Similarly, for Resident #53, there was no documented evidence of edema checks while the resident was receiving Furosemide and Spironolactone for edema. The Director of Nursing (DON) confirmed the absence of edema checks, and the pharmacist did not address this issue in the drug regimen reviews for March and April 2024.
Failure to Monitor Edema and Obtain Laboratory Tests
Penalty
Summary
The facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three of the five sampled residents reviewed for unnecessary medications. Specifically, the facility did not perform edema checks for two residents while they were taking a diuretic and failed to obtain ordered laboratory tests for another resident. Resident #26 had multiple diagnoses including hemiplegia, COPD, diabetes, and end-stage renal disease, among others. The facility did not obtain the Glycated Hemoglobin (A1C) for January and April 2024, the liver function test (LFT) for January 2024, or the complete blood count (CBC), prostatic-specific antigen (PSA), and lipids for July 2023 as ordered by the physician. This was confirmed by the Assistant Director of Nursing (ADON) during an interview on 05/08/2024. Resident #64, who had diagnoses including COPD, hypertension, and cirrhosis of the liver, had a physician's order for Furosemide (Lasix) 40 mg daily for edema. However, the April and May 2024 Medication Administration Records (MAR) showed no documentation of edema checks prior to administering the Lasix. Similarly, Resident #53, with diagnoses including myocardial infarction, obesity, and pulmonary embolism, had orders for Furosemide and Spironolactone for edema, but there was no documented evidence of edema checks. This lack of monitoring was confirmed by the Director of Nursing (DON) during an interview on 05/08/2024.
Deficiencies in Food Storage, Preparation, and Distribution
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an observation of the kitchen environment, the front of the ice machine was found open, exposing the inside of the machine and electrical components. The stand-up refrigerator had a temperature reading of 48 degrees Fahrenheit, and the walk-in refrigerator had a temperature reading of 61 degrees Fahrenheit, both of which are above the recommended safe storage temperatures. Additionally, there were no temperature logs maintained for the refrigerators and freezers. Unlabeled and unidentified food items were found in the stand-up refrigerator, and the Dietary Manager (S11DM) confirmed the lack of proper labeling and temperature logs. The S11DM also demonstrated improper use of chemical test strips for the 3-compartment sink and revealed a lack of training on how to check the sanitizer levels correctly. The 3-compartment sink was found without water in the sanitizer bin, and clean dishes were stacked in an upright position in the dishwashing area, which is not in accordance with professional standards. Further observations revealed that the electric thermometer used to check steam table temperatures was not cleaned between uses. The food temperature log had not been updated since March 24, 2024. The S11DM, who had been employed since April 1, 2024, admitted to having only restaurant management experience and confirmed that she did not receive training on managing a kitchen in a nursing facility. These deficiencies in food storage, preparation, and distribution practices had the potential to affect all residents receiving meals from the kitchen.
Insufficient Nursing Staff and Non-compliance with Care Plans
Penalty
Summary
The facility failed to provide a sufficient number of nursing service personnel to meet the required 2.35 hours of care per patient per day as mandated by state statute 9823, A. The review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form from 03/01/2024 to 05/04/2024 revealed that the facility did not meet the required hours on 11 out of 65 days. This was confirmed by the facility's administrator during an interview. Additionally, the Director of Nursing (DON) confirmed that there was insufficient CNA staffing on the evening and night shifts for multiple days in the last two weeks, affecting the care provided to residents. Resident #38, who has diagnoses of paraplegia, congestive heart failure, and generalized osteoarthritis, reported that CNAs took a long time to answer his call light, especially during the night shift. The DON confirmed the insufficient staffing on the night shift. Similarly, a family member of Resident #39 reported that the night shift was short-staffed, often having only one aide per hall. The DON confirmed that the facility was short one CNA on several shifts in the last two weeks, further corroborating the staffing issues. These deficiencies indicate that the facility did not ensure residents received nursing care in accordance with their care plans 24 hours per day.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to inform residents of changes in Medicare covered services as required. Specifically, the facility did not provide the necessary CMS forms to two residents who were discharged from Medicare Part A services with benefit days remaining. Resident #84 was discharged on April 4, 2024, without receiving Form CMS-10055 and Form CMS-10123. Similarly, Resident #236 was discharged on March 28, 2024, without receiving Form CMS-10123. These forms are essential for informing residents about their Medicare coverage and potential liability for services not covered. An interview with the facility's Minimum Data Set (MDS) nurse confirmed that Resident #236 had benefit days remaining and had a planned discharge. The facility's administrator revealed that the Director of Social Services, who was responsible for completing these forms, had only started her employment the previous week. The administrator confirmed that there was no documentation indicating that the required forms were provided to Residents #84 and #236, highlighting a lapse in the facility's compliance with Medicare notification requirements.
Failure to Immediately Report Abuse
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the facility administration. Resident #16, who had severe cognitive impairment and required extensive assistance with activities of daily living, was found with bruising and scratches on her body. The incident was initially reported by CNAs to an LPN, and an investigation was initiated. However, it was discovered that two CNAs witnessed another CNA physically abusing Resident #16 but did not report the abuse immediately. The abuse was only reported the following day when the CNAs provided statements to the Assistant Director of Nursing (ADON). The investigation revealed that on the day of the incident, Resident #16 had grabbed the necklace of the CNA who then became angry and physically assaulted the resident. The two witnessing CNAs were afraid to report the incident immediately. The facility administration was only notified of the abuse after the statements were collected, and the local Sheriff's department was contacted to start an investigation. The delay in reporting the abuse violated the facility's policy and procedure for abuse, which mandates immediate reporting of any abuse allegations.
Failure to Conduct Quarterly Smoking Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident's safe smoking practices as required by their policy. The policy mandates that smoking assessments be completed on admission, quarterly, with significant changes in condition, and as needed. The resident in question, who has chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease, was admitted to the facility and was assessed as an unsafe smoker. However, the facility did not conduct the required quarterly smoking assessment in February 2024, as confirmed by the review of the resident's medical records and interviews with the Director of Nursing and the Regional Director of Clinical. An observation on May 6, 2024, revealed the resident smoking a cigarette in the designated smoking area, despite the lack of a recent assessment. The resident's quarterly Minimum Data Set (MDS) assessment indicated no cognitive impairment, and her care plan noted extensive to total dependence for all activities of daily living. The failure to conduct the quarterly smoking assessment was confirmed by the facility's Director of Nursing and the Regional Director of Clinical, highlighting a lapse in adherence to the facility's smoking assessment policy.
Failure to Conduct Monthly State Adverse Actions Checks for CNAs
Penalty
Summary
The facility failed to ensure that monthly State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNAs) S23CNA, S24CNA, and S25CNA. Review of the personnel files revealed that S23CNA was hired on 12/08/2023, S24CNA on 08/28/2023, and S25CNA on 02/05/2024. However, the first documented State Adverse Actions check for all three CNAs was on 05/03/2024, with no prior monthly checks recorded. An interview with the S1Administrator confirmed the absence of documentation for the required monthly checks before 05/03/2024, and it was noted that the Human Resource Coordinator responsible for these checks was unavailable during the week of the interview.
Failure to Maintain Safe Resident Care Equipment
Penalty
Summary
The facility failed to maintain all resident care equipment in safe operating condition for two residents. Resident #48, who has severe cognitive impairment and requires a wheelchair for locomotion, was observed with a missing rubber protective cover on the right handle of his wheelchair. This issue was confirmed by an LPN and later acknowledged by the Director of Nursing and the Regional Director of Clinical, who admitted that the wheelchair should have been repaired in a timely manner. The duration of the issue was unknown to the staff involved. Resident #26, who has intact cognition and also requires a wheelchair for locomotion, was observed with a torn right armrest on his wheelchair, exposing the wood portion. This condition was observed on multiple occasions over several days. A CNA confirmed that she transfers the resident using the wheelchair with the torn armrest and admitted that she had never reported the issue. The facility's failure to address these equipment concerns had the potential to affect all 82 residents in the facility.
Failure to Post Survey Results Accessibly
Penalty
Summary
The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. During a Resident Council Meeting, multiple residents were unaware of where the state inspection results were located. An observation with the Administrator revealed that the state inspection results were not labeled and were stored in a clear plastic bin on the wall, out of reach for residents in wheelchairs. The Administrator confirmed that the state inspection results were not labeled and were not within reach of the residents in wheelchairs.
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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