High Hope Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sulphur, Louisiana.
- Location
- 475 High Hope Road, Sulphur, Louisiana 70663
- CMS Provider Number
- 195601
- Inspections on file
- 17
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at High Hope Care Center during CMS and state inspections, most recent first.
A facility failed to provide quarterly statements for a resident’s personal funds account. The resident was her own RP, had a BIMS score of 13, and stated she had personal funds at the facility but had never received a quarterly statement. A staff member said statements were hand delivered to residents who were their own RP, but could not confirm this resident actually received one.
Inaccurate PASARR Level II Coding on MDS Assessments: The facility failed to accurately code PASARR Level II status on MDS assessments for two residents. One resident had psychosis, depression, and anxiety, and another had anxiety, schizophrenia, and intellectual disabilities; both had PASRR Level II determinations in the EMR, but their comprehensive MDS assessments were coded as not indicated. The MDS staff member confirmed the coding errors and stated she had not been aware of or used the PASRR documentation to verify status.
An unlocked med cart was left unattended in a hallway during a med pass, with no nurse in sight and the drawers accessible. The cart contained residents' medications and biologicals, and an LPN later confirmed it was unlocked and out of view after stepping away from it.
Improper Food Storage and Unsanitary Kitchen Surfaces: Bulk dry goods, juices, and snack items were stored in the kitchen without delivery, opening, expiration, or use-by dates. In addition, a rack used for meal covers and a food prep table had grime and water stains, and the kitchen supervisor and ADM confirmed the findings.
A laundry staff member was observed sorting visibly soiled resident laundry without wearing a disposable gown, despite facility policy requiring PPE, including gloves and gowns, when handling contaminated linens. The laundry supervisor and infection preventionist both confirmed that a disposable gown was required for this task.
A resident was transferred to a hospital in an emergency, but the facility did not notify the State's LTC Ombudsman in writing as required. The Social Services Director confirmed the omission after reviewing records, and no policy for Ombudsman notification was provided when requested.
A facility failed to document post-treatment vital signs for a resident requiring dialysis, as mandated by their policy. Despite having a policy in place for hemodialysis care, the facility did not ensure proper documentation on multiple occasions, as confirmed by an LPN and the DON. This oversight indicates a lapse in adhering to professional standards of practice for dialysis care.
A facility failed to refer a resident with a new diagnosis of schizoaffective disorder for a Level II PASARR evaluation. Initially, a Level I PASARR determined no further evaluation was needed, but after the resident's psychiatric hospitalization and new diagnosis, the facility did not submit the required referral, as confirmed by the social worker.
Failure to Provide Quarterly Statements for Resident Personal Funds
Penalty
Summary
The facility failed to provide quarterly statements for resident personal funds accounts for 1 of 5 residents reviewed for personal funds. Resident #17 was admitted on 08/10/2023 with diagnoses including major depressive disorder, panic disorder, and sleep apnea, and was her own responsible party. Her MDS assessment showed a BIMS score of 13, indicating she was cognitively intact. During an interview, Resident #17 stated she had personal funds in an account at the facility and reported that she had never received a quarterly statement since being at the facility. A staff member responsible for sending quarterly statements stated that if a resident was their own RP, the statement would be hand delivered to the resident and confirmed Resident #17 was her own RP and received a hand delivered statement quarterly, but could not confirm that Resident #17 actually received a quarterly statement. There was no evidence presented prior to exit of the survey that the resident had received quarterly statements.
Inaccurate PASARR Level II Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessments related to PASARR Level II determinations for 2 of 3 residents reviewed. Resident #7 was admitted with diagnoses including unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent severe without psychotic features, and generalized anxiety disorder. The EMR contained a PASRR Level II Evaluation Summary and Determination with an issue date of 09/30/2024, but the comprehensive MDS assessment with an ARD of 05/15/2025 coded the PASARR Level II status as not indicated. Resident #58 was admitted with diagnoses including anxiety disorder due to known physiological condition, schizophrenia, and unspecified intellectual disabilities. The EMR contained a PASRR Level II Evaluation Summary and Determination effective 02/13/2026 through 08/14/2026, but the comprehensive MDS assessment with an ARD of 02/24/2026 also coded the PASARR Level II status as not indicated. During interview, the MDS staff member responsible for assessments stated she was unaware of Resident #7's Level II PASARR status and confirmed that Resident #7's MDS was coded incorrectly; she also reviewed Resident #58's PASRR documentation and confirmed the resident had a Level II determination, stating she had not previously used that documentation to verify PASARR status and confirmed the MDS was coded inaccurately.
Unlocked Medication Cart Left Unattended During Medication Pass
Penalty
Summary
The facility failed to ensure drugs and biologicals remained stored in locked compartments during a medication pass when 1 medication cart was left unattended and unlocked. Review of the facility's Medication Storage policy on 03/18/2026 stated that all drugs and biologicals are to be stored in locked compartments and that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart. On 03/17/2026 at 2:51 p.m., Med Cart A was observed midway down the Hall W hallway with no nurse in sight. The cart was positioned with the front facing the center of the hallway, allowing access to the drawers, and the locking mechanism indicated it was unlocked. The drawers were opened successfully and contained residents' medications and associated biologicals. S8LPN later appeared from a nearby resident's room and confirmed the cart was unlocked and not within sight when she stepped away from it.
Improper Food Storage and Unsanitary Kitchen Surfaces
Penalty
Summary
The facility failed to store food in accordance with professional standards in the kitchen. During a tour of the dry food storage area, bulk containers labeled flour, fish fry, and rice were observed without dates showing when they were delivered, opened, placed into the containers, or their use-by dates. In the same area, seven 710-ounce liquid containers were observed without use-by, expiration, or delivery dates, including three concentrated orange juices, one concentrated apple juice, and three concentrated cranberry juices. A drawer containing crackers and snack packs was also observed without use-by dates, including 72 wheat cracker snack packs, 82 cheese crackers, and 87 snack packs. The kitchen supervisor stated the items should have been dated when removed from the original boxes, but the original boxes were no longer available. The facility also failed to maintain sanitary conditions on kitchen equipment and storage surfaces. A two-shelf metal rack used to store hard plastic meal covers had brown grime around the legs and white water stains on the bottom shelf, and the kitchen supervisor confirmed the findings. The bottom shelf of a metal food preparation table also had a buildup of grime around the legs, with hamburger buns stored in a plastic bag inside a hard plastic container on the shelf. The kitchen supervisor stated the prep table should not have been in that condition and that staff should have cleaned the rack and equipment according to the cleaning schedule. The administrator was informed of the kitchen findings and confirmed them.
Failure to Use Required PPE When Sorting Soiled Laundry
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when laundry staff failed to wear required PPE while sorting visibly soiled resident laundry. Facility policy titled "Laundry and Bedding, Soiled" stated that hand hygiene products and appropriate PPE, including gloves and gowns, are available and used while sorting and handling contaminated linens. During a tour of the laundry room, a laundry staff member was observed sorting visibly soiled laundry from residents without wearing a disposable gown, and he acknowledged that the laundry was soiled and that a disposable gown should have been worn. The housekeeping and laundry supervisor confirmed that the staff member was handling contaminated resident laundry and should have been wearing a disposable gown as part of his PPE. The infection preventionist also validated that facility protocol required staff to wear PPE, including disposable gowns, when sorting resident soiled laundry.
Failure to Notify Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to notify the State's Long-Term Care Ombudsman in writing of an emergency transfer for one of three sampled residents reviewed for transfer and discharge requirements. Record review showed that a resident was admitted to the facility and subsequently had an emergency transfer to a local hospital. Examination of the facility's Ombudsman notification list for emergency transfers during the relevant period revealed that this resident's transfer was not included, and there was no evidence that the Ombudsman had been notified as required. The Social Services Director, who was responsible for maintaining the accuracy of the Ombudsman notification list, confirmed during interview and record review that the emergency transfer had occurred and was not reported. Additionally, when requested, the facility did not provide a policy regarding notification of the Ombudsman for emergency transfers by the time of exit.
Failure to Document Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. Specifically, the facility did not collaborate effectively with the dialysis provider through the use of dialysis communication forms. The facility's policy on hemodialysis, last reviewed in January 2025, mandates that residents receive care and services for hemodialysis consistent with professional standards, including ongoing assessment and monitoring for complications before and after dialysis treatments. However, a review of the medical records for a resident with end-stage renal disease, among other diagnoses, revealed that post-treatment vital signs were not documented on multiple occasions between November 2024 and February 2025. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the nursing staff is responsible for assessing and documenting the resident's vital signs before and after hemodialysis treatment. Upon reviewing the resident's dialysis communication binder, both staff members acknowledged that the documentation of vital signs was incomplete. This lack of documentation indicates a failure to adhere to the facility's policy and professional standards of practice for dialysis care, potentially impacting the resident's health monitoring and care coordination with the dialysis provider.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASARR evaluation. The deficiency involved a resident who was initially admitted with diagnoses including recurrent major depressive disorder and anxiety disorder. A Level I PASARR conducted in February 2022 determined that a Level II evaluation was not required at that time. However, the resident was later admitted to an inpatient psychiatric hospital in July 2023 and discharged back to the facility with a new diagnosis of schizoaffective disorder. Despite the new diagnosis, the facility did not submit a Level II PASARR to the state-designated authority as required by their policy. This oversight was confirmed during a record review with the facility's social worker, who acknowledged that the necessary referral had not been made following the resident's new diagnosis. The failure to coordinate the assessment with the PASARR program and refer the resident for a Level II evaluation constitutes the deficiency identified in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
