Highland Place Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 1736 Irving Place, Shreveport, Louisiana 71101
- CMS Provider Number
- 195350
- Inspections on file
- 32
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Highland Place Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with chronic pain did not receive scheduled Morphine due to failures in medication refill and communication processes. Nursing staff did not follow up with the pharmacy or escalate the issue when the medication ran out, resulting in the resident missing three consecutive doses, experiencing severe pain, and requiring transfer to the ER after alternative pain medications proved ineffective.
Two residents with PICC lines did not have care plans addressing their IV antibiotic administration, and one resident did not receive IV antibiotics as ordered, with missed doses confirmed by the DON. Another resident did not receive restorative nursing services as ordered, as staff failed to place the resident on the restorative schedule.
A resident with a PEG tube was observed receiving continuous enteral feeding while lying flat, despite physician orders and facility policy requiring the head of bed to be elevated 30-45 degrees during feeding. Facility leadership confirmed the resident was not positioned correctly at the time of observation.
A resident with a documented preference for white meat chicken was served dark meat during a meal, despite staff being aware of this preference and it being clearly listed on the meal card. Staff and dietary management acknowledged the error and confirmed the resident's preference was not honored.
A resident with Type 2 diabetes did not receive care according to physician orders, including missed blood glucose rechecks after high readings, failure to perform required glucose checks before insulin administration, lack of physician notification for elevated glucose levels, and missed doses of prescribed Lantus insulin. These deficiencies were confirmed through record review and by the DON.
A resident with a gluteal cleft pressure injury did not receive wound care as recommended by a wound NP, as the new treatment orders were not started until more than two weeks after being documented. The delay was due to a misunderstanding by the treatment nurse, who did not initiate the updated care regimen as ordered.
A resident's grievance about delayed call light response was not resolved by the facility. The resident, with intact cognition but physical limitations, experienced long waits for assistance after being incontinent. Despite filing a grievance, neither the resident nor their responsible party received a review of the grievance. Observations confirmed the call light was ignored, and staff interviews revealed the grievance was not communicated back, indicating a failure in the grievance resolution process.
A resident with PTSD was subjected to sexual abuse by another resident who exposed himself and made unwanted advances. The facility failed to separate the perpetrator from the victim and other residents, and staff did not provide immediate protection or support. The incident was not reported to the administration until hours later, indicating a failure in communication and adherence to abuse prevention policies.
A resident was subjected to inappropriate behavior by another resident, including exposure and physical contact, without immediate intervention from facility staff. The administration was not informed until hours later, and the aggressor remained in the shared room without supervision. Interviews revealed a lack of documentation and adherence to the abuse/neglect policy, highlighting a significant lapse in procedures.
A resident with a post-surgical wound experienced unmanaged pain due to the facility's failure to provide appropriate pain management. Despite requesting Tylenol, the LPN on duty informed the resident that no pain medication could be administered due to prescription issues. The resident, experiencing significant pain, called 911 and was admitted to the hospital ER, where she received Dilaudid for acute pain. The facility's pain management policy did not adequately address the administration of pain medication, leading to this deficiency.
A resident with paraplegia and PTSD reported an incident of sexual abuse by another resident, which was captured on video. The facility's ADON was informed but failed to report the incident to the Administrator or state agency within the required timeframe, violating the facility's abuse prevention policy.
A facility failed to thoroughly investigate a sexual abuse allegation involving two residents. A resident reported inappropriate behavior by another resident, supported by video evidence. The investigation was insufficient as the administrator only interviewed staff not present during the incident, contrary to the facility's policy.
A facility failed to document a physician's discharge order for a resident with severe cognitive impairment and multiple diagnoses, including chronic viral hepatitis C. The ADON admitted to misplacing the verbal order and acknowledged the lack of a system for handling verbal orders.
A facility failed to provide transportation for a resident with metastatic cancer to attend scheduled medical appointments, including a lab, oncology visit, and chemotherapy infusion. Despite the facility's policy requiring transportation arrangements, there was no documentation of the resident being transported or attending the appointments, nor any record of refusal. Interviews with staff confirmed the absence of documentation and transportation.
A resident admitted with multiple fractures and hemorrhages had a care plan that was not updated to reflect their improved condition. Despite a July MDS assessment showing cognitive intactness and reduced need for assistance, the care plan still included outdated interventions. Interviews in October revealed the resident was independently performing tasks and had stopped using prescribed devices. The MDS Director acknowledged the care plan should have been revised.
A facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers. Despite being care planned for potential skin integrity issues, the facility did not perform an accurate assessment or notify the MD/NP of the resident's skin condition. Inconsistent assessments by staff led to a lack of attention to the resident's sacral area, potentially worsening the condition.
The facility failed to implement a comprehensive care plan for two residents. One resident did not receive prescribed doses of Keflex due to a lack of communication with the pharmacy, while another resident's care plan was not updated after multiple falls, despite requiring extensive assistance. The DON acknowledged these oversights.
A facility failed to notify a resident's responsible party about a change in medical condition, specifically the initiation of antibiotics for a urinary tract infection. The facility's policy mandates prompt notification of changes, but records lacked documentation of such communication. Interviews with staff, including an LPN and the DON, confirmed the oversight.
A resident with multiple health conditions, including quadriplegia and acute kidney failure, was observed with a urinary catheter drainage bag improperly positioned, with the drain port tubing touching the floor. This was against the facility's CAUTI prevention guidelines, which require the drainage bag to be kept below the bladder level and off the floor. An LPN confirmed the improper positioning, highlighting a failure in adhering to catheter care protocols.
A facility failed to obtain informed consent and a physician's order for bed rail use for a resident with severe cognitive impairment and multiple diagnoses. Despite the facility's policy requiring these steps, the resident's medical records lacked the necessary documentation. Interviews with staff confirmed the presence of bed rails without the required consent and order, highlighting a breach in protocol.
The facility did not ensure that a CNA completed the required annual training on abuse and dementia care. The CNA's personnel record showed the last training was completed over a year ago, contrary to the facility's policy requiring annual training. This was confirmed during an interview with the Staff Development Coordinator, who acknowledged the lack of documentation for the required training.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to request assistance. One resident's call light was found on the ground, inaccessible, while another's was wrapped around a bed wheel, also out of reach. The DON confirmed these deficiencies during interviews.
The facility failed to address ongoing concerns about the laundry service, as reported by residents over several months. Multiple residents experienced issues with missing or incorrectly returned clothing, leading some to have their families handle laundry instead. Staff interviews revealed a lack of a structured laundry schedule and issues with clothing being returned to incorrect rooms, contributing to the problem. Despite acknowledging these issues, the facility did not take prompt action to resolve the concerns.
The facility failed to develop and implement care plans for two residents diagnosed with UTIs. One resident, with a history of chronic conditions, did not have a care plan for their UTI despite having a physician's order for Keflex. Another resident, with multiple health issues, also lacked a care plan for their UTI and was not administered Doxycycline and Acidophilus as ordered. These deficiencies were confirmed by facility staff.
A resident experienced a 13.32% weight loss over three months while being NPO and on PEG tube feedings. The facility failed to revise the care plan to include a dietician consult and weekly weight monitoring, despite the DON acknowledging the weight loss exceeded concern thresholds.
The facility failed to maintain grooming and hygiene for several residents, including untrimmed nails and missed baths. A resident with diabetes had long fingernails despite a care plan for podiatrist monitoring. Another resident with Alzheimer's had dirty nails not cleaned during bathing. A resident with cerebral infarction had jagged nails, and a resident with depressive disorder had a cracked nail unaddressed for days. A resident with mobility issues had long toenails causing discomfort, and another resident reported not receiving scheduled baths, confirmed by missing records.
A resident with a history of blood clots and cellulitis did not receive prescribed ted hose for edema, as they had not arrived from the supplier. Observations confirmed the absence of ted hose on the resident's swollen legs. Additionally, the facility failed to monitor the resident for edema while on diuretics, and the care plan did not address edema. Staff interviews confirmed these oversights, highlighting a failure to adhere to physician orders and care planning.
A resident with a complex medical history and multiple pressure ulcers was readmitted to the facility without timely wound care treatment orders. The facility delayed obtaining and implementing these orders for several days, as confirmed by interviews with the RN/Unit Manager and DON.
The facility failed to conduct quarterly Registered Dietician assessments for a resident receiving tube feeding, with the last documented assessment being in 2021. Additionally, another resident's monthly weights were not recorded in the EHR for two months, despite a policy requiring monthly documentation. The resident had a history of cerebrovascular disease and was on enteral feeding, with a potential weight loss noted.
The facility failed to properly label tube feeding formulas for two residents, omitting the time the feeding was hung, as required by their procedure. This deficiency was confirmed by an LPN during observations.
The facility failed to maintain proper respiratory care and equipment maintenance for residents, as observed in four cases. Equipment such as oxygen concentrators, nebulizers, and masks were not cleaned, labeled, or stored according to facility policy, affecting residents with chronic respiratory conditions. These deficiencies were confirmed by staff interviews.
The facility did not meet the required staffing levels on three weekends during the first fiscal quarter of 2024. On two specific dates, the facility provided fewer hours than required, as confirmed by the Interim Administrator/Regional MDS.
The facility failed to monitor two residents for adverse effects related to their medications. A resident on Lasix and Eliquis was not monitored for edema, bleeding, or bruising, while another resident on Lasix was not monitored for edema. Staff acknowledged the lack of required documentation for these conditions.
The facility failed to ensure the QAA Committee met quarterly, as required. A review of meeting records showed no evidence of quarterly meetings since the last annual survey. During an interview, the Administrator and Regional Director of Clinical Operations admitted they could not provide documentation of the required meetings. This deficiency potentially affected 189 residents.
The facility failed to ensure proper infection control practices and program maintenance. A resident on contact isolation for C-diff was not properly identified, and a CNA did not use the required PPE during care. Additionally, the facility did not maintain infection control tracking and trending for several months, as confirmed by the Infection Preventionist.
The facility did not ensure secure handrails on Hall W, affecting 31 residents. Observations showed a handrail near the exit door lacked an end cap, exposing a sharp edge and a crack. A CNA noted the handrail had been broken for months, and the Maintenance Supervisor confirmed it should have been repaired.
A facility failed to accurately document a resident's discharge status in the MDS assessment. The resident was discharged to another LTC facility, but the MDS incorrectly indicated a discharge to a hospital. This error was confirmed by the RN/MDS Director during a record review.
Failure to Provide Scheduled Pain Medication Resulting in Uncontrolled Pain and Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with chronic pain and multiple medical conditions, including spinal cord injury and chronic pain syndrome, did not receive scheduled Morphine Sulfate as ordered for pain management. The resident's physician had prescribed Morphine 30 mg, two tablets by mouth every eight hours, but the facility ran out of this medication. The last documented dose was administered in the afternoon, after which three consecutive scheduled doses were missed. During this period, the resident experienced severe pain, including a headache and nausea, and reported that alternative pain medications such as oxycodone-acetaminophen and Tylenol were ineffective. The breakdown in medication administration was due to failures in the facility's refill and communication processes. Nursing staff identified that the resident was running low on Morphine and faxed refill requests to the physician. Although the physician indicated that a hard copy prescription was sent to the pharmacy, there was no confirmation that the pharmacy received the request, and the medication was not delivered. Nursing staff did not follow up with the pharmacy as instructed, nor did they escalate the issue to the Unit Manager, DON, or Administrator in a timely manner. The Unit Manager and other staff were aware that the resident was out of Morphine but did not take further action to resolve the situation or notify higher-level staff. As a result, the resident missed three consecutive doses of scheduled Morphine, experienced uncontrolled pain, and ultimately required transfer to the emergency room for severe headache, nausea, and ineffective pain control. Interviews with staff and review of documentation confirmed that the facility failed to ensure the resident received pain medication as ordered, and that communication and follow-up procedures were not properly executed, directly resulting in actual harm to the resident.
Failure to Develop and Implement Care Plans for PICC Line Management and Physician-Ordered Services
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the use of PICC lines for two residents who were admitted with these devices for IV antibiotic administration. Record reviews showed that neither resident had a care plan problem or approaches documented for the management of their PICC lines, as confirmed by the MDS Director. One resident had a PICC line in the left arm, while the other had a PICC line initially in the left jugular vein, later replaced in the right upper inner arm. Both residents' care plans lacked documentation regarding the use and management of these lines for IV antibiotics. Additionally, the facility failed to administer IV antibiotics as ordered for one resident, with medication administration records missing documentation for specific doses. The resident reported not receiving the antibiotics as prescribed, and the DON confirmed the missed doses. Another resident did not receive restorative nursing services as ordered by the physician, with staff interviews revealing that the resident was not placed on the restorative schedule, resulting in the omission of required care. These failures were confirmed through staff interviews and record reviews.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube was observed receiving enteral feeding while lying flat in bed, contrary to physician orders and facility policy. The facility's policy and the resident's care plan both required the head of the bed to be elevated 30-45 degrees during tube feeding and for one hour after feeding. The resident, who had a history of traumatic brain injury and was rarely or never understood, was found supine with the feeding pump infusing, and the head of the bed was not elevated as required. Record review confirmed that the physician's orders specified continuous enteral feeding with the head of bed elevated, and this was also documented in the care plan. During the observation, facility leadership, including the DON and Administrator, acknowledged that the resident was not positioned correctly during the feeding process. The failure to elevate the head of the bed during tube feeding was directly observed and confirmed by staff interviews.
Failure to Honor Resident's Dietary Preference for White Meat
Penalty
Summary
The facility failed to honor a resident's documented dietary preference for white meat chicken during a lunch meal service. On the day of observation, the resident was served two baked chicken legs, which are dark meat, despite their meal card clearly indicating a preference for white meat. Staff interviews confirmed awareness of the resident's dislike for dark meat and acknowledged that the meal provided did not align with the resident's stated preference. The dietary manager also confirmed that the resident's preference should have been followed but was not in this instance.
Failure to Follow Physician Orders and Medication Administration Standards for Diabetic Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident with Type 2 diabetes mellitus and hyperglycemia. Specifically, the facility did not ensure that high blood glucose levels were rechecked as ordered after administering sliding scale insulin for glucose readings greater than 400. Multiple instances were identified where blood glucose levels exceeded 400, insulin was administered per sliding scale, but no evidence was found that glucose was rechecked after three hours as required by the physician's orders. Additionally, the facility did not consistently perform blood glucose checks to determine if sliding scale insulin was needed, as ordered, on certain mornings. There were also multiple occasions where the resident's blood glucose levels were above the threshold requiring physician notification, but there was no documentation that the physician had been notified as ordered. These failures were confirmed through review of the electronic medication administration records (eMAR) and nursing notes, as well as by the Director of Nursing during an interview. Furthermore, the facility did not administer the resident's prescribed morning doses of Lantus insulin on specific dates, as indicated by the absence of documentation in the eMAR. The Director of Nursing confirmed that there was no evidence these doses were given or documented. The facility's medication administration policy requires medications to be administered and documented as ordered, including timely administration, proper documentation, and physician notification when required, but these standards were not met in the care of this resident.
Failure to Timely Implement Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure ulcers for a resident with a gluteal cleft pressure injury. The resident, who had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, muscle weakness, and a nontraumatic intracerebral hemorrhage, was under the care of a wound nurse practitioner (NP) who recommended a specific wound care regimen. The NP's recommendations, which included cleaning the wound with cleanser, applying honey and a dry dressing, and changing the dressing three times per week or as needed, were documented in the resident's record. Despite these recommendations, the treatment administration record showed that the NP's wound care orders were not implemented until more than two weeks after they were made. Interviews with the treatment nurse revealed a misunderstanding regarding whether to continue the previous treatment until supplies were exhausted, despite no such instruction being documented. The NP confirmed that the new wound care orders should have been started as soon as they were given, and the treatment nurse acknowledged that the recommended care was not initiated as ordered.
Failure to Resolve Grievance Regarding Call Light Response
Penalty
Summary
The facility failed to adhere to its Grievance Policy by not resolving a grievance filed by a resident's responsible party regarding the resident's call light not being answered. The grievance, filed on January 31, 2025, highlighted incidents on January 25 and January 31, 2025, where the resident had to wait excessively long for assistance, specifically to be changed after being incontinent. Despite the grievance being filed, the facility did not provide a completed review of the grievance in writing or verbally to the resident or their responsible party. The resident involved had an intact cognitive status with a BIMS score of 15, indicating full cognitive function, but had physical limitations due to cardiopulmonary arrest and was on diuretic therapy. During a surveyor's visit, the resident confirmed that their call light was not answered, and the surveyor observed the call light being ignored. Interviews with staff confirmed that the grievance was not communicated back to the resident or their responsible party, indicating a failure in the facility's grievance resolution process.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse and psychosocial harm, resulting in an Immediate Jeopardy situation. A resident with intact cognition was approached in his bed by another resident who exposed himself and made unwanted sexual advances. Despite the incident being reported, the perpetrator was not immediately separated from the victim or other residents in the shared room, and no one-on-one supervision was provided. The incident involved multiple residents, including a paraplegic resident with PTSD, who reported the abuse to the facility administrator. The staff's response was inadequate, as they did not believe the victim and failed to provide immediate protection or support. The resident was left in the same room with the perpetrator and other residents until later in the day, exacerbating his PTSD symptoms. Interviews with staff revealed a lack of immediate action and documentation regarding the incident. The RN on duty did not witness the abuse but heard the victim's distress and failed to ensure the perpetrator was monitored or separated. The facility's administration was not informed until hours after the incident, highlighting a breakdown in communication and adherence to abuse prevention policies.
Failure to Ensure Resident Safety and Proper Response to Abuse Allegation
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in a deficiency that affected the well-being of a resident. The incident involved a resident who was approached at his bedside by another resident with inappropriate behavior, including exposure and physical contact. Despite the resident's intact cognition and ability to report the incident, the facility staff did not take immediate action to separate the aggressor from the other residents in the shared room. The deficiency was further compounded by the lack of immediate response from the facility's administration. The administrator was not informed of the incident until the resident reported it directly to her office hours later. During this time, the aggressor remained in the shared room with the victim and other residents, without any one-on-one supervision or monitoring, which was a critical oversight in ensuring the safety and well-being of all residents involved. Interviews with facility staff revealed a lack of documentation and adherence to the abuse/neglect policy, particularly in terms of providing one-on-one care and monitoring for the aggressor. The Director of Nursing acknowledged the failure to implement necessary measures following the incident, and the administrator confirmed the absence of documentation for one-on-one supervision. This deficiency highlights a significant lapse in the facility's procedures for handling allegations of abuse and ensuring resident safety.
Failure in Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, resulting in actual harm. Resident #4, who had undergone surgery for the removal of metatarsals, reported pain at her surgical site and requested pain medication. Despite her request for Tylenol, the LPN on duty, S3, informed her that she could not administer any pain medication due to issues with the medication prescription. This led to Resident #4 experiencing unmanaged pain, which she rated as a 6 on a scale of 0-10. The facility's pain management policy, dated April 2022, outlines procedures for evaluating and managing pain, including both pharmacological and non-pharmacological interventions. However, the policy did not address the administration of pain medication as ordered. On the evening of the incident, S3 LPN did not conduct a pain assessment for Resident #4, as she was focused on arranging for the resident's transfer to the hospital. The lack of pain management led Resident #4 to call 911, resulting in her being admitted to the hospital ER, where she received Dilaudid for acute pain. Interviews with the staff and Resident #4 revealed that the resident was aware of the staff's attempts to resolve the prescription issue but was dissatisfied with the lack of immediate pain relief. The Director of Nursing acknowledged that Resident #4 should have received pain medication. The incident highlights a failure in the facility's pain management practices, as the resident did not receive any pain relief during the shift, leading to her hospitalization.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents within the required timeframe. Resident #1, who has diagnoses including unspecified paraplegia, anxiety disorder, depression, and PTSD, reported that Resident #2 approached him inappropriately during the early hours of 12/27/2024. Resident #1 captured the incident on video, showing Resident #2 with his genitals exposed and making inappropriate advances. Despite the incident being reported to the Assistant Director of Nursing (ADON) shortly after it occurred, it was not communicated to the facility's Administrator or the state agency within the mandated two-hour window. The facility's policy requires immediate reporting of such incidents to the Administrator and the state agency, but this protocol was not followed. The ADON acknowledged awareness of the incident but did not report it to the Administrator. The incident was not officially documented until several hours later, and the Administrator confirmed that the incident report was not submitted to the state agency as required. This delay in reporting constitutes a failure to adhere to the facility's abuse prevention policy and state regulations.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents. Resident #1 reported that Resident #2 approached him inappropriately during the early hours of 12/27/2024. Resident #1, who has diagnoses including unspecified paraplegia, anxiety disorder, depression, and post-traumatic stress disorder, stated that Resident #2 grabbed him by the arms and shoulders and exposed himself while making inappropriate comments. Video evidence from Resident #1's cell phone corroborated his account, showing Resident #2 with his genitals exposed and engaging in inappropriate behavior. The facility's investigation into the incident was inadequate. The administrator, who is the designated abuse coordinator, only interviewed two employees who were not present during the incident. The investigation did not include interviews with all staff members who were on duty at the time of the incident, as required by the facility's Abuse Prevention Policy. The administrator acknowledged that a thorough investigation was not conducted, failing to adhere to the policy's standards for addressing and investigating allegations of abuse.
Lack of Documentation for Physician's Discharge Order
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one of the sampled residents. Specifically, there was no documentation of a physician's discharge order for a resident who was discharged to the hospital. The resident had multiple diagnoses, including pain in the left wrist, chronic viral hepatitis C, cognitive communication deficit, and unspecified cannabis use. The resident's Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of 06, reflecting severely impaired cognition. During an interview, the Assistant Director of Nursing (ADON) admitted to misplacing the verbal discharge order from the physician and acknowledged the absence of a system for taking verbal orders.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure that a resident had access to necessary medical services outside the facility, as evidenced by the lack of transportation provided for scheduled medical appointments. The facility's Transportation to Appointments Policy outlines that the Transportation Supervisor or designee is responsible for scheduling and ensuring transportation for residents' medical appointments. However, for a resident with a diagnosis of colon cancer with metastatic cancer to bone, there was no documentation indicating that the resident was transported to or attended their scheduled appointments on November 7, 2024. These appointments included a non-fasting lab, a hematology oncology visit, and a chemotherapy infusion. Interviews with facility staff, including the Director of Nursing and the CNA Supervisor, confirmed that there was no documentation of the resident being transported or attending the scheduled appointments. Additionally, there was no record of the resident refusing to attend these appointments. The lack of documentation and transportation for the resident's critical medical appointments represents a failure to adhere to the facility's policy and ensure the resident's right to access necessary medical care.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to revise the care plan for one of the nine sampled residents, identified as Resident #4. Resident #4 was admitted with multiple serious injuries, including fractures and hemorrhages, and initially required significant assistance with mobility and activities of daily living (ADLs). The care plan, initiated in April and June 2024, included interventions for impaired physical mobility and ADL self-care performance deficits, such as partial weight-bearing instructions and the use of a Miami J-Collar and cam boot. Despite a quarterly MDS assessment in July 2024 indicating that Resident #4 was cognitively intact and required only supervision and setup help for mobility and ADLs, the care plan was not updated to reflect the resident's improved condition. Interviews conducted in October 2024 revealed that Resident #4 was independently performing tasks such as getting out of bed, dressing, and bathing, and had stopped using the prescribed collar and boot. The MDS Director confirmed that the care plan should have been updated following the July assessment.
Failure to Accurately Assess and Report Pressure Ulcer Risk
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers, consistent with professional standards of practice. The resident, who had a history of Spastic Diplegic Cerebral Palsy, Type 2 Diabetes, and other conditions, was totally dependent on staff for bed mobility and transfers. Despite being care planned for potential skin integrity issues, the facility did not perform an accurate assessment or notify the MD/NP of the resident's skin condition. On 09/14/2024, a Licensed Practical Nurse noted a pinkish/red area on the resident's buttock, indicating a stage I and II pressure ulcer, but failed to successfully notify the NP. Subsequent assessments by the treatment nurse and unit manager revealed inconsistencies in the documentation and recognition of the resident's skin condition. The treatment nurse initially reported no skin issues, while the unit manager later identified Moisture Associated Skin Damage (MASD) to the resident's sacrum. The Director of Nursing acknowledged that the MD should have been notified of the initial assessment and that the treatment nurse's assessment was inaccurate, potentially leading to a worsening of the resident's condition.
Deficiencies in Care Plan Implementation and Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their medical and care needs. For one resident, the facility did not follow physician orders for administering Keflex, an antibiotic, via PEG tube. The medication was not administered on specific dates, and there was no activity recorded in the facility's automated medication dispensing system, indicating missed doses. The Director of Nursing acknowledged the oversight, which was due to a failure in communication and verification with the pharmacy. Another resident experienced multiple falls, but the facility did not revise the resident's care plan to include interventions for falls that occurred on two specific dates. Despite the resident being cognitively intact and requiring extensive assistance with mobility and transfers, the care plan was not updated to address the falls. The Director of Nursing confirmed that the care plan should have been revised following these incidents.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident when there was a change in the resident's medical condition. Specifically, the responsible party was not informed about the initiation of antibiotic treatment for a urinary tract infection. The facility's policy requires that the resident, their attending physician, and the responsible party be promptly notified of any changes in the resident's medical or mental condition. However, in this case, the responsible party was not notified when the resident was prescribed Keflex, an antibiotic, to be administered via PEG tube three times a day for seven days. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The records did not show any documentation that the responsible party was informed about the antibiotic order. During interviews, an LPN acknowledged making a progress note entry regarding the new order but could not recall notifying the family. The Director of Nursing also confirmed that the responsible party should have been notified about the antibiotics ordered for the urinary tract infection, indicating a lapse in following the facility's notification policy.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate care to prevent urinary tract infections. The deficiency was identified during a review of the facility's policy and procedure for preventing Catheter-Associated Urinary Tract Infections (CAUTIs), which mandates maintaining unobstructed urine flow and keeping the drainage bag below the level of the bladder without placing it on the floor. However, an observation revealed that the urinary catheter drainage bag of a resident was hanging from the bedframe with the drain port tubing touching the floor, which is against the facility's guidelines. The resident involved had multiple diagnoses, including acute respiratory failure with hypoxia, acute kidney failure, quadriplegia, and essential hypertension. The resident's physician's orders included specific instructions for the care of a suprapubic catheter, which required sterile procedures and monthly changes. Despite these orders, the improper positioning of the catheter drainage bag was noted during an observation, and an LPN confirmed that the bag should not have been touching the floor, indicating a lapse in following the established CAUTI prevention strategies.
Failure to Obtain Consent and Physician's Order for Bed Rails
Penalty
Summary
The facility failed to obtain a written order from a physician and informed consent for the use of bed rails for one of the sampled residents. According to the facility's Bed Rail Policy, it is essential to assess residents for safety risks, review these risks and benefits with the resident or their representative, obtain informed consent, and secure a physician's order before installing bed rails. However, the review of Resident #2's medical records did not reveal any informed consent or physician's order for the use of bed rails, which is a violation of the facility's policy. Resident #2, who was admitted with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage, and severe cognitive impairment, was found to have grab bars on their bed. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the presence of mobility bars on the resident's bed and acknowledged the absence of the required informed consent and physician's order. This oversight indicates a failure to adhere to the established procedures for ensuring the safe and appropriate use of bed rails, as outlined in the facility's policy.
Failure to Complete Required Annual Training for CNA
Penalty
Summary
The facility failed to ensure that required annual training on abuse and dementia care was completed for one direct care staff member, a Certified Nursing Assistant (CNA), out of six direct care staff personnel records reviewed. According to the facility's Abuse Prevention Policy, all staff, including contractors and volunteers, are required to receive annual education and training on abuse, neglect, and exploitation. The personnel record of the CNA in question showed a hire date of September 25, 2018, and indicated that the last documented training on abuse and dementia was completed on June 1, 2023. During an interview conducted on August 13, 2024, the Staff Development Coordinator reviewed the CNA's personnel record and acknowledged the absence of documentation for the required annual training. This oversight highlights a lapse in adherence to the facility's policy on mandatory training, which is crucial for ensuring staff are equipped to handle situations involving abuse, neglect, and exploitation.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach, as required by the facility's procedure. Resident #39 reported not having a call light during an interview, and observations confirmed that the call light was on the ground, wedged between the wall and a piece of furniture, making it inaccessible. This issue persisted over multiple days, as observed on June 3rd and June 5th, 2024. The Director of Nursing (DON) confirmed the deficiency during an interview, acknowledging that the call light should have been within the resident's reach. Similarly, Resident #67, who was at risk for falls due to decreased mobility and a history of falls, also had an inaccessible call light. Observations on June 3rd and June 4th, 2024, revealed that the call light cord was wrapped around and wedged in the bed wheel at the foot of the bed, making it unreachable for the resident. The DON acknowledged this issue during an interview, confirming that the call light was not within the resident's reach, contrary to the care plan's interventions to anticipate and meet the resident's needs.
Failure to Address Laundry Service Concerns
Penalty
Summary
The facility failed to adequately address and act upon the concerns raised by the resident council regarding issues with the laundry service. Over several months, multiple residents reported missing or incorrectly returned clothing items during resident council meetings. These grievances were documented from January to May 2024, with residents expressing dissatisfaction with the slow return of laundry, missing items, and receiving clothes that did not belong to them. Some residents, due to these ongoing issues, opted to have their families handle their laundry instead. The facility's grievance log for May 2024 also recorded complaints about missing clothing, with delayed responses from the facility. Interviews with staff revealed a lack of a structured laundry schedule and issues with clothing being returned to incorrect rooms or floors, contributing to the problem. The Activity Director and Housekeeping/Laundry Supervisor acknowledged the issues, with the latter noting that the return of clothes depended on various factors, including the absence of names on clothing and room changes by residents. Despite these acknowledgments, the facility did not take prompt action to resolve the residents' concerns, leading to continued dissatisfaction and potential impact on all 189 residents.
Failure to Develop and Implement Care Plans for UTIs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents diagnosed with urinary tract infections (UTIs). Resident #25, who has a history of chronic congestive heart failure, primary hypertension, type 2 diabetes, and a UTI, did not have a care plan addressing the UTI despite having a physician's order for Keflex. The resident's electronic health record and comprehensive plan of care lacked any mention of the UTI diagnosis or treatment plan. This oversight was confirmed by an LPN/MDS Nurse during an interview. Similarly, Resident #98, with a medical history including UTI, generalized epilepsy, type 2 diabetes, cerebral infarction, essential hypertension, and aphasia, also lacked a care plan for their UTI. Although there was a physician's order for Macrobid, the care plan did not reflect this diagnosis. Additionally, Resident #98 was not administered Doxycycline and Acidophilus as ordered by the nurse practitioner, as these medications were not entered into the electronic health record or the medication administration record. This failure was confirmed by the Director of Nurses during an interview.
Failure to Revise Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced significant weight loss. The resident, who was NPO and receiving enteral feedings through a PEG tube, showed a weight decrease from 112.6 lbs to 97.6 lbs over a period of approximately three months, indicating a 13.32% weight loss. Despite this significant weight loss, the resident's care plan was not updated to include a dietician consult or the implementation of weekly weight monitoring. During an interview, the Director of Nursing (DON) acknowledged that the resident's weight loss exceeded the thresholds for concern, which should have triggered a dietician consult and weekly weight checks. However, these actions were not documented in the resident's care plan. The DON confirmed that the facility's protocol involves reviewing residents with significant weight loss in monthly meetings and implementing necessary interventions, but these steps were not taken for this resident.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in maintaining grooming and hygiene for several residents. Resident #25, who has a diagnosis of diabetes mellitus and other health issues, was observed with long fingernails despite a care plan that included monitoring by a podiatrist. The resident expressed a need for nail trimming, which was confirmed by staff as not being performed. Similarly, Resident #57, with Alzheimer's disease and other conditions, was found with long, dirty fingernails, which were not cleaned or trimmed during bathing as required. Resident #98, with a history of cerebral infarction and diabetes, was observed with long, jagged fingernails, indicating a failure to follow the care plan that required nail care on bath days. Staff acknowledged the need for frequent trimming due to fast nail growth. Resident #141, with major depressive disorder, had a cracked thumbnail that had not been addressed for several days, despite the resident's request for trimming. This oversight was confirmed by staff, highlighting a lapse in the care plan's execution. Additionally, Resident #120, with multiple fractures and mobility issues, had long, thick toenails causing discomfort, and had not been seen by a podiatrist for about a year, contrary to the care plan. Resident #174 reported not receiving scheduled baths, confirmed by a review of the electronic health record, which showed no record of bathing since admission. The resident had to wash herself at the sink, indicating a failure in the facility's scheduling and documentation processes.
Failure to Follow Physician Orders for Edema Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema, as per physician orders and professional standards of practice. The resident, who had a medical history of blood clots and cellulitis, reported not wearing ted hose despite having a physician's order for them. Observations confirmed the absence of ted hose on the resident's swollen lower extremities on multiple occasions. The resident's medical records indicated a diagnosis of embolism and thrombosis, and orders for ted hose application during the day, as well as medication for DVT and CHF with edema. However, the facility did not ensure the resident received the prescribed ted hose, as they had not arrived from the medical supply company. Additionally, the facility failed to monitor the resident for edema while on diuretics, as required by the physician's orders. The resident's care plan did not address the issue of edema, and the EMAR did not include monitoring tasks for edema related to diuretic use. Interviews with facility staff, including an LPN and the DON, confirmed the oversight in monitoring and the lack of documentation regarding the order and follow-up for the ted hose. This lack of adherence to physician orders and care planning resulted in the resident not receiving the necessary treatment for their condition.
Failure to Timely Implement Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. Upon readmission to the facility, the resident, who had a complex medical history including anoxic brain damage, cardiac arrest, and severe hypoxic ischemic encephalopathy, was not given appropriate wound care treatment orders. The resident was assessed to have a stage IV pressure ulcer on the sacrum, and stage II pressure ulcers on the right arm and left foot. However, the facility did not obtain or implement wound care treatment orders until several days after the resident's readmission. Interviews with facility staff, including a Registered Nurse/Unit Manager and the Director of Nursing, confirmed the delay in obtaining and implementing wound care treatment orders. The staff acknowledged that the orders were not put in place until four days after the resident's readmission, indicating a lapse in the facility's protocol for managing pressure ulcers and ensuring timely care for residents with such conditions.
Failure to Conduct Regular Dietician Assessments and Document Monthly Weights
Penalty
Summary
The facility failed to ensure that Resident #85 received at least quarterly Registered Dietician (RD) assessments as per the facility's policy. The policy required the RD to review all new admissions, tube feedings, and residents on dialysis at least quarterly. However, Resident #85, who was receiving Glucerna via a feeding pump and had multiple diagnoses including hemiplegia, diabetes, and malnutrition, did not have a documented RD assessment since 07/15/2021 until a mini assessment on 06/06/2024. The RD reported that the last assessment was on 03/21/2023, but could not provide documentation, and the mini assessment was conducted without seeing the resident, relying solely on the resident's record. Additionally, the facility did not document monthly weights for Resident #135 in the electronic health record (EHR) as required by the facility's weight management policy. Resident #135, who had a history of cerebrovascular disease and was on enteral feeding, had a recorded weight of 164.4 pounds on 03/01/2024, but no weights were documented for April and May 2024. A handwritten weight of 158.9 pounds was found for May 7, 2024, indicating a potential weight loss. The Director of Nursing confirmed that the weights were not recorded in the EHR for the specified months, which was against the facility's policy.
Failure to Properly Label Tube Feeding Formulas
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents who were receiving tube feeding. The deficiency was identified during a review of the facility's procedures and observations of the residents. The facility's procedure for enteral tube feeding via pump requires that the feeding bag or bottle be labeled with specific information, including the resident's name, room number, type of formula, date and time the formula is hung, and the rate of administration. However, during observations, it was found that the tube feeding formula labels for two residents did not include the time the feeding was hung. Resident #85, who was admitted with diagnoses including hemiplegia, hemiparesis, and Type 2 diabetes mellitus, was observed receiving Glucerna via feeding pump. The label on the feeding formula did not include the time it was hung. Similarly, Resident #161, who had diagnoses including hemiplegia, aphasia, dysphagia, and severe protein-calorie malnutrition, was observed receiving Jevity 1.5 via feeding pump, and the label also lacked the time the feeding was hung. An LPN confirmed that the labels for both residents were incomplete and should have included the time the feeding was hung.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring such care, as evidenced by observations, record reviews, and interviews. Specifically, the facility did not maintain cleanliness and proper labeling of respiratory equipment for four residents. Resident #79's oxygen concentrator and filter were observed with a thick layer of dust, and the oxygen tubing was not dated, contrary to the physician's orders and facility policy. The Director of Nursing confirmed these deficiencies during an interview. For Resident #120, the nebulizer and mask were found on the overbed table without proper labeling or dating, and they were not stored correctly when not in use. This was confirmed by an LPN during an interview. Similarly, Resident #136's nebulizer mask was dated from several weeks prior and was not stored in a plastic bag when not in use, as required by the facility's policy. The LPN confirmed these observations and acknowledged the improper storage and labeling. Resident #139's respiratory care was also deficient, with oxygen tubing and humidifier bottles not labeled or dated, and the nebulizer mask not stored properly. These issues were confirmed by both an LPN and a respiratory therapist, who stated that respiratory supplies should be changed weekly and properly labeled. The facility's failure to adhere to its own respiratory therapy equipment policy resulted in these deficiencies, affecting the care provided to residents with significant respiratory needs.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of residents, specifically on three weekend days during the first fiscal quarter of 2024. A review of the facility's Payroll Based Journal (PBJ) Staffing Data Report indicated that the facility did not meet the minimum required staffing hours on October 21, 2023, and December 16, 2023. On these dates, the facility provided 375.38 hours and 366.9 hours, respectively, while the required hours were 378.35 and 376. Additionally, on October 1, 2023, the facility provided 275.75 hours, exceeding the required 254.85 hours, but this was not the case for the other two dates. During an interview, the Interim Administrator/Regional MDS confirmed the facility's failure to meet the required staffing hours on the specified dates.
Failure to Monitor Residents on Diuretics and Anticoagulants
Penalty
Summary
The facility failed to adequately monitor two residents for potential adverse effects related to their medication regimens, resulting in a deficiency. Resident #27 was prescribed Lasix, a diuretic, to manage peripheral vascular disease and was required to be monitored for edema. Additionally, the resident was on Eliquis, an anticoagulant, necessitating monitoring for abnormal bleeding or bruising. However, a review of Resident #27's medical records revealed a lack of documentation for monitoring these conditions. During an interview, an LPN acknowledged that the necessary monitoring for bleeding and edema was not conducted as required. Similarly, Resident #106 was prescribed Lasix for edema associated with hypertension. The medical records for this resident also lacked documentation of monitoring for edema, which was confirmed during interviews with both an LPN and the Director of Nursing. Both staff members acknowledged the absence of necessary monitoring documentation for the administration of the diuretic, indicating a failure to adhere to the prescribed monitoring protocols for these residents.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee met at least quarterly, as required. This deficiency was identified through a review of the QAA meeting information, which did not provide evidence of any quarterly meetings since the last annual survey conducted on June 8, 2023. During an interview on June 6, 2024, the facility's Administrator and the Regional Director of Clinical Operations acknowledged their inability to provide documentation of the required quarterly QAA meetings. This failure had the potential to affect the 189 residents residing in the facility, as documented by the facility's Long-Term Care Facility Application for Medicare and Medicaid form dated June 3, 2024.
Inadequate Infection Control Practices and Program Maintenance
Penalty
Summary
The facility failed to ensure staff practices were consistent with current infection control principles, specifically in the use of appropriate PPE during resident care. A resident on contact isolation for C-diff was observed without proper signage indicating isolation status, and a CNA was seen providing care without wearing the required PPE, such as a gown and shoe covers. The CNA confirmed the oversight, and the Director of Nursing acknowledged the failure to adhere to the facility's contact isolation policy. Additionally, the facility did not maintain an infection prevention and control program as required. There was no written evidence of implemented infection control policies and procedures for surveillance, tracking, and trending of infections. The Infection Preventionist confirmed that monthly infection control tracking and trending had not been completed for several months, which was a requirement according to the facility's policy.
Insecure Handrails on Hall W
Penalty
Summary
The facility failed to ensure that hallway handrails were securely affixed to the walls, specifically on Hall W, which could potentially affect 31 residents residing there. Observations revealed that the handrail near the exit door on Hall W lacked an end cap, leaving a sharp edge exposed and a crack in the handrail. During an interview, a CNA reported that the handrail had been broken for a couple of months. Further observation with the Maintenance Supervisor confirmed the deficiency, acknowledging that the handrail should have been repaired.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the discharge status of a resident. Specifically, the MDS assessment for a resident who was discharged to another long-term care facility incorrectly indicated that the resident was discharged to a short-term general hospital. This discrepancy was identified during a review of the resident's records and was acknowledged by the Registered Nurse/MDS Director during an interview. The error in the MDS assessment was not aligned with the actual discharge destination as documented in the resident's progress notes.
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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