Lafon Nursing Facility Of The Holy Family
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 6900 Chef Menteur Hwy, New Orleans, Louisiana 70126
- CMS Provider Number
- 195632
- Inspections on file
- 31
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Lafon Nursing Facility Of The Holy Family during CMS and state inspections, most recent first.
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 receiving tube feeding did not have accurate documentation of enteral feeding administration and gastric residual volume (GRV) checks by an LPN. The LPN recorded that feedings were restarted when they were not, and failed to document subsequent GRV checks and the actual time feedings were resumed, contrary to facility policy and professional standards.
A resident with a PEG tube did not have Enhanced Barrier Precaution (EBP) signage posted as required, and staff—including an LPN and two aides—failed to wear gowns during high-contact care activities such as PEG tube care and transfers. Staff interviews revealed they were unaware of the resident's EBP status and acknowledged that proper PPE should have been used.
Two residents in semiprivate rooms did not have ceiling-suspended privacy curtains around their beds, as observed during multiple surveyor visits. Staff and the DON confirmed the absence of required privacy measures for these residents.
A resident was discharged without a completed and accepted home health referral as ordered, and without arrangements for necessary PEG tube feeding equipment and formula. The facility did not ensure the resident's discharge needs were met, resulting in delays in both home health services and delivery of essential feeding supplies.
The facility did not complete required transfer or discharge reports for three discharged residents, omitting essential information such as the reason for transfer, relevant care instructions, discharge location, and a final summary of each resident's status. The administrator confirmed that these reports were incomplete and should have been properly filled out according to facility policy.
The facility failed to post a notice of employees' rights against retaliation for reporting crimes against residents in a conspicuous location. Observations and interviews revealed that no signage was displayed in employee common areas, and staff, including an LPN, the COO, and the Compliance Executive Nurse, were unaware of the requirement. The Administrator confirmed the absence of the signage and lack of awareness of this requirement.
A facility failed to report an abuse allegation involving a resident to the State Survey Agency within the required two-hour timeframe. The incident was discovered two days after it occurred, and the report was delayed. The administrator was aware of the allegation but inaccurately documented the discovery date and time. The CNA involved was suspended pending investigation results.
The facility did not conduct a performance review for a CNA within the required 12-month period. The CNA was hired in March 2023, and the last review was documented in March 2024, with no evidence of a review in the past year. This was confirmed by the HR Director and Administrator.
A facility failed to document monthly weights for a resident, as required by the care plan and facility policy. The resident's care plan included monthly weight evaluations per the dietician's recommendations, but weights for two months were missing. The Compliance Executive Nurse confirmed the absence of documentation, which hindered the dietitian's ability to assess the resident's weight loss percentage.
A facility failed to complete and transmit a Discharge/Transfer MDS assessment for a resident who was transferred to the hospital and subsequently discharged. The absence of this assessment was confirmed by an LPN and the DON, who acknowledged the oversight.
A facility failed to ensure the accuracy of an MDS assessment for a resident. The MDS incorrectly documented the use of bedrails as a physical restraint, despite the resident being cognitively intact and not having bedrails on her bed. Interviews confirmed the error, and the DON indicated that the facility did not use restraints.
The facility did not conduct annual performance evaluations for two CNAs and a Receptionist, as required. Despite being hired well before the survey, there was no documented evidence of these evaluations. This was confirmed by the HR Director and Director of Operations.
The facility failed to ensure safe mechanical lift practices, resulting in a resident's injury when a sling strap broke during a transfer. Another resident was transferred using a sling with altered straps, despite staff acknowledging the defect. These actions violated the facility's policy to discard defective slings.
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.
Failure to Accurately Document Enteral Feeding and Residual Checks
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident receiving enteral nutrition via a PEG tube. According to the facility's policies and the LPN job description, staff are required to document the date, time, and amount of gastric residual volume (GRV) checks, as well as the administration times of enteral feedings. For the resident in question, physician orders specified a continuous feeding regimen with specific start and stop times. However, documentation inconsistencies were identified: the LPN recorded that the resident's enteral feedings were restarted at a certain time, but subsequent observations and interviews revealed that the feeding pump was off and the tubing was not connected at that time. The LPN later acknowledged that the documentation indicating the feeding had been restarted was inaccurate. Further, when the LPN performed a GRV check and later restarted the resident's enteral feeding, these actions were not documented in the resident's medical record as required. The nurse's notes lacked entries for the actual time the feeding was restarted and for the GRV check, including the date, time, and amount. The DON confirmed that the LPN should have accurately documented all relevant information regarding the resident's enteral feeding and residual checks, in accordance with facility policy and professional standards.
Failure to Post EBP Signage and Ensure PPE Use for Resident with Indwelling Device
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring Enhanced Barrier Precaution (EBP) signage was posted for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, as required by facility policy. Observations on two separate occasions revealed that no EBP signage was present on or around the resident's door or bed, despite physician orders and care plan documentation indicating the need for EBP due to the presence of an indwelling medical device. Staff interviews confirmed the absence of signage and acknowledged that it should have been posted to alert staff and visitors. Additionally, staff did not consistently wear the required personal protective equipment (PPE), specifically gowns, during high-contact care activities for the resident on EBP. Observations showed that an LPN performed PEG tube care and two staff members conducted a transfer using a Hoyer lift without wearing gowns, contrary to facility policy and the resident's care plan. Interviews with the involved staff revealed a lack of awareness that the resident was on EBP and an acknowledgment that gowns should have been worn during these activities. The Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP signage and appropriate PPE use were required but not followed in these instances.
Lack of Privacy Curtains in Semiprivate Rooms
Penalty
Summary
The facility failed to provide required privacy measures for residents in semiprivate rooms, as evidenced by the absence of ceiling-suspended privacy curtains around the beds of two residents. Observations conducted on multiple occasions revealed that both residents, who were sharing rooms with roommates, did not have the necessary privacy curtains installed to ensure visual privacy. Staff interviews confirmed that these residents were in semiprivate rooms and acknowledged the lack of privacy curtains. The Director of Nursing also confirmed that residents in such rooms should have ceiling-suspended privacy curtains to maintain privacy.
Failure to Ensure Timely Home Health Referral and PEG Tube Supplies at Discharge
Penalty
Summary
The facility failed to ensure that a resident's discharge needs and physician's orders were met prior to discharge. Specifically, there was no documented evidence that a referral to home health was completed and accepted before the resident was discharged, despite a physician's order requiring home health services. The facility was unable to provide documentation that the home health agency had accepted the referral prior to the resident's discharge, and records showed that acceptance did not occur until after the resident had already left the facility. Additionally, the facility did not clarify or fulfill the discharge orders to ensure the resident had all necessary supplies and equipment for PEG tube feeding at home. The resident, who had a PEG tube for nutritional needs and required a specific feeding formula and pump, was discharged without documented orders or arrangements for these essential items. The referral for the PEG tube feeding pump and formula was not made until after discharge, resulting in a delay in the resident receiving the required equipment and nutrition supplies.
Incomplete Transfer/Discharge Documentation for Discharged Residents
Penalty
Summary
The facility failed to complete required transfer or discharge reports for three residents who were discharged or transferred. Record reviews showed that for each of these residents, the transfer/discharge reports were missing critical information such as the chief complaint or reason for transfer, relevant information including detailed instructions for ongoing care, the location to which the resident was transferred or discharged, and a final summary of the resident's status at the time of discharge. The facility's own policy requires that discharge summaries include a recapitulation of the resident's stay, a final summary of the resident's status, and that this information be available for authorized individuals and agencies with appropriate consent. Interviews confirmed that the administrator was aware that the transfer/discharge reports for these residents were incomplete and acknowledged that the reports should have been completed according to policy. The deficiency was identified through both interviews and record reviews, which consistently showed the absence of required documentation for all three sampled residents investigated for transfer and discharge requirements.
Failure to Post Employee Rights Signage
Penalty
Summary
The facility failed to comply with the requirement to post a notice of employees' rights against retaliation for reporting crimes against residents in a conspicuous location. This deficiency was identified through observations, interviews, and record reviews conducted by surveyors. During an inspection of the employee common areas, it was observed that there was no signage displayed regarding employees' rights against retaliation for reporting suspected crimes. This observation was confirmed by multiple staff members, including an LPN, the COO, and the Compliance Executive Nurse, who all indicated a lack of awareness or evidence of such signage. Further interviews revealed that the facility's Administrator was also unaware of the requirement to post this signage. The absence of the required signage was confirmed by the Administrator, who acknowledged that the facility could not provide any evidence of compliance with this requirement. The deficiency highlights a lack of awareness and implementation of policies to ensure employees are informed of their rights against retaliation, as mandated by the United States Social Security Act Title XI, Part A, Section 1150B(d)(3).
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #1 to the State Survey Agency within the required two-hour timeframe. According to the facility's Abuse Investigation and Reporting policy, any alleged violation involving abuse or resulting in serious bodily injury must be reported immediately, but no later than two hours. The incident occurred on February 19, 2025, and was discovered on February 21, 2025, at 9:39 AM. However, the report was not entered into the Statewide Incident Management System until 11:05 AM on the same day. Interviews revealed that the administrator was made aware of the allegation on February 20, 2025, at 9:15 AM, but the discovery date and time were inaccurately documented. The Certified Nursing Assistant involved was suspended pending investigation results. The administrator confirmed the failure to report the allegation within the required timeframe.
Failure to Conduct Timely Performance Review for CNA
Penalty
Summary
The facility failed to conduct a performance review for a Certified Nursing Assistant (CNA), identified as S8CNA, within the required 12-month period. S8CNA was hired on March 10, 2023, and the last documented performance review was dated March 13, 2024. However, there was no evidence of a performance review being completed within the past 12 months. This deficiency was confirmed through interviews with the Human Resources Director and the Administrator, who both acknowledged the absence of the required performance review for S8CNA.
Failure to Document Monthly Weights for a Resident
Penalty
Summary
The facility failed to document monthly weights for a resident, as required by the care plan and facility policy. The resident was supposed to have monthly weight evaluations as per the dietician's recommendations. However, there were no documented weights for November 2024 and December 2024. This lack of documentation was confirmed by the facility's Compliance Executive Nurse, who acknowledged that the policy mandates monthly weight documentation or an explanation for any missing data. The dietitian was unable to assess the resident's three-month weight loss percentage during a nutritional assessment due to the absence of these records.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to ensure the timely completion and transmission of a Discharge/Transfer Minimum Data Set (MDS) assessment for Resident #66. The resident was admitted to the facility and later transferred to the hospital, after which they were discharged and did not return. Upon review, there was no documented evidence that a transfer and discharge assessment was completed or transmitted for this resident. This deficiency was confirmed through interviews with the LPN responsible for MDS and the Director of Nursing, both acknowledging that the discharge MDS was not completed and transmitted as required.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. The MDS for this resident, with an assessment reference date of August 1, 2024, incorrectly documented the use of bedrails as a physical restraint, despite the resident being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The resident's care plan did not include any documentation regarding the use of restraints, and an observation confirmed that the resident did not have bedrails on her bed. Interviews with the resident and a Licensed Practical Nurse (LPN) confirmed that the MDS was coded in error, and the Director of Nursing (DON) indicated that the facility did not use restraints.
Failure to Conduct Annual Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations and provide in-service education based on these evaluations for two Certified Nursing Assistants (CNAs) and one Receptionist. Specifically, there was no documented evidence of annual performance evaluations for S4CNA, S5CNA, and S6Rec, despite their respective hire dates being well before the time of the survey. This deficiency was confirmed through interviews with the Human Resource Director and the Director of Operations, who acknowledged that the evaluations should have been conducted but were not.
Unsafe Mechanical Lift Practices Lead to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for residents requiring mechanical lift transfers, resulting in an Immediate Jeopardy situation. Specifically, the staff used mechanical lift slings that were not in good condition for two residents. In one instance, a resident was transferred using a mechanical lift when the sling's strap broke, causing the resident to fall and hit her head, leading to a closed head injury. This incident occurred despite the facility's policy requiring staff to discard any worn, frayed, or ripped slings. In another instance, a different resident was transferred using a mechanical lift sling with altered straps, which had been improperly modified by removing the blue loops. Staff members acknowledged the defect but proceeded with the transfer, contrary to the facility's policy and the manufacturer's instructions. Interviews with staff revealed a lack of adherence to the policy of inspecting and discarding defective slings, contributing to the unsafe conditions.
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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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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.
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