Heritage Manor West
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 7060 Cottonwood Blvd, Shreveport, Louisiana 71129
- CMS Provider Number
- 195447
- Inspections on file
- 19
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Heritage Manor West during CMS and state inspections, most recent first.
Failure to follow PEG tube med timing order. A resident with severe cognitive impairment, dysphagia, malnutrition, and a PEG tube had an order for Carafate 1 gm to be given 30 minutes before bolus TF. During observation, an LPN administered the Carafate at the same time as the Isosource 1.5 bolus feeding, and later confirmed the timing.
Failure to provide nail care for a resident with severe cognitive impairment and significant neurologic diagnoses. Observations showed the resident’s fingernails on both hands had grown over the nail bed, and the ADON confirmed the nails needed to be trimmed.
A resident with ESRD and dependence on renal dialysis had an order for hemodialysis three times weekly and a severely impaired BIMS score. The facility failed to complete the dialysis communication sheet for multiple treatments and failed to complete it upon the resident’s return from dialysis on several occasions. An LPN and the DON confirmed the forms should have been completed with each dialysis treatment and were not.
Failure to provide bed hold policy at transfer. The facility did not document that a resident or the resident's representative was given the bed hold notice when the resident was transferred to the hospital. The resident had multiple serious diagnoses, including aneurysm, GI hemorrhage, anemia, COPD, pulmonary edema, and CHF, and the DON confirmed there was no record that the policy was provided during the hospital transfers.
The facility failed to transmit a resident’s discharge MDS assessment to the State within the required timeframe. Record review showed the resident was admitted, later expired and was discharged, and the discharge MDS was signed but not transmitted until after the required 7-day window. The MDS Nurse and Medicare Case Manager both confirmed the late transmission and that it should have been completed earlier.
A resident with dementia and severely impaired cognition had a care plan that still listed a wander/elopement alarm on the left ankle even though the alarm had been removed after an elopement assessment. An RN confirmed the plan was not updated to reflect the change, and the DON agreed the care plan should have been revised.
A resident's narcotic record was not maintained and reconciled when an LPN administered Pregabalin 25 mg but failed to sign it out on the resident's Individual Narcotic Record. During observation, the documented count was 47 while the actual count on the narcotic card was 46, and the LPN confirmed the medication should have been signed out at the time of administration.
A hallway handrail on Hall A was observed without an end cap, leaving a sharp metal piece exposed, and it was not secured to the wall. An S9 service tech confirmed the issue, and the DON later confirmed the handrail should have been repaired.
The facility failed to maintain a clean and sanitary environment for two residents. A resident's wheelchair was found with dried food residue, which was supposed to be cleaned by night shift CNAs. Another resident's restroom had brown stains and splash spots, which were confirmed by housekeeping staff to have not been cleaned daily as required.
A facility failed to implement a care plan by not ensuring a resident's lab work was completed as ordered. The resident, with multiple diagnoses including Alzheimer's and vascular dementia, had a CBC ordered, but the specimen clotted and was not re-drawn. The DON confirmed the lab work was not done.
A resident with diabetes and other chronic conditions reported a black spot on her foot, but the facility failed to provide necessary care. Despite informing the wound care nurse, no action was taken, and the resident was not scheduled to see the podiatrist. The LPN was unaware of the issue, and the CNA reported it without follow-up. This led to a deficiency in care for the resident's foot condition.
A resident with a history of intracranial hemorrhage and requiring total assistance developed a stage 2 pressure ulcer due to the facility's failure to reposition him regularly. Despite having a care plan with interventions like a pressure-relieving mattress, the resident was observed on his back for extended periods, and staff confirmed he had not been repositioned or out of bed as needed.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe. The discharge MDS was dated but still in progress and untransmitted, as confirmed by the Nurse Case Manager.
The facility failed to properly label and change enteral feeding bags for residents with gastrostomy status, as observed in three cases. A resident's feeding bag was not labeled with necessary information, and another resident's bag was reused without being changed for several days. LPNs acknowledged these deficiencies, which were against the facility's policy.
The facility failed to maintain proper nail hygiene for two residents requiring total assistance. One resident, in a persistent vegetative state, and another with cognitive deficits, both had long fingernails. LPNs acknowledged the need for trimming, highlighting a lapse in providing necessary daily living assistance.
Failure to Follow PEG Tube Medication Timing Order
Penalty
Summary
Resident #87 had diagnoses including moderate protein-calorie malnutrition, dysphagia, oropharyngeal phase, encounter for attention to gastrostomy, and pneumonitis due to inhalation of other solids and liquids. Physician orders dated 11/05/2025 directed Carafate 1 gm via PEG tube four times daily for anemia, to be given down the tube 30 minutes prior to bolus feeding, and tube feeding formula orders dated 09/15/2025 directed Isosource 1.5 carton bolus twice daily via PEG tube. Review of the quarterly MDS dated 02/03/2026 showed the resident had a BIMS score of 4 out of 15, indicating severely impaired cognition. During observation on 03/10/2026 at 11:10 a.m., an LPN administered Carafate 1 gm at the same time as the Isosource 1.5 bolus feeding, and during interview on 03/10/2026 at 1:50 p.m., the LPN confirmed the medication was given at the time of the bolus feeding.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to complete activities of daily living received necessary grooming services, specifically nail care. The resident had diagnoses including dysphagia following cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and dementia, and the quarterly MDS assessed the resident with a BIMS score of 03 out of 15, indicating severely impaired cognition. During observations, the resident’s fingernails on the right hand were noted to have grown over the nail bed, and a later observation with the ADON showed the fingernails on the left hand had also grown over the nail bed. The ADON confirmed that the fingernails had grown over the nail bed and needed to be trimmed.
Dialysis Communication Forms Not Completed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident with end stage renal disease and dependence on renal dialysis by not communicating and collaborating with the dialysis facility and by not monitoring the resident for complications after each dialysis treatment. Resident #5 had an order for hemodialysis on Monday, Wednesday, and Friday at 9:30 a.m. and had a BIMS score of 04 out of 15, indicating severely impaired cognition. Review of the dialysis communication forms for February 2026 showed that the forms were not completed at all on 02/04/2026, 02/06/2026, 02/09/2026, and 02/13/2026, and were also not completed upon the resident's return from dialysis on 02/16/2026, 02/18/2026, 02/23/2026, and 02/25/2026. An LPN reviewed the forms and confirmed they should have been completed with each dialysis treatment and were not, and the DON also confirmed the forms should have been completed on each dialysis treatment and were not.
Failure to Provide Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to provide Resident #16 and the resident's representative with the facility bed hold policy at the time of transfer to the hospital, as required for one of two residents reviewed for hospitalization. The facility's Bed Hold Policy stated that when a resident is transferred to the hospital or goes out on therapeutic leave, bed hold notice information is to be provided to the resident, including the duration of the bed-hold according to the state plan and the facility's bed-hold policy, and that in an emergency transfer the written notice must be provided within 24 hours. Resident #16 was admitted on 09/04/2025 and later re-entered on 10/20/2025 with diagnoses including non-ruptured cerebral aneurysm, gastrointestinal hemorrhage, iron deficiency anemia, COPD, acute pulmonary edema, and chronic systolic CHF. The resident's MDS showed hospital discharges in February 2026, and during interview the DON reviewed the record and confirmed there was no documentation that Resident #16 or the responsible party was informed of the facility's bed hold policy at the time of transfer on [DATE] and 02/19/2026.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident #48's assessment data were transmitted to the State within 7 days of assessment. Record review showed the resident was admitted on [DATE], later expired and was discharged on [DATE], and had a discharge MDS assessment with a signed date of [DATE]. During interviews on [DATE] at 8:10 a.m., the MDS Nurse reported that Resident #48 was discharged on [DATE] and that the discharge MDS assessment was not transmitted until [DATE]. The Medicare Case Manager confirmed that the discharge MDS assessment was not transmitted until [DATE] and stated that it should have been completed by [DATE].
Failure to Update Care Plan After Elopement Alarm Removal
Penalty
Summary
The facility failed to revise Resident #14’s plan of care after a change in condition when the resident’s wander/elopement alarm was removed. Resident #14 was admitted on 07/19/2022 with diagnoses including dementia in other diseases, unspecified anxiety disorder, and Alzheimer’s disease, and the Quarterly MDS showed a BIMS score of 6, indicating severely impaired cognition. The comprehensive care plan still listed a wander/elopement alarm on the left ankle as an intervention, but during observation on 03/11/2026 the resident did not have the alarm in place. An RN Medicare Case Manager stated that an elopement assessment had been completed the prior week and the alarm was removed, and she confirmed the care plan was not updated to reflect that removal. The DON also confirmed the care plan should have been revised to reflect the change.
Narcotic Record Not Signed Out for Administered Medication
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure a resident's narcotic record was maintained and reconciled for 1 resident reviewed. The facility's Drug-Controlled Substances Policy dated 09/2025 stated that controlled medications are to be signed out on the Individual Resident Narcotics Record at the time they are administered. During observation on 03/11/2026 at 9:05 a.m. with an LPN, the resident's Individual Narcotic Record for Pregabalin 25 mg showed a documented count of 47, while the actual count on the narcotic card was 46. In interview at that time, the LPN stated she had given the resident Pregabalin but failed to sign it out on the resident's Individual Narcotic Record and confirmed it should have been signed out at the time of administration.
Incomplete and Unsecured Hallway Handrail
Penalty
Summary
The facility failed to ensure all corridors were equipped with a complete and secure handrail. On Hall A, the handrail was observed without an end cap, leaving a sharp metal piece exposed, and it was not secured to the wall. A service technician confirmed the handrail was missing the end cap and was unsecure, and the administrator later confirmed the Hall A handrail should have been repaired.
Failure to Maintain Clean and Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents. Resident #15's wheelchair was observed to have dried white food residue on the seat, armrest, and right wheel. This residue was confirmed by the Assistant Director of Nurses (ADON) to be a buildup from the resident spitting, and it was noted that the certified nursing assistants on the night shift were responsible for cleaning the wheelchair but had not done so. Resident #80's restroom was found to be unclean, with brown-colored splash spots on the wall next to and behind the toilet, as well as brown stains on the toilet seat and inside the toilet. The housekeeper confirmed that the restroom was supposed to be cleaned daily but had not been. The Housekeeping Supervisor also confirmed that the restroom was not cleaned daily as it should have been.
Failure to Complete Ordered Lab Work for Resident
Penalty
Summary
The facility failed to implement a complete care plan for a resident, specifically by not ensuring that the resident's lab work was conducted as ordered. The resident, who was admitted with multiple diagnoses including Alzheimer's disease, moderate protein calorie malnutrition, and vascular dementia, had a physician's order for a Complete Blood Count (CBC) to be performed. However, the medical record did not contain the results of the CBC, as the specimen had clotted and the facility did not follow up to ensure the lab was re-drawn. This oversight was confirmed by the Director of Nurses during an interview, acknowledging that the lab work was not completed as ordered.
Failure to Address Resident's Foot Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a diagnosis of diabetes, peripheral vascular disease, and other chronic conditions, specifically regarding a skin condition on her foot. The resident, who had intact cognition, reported a black spot on her right foot to the wound care nurse multiple times, but no action was taken. An observation confirmed the presence of a black spot on the resident's right great toe. The LPN was unaware of the issue, and the CNA reported noticing the black spot and informing the wound care nurse. Despite the presence of a podiatrist who visits the facility, the resident was not scheduled for an appointment. The Social Service Director confirmed that no nurses had requested the resident to be added to the podiatrist's schedule. A nurse practitioner's notes indicated a toenail injury with fungus, but there was no evidence of further action taken to address the resident's foot condition. This lack of response and coordination among the staff led to the deficiency in care for the resident's foot condition.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide preventive care and treatment consistent with professional standards for a resident at risk of developing pressure injuries. The resident, who was previously independent, was admitted to the facility after treatment for an intracranial hemorrhage and required total assistance with feeding, bed mobility, incontinent care, and transfers. Despite having a care plan that included interventions such as a pressure-relieving mattress and cushion, daily observation for infection, and weekly wound evaluations, the resident developed a stage 2 pressure ulcer on the right gluteus, which was acquired in the facility. Observations revealed that the resident was not repositioned as required, remaining on his back for extended periods despite a posted turning schedule. Interviews with the resident and staff confirmed that the resident had not been out of bed or repositioned regularly, and there was no documentation of the resident refusing care. The wound care nurse indicated that the resident could be moved with a two-person assist using a lift, yet this was not done, contributing to the development of the pressure ulcer.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe. Specifically, the discharge MDS for a resident was dated but remained in progress and had not been transmitted. This was confirmed during an interview with the Nurse Case Manager, who acknowledged that the MDS should have been transmitted.
Failure to Properly Label and Change Enteral Feeding Bags
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with enteral feeding tubes, as evidenced by the lack of proper labeling and timely changing of feeding bags. Resident #2, diagnosed with mild protein calorie malnutrition and gastrostomy status, had an enteral feeding bag that was not labeled with the resident's name, date, time, formula, and nurse initials, as observed on December 9, 2024. The LPN acknowledged the absence of labeling, which was against the facility's policy. Similarly, Resident #4, with diagnoses including dysphagia and moderate protein-calorie malnutrition, had an enteral feeding bag with a torn label and dates from December 6 and 7, 2024, indicating the bag had not been changed since then. The LPN confirmed the bag was reused and lacked proper labeling. Resident #5, with a history of dysphagia and moderate protein-calorie malnutrition, also had an unlabeled enteral feeding bag. The LPN acknowledged the missing labels, which should have included the resident's name, date, time, formula, and nurse initials, as per the facility's policy.
Failure to Maintain Nail Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living for two residents, specifically in maintaining proper nail hygiene. Resident #2, who was admitted with a diagnosis of cerebral infarction and hemiplegia affecting the right dominant side, was observed to have long fingernails on both hands. This resident's MDS assessment indicated a persistent vegetative state and a requirement for total assistance. During an interview, an LPN acknowledged the need for the resident's nails to be trimmed. Similarly, Resident #5, admitted with hemiplegia and a cognitive communication deficit, was also observed to have long fingernails on both hands. An LPN confirmed that the resident's nails were long and should be trimmed. These observations indicate a failure by the facility to ensure that dependent residents received appropriate care for their daily living needs.
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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