Jefferson Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson, Louisiana.
- Location
- 2200 Jefferson Hwy, Jefferson, Louisiana 70121
- CMS Provider Number
- 195272
- Inspections on file
- 42
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Jefferson Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis, requiring substantial assistance with dressing, was observed wearing the same stained hospital gown for multiple days. Despite receiving a bed bath, the resident was redressed in the same soiled gown, and staff confirmed that clothing should have been changed daily.
Nine staff members, including CNAs and a CNA Supervisor, did not follow proper mechanical lift procedures as outlined by facility policy and the manufacturer's guidelines. Staff were observed and reported locking the caster brakes during resident transfers, instead of leaving them unlocked as required, demonstrating a lack of competency in safe lift operation.
Staff failed to maintain accurate medical records by sharing EMR credentials and documenting care activities under the wrong staff accounts. Multiple CNAs admitted to using each other's logins to record ADLs and other care tasks for several residents, resulting in documentation that did not accurately reflect who provided care or when it was delivered.
A resident with physician orders for insulin and specific blood glucose monitoring experienced multiple episodes of elevated blood glucose. Despite orders to notify the physician for high readings, there was no documentation that the physician was informed of these elevated levels, as confirmed by review of records and interviews with the DON.
A resident with a history of atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers did not receive daily wound care as ordered on multiple occasions. Documentation and staff interviews confirmed that wound care was missed, especially on days when the resident attended dialysis, with no evidence of refusal or physician orders to hold care. Nursing staff and the DON acknowledged the lapses in following wound care orders.
The facility did not consistently ensure that LPNs reconciled and documented controlled substances on all medication carts at shift changes, as required by policy. Multiple shifts lacked signatures from either the off-going or oncoming nurse, and some records were incomplete regarding the total number of controlled medication packages. Staff interviews confirmed awareness of the policy but acknowledged lapses in following it, and the DON verified the documentation was not completed as required.
The facility did not ensure its QA Committee followed through on a corrective action plan to address ongoing deficiencies in narcotic count documentation. Despite a QAPI plan requiring weekly audits and nurse signatures, recurring issues with incomplete and inaccurate narcotic reconciliation persisted, and no disciplinary actions were taken against staff for noncompliance.
The facility did not ensure its QAA committee consistently included the required members, such as the MD, Administrator, DON, and three additional staff, during quarterly meetings. Documentation showed that on multiple occasions, either some required members were absent or not enough staff were present, and the facility could not provide evidence to confirm proper attendance.
Three residents, including those with intact and moderate cognitive status, were unable to access their personal funds on weekends due to limited business office hours and lack of communication about alternative access through the DON. Facility policy required reasonable access, but there was no documentation that residents were informed of weekend procedures or that funds were accessed during that time.
A resident was discharged from Medicare Part A skilled services before benefit days were exhausted, but the required Notice of Medicare Non-Coverage (NOMNC) was not provided to the resident or their responsible party. Facility records and staff interviews confirmed the absence of the NOMNC prior to discontinuation of covered services.
A resident's room was not kept in a sanitary condition, as an unknown dried brown substance remained on the wall next to the bed for several days despite housekeeping staff being responsible for cleaning and disinfecting the area. Multiple staff confirmed the deficiency during surveyor observations and interviews.
The facility did not report an injury of unknown origin involving a resident with severe cognitive impairment, nor did it report an incident of resident-to-resident physical aggression, both of which were required by policy. Leadership interviews confirmed that neither event was reported to the State Survey Agency, and there was a lack of clarity among staff regarding reporting requirements.
A resident with severe cognitive impairment was found with a bruise of unknown origin near the eye, and the facility failed to conduct a thorough investigation as required by policy. The administrator did not document security footage reviews or obtain written staff statements, and key staff were not interviewed about the incident. The lack of documentation and incomplete investigation resulted in a failure to properly address the injury.
A resident was discharged without receiving the required 30-day written notification. Review of records and staff interviews confirmed that the mandated notice was not provided prior to the resident's discharge.
The facility did not make required referrals to the Louisiana PASRR program for two residents—one admitted with Major Depressive Disorder and Bipolar II Disorder, and another who developed Major Depressive Disorder after admission. Staff interviews and record reviews confirmed that PASRR Level II evaluations were not completed or referred for these residents, despite their qualifying mental health diagnoses.
A resident admitted with major depressive disorder and bipolar II disorder did not have these psychiatric diagnoses reflected on their Level I PASRR, which was found to be incomplete and undated. Facility staff confirmed the PASRR was inaccurate and not verified for accuracy or completeness, and no documentation was provided to show a complete PASRR was ever done.
A resident who required total assistance with ADLs did not receive necessary nail care, as evidenced by long, yellowed fingernails with visible debris underneath. Staff confirmed the resident's dependence and acknowledged the need for nail care, but documentation and repeated observations showed the care was not provided.
A carton of Med Plus 2.0 nutritional supplement was left opened and unrefrigerated on a medication cart, remaining available for resident use beyond the manufacturer's recommended 4-hour window. An LPN was unaware of the storage requirement, and the DON confirmed the supplement should have been discarded.
Two residents had inaccurate entries in their electronic Medication Administration Records (eMAR), including documentation of wound care assessments and medication administration that did not actually occur. Staff and leadership confirmed that these records were not truthful or accurate, as required by facility policy and professional standards.
A resident did not receive Nystatin powder as prescribed, due to a misunderstanding by the treatment nurse who thought it was ordered as needed. The medication was not applied on multiple occasions, as confirmed by the DON after reviewing the eMAR.
A resident's insulin order was changed by an LPN from once daily to twice daily without a physician's order. The LPN had not completed the required medication competency assessment, which was overlooked during orientation. The facility failed to ensure the LPN demonstrated competency in clarifying physician orders.
The facility failed to ensure complete and accurate documentation of medication administration records for two residents. One resident's eMAR lacked documentation for medications like Gabapentin and eye drops, while another resident's eMAR was missing records for multiple medications, including Aspirin and Insulin. The DON confirmed these omissions, emphasizing the need for proper documentation.
A facility failed to assess a resident for self-administration of medications, as a cognitively intact resident was found with a medicine cup containing nine pills on their bedside table. The facility's policy requires nurses to ensure residents take their medications and not leave them unattended. An LPN left the medications for the resident to self-administer later, assuming they were taken. The DON confirmed this was against policy, and the resident was not care planned for self-administration.
A resident, who was cognitively intact but required assistance with bathing due to limited range of motion, did not receive scheduled baths over several periods from August to October. Despite being scheduled for baths three times a week, documentation showed gaps in care, and the facility could not provide evidence of bathing during these times. The DON confirmed the oversight.
A resident, who required assistance with bathing, was inaccurately documented as receiving showers, while staff and the resident confirmed only bed baths were provided. The DON acknowledged the documentation error, highlighting a failure to maintain accurate medical records.
The facility failed to ensure fall prevention measures for two high-risk residents. One resident did not have a fall mat or dycem as required, and another did not have a fall mat despite a physician's order. Observations and staff interviews confirmed the absence of these safety measures.
The facility failed to sanitize the thermometer when measuring food temperatures and did not perform hand hygiene during meal service. A culinary cook did not sanitize the thermometer between uses, and a CNA did not wash hands or change gloves while assisting residents with meals. Both actions were confirmed as unacceptable by the culinary manager and the DON.
The facility failed to ensure a resident's room and equipment were kept clean. Observations revealed dried substances on the floor and tube feeding pole, and the resident's wheelchair had labels covered in a dark brown substance. Staff confirmed the unsanitary conditions.
The facility failed to check a resident's PEG tube placement before administering enteral nutritional therapy. An LPN did not auscultate the tube placement as required by the facility's policy, and the Quality Assurance Nurse confirmed this procedure should have been followed.
The facility failed to complete quarterly assessments in a timely manner for seven residents, with assessments completed more than 14 days after the ARD. Staff confirmed the late completion, and validation reports corroborated the findings.
The facility failed to submit resident assessments to CMS in a timely manner for nine residents. The assessments were completed but not transmitted within the required 14-day period, and one assessment was rejected due to an invalid date and not resubmitted promptly. This issue was confirmed through record reviews and staff interviews.
Failure to Provide Assistance with Dressing for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with hemiplegia and hemiparesis, who required substantial to maximal assistance with dressing, was not provided appropriate assistance with changing clothes. The resident was observed on three consecutive mornings lying in bed wearing the same hospital gown, which had a visible red stain on the left upper chest area. The resident reported that no staff member had changed her clothes since the initial observation and expressed a desire to have her clothes changed. Further investigation revealed that a Certified Nursing Assistant provided a bed bath to the resident but dressed her in the same soiled hospital gown afterward. The Corporate Nurse acknowledged that residents' clothes should be changed daily and that it was inappropriate to redress a resident in the same clothing after a bath. These findings were based on observations, interviews, and record review, confirming that the facility failed to provide necessary assistance with dressing and changing clothes for a dependent resident.
Staff Lacked Competency in Mechanical Lift Operation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides were competent in the operation of mechanical lifts, as required by both facility policy and the manufacturer's guidelines. Specifically, 9 out of 14 staff members investigated, including CNAs and a CNA Supervisor, demonstrated incorrect procedures during resident transfers using the mechanical lift. The facility's policy and the manufacturer's operating manual both specify that the caster brakes of the mechanical lift should remain unlocked when raising a resident from a bed to allow the lift to center itself and increase stability. However, multiple staff members reported and were observed locking the caster brakes during this process. During an observed transfer, staff locked the caster brakes before raising a resident from the bed, contrary to the required procedure. Interviews with several CNAs confirmed their practice of locking the brakes when lifting or lowering residents, indicating a widespread lack of competency in the correct use of the mechanical lift. Supervisory staff and a corporate nurse acknowledged that staff should be following the manufacturer's guidelines, which were not adhered to during the observed and reported incidents.
Inaccurate Resident Records Due to Shared EMR Credentials
Penalty
Summary
Staff failed to ensure the accuracy and integrity of resident medical records for six out of nine residents reviewed. Documentation in the electronic medical record (EMR) showed that staff members recorded care activities such as bed mobility, toileting, bowel and bladder elimination, turning and positioning, and meal consumption for multiple residents. However, interviews revealed that the staff who documented these activities were not always the ones who provided the care. For example, one CNA's credentials were used by others to document care provided to residents, and another CNA admitted to using a colleague's credentials because she had forgotten her own. Additionally, a CNA was documented as providing a bed bath to a resident on a specific date, but in an interview, she stated she did not care for that resident on that day, and another CNA confirmed she had provided the care but used someone else's credentials to document it. Further interviews with staff, including CNAs and supervisory personnel, confirmed that sharing EMR credentials and documenting under another staff member's login was occurring. The corporate nurse and CNA supervisor both acknowledged that staff credentials should remain confidential and that staff should not document in the EMR using another person's credentials. These actions resulted in inaccurate and unreliable resident records, as the documentation did not accurately reflect who provided care or when it was provided.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels as required by the resident's physician orders. The orders specified that the physician should be called if the resident's blood glucose level was between a certain range, but review of the electronic Medication Administration Record (eMAR) showed several instances where the resident's blood glucose levels were significantly elevated, ranging from 360 mg/dL to 433 mg/dL. Despite these elevated readings, there was no documented evidence that the physician was notified as directed by the orders. Interviews with the Director of Nursing confirmed that nursing staff were expected to notify the physician for any blood glucose level above 352 mg/dL, but the facility was unable to provide documentation that such notifications occurred for the elevated readings identified. This deficiency was identified for one resident out of five sampled for unnecessary medications, based on both record review and staff interviews.
Failure to Provide Ordered Daily Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow physician's orders to provide daily wound care for a resident with unhealed pressure ulcers. Review of the resident's medical record and electronic Medication Administration Record (eMAR) showed that wound care orders, including cleaning and dressing of wounds on the left heel, left great toe, left hip, and sacrum, were not performed on multiple documented dates. There was no evidence in the progress notes that wound care was provided or refused on these dates, and no documentation was available to justify the missed care, such as holding wound care due to dialysis appointments. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident did not receive wound care as ordered on several days, particularly when the resident was out of the facility for dialysis. The staff acknowledged that there were no orders to hold wound care and that care should have been provided before or after dialysis. The resident's medical history included conditions such as atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers, and the Braden Scale assessment indicated a risk for skin breakdown.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an accurate and complete system for reconciling controlled substances across all five medication carts reviewed. According to the facility's policy, both the off-going and oncoming nurses are required to count and document the controlled substances at each shift change, with signatures from both parties on the Controlled Drug Count Record and Package Inventory form. However, multiple instances were identified where either the off-going or oncoming nurse, or both, did not sign the required documentation for various shifts and dates across all medication carts (a through e). In some cases, the total number of controlled medication packages reconciled was also not documented. Record reviews revealed that for numerous shifts, there was no documented evidence that the required reconciliation and documentation of controlled substances occurred. This included missing signatures and incomplete records for both the receipt and disposition of controlled drugs. The facility was unable to provide any additional documentation to demonstrate that the reconciliation process was completed as required by their policy. Interviews with nursing staff confirmed that they were aware of the requirement to reconcile and document controlled substances at each shift change, but admitted to not completing the process as required on specific occasions. The Director of Nursing also confirmed that the Controlled Drug Count Record and Package Inventory sheets were not completed with the necessary signatures at the beginning and/or end of shifts as required.
Failure to Implement QA Plan for Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee effectively implemented a developed plan of action to address identified quality deficiencies related to accurate narcotic count documentation. Despite creating a Quality Assurance Performance Improvement (QAPI) plan that included weekly audits of medication carts and required nurse signatures, recurring problems with incomplete and inaccurate narcotic reconciliation documentation persisted. The Director of Nursing confirmed that, although the issue was identified and interventions such as staff discipline were outlined, no disciplinary actions were taken against nursing staff for ongoing noncompliance, and the documentation issues continued to be observed during the survey.
QAA Committee Lacked Required Members and Attendance at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee was composed of all required members and met at least quarterly, as outlined in its own policy and procedure. According to the facility's policy, the QAA committee should include the Medical Director (MD), the Administrator, the Director of Nursing (DON), and three other staff members designated by the facility. Review of the QAA meeting minutes and sign-in sheets for three separate quarterly meetings revealed that the required composition of the committee was not consistently met. On one occasion, only the DON, Administrator, Dietary Manager, and MD were present, with no evidence of additional staff. On another occasion, the MD and Administrator were absent, and on a third occasion, only the DON, Administrator, and MD were present, again lacking additional staff members. The facility was unable to provide any additional documentation to demonstrate that the required members attended the QAA meetings on the reviewed dates. An interview with the DON confirmed that no further evidence was available to show compliance with the committee composition requirements for those meetings. No information about residents or their medical conditions was included in the report.
Failure to Ensure Resident Access to Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents were able to access and manage their personal funds at all times, as required by policy. Three residents, including two who were cognitively intact and one with moderate cognitive impairment, reported being unable to access their funds on weekends. The facility's policy stated that residents should have reasonable access to their funds and that requests for fifty dollars or less would be honored the same day. However, interviews revealed that the business office was only open for banking hours Monday through Friday, and while a petty cash box was left with the weekend DON, this information was not communicated to residents. There was no documented evidence that residents were informed about how to access their funds on weekends, nor was there documentation that any residents had actually accessed their funds during that time. Staff interviews confirmed that the process for weekend access was not publicized, and the facility lacked records showing that residents were notified of banking hours or that this was discussed during care plan meetings or resident council meetings. The administrator acknowledged that while funds were technically available on weekends, there was no documentation to support this or to show that residents were aware of the process.
Failure to Provide Required Medicare Non-Coverage Notice Prior to Discharge
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from Medicare Part A skilled services before exhausting their benefit days. The resident began receiving Medicare Part A skilled services on 09/23/2024, with the last covered day being 11/03/2024. The facility initiated the discharge from Medicare Part A services, but there was no documented evidence that the required NOMNC was given to the resident or their responsible party prior to the discontinuation of covered services and discharge home. Record review and staff interviews confirmed that the NOMNC was not located or completed for the resident, and the facility was unable to provide documentation that the notice was issued as required. The Social Services Director acknowledged the absence of the NOMNC, and the Administrator confirmed that the facility had identified issues with beneficiary notifications but had not yet implemented a quality assurance process to address the problem.
Failure to Maintain Sanitary Resident Room Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in a resident's room, as evidenced by repeated observations of an unknown dried brown substance on two areas of the wall next to the resident's bed. This substance was noted on four consecutive days during surveyor observations, indicating that the issue persisted over time and was not addressed despite ongoing housekeeping responsibilities. Interviews with the housekeeper responsible for the room revealed that she claimed to have cleaned and wiped all unclean areas, yet the substance remained present during a joint observation. Additional staff, including a business office specialist and the facility administrator, confirmed that the wall was not maintained in a sanitary manner at the time of the observations. The facility's own housekeeping job description required cleaning and disinfecting walls, but this standard was not met in this instance.
Failure to Report Injury of Unknown Origin and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report two separate incidents as required by its Abuse Prevention and Prohibition policy. In the first incident, a resident with severe cognitive impairment was found with a bruise of unknown origin to the right periorbital area. The resident was unable to provide a history of the injury, and there was no documented evidence of a witnessed fall or explanation for the bruise. Despite the lack of a known cause, the administrator and regional administrator did not submit a report to the State Survey Agency, as required for injuries of unknown origin. In the second incident, another resident with severe cognitive impairment was physically pulled from a wheelchair and yelled at by another resident. This event was documented in the facility's incident log and nurse's notes, but there was no evidence that the incident was reported to the State Survey Agency as an allegation of resident-to-resident abuse. Interviews with facility leadership confirmed that the incident was not reported, and there was uncertainty among staff about whether the event constituted a reportable allegation of abuse.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a reddish-blue bruise around the right eye, and was unable to provide a history of the injury. The facility's abuse prevention policy required a comprehensive investigation, including interviews and signed statements from all staff involved, as well as interviews with the resident or their roommate if the resident was unable to communicate. However, the administrator only spot-checked security footage without documenting the review, and did not obtain or document written statements from staff. The CNA Supervisor reported conducting only verbal interviews with two CNAs, but did not document these interviews, and both CNAs later stated they were not interviewed or asked for statements. Additionally, an LPN who was notified of the bruise was not interviewed about the incident. The administrator assumed the injury was caused by a fall, despite no documented falls for the resident, and did not interview staff from other shifts or obtain further evidence. There was no documented evidence to show that a thorough investigation, as required by facility policy, was completed regarding the resident's injury. The lack of documentation and incomplete staff interviews resulted in a failure to properly respond to and investigate the injury of unknown origin.
Failure to Provide 30-Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30-day written notice prior to the discharge of a resident. Review of the electronic medical record showed that the resident was discharged on 02/05/2025 at 3:33PM, but there was no documented evidence that the resident received the mandated 30-day notification before discharge. Interviews with the Social Service Director and the Administrator confirmed that the resident did not receive the 30-day written notification prior to being discharged.
Failure to Refer Residents with Mental Illness for PASRR Evaluation
Penalty
Summary
The facility failed to ensure that referrals were made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for two residents with mental illness diagnoses. One resident was admitted with diagnoses of Major Depressive Disorder and Bipolar II Disorder, but there was no documented evidence that a PASRR Level II evaluation was completed or a referral was made to the PASRR program. Another resident developed a diagnosis of moderate, recurrent Major Depressive Disorder after admission, yet there was also no documentation of a PASRR Level II evaluation or referral for this new diagnosis. Interviews with facility staff confirmed that both residents met criteria requiring a PASRR Level II referral, either due to admission with a mental illness or the onset of a qualifying diagnosis after admission. Record reviews and staff statements indicated that these referrals were not identified or completed during routine audits or at the time of diagnosis, resulting in a failure to coordinate necessary assessments and referrals as required.
Failure to Accurately Complete PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a complete and accurate Level I Pre-Admission Screening and Resident Review (PASRR) was conducted for a resident admitted with diagnoses of major depressive disorder and bipolar II disorder. Record review showed that the resident's Level I PASRR was incomplete, undated, and did not identify any mental illness diagnosis, despite the resident's documented psychiatric conditions. Interviews with facility staff confirmed that the PASRR was inaccurate and incomplete, and there was no documented evidence that a complete Level I PASRR was ever completed or verified for accuracy and completeness for this resident.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A dependent resident who required total assistance with activities of daily living (ADLs) did not receive appropriate nail care. Review of the care task log showed that the resident's nail care was marked as not applicable on the morning of the observed date. Multiple observations throughout the day revealed that all ten of the resident's fingernails were yellowed, extended one-fourth to one-half inch beyond the fingertips, and had an unknown gray substance visible underneath. The resident expressed a desire to have his fingernails cut. Staff interviews confirmed that the resident required total assistance with ADLs, and the Assistant Director of Nursing acknowledged that the resident's nails needed to be cut and cleaned. The repeated observations and documentation review indicated that the facility failed to provide necessary nail care and assistance for this dependent resident.
Improper Storage and Availability of Nutritional Supplement
Penalty
Summary
A carton of Med Plus 2.0 nutritional supplement was found opened and unrefrigerated on a medication cart, with the opened date marked as the previous day. According to the manufacturer's guidelines, the supplement should be used within 4 hours of opening if not refrigerated. Observation confirmed that the supplement was still available for resident consumption well beyond the recommended time frame. An LPN acknowledged not knowing the requirement to discard the supplement after 4 hours if not refrigerated, and the DON confirmed that the supplement should not have been available for use under these conditions.
Inaccurate Documentation in eMAR for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic Medication Administration Record (eMAR) for two residents. For one resident with a history of unhealed pressure ulcers and who was cognitively intact, the eMAR and wound care assessment indicated that a wound care nurse evaluated and treated the resident's wounds on a specific date. However, both the resident and the nurse confirmed that no such evaluation or treatment occurred on that date, and the nurse could not explain why the documentation was inaccurate. Facility leadership, including the Director of Nursing and a corporate nurse, confirmed the documentation was incorrect and should not have been entered as such. For another resident who was admitted to a hospital and later returned to the facility, the eMAR showed that multiple medications and care tasks were documented as completed during the resident's absence from the facility. These included administration of eye drops, tube feedings, repositioning, and other nursing interventions, all recorded as performed by specific LPNs. Interviews with staff confirmed that medications and tasks should only be documented if actually performed, and the Director of Nursing acknowledged that the eMARs should have been accurate and not indicated completion of tasks that did not occur.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident, leading to a deficiency in pharmaceutical services. The resident was prescribed Nystatin powder to be applied to the right abdominal fold twice daily and as needed. However, a review of the electronic Medication Administration Record (eMAR) for September 2024 revealed multiple instances where the medication was not applied as scheduled. Specifically, the Nystatin powder was not administered at 8:00 a.m. on one occasion and at 4:00 p.m. on numerous dates throughout the month. Interviews conducted with the treatment nurse and the Director of Nursing (DON) confirmed the oversight. The treatment nurse mistakenly believed the Nystatin powder was ordered only as needed, which led to the medication not being applied as per the physician's orders. The DON verified that the medication was indeed ordered to be applied twice daily and as needed, acknowledging the failure to adhere to the prescribed regimen on the documented dates.
LPN Changes Insulin Order Without Physician's Approval
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) demonstrated competency in clarifying a physician's order for a medication change. Specifically, an LPN altered a resident's Tresiba insulin order from 30 units once daily to 30 units twice daily without obtaining a physician's order. This change was made despite the resident's care plan indicating that medications should be administered as ordered by the physician. The lack of documented evidence of a physician's order for this change was confirmed through record reviews and interviews. The deficiency was further compounded by the fact that the LPN responsible for the medication change had not completed the competency assessment for medications during their orientation. This oversight was acknowledged by the Assistant Director of Nursing, who admitted to overlooking the completion of the medication competency. The Director of Nursing confirmed that the medication order should not have been changed without a physician's order and acknowledged the incomplete competency assessment for the LPN involved.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to ensure that medication administration records were complete and accurately documented for two of the three residents sampled. For Resident #1, the October 2024 Physician's Orders included medications such as Gabapentin, artificial tears, and Prednisolone-Moxifloxacin-Bromfenac eye drops. However, the electronic Medication Administration Record (eMAR) lacked documented evidence of administration for these medications on specific dates. The Director of Nursing (DON) confirmed these omissions and stated that all medications should have been documented as administered or noted with the appropriate chart code if not administered. Similarly, for Resident #2, the October 2024 Physician Orders included multiple medications such as Aspirin, Ferrous Sulfate, Folic Acid, Insulin Glargine, Levothyroxine Sodium, Norvasc, Zoloft, Fluoxetine HCl, Senna, and Insulin Aspart. The eMAR did not show documented evidence of administration for these medications on specified dates. The DON confirmed these omissions as well, indicating that all medications should have been documented when administered or as applicable.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as evidenced by an incident involving a cognitively intact resident with a Brief Interview for Mental Status score of 15. The facility's Med Pass Guidelines policy, dated 12/04/2017, stipulates that nurses should not leave medications with residents in a cup and must ensure that residents take their medications. However, during an observation, a medicine cup containing nine pills was found on the resident's bedside table. The resident confirmed that an LPN left the pills for self-administration later. The LPN admitted to assuming the resident took the medications while she was present and acknowledged that she should have ensured the medications were taken before leaving the room. The Director of Nursing confirmed that the LPN should not have left medications at the resident's bedside, and the resident was not care planned to have medications at the bedside.
Failure to Provide Scheduled Baths to Resident
Penalty
Summary
The facility failed to provide a dependent resident with scheduled baths, as required by their care plan and the facility's Bed Bath Policy and Procedure. The resident, who was cognitively intact but had limitations in range of motion in both upper and lower extremities, required partial to moderate staff assistance with bathing. Despite being scheduled for baths on Mondays, Wednesdays, and Fridays, the resident reported not receiving a bath for weeks. Documentation from August to October 2024 revealed multiple periods where the resident was not provided a bath, specifically from August 5 to August 9, August 17 to August 26, August 29 to September 3, and October 3 to October 6. The facility was unable to provide any documented evidence that the resident received a bath during these times. The Director of Nursing confirmed the lack of documentation and acknowledged that the resident should have been provided baths according to the schedule.
Inaccurate Bath Documentation for Resident
Penalty
Summary
The facility failed to accurately document the type of bath provided to a resident, leading to a deficiency in maintaining accurate medical records. The resident, who was cognitively intact and required partial to moderate staff assistance with bathing due to limitations in range of motion, was documented as having received showers on multiple occasions in August 2024. However, interviews with the resident and staff, including CNAs and the shower aide, confirmed that the resident only received bed baths and did not take showers. The discrepancy in documentation was acknowledged by the Director of Nursing, who confirmed that the bath records should have accurately reflected the type of bath the resident received. This inaccuracy in documentation was identified during a review of the resident's care plan and bath log, highlighting a failure to adhere to accepted professional standards in maintaining medical records.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall prevention measures were in place for two residents identified as high risk for falls. Resident #44, who had moderate cognitive impairment and a history of unwitnessed falls, did not have a fall mat at his bedside or a dycem in his wheelchair as required by his care plan. Multiple observations confirmed the absence of these safety measures, and interviews with staff revealed a lack of awareness or adherence to the resident's fall prevention interventions. Similarly, Resident #98, diagnosed with Parkinsonism, lack of coordination, and muscle weakness, did not have a fall mat at the bedside despite a physician's order and a high fall risk assessment. Observations over several days confirmed the absence of the fall mat, and staff interviews indicated that the fall mat was not consistently in place. The Director of Nursing confirmed that both residents should have had the specified fall prevention measures in place at all times.
Failure to Sanitize Thermometer and Perform Hand Hygiene
Penalty
Summary
The facility failed to sanitize the thermometer when measuring internal food temperatures and did not perform hand hygiene during meal service. Specifically, a culinary cook did not sanitize the thermometer before and between measuring the temperatures of various foods, including pureed cauliflower, lasagna, broccoli, brown gravy, and chicken noodle soup. The cook used a dishtowel and paper towels to wipe the thermometer instead of sanitizing it, and even dropped the thermometer into the chicken noodle soup without disposing of the contaminated soup. The culinary manager confirmed that the cook's actions were not acceptable and did not follow proper sanitization procedures. Additionally, a CNA failed to perform hand hygiene while assisting residents with meal distribution. The CNA did not wash hands before or after handling food trays, opening drinks, unwrapping utensils, or assisting residents in various rooms. The CNA also used the same gloves to handle multiple food trays and residents without changing them or performing hand hygiene. Both the CNA and the Director of Nursing acknowledged that the observed practices did not adhere to the facility's hand hygiene policy and were unacceptable.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to ensure a resident's room and equipment were kept clean for one of the four residents reviewed for environment. Observations on three consecutive days revealed large areas of a dried tan substance on the floor near the resident's tube feeding pole and on the base of the tube feeding pole. Additionally, the resident's wheelchair had two law labels covered in a dark brown substance. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the resident's floor, tube feeding pole, and wheelchair were not sanitary and should have been kept clean.
Failure to Check PEG Tube Placement Before Feeding
Penalty
Summary
The facility failed to check the placement of a resident's PEG tube prior to administering enteral nutritional therapy. Specifically, an LPN did not auscultate the tube placement before administering a bolus feeding to a resident diagnosed with dysphagia and gastrostomy status. The facility's policy required checking the tube's position by listening for air movement in the stomach, but this step was not followed. The deficiency was observed during an inspection, where the LPN admitted to not performing the required auscultation before administering the feeding. The resident's care plan also specified the need to check the tube placement before feedings, which was not adhered to. The Quality Assurance Nurse confirmed that the procedure should have been followed as per the facility's policy.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to complete quarterly assessments in a timely manner for seven residents. The assessments for these residents were completed more than 14 days after the Assessment Reference Date (ARD), which is not in compliance with the required timeline. Specifically, the assessments for Resident #45, Resident #56, Resident #74, Resident #88, Resident #132, Resident #149, and Resident #164 were all completed late, with completion dates ranging from 18 to 39 days after the ARD. During interviews, both the MDS Nurse and the Director of Nursing confirmed that the assessments were completed late and acknowledged that they should have been completed within the required timeframe. The facility's Final Validation Reports also confirmed the late completion of these assessments. This deficiency was identified through record reviews and staff interviews, highlighting a failure in the facility's process for timely resident assessments.
Failure to Submit Resident Assessments Timely
Penalty
Summary
The facility failed to submit resident assessments to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for nine residents. The assessments for these residents were completed but not transmitted within the required 14-day period. Specifically, the assessments for Resident #6, Resident #20, Resident #92, Resident #103, Resident #120, Resident #130, Resident #147, Resident #162, and Resident #170 were all submitted late, with delays ranging from several days to over a month past the completion date. Additionally, Resident #130's assessment was rejected by CMS due to an invalid date and was not resubmitted in a timely manner. This issue was confirmed through record reviews and interviews with facility staff, including the MDS Nurse and the Director of Nursing, who acknowledged the delays and the failure to meet the submission requirements. The deficiencies were identified during a review of the facility's Final Validation Reports and interviews with staff members. The MDS Nurse was unaware of the rejection of Resident #130's assessment and confirmed that the other assessments were submitted late. The Director of Nursing also confirmed the late submissions. These findings indicate a systemic issue with the timely submission of resident assessments, which is a critical regulatory requirement for ensuring accurate and up-to-date resident information is available to CMS.
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.
