Evangeline Oaks Guest House
Inspection history, citations, penalties and survey trends for this long-term care facility in Carencro, Louisiana.
- Location
- 240 Arceneaux Road, Carencro, Louisiana 70520
- CMS Provider Number
- 195578
- Inspections on file
- 30
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Evangeline Oaks Guest House during CMS and state inspections, most recent first.
A resident with a chronic stage 4 sacral pressure ulcer, diabetes, and UTI received ordered wound care during which a treatment nurse and a CNA failed to follow the facility’s hand hygiene and Enhanced Barrier Precautions policies. Despite an EBP sign on the door requiring gown and glove use for wound care, neither staff member wore a gown. The nurse repeatedly removed soiled gloves, placed them on the bedside table and bed linens, and donned clean gloves without performing hand hygiene between glove changes, including after cleansing the wound and while cleaning multiple episodes of bowel incontinence and changing briefs. Used gloves were not discarded in the trash as required. In interviews, the nurse and CNA acknowledged they knew the requirements for hand hygiene and PPE use, while the DON and another nurse confirmed that gown and glove use and hand hygiene between glove changes were required for this resident’s wound care.
A resident with hemiplegia, hemiparesis after cerebral infarction, and type 2 DM had a care plan and MD order requiring heel lift boots while in bed due to risk for skin breakdown related to decreased mobility and incontinence. On multiple observations, the resident was in bed without the heel lift boots. A CNA reported not knowing the resident was supposed to wear the boots or where they were located, and an LPN stated she was not very familiar with the resident’s care. After reviewing the orders, the LPN confirmed the resident had an order for heel lift boots while in bed and that they were not in use as ordered.
An agency RN providing wound care to a resident with a stage 4 sacral pressure ulcer, diabetes, and UTI failed to follow infection control practices and had no documented competency validation. During an observed treatment, the RN and a CNA did not wear gowns despite Enhanced Barrier Precautions signage, and the RN repeatedly changed gloves without performing hand hygiene, placed used gloves on surfaces instead of discarding them, and continued wound care and incontinence care without sanitizing or washing hands. The RN later acknowledged not using hand sanitizer or soap and water between glove changes, not changing gloves after cleansing the wound before applying gentian violet, and placing soiled gloves on the bed. She reported having performed wound care for all residents for two weeks without training on facility policies or procedures and without shadowing another treatment nurse, and the administrator confirmed there was no documentation of training or competency assessment for this agency RN.
A resident with multiple serious health conditions experienced a fall during staff assistance, but the LPN on duty failed to immediately notify the correct physician and responsible party, instead notifying the wrong individuals. Facility leadership confirmed that required notifications were not made promptly, in violation of facility policy.
A resident with end stage renal disease, diabetes, and atrial fibrillation experienced a fall from a wheelchair on a van lift before dialysis. The resident's representative was not promptly notified and later expressed concerns to the DON. Despite facility policy requiring grievances to be filed and investigated, no grievance was documented for this incident.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific staff actions or resident involvement are provided.
A LPN's BLS certification expired and was not renewed as required by facility policy, as confirmed by personnel record review and interviews with the LPN and DON.
A resident with multiple chronic conditions did not receive laboratory tests as ordered by the physician, including a lipid panel, PSA, and urine for microalbumin, which were scheduled for June. The DON confirmed that these tests were not completed as required.
A resident dependent on staff for toileting and personal hygiene due to hemiplegia and incontinence was not provided with incontinent care every two hours as required by the care plan. The resident participated in activities and was brought to lunch without being checked or changed, resulting in her being found soaking wet after more than five hours without care. Staff interviews confirmed the lapse in following the care plan.
A resident with COPD and other medical conditions was not provided with continuous oxygen therapy as ordered by the physician. Observations showed the resident was without oxygen during activities and meals, and staff confirmed the oxygen tank was empty and the therapy was not being administered as required.
A resident with multiple respiratory and cardiac conditions was found to have an oxygen nasal cannula not stored in a sealed bag as required, and physician orders for BIPAP lacked clear instructions on when it should be used. Staff confirmed the equipment was not stored properly and that BIPAP use was not clearly defined, leading to deficiencies in respiratory care.
A resident's medical record indicated that daily cleaning of a CPAP/BIPAP mask was completed, but direct observation revealed the mask was still soiled. An LPN admitted to documenting the cleaning before performing the task, contrary to facility policy, and the DON confirmed that such documentation practices were not allowed.
The facility did not update the nurse staffing information daily as required. Observations on March 3, 2025, revealed that the posted data was from February 11 and 12, 2025. The DON confirmed the information was outdated and should have been updated daily.
A resident with severe cognitive impairment and multiple diagnoses, including Huntington disease, was found with long and unclean fingernails despite having an order for nail care. The facility's staff, including a CNA and the Quality Assurance Nurse, confirmed the need for trimming and cleaning, highlighting a failure to adhere to the facility's nail care policy.
A resident, who was cognitively intact, was injured when hit by a door in the facility. The incident occurred on a specific date, but the physician and responsible party were not notified until two days later, contrary to the facility's policy. Interviews revealed that the delay was due to a lack of awareness by the staff involved, and the Director of Nursing confirmed the notification should have been immediate.
A facility failed to write a telephone order and obtain a wound culture in a timely manner for a resident with severe pressure ulcers and other conditions. The treatment nurse noted a strong odor and drainage from the wounds and received orders to collect wound cultures. However, the cultures were not collected and sent to the lab until two days later, and no telephone order was documented, leading to a deficiency.
A facility failed to document an incident where a resident was hit in the head by a door opened by an LPN. The resident, who was cognitively intact, recalled the incident, but the nurse's notes did not reflect this occurrence. The DON confirmed the incident should have been documented, highlighting a deficiency in maintaining accurate medical records.
A resident in the facility, with moderately intact cognition, reported and was observed to have a room with a rotten back door frame and damaged wall. The Maintenance Supervisor and Administrator confirmed the poor condition, acknowledging the failure to maintain a safe and comfortable environment.
The facility failed to ensure residents received mail on Saturdays, affecting 95 residents. The Business Office was closed on weekends, and weekend staff did not have access to retrieve the mail, which was then distributed on Mondays. The Director of Nursing was unaware of the mail delivery process, and the local post office confirmed that someone from the facility had requested no weekend mail delivery.
The facility failed to store food in accordance with professional standards by not following appropriate food handling practices. Expired food items were found in the walk-in cooler and dry storage area, and several opened items were not labeled with the date and time they were opened. Additionally, temperature logs for the kitchen's coolers and freezer were absent for an entire week.
A resident with severe cognitive impairment and multiple diagnoses was addressed as 'girl' by a CNA when she requested ice, which she found disrespectful. The resident expressed her preference to be called by her name, and the DON confirmed that the facility's policy on dignity and respect was not followed.
The facility failed to organize monthly resident council meetings as required. While meetings were documented for January and February 2024, there were no records for March and April 2024. Interviews with residents and the Activity Director confirmed the lack of monthly meetings, with the Activity Director unable to provide supporting documentation.
A resident with chronic pain and an above-knee amputation reported a cracked and peeling ceiling in his room, which had been in disrepair since his admission. Maintenance staff confirmed the issue and admitted that their routine checks did not include ceilings, focusing only on call lights and beds.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly coded for receiving an injectable medication, while another was not coded for the use of a lap tray restraint despite multiple observations and physician orders indicating its use.
The facility failed to implement person-centered care plans by not repositioning a resident every two hours and not providing necessary communication tools, and by not monitoring bedframe padding for another resident as required.
The facility failed to invite a resident and their Responsible Party (RP) to the care planning meeting, despite the resident having intact cognition and expressing concerns about their care. The facility's policy required such invitations and documentation if participation was not practicable, but neither was done in this case.
A facility failed to ensure a resident with multiple diagnoses participated in activities as per her care plan after returning from the hospital. Staff were unaware of her return and did not assist her in engaging in activities, leading to a deficiency.
A resident with an indwelling urinary catheter was observed multiple times without the catheter being properly secured to his thigh, contrary to his care plan. The facility's nursing staff failed to implement the intervention to tape the catheter, as confirmed by an LPN and the MDS coordinator, indicating a lapse in following established protocols to prevent urinary catheter-associated complications.
The facility failed to maintain a medication error rate below five percent by administering medications late for two residents during the morning medication pass. The errors were confirmed by an LPN, resulting in a calculated error rate of 6.25%, exceeding the acceptable threshold.
The facility failed to submit accurate payroll data for RN staffing, missing 8 consecutive hours of RN coverage on several weekend days. The issue was confirmed through data review and staff interviews, with the Office Manager unable to identify the specific problem.
A facility failed to maintain an infection prevention and control program when a housekeeper exited a resident's contact isolation room with soiled PPE. The resident had an ESBL infection, and the housekeeper was unaware of the requirement to change PPE each time she entered and exited the room. This was confirmed by an LPN and the Director of Nursing/Infection Control Preventionist.
The facility failed to provide accessible call systems for three residents, leading to their inability to call for assistance. One resident's call bell was clamped to a curtain, another's was placed out of reach on the bed, and a third resident was unable to use the press button call bell due to contracted hands. These deficiencies were confirmed by staff observations and interviews.
The facility failed to maintain a clean, comfortable, and homelike environment, with multiple rooms observed to have various deficiencies such as soiled items on the floor, leaking faucets, and unclean surfaces. Interviews confirmed that these issues should have been reported and addressed.
The facility failed to ensure a resident's urinary catheter bag was kept private, as observed when the resident was in the dining room with the bag uncovered. An LPN/CNA Supervisor acknowledged the oversight, which violated the facility's dignity policy.
An LPN left a medication cart unlocked and unattended with the keys on top while at the nurses' station. Another LPN/CNA Supervisor confirmed the cart should not have been left unlocked and unattended. The DON stated the cart should be locked when not in use and keys should not be left on top.
The facility failed to ensure proper laundry processing by not connecting the detergent dispenser hose to a washing machine, leading to unsanitary conditions for residents' clothing and linens. This issue was observed and confirmed by the Housekeeping Supervisor and Laundry Staff, who admitted to using the machine without detergent for multiple loads.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to wound care for one resident. The facility’s hand hygiene policy required use of alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after contact with a resident’s skin, after handling used dressings or contaminated equipment, and after removing gloves. The facility’s Enhanced Barrier Precautions (EBP) policy required gown and glove use for high-contact resident care activities, including wound care, for residents with wounds, and specified that EBPs remain in place for the duration of the resident’s stay or until wound resolution. The resident involved had a stage 4 sacral pressure ulcer, type 2 diabetes, and a UTI, with a physician’s order for sacral wound care including cleansing, application of gentian violet, collagen, and silver alginate, and covering with a dry dressing. During an observed wound care treatment, the treatment nurse and a CNA entered the resident’s room, which had an EBP sign posted instructing staff to wear gown and gloves for wound care, but neither staff member wore a gown. The treatment nurse removed the resident’s soiled dressing, removed her gloves, placed them on the bedside table, and donned clean gloves without performing hand hygiene between glove changes. She then cleansed the wound and applied gentian violet without changing gloves or performing hand hygiene after cleansing the wound. When the resident had a bowel movement, the nurse removed her gloves, placed them on the bed sheet, left the room without performing hand hygiene, returned with wipes and gloves, and again donned clean gloves without hand hygiene before cleaning the bowel movement. The nurse continued to alternate between cleaning bowel movements, changing briefs, and performing wound care while repeatedly removing used gloves, placing them on the bed sheet, and donning clean gloves without performing hand hygiene between glove changes or after glove removal. She exited and re-entered the room without hand hygiene after glove removal and did not discard used gloves in the trash as required. In interviews, the nurse acknowledged she did not bring hand sanitizer into the room, did not perform hand hygiene between glove changes, did not change gloves after cleansing the wound before applying gentian violet, and placed soiled gloves on the resident’s bed instead of discarding them. The CNA confirmed awareness of the EBP sign and the requirement to wear a gown and gloves for direct care but did not wear a gown. The DON/infection control nurse and another nurse assisting with infection control confirmed that hand hygiene between glove changes, proper glove disposal, and use of gown and gloves for wound care under EBP were required and were not followed in this instance.
Failure to Follow Care Plan and MD Orders for Heel Lift Boots
Penalty
Summary
The deficiency involves the facility’s failure to implement a complete care plan and follow physician’s orders for a resident who required heel lift boots while in bed. The resident’s EHR showed an admission date of 12/22/2005 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The resident’s care plan identified a potential for skin breakdown related to decreased mobility, incontinence, and hemiplegia, with an intervention specifying heel lift boots while in bed. A physician’s order dated 03/24/2025 also directed that the resident wear heel lift boots while in bed every day shift. On multiple observations, the resident was found in bed without the ordered heel lift boots. On 02/23/2026 at 2:50 p.m., and again on 02/24/2026 at 9:11 a.m. and 10:55 a.m., the resident was observed in bed without the heel lift boots in place. When questioned, the CNA who entered the room stated she did not know the resident was supposed to have heel lift boots on and did not know where they were in the room. The LPN assigned to the resident for that shift stated she was not very familiar with the resident’s care because she was not normally assigned to that resident. After reviewing the orders, the LPN confirmed there was an order for heel lift boots while in bed and acknowledged that the resident should have been wearing them but was not.
Lack of Competency Validation and Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to ensure that an agency treatment nurse had the necessary competencies and followed infection control practices while providing wound care to a resident with a stage 4 sacral pressure ulcer, type 2 diabetes, and a UTI. The resident had a physician’s order for sacral wound care that included cleansing with wound cleanser, applying gentian violet, collagen, and silver alginate, and covering with a dry dressing. During an observed wound care procedure, the agency nurse and a CNA did not wear gowns despite an Enhanced Barrier Precautions sign on the resident’s door requiring gowns and gloves for wound care. The nurse repeatedly removed soiled dressings and handled the wound and surrounding areas without performing hand hygiene between glove changes, and placed used gloves on the bedside table and bed sheets instead of discarding them appropriately. During the procedure, the resident had two bowel movements, and the nurse left and re-entered the room multiple times, changing gloves but never performing hand hygiene with sanitizer or soap and water between glove changes or before resuming wound care. The nurse confirmed in interviews that she did not bring hand sanitizer into the room, did not perform hand hygiene between glove changes, did not change gloves after cleansing the wound before applying gentian violet, and placed soiled gloves on the bed instead of discarding them. She also stated she had been performing wound care for all residents for the previous two weeks without being trained on the facility’s policies and procedures, without shadowing or receiving direction from the prior treatment nurse, and with only the physician’s orders as guidance. The administrator confirmed there was no documented evidence that this agency nurse had been trained on facility policies and procedures or that her competency to provide wound care for all residents had been verified.
Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's physician and responsible party following an incident in which the resident experienced a fall during staff assistance. According to the facility's policy, the attending physician and the resident's family are to be promptly notified and the time of notification documented. However, review of the incident report revealed that the wrong physician and responsible party were notified after the fall. The resident involved had significant medical conditions, including end stage renal disease, dependence on renal dialysis, type 2 diabetes, and atrial fibrillation. Interviews with facility staff confirmed that the LPN on duty did not immediately notify the correct physician or responsible party, mistakenly believing there was a 72-hour window for notification. The Director of Nursing and the Administrator both verified that the correct notifications were not made as required by policy. The deficiency was identified through record review and staff interviews, which showed a failure to follow established procedures for timely and accurate notification after a resident injury.
Failure to File Grievance After Resident Incident
Penalty
Summary
The facility failed to file a grievance for one resident after an incident involving a fall from a wheelchair on a van lift prior to the resident's scheduled dialysis. The facility's policy states that any resident, family member, or appointed representative may file a grievance or complaint regarding care, treatment, staff behavior, theft, or any other concerns, and that grievances may be submitted orally or in writing. Upon receipt, the grievance officer is required to review and investigate the allegations and submit a written report to the Administrator within five working days. However, review of the facility's grievance log showed no grievance was filed for this incident. The resident involved had multiple diagnoses, including end stage renal disease, dependence on renal dialysis, type 2 diabetes, and atrial fibrillation. The resident's representative reported being upset due to delayed notification about the fall and subsequently spoke in person with the DON about her concerns. The DON confirmed the conversation but denied filing a grievance, and the incident was not documented in the grievance log as required by facility policy.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Lapse in Staff BLS/CPR Certification
Penalty
Summary
The facility failed to ensure that staff maintained current CPR certification as required by its policy and procedures. Specifically, one LPN's BLS certification had expired and was not renewed by the required date, as confirmed through personnel record review and interviews with both the LPN and the Director of Nursing. The facility's policy mandates that key clinical staff maintain up-to-date BLS/CPR certification, but this requirement was not met in this instance.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to implement the plan of care by not following physician orders for laboratory testing for one of three sampled residents. Record review showed that a resident with diagnoses including essential hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia, and hyperlipidemia was readmitted to the facility and had physician orders for a lipid panel every six months and annual PSA and urine for microalbumin tests, all scheduled for June. Further review of the resident's medical record did not reveal evidence that these laboratory tests were obtained as ordered during the specified month. During an interview and record review with the Director of Nursing, it was confirmed that the required laboratory tests were not completed as per the physician's orders.
Failure to Provide Timely Incontinent Care per Care Plan
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis, hypertension, and COPD was assessed as cognitively intact but dependent on staff for mobility, toileting, and personal hygiene due to limited range of motion and incontinence. The resident's care plan required staff to check for dryness and provide personal care every two hours. On the day in question, the resident was observed participating in activities and then brought to the dining room for lunch without being returned to her room for incontinent care as specified in her care plan. Later, when the resident was transferred to bed after lunch, her pants were found to be soaking wet. Staff confirmed that the resident had not been changed or provided with incontinent care for over five hours, with the last care provided early that morning. Interviews with the DON and CNA supervisor confirmed that the resident should have been checked and provided with care every two hours, and that this did not occur as required.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebrovascular disease, hypertension, and COPD was admitted to the facility and had a physician's order for continuous oxygen at 2 liters per nasal cannula to maintain oxygen saturation above 92%. The resident's care plan included interventions for respiratory therapy, assessment for respiratory distress, and administration of oxygen as ordered. Despite these orders, multiple observations on the same day revealed the resident was not receiving oxygen while in the dayroom and dining room, even though an oxygen tank was present in the wheelchair holder. Staff interviews confirmed the deficiency: a CNA was unaware of the resident's oxygen needs, and an LPN verified that the oxygen tank was empty and that the resident was not receiving the ordered continuous oxygen therapy. The DON also confirmed that the resident should have been on continuous oxygen per the physician's order. These findings indicate that the facility failed to ensure the resident received safe and appropriate respiratory care as ordered.
Failure to Store Respiratory Equipment Properly and Specify BIPAP Use
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring proper storage of respiratory equipment and by not specifying the frequency for BIPAP use in the physician's orders. Specifically, a resident with diagnoses including COPD, heart failure, dementia, morbid obesity, and obstructive sleep apnea was observed with an oxygen nasal cannula hanging freely from a wheelchair and not stored in a sealed, dated storage bag as required by facility policy. Staff interviews confirmed that the nasal cannula should have been stored properly when not in use, but this was not done after the resident was transferred to bed. Additionally, the physician's orders for the resident included the use of BIPAP but did not indicate when the BIPAP should be applied. Staff interviews revealed that the resident only wore BIPAP at night, and the DON stated that BIPAP should be applied any time the resident was sleeping, including naps. The lack of a specified frequency for BIPAP use in the physician's orders contributed to the deficiency in respiratory care for the resident.
Inaccurate Documentation of CPAP Cleaning
Penalty
Summary
The facility failed to ensure that medical records were accurately documented and maintained in accordance with professional standards for one resident. The facility's policy requires concise, accurate, and complete documentation of assessments, interventions, and treatments. A review of a resident's medical record showed a physician's order for daily cleaning of a CPAP/BIPAP mask and tubing, which was documented as completed on the Medication Administration Record (MAR) for a specific date. However, direct observation of the resident's CPAP mask on that date revealed brown residue and beard hairs inside the mask, indicating it had not been cleaned as required. Further investigation included an interview with an LPN who admitted to documenting the cleaning of the CPAP mask before actually performing the task, stating that she was allowed to document tasks as complete even if they had not yet been done. The Director of Nursing later clarified that nurses were not permitted to document completion of tasks prior to actually completing them. This discrepancy between documentation and actual care provided led to the deficiency cited in the report.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was updated and posted daily as required. On March 3, 2025, at 10:00 AM, an observation was made of the nurse staffing data displayed on a whiteboard at the facility's entrance. The data showed dates from February 11 and February 12, 2025, indicating that the information had not been updated for several weeks. During an interview at 10:45 AM on the same day, the Director of Nursing (S1DON) confirmed that the staffing data was outdated and acknowledged that it should have been updated daily but was not.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary grooming services to a resident who was unable to perform activities of daily living independently. The resident, diagnosed with Huntington disease, mood affective disorder, depression, and anxiety disorder, was severely impaired cognitively with a BIMS score of 6 and required maximum assistance for all activities of daily living. Despite having an active physician's order to trim nails as needed, the resident was observed with long and unclean fingernails, with a dark brown substance accumulated under them. On the morning of March 5, 2025, a Certified Nursing Assistant (CNA) confirmed the resident's fingernails were long and dirty, requiring trimming and cleaning. This observation was further corroborated by the Quality Assurance Nurse, who also confirmed the need for nail care. The Director of Nursing acknowledged that the resident's nails should have been trimmed and cleaned, indicating a lapse in the facility's adherence to its policy and procedure for nail care, which mandates regular cleaning and trimming of nails.
Failure to Notify Physician and Responsible Party of Resident Injury
Penalty
Summary
The facility failed to ensure immediate notification of a resident's physician and responsible party following an incident where the resident was injured. Resident #5, who was cognitively intact with a BIMS score of 14, was hit in the head by a door on 01/04/2025. The incident report indicated that the physician and responsible party were not notified until 01/06/2025, two days after the incident occurred. This delay in communication was contrary to the facility's policy, which requires prompt notification of such incidents. Interviews conducted during the investigation revealed that the resident experienced a headache following the incident and requested to be sent to the emergency room. The LPN who attended to the resident on 01/06/2025 confirmed that neither the nurse practitioner nor the responsible party was aware of the incident until that day. Additionally, an agency LPN stated she was unaware of the incident, which contributed to the lack of timely notification. The Director of Nursing acknowledged the delay in notifying the responsible parties and confirmed that the notification should have occurred on the day of the incident.
Failure to Timely Obtain and Document Wound Culture Order
Penalty
Summary
The facility failed to write a telephone order and obtain a wound culture in a timely manner as ordered by a physician for a resident. The resident was admitted with multiple severe conditions, including stage 4 pressure ulcers, sepsis, and severe protein-calorie malnutrition. On a specific date, the treatment nurse noted a strong odor and drainage from the resident's wounds and contacted the wound care clinic. The physician ordered wound cultures to be collected and sent to the lab on the same day. However, the wound cultures were not collected and sent to the lab until two days later. The Director of Nursing confirmed that there was no telephone order written by the treatment nurse for the wound cultures, and the delay in sending the cultures to the lab was not in accordance with the physician's orders. This failure to act promptly and document the order led to a deficiency in the facility's care for the resident.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by not documenting an incident involving a resident. The incident occurred when a resident, who was cognitively intact with a BIMS score of 14, was hit in the head by a door opened by a nurse. The resident, who had diagnoses including anxiety disorder, fibromyalgia, and osteoarthritis, recalled the incident and stated that the door hit her head, causing her to also hit her head on the wall. However, a review of the resident's nurse's notes from the date of the incident did not reveal any documentation of this occurrence. Interviews conducted with the involved parties confirmed the incident. The Agency Licensed Practical Nurse (LPN) involved in the incident recalled opening the door and hitting the resident's food tray but was unaware that the resident's head was hit. The Director of Nursing (DON) also recalled the incident and acknowledged that the nurse should have documented it in the nurse's notes. Despite the incident being reported in the facility's Incident Report, the lack of documentation in the resident's medical records constitutes a failure to adhere to the facility's policy on charting and documentation.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as evidenced by the condition of a resident's room. The resident, who was admitted with diagnoses including Unspecified Dementia and Essential Hypertension, had a moderately intact cognitive status with a BIMS score of 10. During an observation and interview, the resident expressed concerns about the rotten wood on the back door frame of his room. The observation confirmed the presence of rotten wood on the bottom left side of the door frame, approximately one foot in height. Additionally, two breaks in the sheetrock were observed on the north wall, left side of the resident's bed. Further interviews and observations with the Maintenance Supervisor and the Administrator confirmed the poor condition of the door frame and the wall. The Maintenance Supervisor demonstrated the extent of the damage by kicking the lower portion of the door frame, causing the wood to crumble. Both the Maintenance Supervisor and the Administrator acknowledged that the door frame and the wall should not have been in such a state, indicating a failure to provide a safe and well-maintained environment for the resident.
Failure to Ensure Timely Mail Delivery on Weekends
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, which had the potential to affect 95 residents. The facility's policy stated that mail and packages would be delivered to residents within 24 hours of delivery, except on weekends and holidays. However, it was found that the facility did not receive mail from the post office on Saturdays or Sundays, as confirmed by a document dated 05/21/2024 and signed by the Administrator. During a resident council meeting, a resident voiced concerns about not receiving mail on Saturdays, stating that the Business Office did not work on weekends. An interview with the Business Office staff confirmed that the office was closed on weekends and weekend staff did not have access to retrieve the mail, which was then distributed on Mondays by the Activity Director. Further interviews revealed that the Director of Nursing was unaware of the mail delivery process on Saturdays. A call to the local post office confirmed that someone from the facility had requested that mail not be delivered on weekends, although the postal employee could not confirm who made this request or how long it had been in effect. This failure to ensure timely mail delivery on weekends was a clear deviation from the facility's policy and affected the residents' access to communication methods.
Failure to Follow Food Handling Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards by not following appropriate food handling practices. During a tour of the kitchen, expired food items were found in the walk-in cooler and dry storage area. Specifically, six unopened containers of yogurt and three unopened containers of orange jello were past their expiration dates. Additionally, several opened food items, including containers of ranch dressing, sliced jalapenos, pickles, mayonnaise, sour cream, honey mustard, lemon juice, yellow mustard, and a gallon of milk, were not labeled with the date and time they were opened. The Dietary Supervisor confirmed these items were expired and should have been discarded, and that the opened items should have been labeled with the date and time they were opened but were not. Further observations revealed two opened squeeze bottles of grape jelly on the counter that were not labeled with the date and time they were opened. In the dry storage room, several opened food items, including pasta, chocolate cake mix, bread crumbs, taco seasoning, and peanut butter, were found to be expired. Additionally, the temperature logs for the kitchen's reach-in cooler, walk-in cooler, and walk-in freezer were absent for an entire week. The Dietary Supervisor confirmed that temperatures were supposed to be checked and logged daily but were not done for the specified week.
Failure to Address Resident Respectfully
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not addressing her by her name. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 06, and multiple diagnoses including Bipolar disorder, Chronic kidney disease stage 4, and Type 2 diabetes mellitus. During observation rounds, the resident asked a CNA for some ice and was addressed as 'girl' by the CNA, which the resident found disrespectful and inappropriate given her age and preference to be called by her name. The resident expressed her dissatisfaction with being called 'girl' and emphasized her desire to be addressed by her name. The CNA involved denied speaking to the resident in a disrespectful manner. However, the Director of Nursing (DON) confirmed that the facility's goal is to make residents feel valued and cared for, and acknowledged that the resident should not have been addressed as 'girl'. The facility's policy on dignity and respect clearly states that residents should be addressed by their name of choice and not labeled, which was not adhered to in this instance.
Failure to Conduct Monthly Resident Council Meetings
Penalty
Summary
The facility failed to organize resident group meetings monthly, as required. A review of the Resident Council Meeting Binder showed that meetings were held in January and February 2024, but there were no records of meetings for March and April 2024. Interviews with the Resident Council President and three other residents confirmed that the facility had not been conducting monthly meetings. The Activity Director claimed that monthly meetings were being held but could not provide documentation to support this claim.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident diagnosed with chronic pain and acquired absence of the right leg above the knee. The resident, who had intact cognition, reported that the ceiling across from his bed was cracked, peeling, and hanging since his admission. Maintenance staff confirmed the disrepair and admitted that ceilings were not part of their routine checks, which only included call lights and beds. The maintenance supervisor corroborated this, revealing that the maintenance log only documented checks for beds and call lights.
Inaccurate MDS Assessments for Medications and Restraints
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. Resident #63's quarterly MDS assessment inaccurately indicated that the resident had received an injectable medication for one day in April 2024. However, a review of the resident's electronic Medication Administration Record (eMAR) for April 2024 showed no evidence of any injectable medication being administered. The Minimum Data Set Coordinator (MDSC) confirmed the inaccuracy after reviewing the records and was unable to recall any injectable medication given to the resident during that period. Resident #89's quarterly MDS assessment failed to accurately reflect the use of a restraint. The resident, who had diagnoses including Alzheimer's Disease and Congested Heart Failure, was observed multiple times with a lap tray in place, which was used as a restraint for poor trunk control. Despite this, the MDS assessment did not code the resident for the use of any restraints. The MDSC confirmed that the resident should have been coded for the use of a restraint, as indicated by the resident's care plan and physician orders. The failure to accurately code the use of restraints was verified through interviews and record reviews.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for Resident #198 by not ensuring she was repositioned every two hours and not providing a notebook and pen for communication. Despite the care plan indicating the need for these interventions due to her immobility and difficulty making herself understood, observations on multiple occasions revealed that Resident #198 was not repositioned as required and did not have the necessary communication tools. Staff members, including an LPN and Social Services, confirmed the absence of these items and were unaware of the resident's needs as outlined in her care plan. Additionally, the facility failed to monitor the padding on Resident #82's bedframe as required. The resident's physician's orders and MAR indicated that padding should be monitored every shift for safety. However, observations on multiple occasions showed that the padding was on the floor and not attached to the bedframe. An LPN confirmed that the padding was not intact and should have been monitored every shift, indicating a failure to adhere to the care plan and physician's orders for Resident #82.
Failure to Invite Resident and RP to Care Planning Meeting
Penalty
Summary
The facility failed to ensure that a resident and/or a resident's Responsible Party (RP) was invited to the resident's care planning meeting. This deficiency was identified for one resident out of a sample of 34, with the potential to affect a census of 95. The facility's policy stated that the interdisciplinary team is responsible for the development of resident care plans and that residents and their representatives are encouraged to participate. However, the policy also required documentation if participation was not practicable, which was not done in this case. Resident #70, who had a BIMS score of 14 indicating intact cognition, reported that he had never been invited to a care plan meeting despite expressing concerns about his catheter. The Minimum Data Set Coordinator (MDSC) confirmed that invitations were typically sent to the RP, but not to the residents, and that there was no documentation indicating that Resident #70 or his RP had been informed or had refused to attend. The RP also confirmed that she had never received an invitation to the care plan meeting.
Failure to Provide Activities Based on Care Plan
Penalty
Summary
The facility failed to ensure that activities were provided based on the care plan for a resident diagnosed with Major Depressive Disorder, Pneumonia, Cerebrovascular accident, and Adult failure to thrive. The resident's care plan included an intervention to encourage participation in at least one activity per week and to assist the resident with activities as needed. However, after the resident's return from the hospital, there was no record of the resident being engaged in any activities, and observations confirmed that the resident remained in her room while other residents participated in activities in common areas. Interviews with staff revealed that the Activity Director was not aware of the resident's return from the hospital until the day after, and the Social Services staff confirmed that the resident had not been assisted to participate in activities since her return. Prior to hospitalization, the resident was regularly up and out of her room, indicating a significant change in the resident's engagement in activities post-hospitalization. This lack of engagement in activities was not in accordance with the resident's care plan, leading to the identified deficiency.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an indwelling urinary catheter. Resident #70, who had diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Chronic Kidney Disease, was observed on multiple occasions without his catheter being properly secured to his thigh as per his care plan. The catheter bag was observed hung on the bed rail and chair below his waist, and the catheter tubing was not taped to his thigh, which was confirmed by an LPN during an interview. The resident's care plan specifically included an intervention to tape the catheter to his thigh to prevent complications such as urinary tract infections (UTIs). However, this intervention was not implemented by the nursing staff, as confirmed by the MDS coordinator who stated that all nurses have access to the care plan and are responsible for ensuring that all interventions are followed. The observations and interviews revealed that the facility did not adhere to its own policy titled 'Catheter Care, Urinary,' which aims to prevent urinary catheter-associated complications, including UTIs. The failure to secure the catheter as per the care plan indicates a lapse in following established protocols, potentially putting the resident at risk for complications. This deficiency was identified during a review of the resident's care and through direct observations and interviews with the nursing staff, highlighting a gap in the implementation of the resident's care plan and the facility's catheter care policy.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that their medication error rate was less than five percent by not administering medications at the right time for two residents during the morning medication pass. Specifically, the facility's policy allowed for medications to be administered within two hours before or after their prescribed time. However, during an observation on 05/20/2024, it was noted that medications for two residents were administered late. Resident #51 had an order for Rivastigmine 6 mg to be administered at 8 a.m. and 8 p.m., but it was given at 10:20 a.m. Resident #90 had an order for Gabapentin 100 mg to be administered twice a day, but it was given at 10:27 a.m. The errors were confirmed by the LPN during an interview. There were 32 opportunities for medication administration observed, with 2 errors noted, resulting in a calculated error rate of 6.25%. This error rate exceeds the acceptable threshold of less than five percent, as stipulated by the facility's policy. The deficient practice had the potential to affect a census of 95 residents in the facility.
Failure to Submit Accurate RN Staffing Data
Penalty
Summary
The facility failed to ensure accurate payroll data information was submitted for direct care staffing as required. The review of the facility's Payroll Base Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2024 revealed that the facility did not submit staffing data that verified 8 consecutive hours of Registered Nurse (RN) coverage during several weekend days. Specifically, the facility lacked RN coverage for 8 consecutive hours on 10/14/2023, 10/15/2023, 10/28/2023, 10/29/2023, 11/11/2023, 11/12/2023, 11/25/2023, 11/26/2023, 12/09/2023, 12/10/2023, and 12/23/2023. This deficiency was identified through data review and interviews with the facility's staff, including the Consultant Administrator, Administrator, and Office Manager, who confirmed the issue during the survey conducted on 05/20/2024. During the interview, the Office Manager stated that she had attempted to communicate with CMS to correct the missing RN hours but had no documentation or evidence of such contact. She provided the RN clock-in data for the days in question, which confirmed that an RN was not present in the facility for at least 8 hours on the flagged weekend days. The Office Manager speculated that there might have been an error with the RN's PBJ number, leading to a transmission error, but she could not specifically identify the problem. The PBJ Staffing Report 1705D marked the RN coverage data as an infraction, confirming the facility's failure to submit the required staffing data to CMS accurately.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to maintain an infection prevention and control program as evidenced by staff not removing PPE before exiting a resident's room who was on contact isolation precautions. The facility's policy required staff to wear gloves, gowns, and masks when entering the room and to remove these items before leaving. However, a housekeeper was observed exiting the room with soiled gloves and a soiled gown, which was against the facility's policy. This incident was confirmed by a Licensed Practical Nurse (LPN) who stopped the housekeeper from fully exiting the room with the soiled PPE. The resident involved had been admitted with diagnoses including Schizoaffective disorder, Bipolar disorder, and Chronic obstructive pulmonary disease, and was on contact isolation due to an Extended-spectrum beta-lactamase (ESBL) infection in the urine. The housekeeper was unaware of the requirement to change PPE each time she entered and exited the room, which was confirmed during an interview. The Director of Nursing/Infection Control Preventionist also confirmed that the housekeeper should not have exited the room with soiled PPE.
Failure to Provide Accessible Call Systems
Penalty
Summary
The facility failed to provide a functional call system for three residents, leading to deficiencies in their ability to call for assistance. Resident #37, who has a history of Type 2 diabetes mellitus, chronic kidney disease, atherosclerotic heart disease, and weakness, was observed unable to reach her call bell, which was clamped to the curtain instead of being within her reach. This was confirmed by an LPN who acknowledged that the call bell should not have been placed there. Similarly, Resident #62, diagnosed with end-stage renal disease, Type 2 diabetes mellitus, and peripheral vascular disease, was found unable to reach her call bell, which was placed in the middle of her bed. The resident expressed that she could not call for assistance to obtain a meal tray after returning from dialysis, and this was confirmed by a CNA who admitted the call bell should have been within reach. Resident #83, who suffers from acute embolism and thrombosis of unspecified deep veins of the lower extremity and major depressive disorder, was found unable to use her call bell due to her hands being contracted and clenched in a fist. The resident stated she had been hollering for help for a long time without response. A CNA confirmed that the resident was unable to use the press button call bell, and the DON also verified that the call bell was inappropriate for the resident's condition. These observations and interviews highlight the facility's failure to ensure that call systems were accessible and usable for these residents, as required by their care plans and facility policy.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents. Observations revealed multiple deficiencies across several rooms. Room A had a tan blanket, pillow, blue gloves, an adult brief, green clothing hanger, and two turn cushions on the floor. Room B and C had a white substance at the base of the faucets, with Room C's faucet leaking. Room D had a blue surgical mask and paper on the floor. Room E had paper towel, a brown cigarette bud, brown colored stains on the fall mats, a purple pillow on the floor, and a large brown stain in the corner of the room on the floor. Room F had three dresser drawers with a green and white substance on the exterior of the drawers. Room G had a towel on the floor inside the shower. Interviews with the housekeeping supervisor and an LPN confirmed that the rooms should not have paper, clothing, and soiled gloves on the floor. They also acknowledged that the faucets with the white substance and the leaking faucet should have been reported and replaced. The housekeeping supervisor added that the dresser in Room F needs to be replaced. The facility's maintenance problem document did not reveal that the faucets in Rooms B and C were in disrepair, indicating a failure in reporting and addressing maintenance issues in a timely manner.
Failure to Maintain Privacy of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure that Resident #4 was treated with respect and dignity by not keeping the urinary catheter bag contained and private. The facility's Quality of Life - Dignity policy, revised on October 4, 2022, mandates that residents be treated with dignity and respect at all times, including helping residents keep urinary catheter bags contained and private. Resident #4, who has diagnoses including Schizophrenia, Hydronephrosis with renal and ureteral calculous obstruction, and Benign prostatic hyperplasia, was observed on April 15, 2024, sitting in his wheelchair in the dining room with his urinary catheter bag uncovered. During an interview at the same time, an LPN/CNA Supervisor acknowledged that the catheter bag was uncovered and should have been in a privacy bag.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure a medication cart was locked and the medication cart keys were not left on top of the cart when left unattended and/or out of view during medication administration. On 04/16/2024 at 2:14 p.m., an LPN left her medication cart unlocked and unattended while she sat at the nurses' station talking on the telephone and with other staff. Further observation at 2:15 p.m. revealed that the LPN left the medication cart keys on top of the unlocked and unattended medication cart. An immediate interview with another LPN/CNA Supervisor confirmed that the cart should not have been left unlocked and unattended. The LPN admitted to leaving the cart unlocked and unattended with the keys on top. The Director of Nursing stated that the medication cart should be locked at all times when the nurse was not administering medications and that the keys should not have been left on top of an unattended medication cart.
Failure to Ensure Proper Laundry Processing
Penalty
Summary
The facility failed to properly process potentially contaminated resident clothing and linens, leading to a deficiency in producing sanitary laundry and preventing the transmission of communicable diseases. During an observation in the laundry room, it was found that one of the washing machines had its detergent dispenser hose disconnected, which meant that detergent was not being dispensed during wash cycles. This issue was confirmed by the Housekeeping Supervisor, who acknowledged that the hose should have been connected for proper washing. The Laundry Staff also admitted to using the machine for multiple loads of laundry without the detergent dispenser hose being connected, indicating a lack of awareness about the necessity of the hose for proper detergent dispensing. The facility's policies on laundry processing were reviewed and found to be lacking in specific dates, which could contribute to the oversight. The Laundry Staff reported seeing the disconnected hose since the previous day and continued to use the machine without detergent, further exacerbating the issue. This failure to ensure proper laundry processing procedures compromised the sanitary condition of the residents' clothing and linens, potentially increasing the risk of communicable disease transmission among the 98 residents in the facility.
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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